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Objective: This study aims to determine the associations between specialty type and practice location at postgraduate year 10 (PGY10), matched with PGY5 and PGY8 work locations, and earlier rural exposure/experience., Design and Setting: A cohort study of medicine graduates from nine Australian universities., Participants: 1220 domestic medicine graduates from the class of 2011., Outcome Measures: Practice location recorded by the Australian Health Practitioner Regulation Agency in PGY10; matched graduate movement between PGYs 5, 8 and 10 as classified by the Modified Monash Model, stratified by specialty type (predominantly grouped as general practitioner (GP) or non-GP)., Results: At PGY10, two-thirds (820/1220) had achieved fellowship. GPs were 2.8 times more likely to be in non-metropolitan practice (28% vs 12%; 95% CI 2.0 to 4.0, p<0.001) than graduates with non-GP (all other) specialist qualifications. More than 70% (71.4%) of GPs who were in non-metropolitan practice in PGY5 remained there in both PGY8 and PGY10 versus 29.0% of non-GP specialists and 36.4% of non-fellowed graduates (p<0.001). The proportion of fellowed graduates observed in non-metropolitan practice was 14.9% at PGY5, 16.1% at PGY8 and 19.0% at PGY10, with this growth predominantly from non-GP specialists moving into non-metropolitan locations, following completion of metropolitan-based vocational training., Conclusions: There are strong differences in practice location patterns between specialty types, with few non-GP specialists remaining in non-metropolitan practice between PGY5 and PGY10. Our study reinforces the importance of rural training pathways to longer-term work location outcomes and the need to expand specialist vocational training which supports more rural training opportunities for trainees outside general practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction/aim: Despite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission., Methods: Multisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019., Results: Of 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. "Not-for-resuscitation" orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001)., Conclusions: End-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations., Competing Interests: Disclosures The authors declare that there is no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

People are drawn to and like others who are physically attractive. In the present research, we investigated the influence of trait self-control on individuals' interest in relationships with physically attractive others. We hypothesized that high (vs. low) self-control individuals would approach relationships by considering information beyond appearance about potential partners, including partners' self-control. We additionally explored the influence of other traits (e.g., Big 5, self-esteem, and attachment styles) on relationship interest. Across studies, we consistently found that individuals with higher self-control avoided pursuing relationships with attractive individuals who display low self-control. In Study 3, we observed a similar pattern for three other traits: conscientiousness, extraversion, and positivity embracement. These results suggest perceivers' self-control shapes relationship interest, particularly when attractive individuals possess less desirable qualities. The findings extend past research that attractiveness increases interest in others and highlights the potential for trait self-control to direct relationship interest during initial interactions., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Members of dual-smoker couples (in which both partners smoke) are unlikely to try to quit smoking and are likely to relapse if they do make an attempt. The purpose of this study was to investigate the feasibility, tolerability, and preliminary outcomes of dyadic adaptations of financial incentive treatments (FITs) to promote smoking cessation in dual-smoker couples., Aims and Methods: We enrolled 95 dual-smoker couples (N = 190) in a three-arm feasibility RCT comparing two partner-involved FITs (single vs. dual incentives) against a no-treatment control condition. Participants in all conditions were offered nicotine replacement and psychoeducation. A 3-month follow-up provided information about retention, tolerability (ie, self-reported benefits and costs of the study), and preliminary efficacy (ie, program completion, quit attempts, point-prevalent abstinence, and joint quitting)., Results: Results suggest dyadic adaptations were feasible to implement (89% retention rate) and highly tolerable for participants (p < .001). Neither feasibility nor tolerability varied across the treatment arm. Preliminary efficacy outcomes indicated partner-involved FITs have promise for increasing smoking cessation in dual-smoker couples (OR = 2.36-13.06)., Conclusions: Dyadic implementations of FITs are feasible to implement and tolerable to participants., Implications: The evidence that dyadic adaptations of FITs were feasible and tolerable, and the positive preliminary efficacy outcomes suggest that adequately powered RCTs formally evaluating the efficacy of dyadic adaptations of FITs for dual-smoker couples are warranted., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Australia has a doctor shortage in rural settings, and rural placements for medical students have an important role in increasing the likelihood of students staying in rural settings throughout their careers. However, to date there is limited research regarding medical student perceptions of rural placement quality., Objective: We aimed to determine factors that impact the overall medical student experience during rural placements., Design: Cross-sectional survey., Setting: Rural/remote clinical schools across Australia., Participants: Medical students on rural/remote clinical placements for at least 6 months., Main Outcome Measures: To assess factors impacting student experience on rural placements, we conducted a cross-sectional survey, known as the Australian Rural Clinical School Support Survey (ARCSSS) which was completed online by medical students across Australia. Demographic data were collected in addition to responses regarding academic teaching, extracurricular activities, and support services. Multiple choice and Likert scale questions were utilised., Results: A total of 107 responses to our survey were analysed. The majority of participants were female (66.4%), and in their middle years of clinical education (55.1%). Overall, respondents showed high levels of satisfaction with clinical school supervisors, and clinical education. A high proportion of respondents indicated minimal accessibility of health and other support services. While a large proportion of participants indicated satisfaction with the rural placements, it was demonstrated that students were generally dissatisfied with school wellness activities and extracurricular activities. Financial insecurity was noted., Conclusion: The findings from our survey indicate there are numerous areas in which rural placements have been effective for medical students, and others in which improvement is needed. Furthermore, more research is required to better develop well-being initiatives that are effective in improving overall experience., (© 2023 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance Ltd.)

