Supervision and feedback for junior medical staff in Australian emergency departments: findings from the emergency medicine capacity assessment study

<p>Abstract</p> <p>Background</p> <p>Clinical supervision and feedback are important for the development of competency in junior doctors. This study aimed to determine the adequacy of supervision of junior medical staff in Australian emergency departments (EDs) and perceived feedback provided.</p> <p>Methods</p> <p>Semi-structured telephone surveys sought quantitative and qualitative data from ED Directors, Directors of Emergency Medicine Training, registrars and interns in 37 representative Australian hospitals; quantitative data were analysed with SPSS 15.0 and qualitative data subjected to content analysis identifying themes.</p> <p>Results</p> <p>Thirty six of 37 hospitals took part. Of 233 potential interviewees, 95 (40.1%) granted interviews including 100% (36/36) of ED Directors, and 96.2% (25/26) of eligible DEMTs, 24% (19/81) of advanced trainee/registrars, and 17% (15/90) of interns. Most participants (61%) felt the ED was adequately supervised in general and (64.2%) that medical staff were adequately supervised. Consultants and registrars were felt to provide most intern supervision, but this varied depending on shift times, with registrars more likely to provide supervision on night shift and at weekends. Senior ED medical staff (64%) and junior staff (79%) agreed that interns received adequate clinical supervision. Qualitative analysis revealed that good processes were in place to ensure adequate supervision, but that service demands, particularly related to access block and overcrowding, had detrimental effects on both supervision and feedback.</p> <p>Conclusions</p> <p>Consultants appear to provide the majority of supervision of junior medical staff in Australian EDs. Supervision and feedback are generally felt to be adequate, but are threatened by service demands, particularly related to access block and ED overcrowding.</p

Growth hormone prescribing and initial BMI SDS: Increased biochemical adverse effects and costs in obese children without additional gain in height

BACKGROUND: Recombinant human growth hormone (rhGH) treatment in children is usually prescribed using actual body weight. This may result in inappropriately high doses in obese children. METHODS: Retrospective audit of all paediatric patients treated with rhGH 2010-14 at a tertiary paediatric hospital in the UK. Change in height SDS and IGF-I SDS during the first year of treatment was stratified by initial BMI SDS in a mixed cohort, and a subgroup of GH deficient (GHD) patients. Alternative doses for those BMI SDS ≥2.0 (Obese) were calculated using BSA, IBW and LBW. RESULTS: 354 patients (133 female) received rhGH, including 213 (60.2%) with GHD. Obesity was present in 40 patients (11.3%) of the unselected cohort, and 32 (15.0%) of the GHD cohort. For GHD patients, gain in height SDS was directly related to BMI SDS, except in obese patients (p<0.05). For both the entire cohort, and GHD patients only, IGF-1 SDS was significantly higher in obese patients (p<0.0001 for both groups). Cross sectional data identified 265 children receiving rhGH, 81 (30.5%) with a BMI-SDS ≥1.75. Alternate prescribing strategies for rhGH prescribing in obese patients suggest a saving of 27% - 38% annually. CONCLUSIONS: Gain in IGF-I SDS is greater in obese children, and is likely to be related to relatively higher doses of rhGH. Additional gain in height was not achieved at the higher doses administered to obese children. Alternative dosing strategies in the obese patient population should be examined in rigorous clinical trials

The impact of delays to admission from the emergency department on inpatient outcomes

<p>Abstract</p> <p>Background</p> <p>We sought to determine the impact of delays to admission from the Emergency Department (ED) on inpatient length of stay (LOS), and IP cost.</p> <p>Methods</p> <p>We conducted a retrospective analysis of 13,460 adult (≥ 18 yrs) ED visits between April 1 2006 and March 30 2007 at a tertiary care teaching hospital with two ED sites in which the mode of disposition was admission to ICU, surgery or inpatient wards. We defined ED Admission Delay as ED time to decision to admit > 12 hours. The primary outcomes were IP LOS, and total IP cost.</p> <p>Results</p> <p>Approximately 11.6% (n = 1558) of admitted patients experienced admission delay. In multivariate analysis we found that admission delay was associated with 12.4% longer IP LOS (95% CI 6.6% - 18.5%) and 11.0% greater total IP cost (6.0% - 16.4%). We estimated the cumulative impact of delay on all delayed patients as an additional 2,183 inpatient days and an increase in IP cost of $2,109,173 at the study institution.</p> <p>Conclusions</p> <p>Delays to admission from the ED are associated with increased IP LOS and IP cost. Improving patient flow through the ED may reduce hospital costs and improve quality of care. There may be a business case for investments to reduce emergency department admission delays.</p

