General practice registrars’ intentions for future practice: Implications for rural medical workforce planning

The models of practice that general practice registrars (GPRs) envisage undertaking will affect workforce supply. The aim of this research was to determine practice intentions of current GPRs in a regional general practice training program (Coast City Country General Practice Training). Questionnaires were circulated to 220 GPRs undertaking general practice placements to determine characteristics of ideal practice models and intentions for future practice. Responses were received for 99 participants (45%). Current GPRs intend to work an average of less than eight half-day sessions/week, with male participants intending to work more hours (t(91) = 3.528, P = 0.001). More than one-third of this regional cohort intends to practice in metropolitan centres. Proximity to family and friends was the most important factor influencing the choice of practice location. Men ranked remuneration for work as more important (t (88) = –4.280, P \u3c 0.001) and women ranked the ability to work part-time higher (t(94) = 3.697, P \u3c 0.001). Fee-for-service payment alone, or in combination with capitation, was the preferred payment system. Only 22% of Australian medical graduates intend to own their own practice compared with 52% of international medical graduates (χ2(1) = 8.498, P = 0.004). Future general practitioners (GPs) intend to work fewer hours than current GPs. Assumptions about lifestyle factors, practice models and possible professional roles should be carefully evaluated when developing strategies to recruit GPs and GPRs into rural practice

Prevention of osteoporotic refractures in regional Australia

Objective: Clinical guidelines recommend that patients who sustain a minimal trauma fracture (MTF) should receive a bone mineral density (BMD) scan and bisphosphonate (or equivalent) therapy if diagnosed with osteoporosis. A pilot fracture liaison service (FLS) was implemented in regional NSW to improve adherence to the guidelines. Design: Prospective cohort study with an historical control. Setting: Primary care. Participants: Control (n = 47) and cohort (n = 93) groups comprised patients consenting to interview who presented with a MTF to the major referral hospital 4 months before and 12 months after FLS implementation respectively. Main outcome measures: Primary outcome measures were the rates of BMD scans and anti-osteoporotic medication initiation/review after MTF. Hospital admission data were also examined to determine death and refracture rates for all patients presenting during the study period with a primary diagnosis of MTF within 3 years of their initial fracture. Results: Although there was no improvement in BMD scanning rates, the reported rate of medication initiation/review after fracture was significantly higher (P \u3c 0.05) in the FLS cohort. However, once adjusted for age, this association was not significant (P = 0.086). There was a lower refracture rate during the cohort period (P = 0.013), however, there were significantly more deaths (P = 0.035) within 3 years of initial fracture. When deaths were taken into account via competing risk regression, patients in the cohort period were significantly less likely to refracture than those in the control period (Hazard ratio = 0.576, P = 0.032). Conclusions: A rurally based nurse-led FLS was associated with modest improvement after MTF. Consideration should be given to ways to strengthen the model of care to improve outcomes

Novel candidate genes underlying extreme trophic specialization in Caribbean pupfishes

The genetic changes responsible for evolutionary transitions from generalist to specialist phenotypes are poorly understood. Here we examine the genetic basis of craniofacial traits enabling novel trophic specialization in a sympatric radiation of Cyprinodon pupfishes endemic to San Salvador Island, Bahamas. This recent radiation consists of a generalist species and two novel specialists: a small-jawed "snail-eater" and a large-jawed "scale-eater." We genotyped 12 million single nucleotide polymorphisms (SNPs) by whole-genome resequencing of 37 individuals of all three species from nine populations and integrated genome-wide divergence scans with association mapping to identify divergent regions containing putatively causal SNPs affecting jaw size-the most rapidly diversifying trait in this radiation. A mere 22 fixed variants accompanied extreme ecological divergence between generalist and scale-eater species. We identified 31 regions (20 kb) containing variants fixed between specialists that were significantly associated with variation in jaw size which contained 11 genes annotated for skeletal system effects and 18 novel candidate genes never previously associated with craniofacial phenotypes. Six of these 31 regions showed robust signs of hard selective sweeps after accounting for demographic history. Our data are consistent with predictions based on quantitative genetic models of adaptation, suggesting that the effect sizes of regions influencing jaw phenotypes are positively correlated with distance between fitness peaks on a complex adaptive landscape

Orthopedic surgeons\u27 attitudes to osteoporosis investigation and management after minimal trauma fracture