Context: Despite clear benefit from palliative care in end-stage chronic, non-malignant disease, access for rural patients is often limited due to workforce gaps and geographical barriers., Objectives: This study aimed to understand existing rural service structures regarding the availability and provision of palliative care for people with chronic conditions., Methods: A cross-sectional online survey was distributed by email to rural health service leaders. Nominal and categorical data were analyzed descriptively, with free-text questions on barriers and facilitators in chronic disease analyzed using qualitative content analysis., Results: Of 42 (61.7%) health services, most were public (88.1%) and operated in acute (19, 45.2%) or community (16, 38.1%) settings. A total of 17 (41.5%) reported an on-site specialist palliative care team, primarily nurses (19, 59.5%). Nearly all services (41, 95.3%) reported off-site specialist palliative care access, including: established external relationships (38, 92.7%); visiting consultancy (26, 63.4%); and telehealth (18, 43.9%). Perceived barriers in chronic disease included: lack of specific referral pathways (18; 62.1%); negative patient expectations (18; 62.1%); and availability of trained staff (17; 58.6%). Structures identified to support palliative care in chronic disease included: increased staff/funding (20, 75.0%); formalized referral pathways (n = 18, 64.3%); professional development (16, 57.1%); and community health promotion (14, 50%)., Conclusion: Palliative care service structure and capacity varies across rural areas, and relies on a complex, at times ad hoc, network of onsite and external supports. Services for people with chronic, non-malignant disease are sparse and largely unknown, with a call for the development of specific referral pathways to improve patient care., (Copyright © 2023 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To examine associations between extended medical graduates' rural clinical school (RCS) experience and geographic origins with practising in rural communities five and eight years after graduation., Design, Participants: Cohort study of 2011 domestic medical graduates from ten Australian medical schools with rural clinical or regional medical schools., Main Outcome Measures: Practice location types eight years after graduation (2019/2020) as recorded by the Australian Health Practitioner Regulation Agency, classified as rural or metropolitan according to the 2015 Modified Monash Model; changes in practice location type between postgraduate years 5 (2016/2017) and 8 (2019/2020)., Results: Data were available for 1321 graduates from ten universities; 696 were women (52.7%), 259 had rural backgrounds (19.6%), and 413 had extended RCS experience (31.3%). Eight years after graduation, rural origin graduates with extended RCS experience were more likely than metropolitan origin graduates without this experience to practise in regional (relative risk [RR], 3.6; 95% CI, 1.8-7.1) or rural communities (RR, 4.8; 95% CI, 3.1-7.5). Concordance of location type five and eight years after graduation was 92.6% for metropolitan practice (84 of 1136 graduates had moved to regional/rural practice, 7.4%), 26% for regional practice (56 of 95 had moved to metropolitan practice, 59%), and 73% for rural practice (20 of 100 had moved to metropolitan practice, 20%). Metropolitan origin graduates with extended RCS experience were more likely than those without it to remain in rural practice (RR, 2.0; 95% CI, 1.3-2.9) or to move to rural practice (RR, 1.9; 95% CI, 1.2-3.1)., Conclusion: The distribution of graduates by practice location type was similar five and eight years after graduation. Recruitment to and retention in rural practice were higher among graduates with extended RCS experience. Our findings reinforce the importance of longitudinal rural and regional training pathways, and the role of RCSs, regional training hubs, and the rural generalist training program in coordinating these initiatives., (© 2022 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

The critical importance of primary health care in maintaining a healthy population is well established internationally. Nevertheless, general practitioner care is not always easily accessible for some patients in Australia, particularly in rural regions. This is partly due to an insufficient number of medical graduates entering and being retained in the rural general practitioner workforce. Key elements of international and national programs designed to address this shortfall are discussed and include the use of entry requirements that preferentially select for applicants from a rural residence background, and immersion of medical students for a large share, or entire duration, of their training in rural communities. In addition, other factors that can influence decisions to enter and stay in rural practice are discussed.

Objective: The project aims to build a framework for conducting clinical trials for long-term interplanetary missions to contribute to innovation in clinical trials on Earth, especially around patient involvement and ownership., Methods: We conducted two workshops in which participants were immersed in the speculative scenario of an interplanetary mission in which health problems emerged that required medical trials to resolve. The workshops used virtual reality and live simulation to mimic a zero-gravity environment and visual perception shifts and were followed by group discussion., Results: Some key aspects for the framework that emerged from the workshops included: (a) approaches to be inclusive in the management of the trial, (b) approaches to be inclusive in designing the research project (patient preference trials, n-of-1 trials, designing clinical trials to be part of a future prospective meta-analysis, etc), (c) balancing the research needs and the community needs (eg, allocation of the participants based on both research and community need), (d) ethics and partnerships (ethics and consent issues and how they relate to partnerships and relationships)., Conclusion: In identifying some key areas that need to be incorporated in future planning of clinical trials for interplanetary missions, we also identified areas that are relevant to engaging patients in clinical trials on Earth. We will suggest using the same methodology to facilitate more in-depth discussions on specific aspects of clinical trials in aerospace medicine. The methodology can be more widely used in other areas to open new inclusive conversations around innovating research methodology., (© 2020 The Authors. Journal of Evidence-Based Medicine published by Chinese Cochrane Center, West China Hospital of Sichuan University and John Wiley & Sons Australia, Ltd.)

