Experience with a Clinical Audit Requirement for Interns in the Emergency Department

BACKGROUND: The clinical audit is an important evaluation tool to ensure quality assurance. A clinical audit requirement for interns during their emergency department (ED) term may be a valuable educational activity.METHODS: The Emergency Audit Initiative (EAI) Program was initiated at Redcliffe Hospital in January 2018. Interns, who were paired with a staff specialist audit mentor, chose a topic of interest and carried out a clinical audit during their 10-week ED term. At the end of term, interns formally presented audit findings in a grand round setting. Interns and staff specialists were surveyed at the end of the intern year regarding aspects of the program. Surveys aimed to assess: (1) value of the program as an educational activity, (2) availability of time and resources to conduct the audit, and (3) perceived impact on practice.RESULTS: During the first year of the program, 27 clinical audits were carried out. 16 interns (59%) and 8 staff specialists (57%) responded to the surveys. Interns and staff specialists reported that the audit was a valuable educational experience (88% and 100%). Interns also reported that they had adequate time (94%) and resources (81%) to conduct the audit. Interns and staff specialists however reported only a modest impact on clinical practice because of the audit program.CONCLUSIONS: Our experience with the EAI program suggests that incorporating a clinical audit requirement into the ED term is possible. Interns and staff specialists reported it to be a beneficial educational and professional development activity.</p

Environmental oxygen tension regulates the energy metabolism and self-renewal of human embryonic stem cells

Energy metabolism is intrinsic to cell viability but surprisingly has been little studied in human embryonic stem cells (hESCs). The current study aims to investigate the effect of environmental O2 tension on carbohydrate utilisation of hESCs. Highly pluripotent hESCs cultured at 5% O2 consumed significantly more glucose, less pyruvate and produced more lactate compared to those maintained at 20% O2. Moreover, hESCs cultured at atmospheric O2 levels expressed significantly less OCT4, SOX2 and NANOG than those maintained at 5% O2. To determine whether this difference in metabolism was a reflection of the pluripotent state, hESCs were cultured at 5% O2 in the absence of FGF2 for 16 hours leading to a significant reduction in the expression of SOX2. In addition, these cells consumed less glucose and produced significantly less lactate compared to those cultured in the presence of FGF2. hESCs maintained at 5% O2 were found to consume significantly less O2 than those cultured in the absence of FGF2, or at 20% O2. GLUT1 expression correlated with glucose consumption and using siRNA and chromatin immunoprecipitation was found to be directly regulated by hypoxia inducible factor (HIF)-2? at 5% O2. In conclusion, highly pluripotent cells associated with hypoxic culture consume low levels of O2, high levels of glucose and produce large amounts of lactate, while at atmospheric conditions glucose consumption and lactate production are reduced and there is an increase in oxidative metabolism. These data suggest that environmental O2 regulates energy metabolism and is intrinsic to the self-renewal of hESCs

Nurse practitioners in the emergency department: establishing a successful service

Background: A regional hospital emergency department was facing increasing patient presentations, medical workforce shortages and long delays for patients to be seen. Furthermore, a high percentage of low acuity ambulatory patients were not waiting to be seen. Aim: To introduce a sustainable / long-term nurse practitioner (NP) led model of care to address the identified emergency department service requirements for low acuity ambulatory patients. Methods: A descriptive exploratory design was used to establish and monitor a NP model. Organisational support and a steering committee was used to monitor clinical safety and patient satisfaction. Data was collected in relation to number of patients seen, conditions managed by nurse practitioners, time to treatment, length of stay and compliments and complaints received. Findings: NPs within this service now comprise 10% of the treating clinician workforce, see 15% of total presentations, contribute to a reduction in waiting time, length of stay within the targeted cohort and meeting National Emergency Access Targets 95% of the time. Discussion: Establishment of a NP model has been successful at addressing the needs of low acuity patients in the emergency department as evidenced by reduced waiting times, length of stay and customer satisfaction. We attribute this success to the following three key factors: targeting a patient population, commitment to the service and adaptability. Conclusion: Development of a dedicated NP model has enabled the emergency department to safely and sustainably provide care to low acuity ambulatory patients

Regional nodal metastasis and 5-year survival in patients with thin melanoma in Queensland: a population-based study

Background: Optimal management of regional lymph nodes for thin cutaneous melanoma is uncertain. We evaluated regional lymph node involvement and 5-year melanoma-specific survival (MSS) in patients with thin (≤1 mm) primary melanoma. Methods: Patients with a melanoma, American Joint Committee on Cancer Staging 8th Edition pT1a (60 years. The 5-year MSS was similar for observed and SLNB cohorts (99.66% versus 98.92%) but worse for T1b lesions (98.90%) and clinical nodal recurrence (66.89%). Conclusion: Overall prognosis for T1 melanoma is excellent with nodal involvement being rare. However, the American Joint Committee on Cancer 8th Edition T1b melanoma correlates with significantly worse 5-year MSS and increased regional nodal recurrence (notably for 0.8–1.0 mm lesions with ulceration). Further characterization of high-risk groups for nodal positivity that impacts patient outcome is needed for the pT1 melanoma cohort

GLUT1 expression parallels glucose utilisation and is directly regulated by HIF-2α under hypoxic conditions.

<p>RT-qPCR was used to quantify <i>GLUT1</i> mRNA expression in Hues7 hESCs cultured at either 5% O₂, or 20% O₂ on day three post-passage (A). All data has been normalised to <i>UBC</i> and to 1 for 5% O₂. *P<0.05 significantly different to 5% O₂ (n = 3). Using siRNA to silence HIF-α subunits in Hues7 hESCs cultured at 5% O₂, <i>GLUT1</i> mRNA was found to be regulated by HIF-2α (B). All data has been normalised to <i>UBC</i> and to 1 for the transfection control. *P<0.05 significantly different to transfection control (n = 6). Using ChIP HIF-2α was found to bind to the proximal promoter of GLUT1 only in hESCs cultured at 5% O₂. ChIP assays were performed with either a HIF-2α or IgG control antibody on chromatin isolated from Hues7 hESCs cultured at either 20% O₂ or 5% O₂. DNA enrichment is expressed as a percentage of input (non-immunoprecipitated chromatin). *P<0.05, **P<0.01, NS indicates no significant difference (n = 5).</p

hESCs maintained at atmospheric O₂ levels express reduced levels of pluripotency markers compared to those cultured at 5% O₂.

<p>Hues7 hESCs were cultured at either 5% O₂, 5% O₂ with FGF2 removed for 16 hours (5% O₂– FGF2) or 20% O₂. Protein was isolated and OCT4 (A and B), SOX2 (C and D) and NANOG (E and F) quantified using Western blotting. All data has been normalised to β-actin and to 1 for 5% O₂. *P<0.05, **P<0.01, ***P<0.001 significantly different from 5% O₂ (n = 3–4).</p