Background: The investigation and treatment of osteoporosis after minimal trauma fracture (MTF) is regarded as sub-optimal. There is strong evidence of the benefit of identifying and treating osteoporosis after MTF and there has been discussion of the possible role that orthopaedic surgeons might play in the management of osteoporosis after MTF. Questions/purposes: The study surveyed orthopaedic surgeons in rural and regional south east Australia to determine their attitudes to investigation and management of osteoporosis, the role health professionals should play, and the communication and co-ordination of follow-up care. Methods: A survey was developed and piloted prior to being posted to 69 orthopaedic surgeons asking for their opinions about the general management of osteoporosis, and the roles and responsibilities of health professionals in dealing with osteoporosis following a MTF. Results: Responses were received from 42 participants (60.8 %) with the majority of respondents agreeing that it is important to treat osteoporosis following MTF. Less than 15 % of respondents felt that it was their responsibility to initiate discussion or treatment or investigation after MTF. No respondent felt that the co-ordination of osteoporosis care was good and 45% stated it was poor. Communication after discharge is mostly left to the hospital (30%) while 20% stated they did not follow up at all. Conclusions: This study shows that many rural orthopaedic surgeons believe that follow-up in regard to osteoporosis after MTF is important, that responsibility for follow-up diagnosis and management of osteoporosis lies with primary health care and the current communication systems are poor

Association of waist circumference with outcomes in an acute general surgical unit

Background: Obesity prevalence is increasing in Australia, particularly in non-metropolitan areas. The effect of obesity on acute surgical outcomes is not known. We aimed to record waist circumference (WC) (surrogate for obesity) amongst acute surgical unit (ASU) patients in a New South Wales regional hospital, and compare outcome measures (length of stay (LOS), unplanned return to theatre, readmission rates, intensive care unit (ICU) admission and mortality). Methods: Retrospective cohort study of 4 months of consecutive ASU admissions, excluding age Results: Of 695 admissions, 512 met the inclusion criteria (47.1% female, average age 52.8 years (SD 22.3)), with 85.1% (P \u3c 0.001) of females and 69.4% (P =0.166)ofmales having an increased- or high-risk WC. This compares to rates amongst inner regional populations of 71.0% (female) and 66.4% (male). LOS was longer for high-risk patients (5.0 days versus 3.7 days, P = 0.002). However, the mean age of high-risk patients was greater (56.6 years versus 46.9 years, P = 0.001) and LOS was longer for those aged ≥60 (P \u3c 0.001). After controlling for age, high-risk WC was not associated with any outcome measure, except amongst ICU admissions, where high-risk patients stayed longer (15.5 days versus 6.8 days, P \u3c0.001). Conclusion: Increased- and high-risk WC was overrepresented amongst female ASU patients. High-risk WC was associated with a significantly greater LOS in patients admitted to ICU. High-risk WC was not associated with other outcomes independent of age. WC is useful for quantifying obesity in the inpatient settin

Equine Cyathostominae can develop to infective third-stage larvae on straw bedding

Background Domesticated grazing animals including horses and donkeys are frequently housed using deep litter bedding systems, where it is commonly presumed that there is no risk of infection from the nematodes that are associated with grazing at pasture. We use two different approaches to test whether equids could become infected with cyathostomines from the ingestion of deep litter straw bedding. Methods Two herbage plot studies were performed in horticultural incubators set up to simulate three straw bedding scenarios and one grass turf positive control. Faeces were placed on 16 plots, and larval recoveries performed on samples of straw/grass substrate over 2- to 3-week periods. Within each incubator, a thermostat was set to maintain an environmental temperature of approximately 10 °C to 20 °C. To provide further validation, 24 samples of straw bedding were collected over an 8-week period from six barns in which a large number of donkeys were housed in a deep litter straw bedding system. These samples were collected from the superficial bedding at 16 sites along a “W” route through each barn. Results No infective larvae were recovered from any of the plots containing dry straw. However, infective cyathostomine larvae were first detected on day 8 from plots containing moist straw. In the straw bedding study, cyathostomine larvae were detected in 18 of the 24 samples. Additionally, in the two barns which were sampled serially, the level of larval infectivity generally increased from week to week, except when the straw bedding was removed and replaced. Conclusions We have demonstrated that equine cyathostomines can develop to infective larvae on moist straw bedding. It is therefore possible for a horse or donkey bedded in deep litter straw to become infected by ingesting the contaminated straw. This has implications for parasite control in stabled equids and potentially in housed ruminants, and further investigation is required in order to establish the relative infective pressure from pasture versus straw bedding

Effect of medical student preference on rural clinical school experience and rural career intentions