Background: The ASTRAL trial showed no difference in clinical outcomes between medical therapy and revascularization for atherosclerotic renal vascular disease (ARVD). Here we report a sub-study using echocardiography to assess differences in cardiac structure and function at 12 months., Methods: ASTRAL patients from 7 participating centres underwent echocardiography at baseline and 12 months after randomisation. Changes in left ventricular ejection fraction (LVEF), left ventricular mass (LVM), left atrial diameter (LAD), aortic root diameter (AoRD), E:A, and E deceleration time (EDT) were compared between study arms. Analyses were performed using t-tests and multivariate linear regression., Results: Ninety two patients were included (50 medical versus 42 revascularization). There was no difference between arms in any baseline echocardiographic parameter. Comparisons of longitudinal changes in echocardiographic measurements were: δLVEF medical 0.8 ± 8.7% versus revascularization - 2.8 ± 6.8% (p = 0.05), δLVM - 2.9 ± 33 versus - 1.7 ± 39 g (p = 0.9), δLAD 0.1 ± 0.4 versus 0.01 ± 0.5 cm (p = 0.3), δAoRD 0.002 ± 0.3 versus 0.06 ± 0.3 cm (p = 0.4), δE:A - 0.0005 ± 0.6 versus 0.03 ± 0.7 (p = 0.8), δEDT - 1.1 ± 55.5 versus - 9.0 ± 70.2 ms (p = 0.6). In multivariate models, there were no differences between treatment groups for any parameter at 12 months. Likewise, change in blood pressure did not differ between arms (mean δsystolic blood pressure medical 0 mmHg [range - 56 to + 54], revascularization - 3 mmHg [- 61 to + 59], p = 0.60)., Conclusions: This sub-study did not show any significant differences in cardiac structure and function accompanying renal revascularization in ASTRAL. Limitations include the small sample size, the relative insensitivity of echocardiography, and the fact that a large proportion of ASTRAL patient population had only modest renal artery stenosis as described in the main study.

Introduction: Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs' 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background., Methods: All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2-5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a 'rural' area (ASGC categories RA2-5 or MMM categories 3-7) or 'metropolitan' area. Pearson's χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated., Results: Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3-76.6% and the proportion who had participated in extended RCS placement had a range of 13.7-74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8-55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3-7), range 4.5-29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2-2.1, p=0.004) using ASGC criteria. Using the MMM 3-7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8-3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system &#40;ASGC, MMM&#41; used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally., Conclusion: Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.

Discussions regarding overweight may be infrequent in Australian general practice. General practitioners (GPs) may find these discussions difficult to initiate if they are unsure of the language to use, or if patients would find it acceptable to be weighed. Overweight and obesity are more prevalent in rural areas than in metropolitan areas, and strategies to address the health risks associated with these conditions need to be tailored to rural communities. The aims of this study were to identify the language preferred by an Australian adult sample with a range of body sizes, to assess acceptability of routine weight measurement by GPs, and to assess potential influence of gender, body size and rurality on these preferences. A questionnaire was distributed through the authors' informal networks using email and social media. Australian adults were eligible to participate. Respondents (n=771) were predominantly female, health professionals and resided in rural areas. The preferred language was weight neutral ('weight') or linked to health ('your weight may be damaging your health', 'you are above your healthy weight range'). Preferred language appeared to be influenced by gender and body size but not rurality. Most respondents (76%) would find it acceptable to be weighed regularly by their GP.

Discussion: Regional Australia remains a district of workforce shortage for nephrology. Thus, it is imperative that patients who have the greatest need for nephrologist services are effectively identified upon referral. The aim of this study was to assess referrals to a regional nephrology service against Australian guidelines by assessing the patient’s renal function and the information contained in the referral document at the time of first consultation. We conducted a retrospective study of all referrals to a regional Australian nephrology service between 2013 and 2015. The 582 referrals that met the inclusion criteria were compared with Australian nephrology referral guidelines. Less than half of the referral documents (n = 253; 43.5%) described a clinical situation that met referral guidelines, typically due to insufficient pathology investigation. However, after consideration of renal functional test results performed at the initial consultation, an additional 82 cases met referral guidelines (n = 335; 57.6%). More than 40% of nephrology referrals to a regional Australian service did not meet Australian nephrology referral guidelines. This has implications for a regional nephrology service that is experiencing workforce pressures, in addition to the health system more broadly, and for patients. Many referrals contained insufficient information to allow differentiation of patients who would benefit most from nephrology care from patients who could be appropriately managed within primary care.

