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

Direct Measurement of Periodic Electric Forces in Liquids

The electric forces acting on an atomic force microscope tip in solution have been measured using a microelectrochemical cell formed by two periodically biased electrodes. The forces were measured as a function of lift height and bias amplitude and frequency, providing insight into electrostatic interactions in liquids. Real-space mapping of the vertical and lateral components of electrostatic forces acting on the tip from the deflection and torsion of the cantilever is demonstrated. This method enables direct probing of electrostatic and convective forces involved in electrophoretic and dielectroforetic self-assembly and electrical tweezer operation in liquid environments

Whole blood NAD and NADP concentrations are not depressed in subjects with clinical pellagra

Population surveys for niacin deficiency are normally based on clinical signs or on biochemical measurements of urinary niacin metabolites. Status may also be determined by measurement of whole blood NAD and NADP concentrations. To compare these methods, whole blood samples and spot urine samples were collected from healthy subjects (n = 2) consuming a western diet, from patients (n = 34) diagnosed with pellagra and attending a pellagra clinic in Kuito (central Angola, where niacin deficiency is endemic), and from female community control subjects (n = 107) who had no clinical signs of pellagra. Whole blood NAD and NADP concentrations were measured by microtiter plate-based enzymatic assays and the niacin urinary metabolites 1-methyl-2-pyridone-5-carboxamide (2-PYR) and 1-methylnicotinamide (1-MN) by HPLC. In healthy volunteers, inter- and intra-day variations for NAD and NADP concentrations were much lower than for the urinary metabolites, suggesting a more stable measure of status. However, whole blood concentrations of NAD and NADP or the NAD:NADP ratio were not significantly depressed in clinical pellagra. In contrast, the concentrations of 2-PYR and 1-MN, expressed relative to either creatinine or osmolality, were lower in pellagra patients and markedly higher following treatment. The use of the combined cut-offs (2-PYR <3.0 micromol/mmol creatinine and 1-MN <1.3 micromol/mmol creatinine) gave a sensitivity of 91% and specificity of 72%. In conclusion, whole blood NAD and NADP concentrations gave an erroneously low estimate of niacin deficiency. In contrast, spot urine sample 2-PYR and 1-MN concentrations, relative to creatinine, were a sensitive and specific measure of deficiency

Sexual Health Education: an evaluation of the Northumbria Integrated Sexual Health Education (NISHE) Workforce Development Package delivered by UWE, Bristol

Background: Sexual health and wellbeing is a central focus of public health policy and service development in England (Department of Health (DH) 2013a, 2013b, Public Health England (PHE) 2015). Historically, services in the UK have been delivered through Family Planning clinics for contraceptive services or Genito-Urinary (GUM) clinics for sexual health issues. Current NHS Service Specifications for sexual health services emphasise an integrated service, delivered by a single health professional (DH 2013b), which has significant implications for the sexual health workforce. Within the South West, there was a disparity of sexual health education provision with little emphasis on the practical competence element. In order to equip sexual health nurses with the appropriate knowledge and skills to deliver an integrated sexual health service, the University of the West of England (UWE) entered a formal agreement with a partner university who had developed an educational package. UWE commenced delivery of two new sexual health modules in September 2013, incorporating both a newly developed classroom delivered Foundations of Sexual Health module and an established Integrated Sexual Health Education module which incorporated a practice placement, mentor support and blended learning approaches to deliver the theory element. This package had previously been successfully delivered in the North of England (McNall and Kain 2010). Aims This research, conducted between 2013 and 2015, explored the transferability of the model to the South West region and the degree to which the educational delivery met service demands in relation to integrated sexual health provision. Research Methodology: Data were collected using quantitative and qualitative methods, specifically longitudinal baseline and follow-up survey data from students (n=49) using two validated self-efficacy scales, focus groups with students (n=22) and semi-structured interviews with students (n=7) and strategic managers (n=6). Quantitative analysis of questionnaire data was conducted on baseline and follow-up data using SPSS version 2.2. The data exploring self-efficacy were analysed using Wilcoxon tests and Friedman’s tests. Descriptive statistics and frequencies were used to examine the characteristics of the study population. Qualitative analysis was conducted through thematic analysis and constant comparative methods (Braun and Clarke 2006). Key Findings: The results indicated that students who undertook the modules demonstrated significant increases in self-efficacy when using the evidence base in sexual health practice and when communicating in difficult situations. The highest percentage point increase in self-efficacy occurred when the students completed both modules rather than one in isolation. Service manager and student expectation regarding the instructional immediacy and technological specification of the e-learning package were not always met but the electronic mode of delivery was praised for its flexibility, especially important given the large geographical spread of students. Service managers and students were aware of the move to integrated service delivery but were often frustrated by structural restraints that impeded innovation and practice development, such as fragmented commissioning arrangements or lack of collocated services. Although these restraints limited the impact that new learning could have on the service that was offered to patients, there was some evidence that the students were using their professional autonomy to manipulate the system, in line with Lipsky’s (1980) concept of street level bureaucracy. Recommendations: Consideration should be given to the balance of e-learning and face-to-face contact within modules, to enhance instructional immediacy and increase student satisfaction. E-learning packages should be reviewed to meet student expectation by incorporating interactive technology and opportunities for collaborative learning. In addition, where service delivery is in a state of flux, modules should incorporate elements of leadership development to enable practitioners to initiate and manage change in practice

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

Low and deficient niacin status and pellagra are endemic in postwar Angola

BACKGROUND: Outbreaks of pellagra were documented during the civil war in Angola, but no contemporary data on the incidence of pellagra or the prevalence of niacin deficiency were available. OBJECTIVE: The objective was to investigate the incidence of pellagra and the prevalence of niacin deficiency in postwar Angola and their relation with dietary intake, poverty, and anthropometric status. DESIGN: Admissions data from 1999 to 2004 from the pellagra treatment clinic in Kuito, Angola, were analyzed. New patients admitted over 1 wk were examined, and urine and blood samples were collected. A multistage cluster population survey collected data on anthropometric measures, household dietary intakes, socioeconomic status, and clinical signs of pellagra for women and children. Urinary excretion of 1-methylnicotinamide, 1-methyl-2-pyridone-5-carboxymide, and creatinine was measured and hemoglobin concentrations were measured with a portable photometer. RESULTS: The incidence of clinical pellagra has not decreased since the end of the civil war in 2002. Low excretion of niacin metabolites was confirmed in 10 of 11 new clinic patients. Survey data were collected for 723 women aged 15-49 y and for 690 children aged 6-59 mo. Excretion of niacin metabolites was low in 29.4% of the women and 6.0% of the children, and the creatinine-adjusted concentrations were significantly lower in the women than in the children (P < 0.001, t test). In children, niacin status was positively correlated with the household consumption of peanuts (r = 0.374, P = 0.001) and eggs (r = 0.290, P = 0.012) but negatively correlated with socioeconomic status (r = -0.228, P = 0.037). CONCLUSIONS: The expected decrease in pellagra incidence after the end of the civil war has not occurred. The identification of niacin deficiency as a public health problem should refocus attention on this nutritional deficiency in Angola and other areas of Africa where maize is the staple

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

Exponential Kleisli monoids as Eilenberg-Moore algebras

Lax monoidal powerset-enriched monads yield a monoidal structure on the category of monoids in the Kleisli category of a monad. Exponentiable objects in this category are identified as those Kleisli monoids with algebraic structure. This result generalizes the classical identification of exponentiable topological spaces as those whose lattice of open subsets forms a continuous lattice.Comment: v2: minor typos correcte