Exposure to benzene at work and the risk of leukemia: a systematic review and meta-analysis

Background A substantial number of epidemiologic studies have provided estimates of the relation between exposure to benzene at work and the risk of leukemia, but the results have been heterogeneous. To bridge this gap in knowledge, we synthesized the existing epidemiologic evidence on the relation between occupational exposure to benzene and the risk of leukemia, including all types combined and the four main subgroups acute myeloid leukemia (AML), acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), and chronic myeloid leukemia (CML). Methods A systematic literature review was carried out using two databases 'Medline' and 'Embase' from 1950 through to July 2009. We selected articles which provided information that can be used to estimate the relation between benzene exposure and cancer risk (effect size). Results In total 15 studies were identified in the search, providing 16 effect estimates for the main analysis. The summary effect size for any leukemia from the fixed-effects model was 1.40 (95% CI, 1.23-1.57), but the study-specific estimates were strongly heterogeneous (I2 = 56.5%, Q stat = 34.47, p = 0.003). The random-effects model yielded a summary- effect size estimate of 1.72 (95% CI, 1.37-2.17). Effect estimates from 9 studies were based on cumulative exposures. In these studies the risk of leukemia increased with a dose-response pattern with a summary-effect estimate of 1.64 (95% CI, 1.13-2.39) for low (< 40 ppm-years), 1.90 (95% CI, 1.26-2.89) for medium (40-99.9 ppm-years), and 2.62 (95% CI, 1.57-4.39) for high exposure category (> 100 ppm-years). In a meta-regression, the trend was statistically significant (P = 0.015). Use of cumulative exposure eliminated heterogeneity. The risk of AML also increased from low (1.94, 95% CI, 0.95-3.95), medium (2.32, 95% CI, 0.91-5.94) to high exposure category (3.20, 95% CI, 1.09-9.45), but the trend was not statistically significant. Conclusions Our study provides consistent evidence that exposure to benzene at work increases the risk of leukemia with a dose-response pattern. There was some evidence of an increased risk of AML and CLL. The meta-analysis indicated a lack of association between benzene exposure and the risk of CML

A powerful method for detecting differentially expressed genes from GeneChip arrays that does not require replicates

BACKGROUND: Studies of differential expression that use Affymetrix GeneChip arrays are often carried out with a limited number of replicates. Reasons for this include financial considerations and limits on the available amount of RNA for sample preparation. In addition, failed hybridizations are not uncommon leading to a further reduction in the number of replicates available for analysis. Most existing methods for studying differential expression rely on the availability of replicates and the demand for alternative methods that require few or no replicates is high. RESULTS: We describe a statistical procedure for performing differential expression analysis without replicates. The procedure relies on a Bayesian integrated approach (BGX) to the analysis of Affymetrix GeneChips. The BGX method estimates a posterior distribution of expression for each gene and condition, from a simultaneous consideration of the available probe intensities representing the gene in a condition. Importantly, posterior distributions of expression are obtained regardless of the number of replicates available. We exploit these posterior distributions to create ranked gene lists that take into account the estimated expression difference as well as its associated uncertainty. We estimate the proportion of non-differentially expressed genes empirically, allowing an informed choice of cut-off for the ranked gene list, adapting an approach proposed by Efron. We assess the performance of the method, and compare it to those of other methods, on publicly available spike-in data sets, as well as in a proper biological setting. CONCLUSION: The method presented is a powerful tool for extracting information on differential expression from GeneChip expression studies with limited or no replicates

Perceptions of nurse practitioners by emergency department doctors in Australia

BACKGROUND: The Australian Medical Association is strongly opposed to the nurse practitioner (NP) role with concerns that NPs may become doctor substitutes without the requisite training and education that the medical role demands. Despite this, NPs have been heralded by some as a potential solution to the access block, workforce shortage and increased demand affecting emergency departments (EDs). AIMS: The purpose of this study was to determine the perception of NPs by medical staff working in Australian EDs. METHODS: Semi-structured telephone interviews were conducted with closed and open-ended questions. Participants were drawn from a representative stratified sample of two city, two metropolitan and two provincial hospitals of each State/Territory. RESULTS: A total of 95 doctors from 35 EDs participated in this study including 36 Departmental Directors; 36% of participating Directors indicated having an NP on staff. Doctors were strongly opposed to the statement that NPs could replace either nurses or other prevocational doctors; 71 interviewees commented on the role of NPs in the ED. Thematic analyses revealed polarised views held by doctors. Eight major themes were identified, the most common being that there is a lack of clarity of the NP role definition, their scope of practice and differentiation from the medical role. CONCLUSION: Although ED NPs represent a highly skilled professional group their role is poorly understood by ED doctors. Opposition to the NP role is a significant barrier to the introduction of great numbers of ED NPs as a strategy to overcome the medical workforce shortage. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s12245-010-0214-8) contains supplementary material, which is available to authorized users