Background: General practitioners (GPs) have a crucial role to play in engaging patients in discussions about overweight and obesity. However, such discussions are currently uncommon. The aim of this study was to examine how GPs in rural areas talk about overweight and obesity with their patients, specifically to identify key barriers to effective conversations., Methods: This study used a qualitative methodology. Semi-structured interviews were conducted with GPs (n = 7) and patients (n = 7) across two rural areas., Results: Key barriers to effective conversations between GPs and patients about overweight and/or obesity include: uncertainty about appropriate language; lack of time; concerns about compromising mutual trust and rapport; concerns about patient readiness; concerns about patients' mental health and how this may be impacted by discussing a potentially upsetting and stigmatising topic; and lack of effective and individualised treatment and/or referral options., Discussion: The findings suggest that responses to overweight and obesity need to be localised and tailored. Structural-level change is required to enable better responses to overweight and obesity, including multidisciplinary team approaches.

Background: Cardiac abnormalities are frequent in patients with atherosclerotic renovascular disease (ARVD). The Angioplasty and Stenting for Renal Artery Lesions (ASTRAL) trial studied the effect of percutaneous renal revascularization combined with medical therapy compared with medical therapy alone in 806 patients with ARVD., Methods: This was a pre-specified sub-study of ASTRAL (clinical trials registration, current controlled trials number: ISRCTN59586944), designed to consider the effect of percutaneous renal artery angioplasty and stenting on change in cardiac structure and function, measured using cardiac magnetic resonance (CMR) imaging. Fifty-one patients were recruited from six selected ASTRAL centres. Forty-four completed the study (medical therapy n = 21; revascularization n = 23). Full analysis of CMR was possible in 40 patients (18 medical therapy and 22 revascularization). CMR measurements of left and right ventricular end systolic (LV and RVESV) and diastolic volume (LV and RVEDV), ejection fraction (LVEF) and mass (LVM) were made shortly after recruitment and before revascularization in the interventional group, and again after 12 months. Reporting was performed by CMR analysts blinded to randomization arm., Results: Groups were well matched for mean age (70 versus 72 years), blood pressure (148/71 versus 143/74 mmHg), degree of renal artery stenosis (75 versus 75%) and comorbid conditions. In both randomized groups, improvements in cardiac structural parameters were seen at 12 months, but there were no significant differences between treatment groups. Median left ventricular changes between baseline and 12 months (medical versus revascularization) were LVEDV -1.9 versus -5.8 mL, P = 0.4; LVESV -2.1 versus 0.3 mL, P = 0.7; LVM -5.4 versus -6.3 g, P = 0.8; and LVEF -1.5 versus -0.8%, P = 0.7. Multivariate regression also found that randomized treatment assignment was not associated with degree of change in any of the CMR measurements., Conclusions: In this sub-study of the ASTRAL trial, renal revascularization did not offer additional benefit to cardiac structure or function in unselected patients with ARVD., (© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Context: Longitudinal integrated clerkships (LIC) are widely used as an educational method, particularly in rural areas. They are good for facilitating hands-on learning and deep relationships between student, patients, and supervisors., Objectives: This study sought to examine and compare learning experience of third-year rural medical students studying specialties (women's health, aged care, child and adolescent heath, mental health, general practice) by either a traditional hospital-based rotation or a LIC in a rural general practice setting., Methods: Data was collected from two groups of rural students (LIC; traditional hospital-based) over two academic years, utilizing focus groups to investigate general experiences of living and learning rurally, within the different educational models., Results: Results reaffirmed that there was no perceived academic disadvantage to studying medicine rurally. Studying medicine in a rural area provides increased access to patients, more hands-on experience, and close relationships with patients and colleagues. LIC students reported increased confidence in clinical skills, felt better prepared for internship, however experienced more social isolation than students in hospital-based rotations., Conclusions: Students undergoing a rural LIC feel more confident in their clinical skills and preparedness for practice than other rural students. This study supports the use of LICs as a powerful educational tool.

Chronic ill health has recently emerged as the most important health issue on a global scale. Rural communities are disproportionally affected by chronic ill health. Many health systems are centred on the management of acute conditions and are often poorly equipped to deal with chronic ill health. Cardiovascular disease (CVD) is one of the most prominent chronic ill health conditions and the principal cause of mortality worldwide. In this paper, CVD is used as an example to demonstrate the disparity between rural and urban experience of chronic ill health, access to medical care and clinical outcomes. Advances have been made to address chronic ill health through improving self-management strategies, health literacy and access to medical services. However, given the higher incidence of chronic health conditions and poorer clinical outcomes in rural communities, it is imperative that integrated health care emphasises greater collaboration between services. It is also vital that rural GPs are better supported to work with their patients, and that they use consumer-directed approaches to empower patients to direct and coordinate their own care.