Introduction: The key parameter for rural clinical schools (RCSs) is to provide at least 1 year of clinical training in rural areas for 25% of Australian Commonwealth supported medical students with the intent to influence future rural medical workforce outcomes. The objective of this study was to describe the association between a medical student’s selection preference and their RCS experience and rural career intent. Methods: Medical students completing an RCS placement in 2012 and 2013 were encouraged to complete a survey regarding their experience and future career intent. Data were analysed to compare medical students for whom the RCS was their first choice with students who described the RCS as other than their first preference. Results: Students for whom RCS was their first choice (724/1092) were significantly more likely to be female, come from a rural background and be from an undergraduate program. These students reported more positive experiences of all aspects of the RCS program (costs, access, support and networks, safety) and were 2.36 times more likely to report intentions to practice in a non-metropolitan area (odds ratio(OR)=2.36 (95% confidence interval(CI)=1.82–3.06), p\u3c0.001). This was true for students of rural (OR=3.11 (95%CI=1.93–5.02), p\u3c0.001) and metropolitan backgrounds (OR=2.07 (95%CI=1.48–2.89), p\u3c0.001). More students in the first-choice group (68.8%) intended to practice in a regional area (not a capital or major city), significantly higher than the 48.4% of participants in the other-preference group (χ2 (1) 42.79, p\u3c0.001). Conclusions: The decision to choose an RCS placement is a marker of rural career intention and a positive rural training experience for students of both rural and metropolitan backgrounds. It may be important to identify other-preference students and their specific social support needs to ensure a positive perception of a future rural career

Building research capacity at The University of Notre Dame Australia, School of Medicine, Sydney, to improve chronic disease management

The research focus for this study is osteoporosis (OP) in community-dwelling older adults. APHCRI funding is enabling development of research capacity in primary care at the University of Notre Dame Australia Clinical School by supporting employment of a Post-Doctoral Fellow to be based at the School's Wagga Wagga Rural Clinical School to assist in the development and implementation of an osteoporosis project in collaboration with the Murrumbidgee integrated primary health care centre and the UNSW Rural Clinical School with 'in kind' support from the the University of Notre Dame Australia Clinical School. This aligns with Notre Dame's key focus area of health research and engagement with the community.The research reported in this paper is a project of the Australian Primary Health Care Research Institute which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research Evaluation and Development Strategy

New exercise-integrated technology can monitor the dosage and quality of exercise performed against an elastic resistance band by adolescents with patellofemoral pain:an observational study

Question: Is the exercise-integrated Bandcizer™ system feasible for recording exercise dosage (time under tension (TUT) and repetitions) and pain scores among adolescents with patellofemoral pain? Do adolescents practise the exercises as prescribed (TUT and repetitions)? Do adolescents accurately report the exercises they do in an exercise diary? Design: Observational feasibility study. Participants: Twenty adolescents between 15 and 19 years of age with patellofemoral pain. Intervention: Participants were prescribed three exercise sessions per week (one with and two without supervision) for 6 weeks. The exercises included three hip and one knee exercise with an elastic resistance band. Participants were instructed to perform three sets with a predefined TUT (3 seconds concentric; 2 seconds isometric; 3 seconds eccentric; 2 seconds pause), equating to 80 seconds for 10 repetitions (one set). Outcome measures: The exercise-integrated system consisted of a sensor attached to the elastic resistance band that was connected to the Bandtrainer app on an electronic tablet device. Pain intensity was reported on a visual analogue scale on the app. Participants also completed a self-report exercise diary. Results: No major problems were reported with the system. Participants performed 2541 exercise sets during the 6 weeks; 5% were performed with the predefined TUT (ie, within 10 seconds of the 80-second target) and 90% were performed below the target TUT. On average, the participants received 15% of the instructed exercise dosage based on TUT. The exercise dosage reported in the exercise diaries was 2.3 times higher than the TUT data from the electronic system. Pain intensity was successfully collected in 100% of the exercise sets. Conclusion: The system was feasible for adolescents with patellofemoral pain. The system made it possible to capture detailed data about the TUT, repetitions and sets during home-based exercises together with pain intensity before and after each exercise. [Rathleff MS, Bandholm T, McGirr KA, Harring SI, Sørensen AS, Thorborg K (2016) New exercise-integrated technology can monitor the dosage and quality of exercise performed against an elastic resistance band by adolescents with patellofemoral pain: an observational study. Journal of Physiotherapy 62: 159–163