Australian GP attitudes to clinical practice guidelines and some implications for translating osteoarthritis care into practice

Abstract Clinical practice guidelines (CPGs) have been shown to improve processes of care and health outcomes, but there is often a discrepancy between recommendations for care and clinical practice. We sought to explore general practitioner attitudes toward CPGs, in general and specifically for osteoarthritis (OA) with the implications for translating OA care into practice. A self-administered questionnaire was conducted in January 2013 of a sample of 228 GPs in New South Wales and South Australia. Seventy-nine GPs returned questionnaires (response rate 35%). Nearly all GPs considered that CPGs support decision making in practice (94%) and medical education (92%). Very few respondents regarded CPGs as a threat to clinical autonomy, and most recognised that individual patient circumstances must be taken into account. Shorter CPG formats were preferred over longer and more comprehensive formats, with preferences being evenly divided amongst respondents for short, 2-3 page summaries, flowcharts or algorithms and single page checklists. GPs considered accessibility to CPGs to be important, and electronic formats were popular. Familiarity and use of The Royal Australian College of General Practitioners OA Guideline was poor with most respondents either not aware of it (30%: 95% CI 27% - 41%), had never used it (19%; 95% CI 12% - 29%), or rarely used it (34%; 95% CI 25% - 45%). If CPGs are to assist with the translation of evidence into practice, they must be easily accessible and in a format that encourages use. Key words: arthritis, primary care, evidence-based medicine, decision making Summary statement What is known about the topic? • Clinical practice guidelines (CPGs) can improve processes of care and health outcomes, however, there is often a gap between evidence-based recommendations for care and clinical practice. What does this paper add? • A better understanding of GP attitudes toward CPGs helps to explain potential barriers to the uptake of evidence-based practice and provides guidance on remedial action that may lead to better health outcomes.a National Health and Medical Research Council Program Grant (Australia, no.568612

Public perception of dentists' ability to manage a medical emergency

The importance of dentists to be able to manage a medical emergency in dental practice has been an established concept for many years, with medical emergency training being incorporated into dental undergraduate training programs as far as back as 1981. However, for far longer than this, dentists have held a professional role in the staffing of military field hospitals, providing emergency care to injured and ill members of the armed forces. Despite awareness of the importance of such skills, Australian studies have shown dentists often lack appropriate proficiencies and equipment for the effective and efficient management of medical crises that may arise as a part of routine dentistry. The only identified literature review on medical emergencies within dentistry recently found the majority of both students and graduate dentists were unable to correctly perform life support procedures3. This is a finding of concern when recent studies on the prevalence of medical emergencies in dentistry suggest that the incidence may be increasing, due to a myriad of factors. The populations of developed countries are generally getting older and consequently suffer from more acute and chronic conditions; notably, it has been argued that patients with multiple chronic diseases are more likely to suffer from a medical emergency. Simultaneously, a greater number of practitioners are utilising drugs such as sedatives compared to years past. These findings coincide with observations that dentists are being taught less clinical medical science than they have historically, and are further being seen as service providers to a consumerist public, rather than their trained role as health professionals. Although all schools of dentistry in Australia require their students to hold first aid and basic life support (BLS) certification, the requirements for practicing dentists to undergo ongoing training or medical emergency certification varies across countries and governing bodies. Australian dentists are not specifically required to undergo ongoing training in the management of medical emergencies, despite it being strongly recommended by the Australian Dental Association. Further, the public's expectation of dentists' competence in medical emergency management is likely much higher than what dentists may hold of themselves15, and reports on unpublished studies corroborate this suggestion. In the current military framework, Australian Defence Force (ADF) Dental Officers (DO) are often involved in the early triaging and stabilisation of injured members who have been evacuated to a role two facility but are not yet in receipt of advanced medical care. This too mandates a high level of knowledge and proficiency in emergency medical management. Given the special semi-autonomous status afforded to the self-regulation of dentistry there is a professional responsibility to meet or exceed public expectations, or such deficiencies may be legislatively mandated. To date, no published studies could be found examining the public's opinion of dentists' ability to manage a medical emergency in a dental setting, nor whether a patient's own medical status impacts on whether they visit a dentist because of concerns about a medical emergency. Based on this, the aim of this research is to quantify the public's attitudes towards dentists’ proficiency in a medical crisis

Integration and segregation across large-scale intrinsic brain networks as a marker of sustained attention and task-unrelated thought

Sustained attention is a fundamental cognitive process that can be decoupled from distinct external events, and instead emerges from ongoing intrinsic large-scale network interdependencies fluctuating over seconds to minutes. Lapses of sustained attention are commonly associated with the subjective experience of mind wandering and task-unrelated thoughts. Little is known about how fluctuations in information processing underpin sustained attention, nor how mind wandering undermines this information processing. To overcome this, we used fMRI to investigate brain activity during subjects’ performance (n=29) of a cognitive task that was optimized to detect and isolate continuous fluctuations in both sustained attention (via motor responses) and task-unrelated thought (via subjective reports). We then investigated sustained attention with respect to global attributes of communication throughout the functional architecture, i.e., by the segregation and integration of information processing across large scale-networks. Further, we determined how task-unrelated thoughts related to these global information processing markers of sustained attention. The results show that optimal states of sustained attention favor both enhanced segregation and reduced integration of information processing in several task-related large-scale cortical systems with concurrent reduced segregation and enhanced integration in the auditory and sensorimotor systems. Higher degree of mind wandering was associated with losses of the favored segregation and integration of specific subsystems in our sustained attention model. Taken together, we demonstrate that intrinsic ongoing neural fluctuations are characterized by two converging communication modes throughout the global functional architecture, which give rise to optimal and suboptimal attention states. We discuss how these results might potentially serve as neural markers for clinically abnormal attention