Objective: To determine whether a short-term placement of metropolitan medical students in a rural environment can improve their knowledge of, and change their attitudes to, rural health issues., Design and Participants: Medical students taking part in the March and May 2013 3-week Rural Health Modules (RHMs) were invited to participate in focus groups and complete questionnaires before undertaking the RHM, after a 2-day rural orientation and at the end of the RHM. Students were asked to comment on a range of issues affecting rural health care including their attitude to pursuing a rural career. Focus group transcripts were thematically analysed and questionnaire data were statistically analysed., Setting: The RHM is a 3-week program designed and run by the University of Melbourne's Rural Health Academic Centre., Main Outcome Measures: Responses to questionnaire items from before and after completing the RHM, scored on a seven-point Likert scale., Results: 69 of the 101 RHM students took part in this study. The focus groups identified five main themes in rural health care: access; teamwork, models of care and generalist practice; overlapping relationships; indigenous health; and working in a rural career. In all five areas, a change was seen in the depth of knowledge students had about these issues and in the students' attitudes towards rural health care. The questionnaires also showed a significant shift in the students' appreciation of, and positivity towards, rural health issues., Conclusion: Undertaking a 3-week RHM changed students' perceptions of rural health and significantly improved their knowledge of issues facing rural health practitioners and patients.

Objective: To propose a model of mentoring suitable for rural and remote health professionals., Design: Given the rural and remote health workforce shortage, mentoring is proposed as a workforce retention strategy. Mentoring literature was reviewed; aspects of mentoring highlighted in the literature were considered to ascertain their suitability for rural and remote health professionals., Method: A total of 39 mentoring papers were reviewed to outline key factors in mentoring rural and remote health professionals. Using this literature, key ways that rural and remote practice enhance or are barriers to mentoring were identified. From this, a model for mentoring rural and remote health practitioners, students and academics was developed., Results: Four models of mentoring were identified: the cloning, nurturing, friendship and apprenticeship models. The apprenticeship model was identified as suitable for students, the nurturing model as suited to new health professionals to rural and remote settings and the friendship model for senior practitioners/academics. Factors more likely to enable mentoring in rural and remote settings were identified as feelings of obligation by senior practitioners, strong relationships between staff, blurred work/social boundaries, lack of hierarchy, inter-professional practice and technology. The barriers identified included workloads, access to mentors, fee-for-service system for some practitioners, conflicts which could jeopardise working and business relationships, and feelings of being judged., Conclusions: A model of mentoring for rural and remote health professionals was presented. Given the potential to strengthen and increase the rural and remote health workforce, trialling such a model is worthwhile and evaluation would identify its impact., (© 2014 The Authors. Australian Journal of Rural Health © National Rural Health Alliance Inc.)

The eggs of gannets from two Scottish colonies (Ailsa Craig, Bass Rock) of golden eagles from the Hebrides and Highlands and of merlin eggs from the Scottish borders were analyzed for 52 PAHs, including 2-7 ring parent and alkylated PAHs. Phenanthrene was the most abundant PAH in gannet eggs from Ailsa Craig, and methylnaphthalenes predominated in the eggs from other locations and species. Most PAHs were detected in eggs but none were at likely embryotoxic concentrations. The sum concentrations for all the PAHs analyzed (3.1-5.7 ng g(-1) wet wt.) and for the U.S. EPA 16 priority PAHs (2.0-4.3 ng g(-1) wet wt.) did not differ significantly between species or locations. This uniform, low-level accumulation suggests background exposure to diffuse sources. PCA indicated that 3 ring parent and alkylated PAHs predominated in the eggs of merlins and gannets from Ailsa Craig and Hebridean golden eagles; other eggs had a more mixed profile. Source signature diagnostics largely suggested a petrogenic origin for the PAHs in the merlin eggs that we analyzed but otherwise gave equivocal results and further work is needed to determine which diagnostics can be successfully applied to PAHs in eggs.

Background: Patients with atherosclerotic renovascular disease (ARVD) are at increased risk of heart disease because of the association with hypertension, coronary artery disease, cardiac failure and chronic kidney disease (CKD). A previous echocardiographic cross-sectional study showed that only 5% of patients with ARVD had normal cardiac structure and function at baseline. In this longitudinal study of the same patient cohort the progression of cardiac dysfunction and factors which predict declining cardiac function in patients with ARVD were delineated., Methods: Seventy-nine patients were available for baseline analysis, but 16 withdrew from follow-up during the study. Forty-three patients (27M and 16F, age at study entry [mean +/- SD] 69.7 +/- 8.0 years) who were managed conservatively and 8 (age 69.8 +/- 5.7) who were managed with renal revascularization underwent echocardiography and 24 h ambulatory blood pressure investigations at baseline and 12 months thereafter. The two data sets were interrogated to determine changes in blood pressure and cardiac status (morphological and functional); baseline factors which predicted such changes were ascertained. Twelve patients underwent baseline investigation but did not complete follow-up because of death (nine patients) or requirement of dialysis (three patients)., Results: Conservatively managed patients: At 12 months eGFR, (38.6 +/- 18.3 vs 35.0 +/- 18.5 ml/min; P = 0.001) had fallen whilst proteinuria had increased (0.3 +/- 0.4 vs 0.6 +/- 0.8 g/24 h; P = 0.001). Despite no increase in the number of blood pressure medications there was a fall in blood pressure between baseline and follow-up investigations (140.0 +/- 16.5/75.3 +/- 11.8, MAP 98.6 +/- 12.3 mmHg vs 135.7 +/- 16.1/69.6 +/- 9.1, MAP 92.5 +/- 10.2 mmHg; P < 0.001 for diastolic blood pressure and MAP). At 12 months, there was an increase in the number of patients with LVH (72.9% vs 81.4%). There were increases in left ventricular dimensions [left ventricular end diastolic diameter (5.1 +/- 0.8 vs 5.5 +/- 0.8 cm; P = 0.009), and left ventricular end diastolic volume (140.9 +/- 39.5 vs 163.3 +/- 61.0 ml; P = 0.01)]. There was no significant relationship of these changes in cardiac parameters to anatomical severity of renal artery disease but patients with severe renal dysfunction at baseline had an increase in left ventricular dilatation at follow-up. Linear regression analysis revealed an association between elevated time-averaged PTH and LV dilatation [beta-coefficient and 95% confidence intervals, 0.18 (0.04, 0.32); P = 0.01]. Revascularization: No significant changes in any biochemical or echocardiographic parameters were seen between baseline and 1 year investigations in this small sub-group., Conclusion: Patients with ARVD exhibit a high prevalence of LVH at diagnosis and progressive left ventricular dilatation over the first year after diagnosis. This dilatation is associated with severe renal impairment at baseline and not associated with anatomical severity of renal artery disease.