The biogeography of South African terrestrial plant invasions

Thousands of plant species have been introduced, intentionally and accidentally, to South Africa from many parts of the world. Alien plants are now conspicuous features of many South African landscapes and hundreds of species have naturalised (i.e. reproduce regularly without human intervention), many of which are also invasive (i.e. have spread over long distances). There is no comprehensive inventory of alien, naturalised, and invasive plants for South Africa, but 327 plant taxa, most of which are invasive, are listed in national legislation. We collated records of 759 plant taxa in 126 families and 418 genera that have naturalised in natural and semi-natural ecosystems. Over half of these naturalised taxa are trees or shrubs, just under a tenth are in the families Fabaceae (73 taxa) and Asteraceae (64); genera with the most species are Eucalyptus,Acacia, and Opuntia. The southern African Plant Invaders Atlas (SAPIA) provides the best data for assessing the extent of invasions at the national scale. SAPIA data show that naturalised plants occur in 83% of quarter-degree grid cells in the country. While SAPIA data highlight general distribution patterns (high alien plant species richness in areas with high native plant species richness and around the main human settlements), an accurate, repeatable method for estimating the area invaded by plants is lacking. Introductions and dissemination of alien plants over more than three centuries, and invasions over at least 120 years (and especially in the last 50 years) have shaped the distribution of alien plants in South Africa. Distribution patterns of naturalised and invasive plants define four ecologically-meaningful clusters or “alien plant species assemblage zones”, each with signature alien plant taxa for which trait-environment interactions can be postulated as strong determinants of success. Some widespread invasive taxa occur in high frequencies across multiple zones; these taxa occur mainly in riparian zones and other azonal habitats,or depend on human-mediated disturbance, which weakens or overcomes the factors that determine specificity to any biogeographical region

ParaMED Home: A protocol for a randomised controlled trial of paramedic assessment and referral to access medical care at home

<p>Abstract</p> <p>Background</p> <p>In Australia approximately 25% of Emergency Department (ED) attendances are via ambulance. ED overcrowding in Australia, as in many countries, is common. Measures to reduce overcrowding include the provision of enhanced timely primary care in the community for appropriate low risk injury and illness. Therefore paramedic assessment and referral to a community home hospital service, in preference to transfer to ED, may confer clinical and cost benefit.</p> <p>Methods/Design</p> <p>A randomised controlled trial. Consenting adult patients that call an ambulance and are assessed by paramedics as having an eligible low risk problem will be randomised to referral to ED via ambulance transfer or referral to a rapid response service that will assess and treat the patient in their own residence. The primary outcome measure is requirement for unplanned medical attention (in or out of hospital) in the first 48 hours. Secondary outcomes will include a number of other clinical endpoints. A cost effectiveness analysis will be conducted.</p> <p>Discussion</p> <p>If this trial demonstrates clinical non-inferiority and cost savings associated with the primary assessment service, it will provide one means to safely address ED overcrowding.</p> <p>Trial Registration</p> <p>Australian and New Zealand Clinical Trials Registry Number <a href="http://www.anzctr.org.au/trial_view.aspx?ID=335818">12610001064099</a></p

Pituitary pathology and gene expression in acromegalic cats

© 2019 Endocrine Society. The prevalence of GH-secreting pituitary tumors in domestic cats (Felis catus) is 10-fold greater than in humans. The predominant inhibitory receptors of GH-secreting pituitary tumors are somatostatin receptors (SSTRs) and D2 dopamine receptor (DRD2). The expression of these receptors is associated with the response to somatostatin analog and dopamine agonist treatment in human patients with acromegaly. The aim of this study was to describe pathological features of pituitaries from domestic cats with acromegaly, pituitary receptor expression, and investigate correlates with clinical data, including pituitary volume, time since diagnosis of diabetes, insulin requirement, and serum IGF1 concentration. Loss of reticulin structure was identified in 15 of 21 pituitaries, of which 10 of 15 exhibited acinar hyperplasia. SSTR1, SSTR2, SSTR5, and DRD2 mRNA were identified in the feline pituitary whereas SSTR3 and SSTR4 were not. Expression of SSTR1, SSTR2, and SSTR5 was greater in acromegalic cats compared with controls. A negative correlation was identified between DRD2 mRNA expression and pituitary volume. The loss of DRD2 expression should be investigated as a mechanism allowing the development of larger pituitary tumors