The comorbidities of dysmenorrhea: a clinical survey comparing symptom profile in women with and without endometriosis

Purpose: Dysmenorrhea is a common disorder that substantially disrupts the lives of young women. The frequency of 14 associated symptoms both within and outside the pelvis was determined. Patients and methods: Symptom questionnaires were completed by 168 women with dysmenorrhea, allocated to three groups based on their diagnostic status for endometriosis confirmed (Endo+), endometriosis excluded (Endo−), or endometriosis diagnosis unknown (No Lap). Those with endometriosis confirmed were further divided into current users (Endo+ Hx+) and non-users of hormonal treatments (Endo+ Hx–). Users of hormonal treatments were further divided into users (Endo+ Hx+ LIUCD+) and non-users (Endo+ Hx+ LIUCD–) of a levonorgestrel-releasing intra-uterine contraceptive device (LIUCD). The frequency and number of symptoms within groups and the effect of previous distressing sexual events were sought. Results: Women with and without endometriosis lesions had similar symptom profiles, with a mean of 8.5 symptoms per woman. Only 0.6% of women reported dysmenorrhea alone. The presence of stabbing pelvic pains was associated with more severe dysmenorrhea (P=0.006), more days per month of dysmenorrhea (P=0.003), more days per month of pelvic pain (P=0.016), and a diagnosis of migraine (P=0.054). The symptom profiles of the Endo+ Hx+ and Endo+ Hx– groups were similar. A history of distressing sexual events was associated with an increased number of pain symptoms (P=0.003). Conclusion: Additional symptoms are common in women with dysmenorrhea, and do not correlate with the presence or absence of endometriosis lesions. Our study supports the role of central sensitization in the pain of dysmenorrhea. The presence of stabbing pelvic pains was associated with increased severity of dysmenorrhea, days per month of dysmenorrhea, days per month of pelvic pain, and a diagnosis of migraine headache. A past history of distressing sexual events is associated with an increased number of pain symptoms

Anticipated psychosocial stress informs sustained attention performance: A behavioral and physiological perspective

The ability to sustain attention is paramount to the completion of daily activities, such as driving or attending to a lecture. Previous studies have suggested that stress prior to cognitive testing leads to changes in attentional performance based on stressor context, but the impact of anticipated stress on attention remains unclear. To answer this question, the current study examined a sample of thirty-one undergraduate students (age 18-35, M=21.5, S.D.=3.1) who either anticipated a psychosocial stressor or completed guided meditation before completing a go/no-go sustained attention task (gradCPT). Subjective measures of anxiety, self-esteem, extraversion, and neuroticism were also gathered along with heart rate and electrodermal activity measures to objectively determine stress reactivity. Correlational analyses revealed negative associations between state anxiety and commission errors (r=-0.5, p=0.048), reaction time variability (r=-0.522, p=0.038), and a positive association between state anxiety and accuracy (d’) (r=0.521, p=0.038) in the stress condition exclusively. When controlling for state anxiety, mixed design ANOVAs revealed a significant main effect of condition on d’ (F(1,28)=5.54, p=0.026), where the stress group showed lower d’. Further, data showed a trend of an interaction on reaction time variability (F(1,28)=3.49, p=0.072) where increased variability across the task duration occurred as a function of condition assignment, and a trend of a main effect of condition (F(1,28)=3.93, p=0.057) suggesting more commission errors under stress. The results suggest that anticipation of a stressor does impact sustained attention, but that performance may exist on a spectrum based on subjective appraisal of the stressor. (Author abstract)Brau, J.M., Fortenbaugh, F.C., & Esterman, M. (2021). Anticipated psychosocial stress informs sustained attention performance: A behavioral and physiological perspective. Retrieved from http://academicarchive.snhu.ed

Physical activity habits and preferences in the month prior to a first-ever stroke

Background. Physical inactivity is a powerful risk factor for stroke and other chronic diseases. The aim of this study was to explore physical activity habits and preferences in the month leading up to a first-ever stroke, and to determine whether participants were aware of the link between stroke and physical activity. Methods. We undertook an observational study with 81 participants recently admitted to a stroke unit. Participants reported their pre-morbid physical activity preferences and habits and completed the Barriers to Physical Activity and Disability Survey. Data were analysed with summative content analysis and descriptive statistics. Results. Only 31% of participants were aware that physical inactivity was associated with stroke. Most participants defined physical activity with examples of instrumental activities of daily living (IADL) and walking (48% of responses), and IADLs constituted their most frequent regular physical activity (38% of responses). The barriers to physical activity reported by participants most frequently were lack of motivation (52%), lack of interest (50%) and lack of energy (42%). Conclusions. Regular physical activity is important to prevent stroke and other chronic diseases but adults at risk of stroke have little awareness of the risks of physical inactivity and little motivation to undertake regular exercise.Michelle N. McDonnell, Adrian J. Esterman, Rosena S. Williams, Jenny Walker, Shylie F. Mackintos