The combined effect of a chemical (fluoranthene) and a nonchemical stress (reduced soil moisture content) to the widely distributed earthworm Lumbricus rubellus were investigated in a laboratory study. Neither fluoranthene (up to 500 microg/g) nor low soil moisture (15% below optimal) had a significant effect on the survival of the exposed worms, but a significant effect on reproduction (cocoon production rate) was found for both stressors (p < 0.001 in both cases). The response of cocoon production to each stressor could be well described by a logistic model; this suggested that the joint effects may be applicable to description using the independent action (IA) model that is widely used in pharmacology and chemical mixture risk assessment. Fitting of the IA model provided a good description of the combined stressor data (accounting for 53.7% of total variation) and was the most parsimonious model describing joint effect (i.e., the description of the data was not improved by addition of further parameters accounting for synergism or antagonism). Thus, the independent action of the two responses was further supported by measurement of internal fluoranthene exposure. The chemical activity of fluoranthene in worm tissue was correlated only with soil fluoranthene concentration and not with soil moisture content. Taken together these results suggest that the IA model can help interpret the joint effects of chemical and nonchemical stressors. Such analyses should, however, be done with caution since the literature data set suggests that there may be cases where interactions between stressors result in joint effects that differ significantly from IA predictions.

Background and Aims: Patients with atheromatous renovascular disease (ARVD) have high cardiovascular morbidity and mortality. The cardiac markers N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin (cTnT) are easily measured, yet not widely used in renal patients as they are thought to be inaccurate in renal disease. We aimed to see if these markers could be used as prognostic indicators of cardiovascular events (CVEs) and death in ARVD., Methods: Subjects with ARVD treated in 1 renal center in 2003 were prospectively followed up. NT-proBNP and cTnT at baseline were correlated with CVEs and death, echocardiographic findings and degree of renal artery stenosis. Cutoff levels of 0.03 ng/ml (cTnT) and 43 pmol/l (NT-proBNP) were used., Results: Eighty-two patients (mean +/- SD age 69 +/- 8 years, mean follow-up 40.2 +/- 16.6 months) were suitable for analysis. Twenty-nine percent of patients suffered new CVEs, and 37.8% died. Renal function was a significant predictor of CVEs and death. Patients with a raised NT-proBNP were more likely to die than those in the same chronic kidney disease (CKD) category with normal levels (p < 0.0001) even after adjusting for multivariate factors (hazard ratio 8.3 for high proBNP vs. 3.6 for low proBNP in CKD stage 4-5)., Conclusion: No study to our knowledge has looked at both NT-proBNP and cTnT as outcome markers in ARVD. Our study shows that renal function is more important as a marker of suffering a CVE. However, raised NT-proBNP is associated with a greater likelihood of death when subdivided by CKD stage. Early risk stratification by simple measurement of these biomarkers may aid in intensifying management in high-risk patients, although further studies to assess the value of this approach are warranted., (Copyright 2009 S. Karger AG, Basel.)

Patients with chronic kidney disease have a high burden of cardiovascular morbidity and mortality. The vast majority of patients with chronic kidney disease do not progress to end stage renal failure, but do have a significantly higher incidence of all cardiovascular co-morbidities. Traditional cardiovascular risk factors only partially account for this increased incidence of cardiovascular disease. In patients with kidney disease the basic biology underlying cardiovascular disease may be similar to that in patients without kidney disease, but it would seem many more risk factors are involved as a consequence of renal dysfunction. Although emphasis is placed on delaying the progression of chronic kidney disease, it must be appreciated that for many patients it is vital to address their cardiovascular risk factors at an early stage to prevent premature cardiovascular death. This review examines available epidemiological evidence, discusses common cardiovascular risk factors in patients with chronic kidney disease, and suggests possible treatment strategies. Potential areas for important research are also described.

Fail-to-hatch kestrel (Falco tinnunculus) eggs collected at the end of the 1999 and 2005 breeding seasons from nest boxes in and around the city of Rome, Italy, were analyzed by gas chromatography with electron capture detection for their PCB content and for the presence of DDT derivatives and other organochlorines. Among the various PCBs, congeners 153 and 180 were detected in all the eggs and showed the highest concentrations. Eggs collected from the same nest from a polluted location in Rome during 2 different years showed similar type and number of PCB congeners. These data and the fact that eggs from another nest near a sulphate mine had, atypically, low-chlorinated congeners support the conclusion that eggs of this species, whose adults in the Mediterranean and continental Europe perform only short or no migration movements, might be indicative of local pollution. When multiple eggs in the same clutch were analyzed, the PCBs were similar in type but their concentration decreased within clutch, likely in parallel to the laying order.

Most organochlorine (OC) use has been banned in Spain, but these compounds are persistent and may still adversely affect predatory birds. Data generally are lacking, however. Residues of hexachlorobenzene, alpha-hexachlorocyclohexane, lindane, hexachloro-octahydro-epoxy-dimethanonaphthalene, DDT, dichlorodiphenyldichloroethane, dichlorodiphenyldichloroethylene (DDE), and polychlorinated biphenyls (PCBs) were measured in 22 failed eggs of booted eagles (Hieraaetus pennatus) and goshawks (Accipiter gentilis) from southeastern Spain; both species are declining in this region. Hexachloro-octahydro-epoxy-dimethanonaphthalene, DDE, and sum PCB congener concentrations were significantly higher in booted eagle than in goshawk eggs, and an inverse relationship was found between shell thickness and DDE concentrations in booted eagles. Organochlorides may have been associated with the failure of some booted eagle eggs, but concentrations in booted eagle and goshawk eggs decreased over the period during which populations have dwindled. Thus, although OCs may be a contributory factor, they are unlikely to be the primary cause of the recent population declines in southeastern Spain.

The polycyclic aromatic hydrocarbons (PAHs) naphthalene, acenaphthylene, acenaphthene, fluorene, fluoranthene, pyrene, benzo[a]anthracene, chrysene, benzo[b]fluoranthene, benzo[k]fluoranthene, benzo[a]pyrene, ideno[1,2,3,-cd]-pyrene, dibenz[a,h]anthracene, benzo[g,h,i]perylene and the polychlorinated biphenyls (PCBs) 8, 18, 28, 29, 31, 52, 77, 101, 105, 114, 118, 123, 126, 128, 138, 141, 149, 153, 156, 157, 163, 169, 170, 171, 180, 183, 187, 189, 194, 199, 201, 206, and 209 were measured in -200 rural soils across Great Britain (GB). Dominance of soil PAH profiles by heavier compounds (4-6 rings) provided initial evidence for the importance of source in governing soil PAH concentrations. No relationship was found between soil organic matter (SOM) and sum concentration of total and "heavy" PAHs, although there was a weak positive relationship with lighter compounds. A spatial statistical technique showed that highest soil PAH concentrations were usually found close to industrial/urban centers where presumably source intensity is highest. PCBs clustered into seven groups, five of which contained a single "dioxin like" PCB, one contained lighter congeners (2-4 chlorines), and one contained heavy congeners (5-10 chlorines). Linear regressions with SOM explained up to 24.3% of variation for the sum concentration of penta- to deca- congeners, but <1% for the lighter congener groups. No significant relationships were found with latitude. Spatial statistical techniques showed clusters of high soil PCB concentrations predominantly in west and south east GB, either associated with urbanized areas or on the West coast.

A close relationship exists between cardiovascular and renal disease; they often occur concomitantly, and abnormalities in either system are pathophysiologically important in both causing disease and determining clinical outcome in the other. Whilst the main focus of the article relates to the adverse association between atherosclerotic renovascular disease (ARVD) and the cardiovascular system, it is important to briefly review relevant epidemiology.

Atherosclerotic renovascular disease (ARVD) is associated with heart disease. There has been no systematic study of cardiac structure and function in patients with this condition. In this study, the epidemiology of cardiac changes and their relationship to renal function, renovascular anatomy, and BP are delineated. With the use of a cross-sectional design, 79 patients with ARVD and 50 control patients without ARVD underwent echocardiography and 24-h ambulatory BP monitoring. Clinical and biochemical data were collected. Results were analyzed according to renal function, residual renal artery patency, and unilateral or bilateral ARVD. Only 4 (5.1%) patients with ARVD had normal cardiac structure and function. Patients with ARVD (age 70.7 +/- 7.5 yr; estimated GFR 36 +/- 19 ml/min) had significantly more cardiovascular comorbidity (77.2 versus 42.0%; P < 0.001), greater prevalence of left ventricular (LV) hypertrophy (78.5 versus 46.0%; P < 0.001) and LV diastolic dysfunction (74.6 versus 40.0%; P < 0.001), and greater LV mass index (183 +/- 74 versus 116 +/- 33 g/m2; P < 0.001) and LV end-diastolic volume index (82 +/- 35 versus 34 +/- 16 ml/m2; P < 0.001) than control subjects. BP was similar for both patient groups. For patients with ARVD, neither renal function nor renal artery patency predicted a difference in echocardiographic or ambulatory BP monitoring parameters. Patients with bilateral ARVD had greater LV mass index and LV dilation than patients with unilateral disease. Patients with ARVD exhibit a high prevalence of cardiac morphologic and functional abnormalities at early stages of renal dysfunction. Such patients must be identified early in their disease course to allow risk factor modification.