Pre-pregnancy predictors of hypertension in pregnancy among Aboriginal and Torres Strait Islander women in north Queensland, Australia; a prospective cohort study

BACKGROUND Compared to other Australian women, Indigenous women are frequently at greater risk for hypertensive disorders of pregnancy. We examined pre-pregnancy factors that may predict hypertension in pregnancy in a cohort of Aboriginal and Torres Strait Islander women in north Queensland. METHODS Data on a cohort of 1009 Indigenous women of childbearing age (15–44 years) who participated in a 1998–2000 health screening program in north Queensland were combined with 1998–2008 Queensland hospitalisations data using probabilistic data linkage. Data on the women in the cohort who were hospitalised for birth (n = 220) were further combined with Queensland perinatal data which identified those diagnosed with hypertension in pregnancy. RESULTS Of 220 women who gave birth, 22 had hypertension in the pregnancy after their health check. The mean age of women with and without hypertension was similar (23.7 years and 23.9 years respectively) however Aboriginal women were more affected compared to Torres Strait Islanders. Pre-pregnancy adiposity and elevated blood pressure at the health screening program were predictors of a pregnancy affected by hypertension. After adjusting for age and ethnicity, each 1 cm increase in waist circumference showed a 4% increased risk for hypertension in pregnancy (PR 1.04; 95% CI; 1.02-1.06); each 1 point increase in BMI showed a 9% adjusted increase in risk (1.09; 1.04-1.14). For each 1 mmHg increase in baseline systolic blood pressure there was an age and ethnicity adjusted 6% increase in risk and each 1 mmHg increase in diastolic blood pressure showed a 7% increase in risk (1.06; 1.03-1.09 and 1.07; 1.03-1.11 respectively). Among those free of diabetes at baseline, the presence of the metabolic syndrome (International Diabetes Federation criteria) predicted over a three-fold increase in age-ethnicity-adjusted risk (3.5; 1.50-8.17). CONCLUSIONS Pre-pregnancy adiposity and features of the metabolic syndrome among these young Aboriginal and Torres Strait Islander women track strongly to increased risk of hypertension in pregnancy with associated risks to the health of babies.Sandra K Campbell, John Lynch, Adrian Esterman and Robyn McDermot

Current and emerging pharmacotherapeutic options for smoking cessation

Tobacco smoking remains the single most preventable cause of morbidity and mortality in developed countries and poses a significant threat across developing countries where tobacco use prevalence is increasing. Nicotine dependence is a chronic disease often requiring multiple attempts to quit; repeated interventions with pharmacotherapeutic aids have become more popular as part of cessation therapies. First-line medications of known efficacy in the general population include varenicline tartrate, bupropion hydrochloride, nicotine replacement therapy products, or a combination thereof. However, less is known about the use of these products in marginalized groups such as the indigenous, those with mental illnesses, youth, and pregnant or breastfeeding women. Despite the efficacy and safety of these first line pharmacotherapies, many smokers continue to relapse and alternative pharmacotherapies and cessation options are required. Thus, the aim of this review is to summarize the existing and developing pharmacotherapeutic and other options for smoking cessation, to identify gaps in current clinical practice, and to provide recommendations for future evaluations and research.Kristin V. Carson, Malcolm P. Brinn, Thomas A. Robertson, Rachada To-A-Nan, Adrian J. Esterman, Matthew Peters and Brian J. Smit

Potently neutralizing and protective anti-human metapneumovirus antibodies target diverse sites on the fusion glycoprotein

Human metapneumovirus (hMPV) is a leading cause of acute lower respiratory tract infections in high-risk populations, yet there are no vaccines or anti-viral therapies approved for the prevention or treatment of hMPV-associated disease. Here, we used a high-throughput single-cell technology to interrogate memory B cell responses to the hMPV fusion (F) glycoprotein in young adult and elderly donors. Across all donors, the neutralizing antibody response was primarily directed to epitopes expressed on both pre- and post-fusion F conformations. However, we identified rare, highly potent broadly neutralizing antibodies that recognize pre-fusion-specific epitopes and structurally characterized an antibody that targets a site of vulnerability at the pre-fusion F trimer apex. Additionally, monotherapy with neutralizing antibodies targeting three distinct antigenic sites provided robust protection against lower respiratory tract infection in a small animal model. This study provides promising monoclonal antibody candidates for passive immunoprophylaxis and informs the rational design of hMPV vaccine immunogens.We acknowledge the Immune Monitoring and Flow Cytometry Resource (IMFCSR) at the Norris Cotton Cancer Center at Dartmouth supported by NCI Cancer Center Support Grant 5P30CA023108-41. This work was funded in part by Welch Foundation grant number F-0003-19620604.S