Potential contamination at ex-industrial sites means that, prior to change of use, it will be necessary to quantify the extent of risks to potential receptors. To assess ecological hazards, it is often suggested to use biological assessment to augment chemical analyses. Here we investigate the potential of a commonly recommended bioassay, the earthworm reproduction test, to assess the status of urban contaminated soils. Sample points at all study sites had contaminant concentrations above the Dutch soil criteria Target Values. In some cases, the relevant Intervention Values were exceeded. Earthworm survival at most points was high, but reproduction differed significantly in soil from separate patches on the same site. When the interrelationships between soil parameters and reproduction were studied, it was not possible to create a good model of site soil toxicity based on single or even multiple chemical measurements of the soils. We thus conclude that chemical analysis alone is not sufficient to characterize soil quality and confirms the value of biological assays for risk assessment of potentially contaminated soils.

Biological indicators can be used to assess polluted sites but their success depends on the availability of suitable assays. The aim of this study was to investigate the performance of two earthworm biomarkers, lysosomal membrane stability measured using the neutral red retention assay (NRR-T) and the total immune activity (TIA) assay, that have previously been established as responsive to chemical exposure. Responses of the two assays were measured following in situ exposure to complexly contaminated field soils at three industrial sites as well as urban and rural controls. The industrial sites were contaminated with a range of metal (cadmium, copper, lead, zinc, nickel and cobalt) and organic (including polycyclic aromatic hydrocarbons) contaminants, but at concentrations below the 'New Dutch List' Intervention concentrations. Exposed earthworms accumulated both metals and organic compounds at the contaminated sites, indicating that there was significant exposure. No effect on earthworm survival was found at any of the sites. Biomarker measurements, however, indicated significant effects, with lower NRR-T and TIA found in the contaminated soils when compared to the two controls. The results demonstrate that a comparison of soil pollutant concentrations with guideline values would not have unequivocally identified chemical exposure and toxic effect for soil organisms living in these soils. However, the earthworm biomarkers successfully identified significant exposure and biological effects caused by the mixture of chemicals present.

PCB congener concentrations in the water column of a highly industrialized river catchment, the Aire/Calder, in N.E. England were determined weekly on a routine basis, and 2 hourly through selected high flow (flood) events. Bed, suspended and floodplain sediment PCB congener concentrations were also determined along transects of the rivers investigated. Weekly monitoring revealed that the sum of 11 quantified (Sigma11) PCBs rose in concentration by two orders of magnitude during late summer compared to their winter minimum values. This rise was concurrent with sustained periods of low flow. SigmaPCB concentrations were rapidly diluted during high flow (flood) events. Suspended sediment was, on average, 13 times more contaminated with PCBs than bed sediment, with means of 4.0 and 53.8 ng/g, respectively, while floodplain samples had an intermediate concentration of 29.8 ng/g. Principle components analysis (PCA) of congener profiles showed that all three sediment types were similar, but that congener profiles differed considerably between sediment and whole-water samples. There was no change in the percentage contribution of individual PCB congeners apparent from weekly whole-water monitoring. However, the congener pattern in whole-waters changed systematically during high flow events. PCA showed that whole-water samples collected during high flow events had progressively more sediment characteristics, and then returned to whole-water characteristics on cessation of the event. The PCA evidence, dilution of PCB concentrations during events, and suspended sediments more contaminated than bed sediments, indicate that the major sources of PCBs in this catchment are current inputs from sewage treatment works, rather than remobilization of bed sediments.

Atherosclerotic renovascular disease (ARVD) commonly causes renal failure and hypertension and is accompanied by high cardiovascular comorbidity and mortality. Interrelationships between these factors remain poorly understood. Patients with ARVD presenting to a single center between 1995 and 1999 were followed up, with prospective collection of clinical and biochemical data. Fifty men and 48 women were identified. Mean age at entry was 68.7 +/- 8.3 (SD) years, and baseline creatinine clearance (CrCl) was 35.5 +/- 20.7 mL/min. During follow-up (27.7 +/- 18.7 months), 10 patients required dialysis therapy, 11 patients underwent revascularization, and 35 patients (36%) died. Patients in whom renal function deteriorated during follow-up (n = 61) had similar ages, baseline CrCls, blood pressures, and comorbidities compared to patients with stable function. Mortality (55.7% versus 27.0%; P < 0.01) and proteinuria (protein, 1.3 +/- 1.6 versus 0.3 +/- 0.4 g/24 h; P < 0.001) were greater in patients with declining function. Baseline renal function was not significantly related to blood pressure, proteinuria, or change in renal function during follow-up (change in CrCl), but patients with a lower CrCl had increased mortality. There was no increase in cardiovascular comorbidity in groups with lower renal function. Patients with the most severe anatomic ARVD had worse hypertension and increased mortality, but severity of ARVD was unrelated to extent of renal dysfunction and proteinuria at baseline. Lack of correlation between renal artery anatomy and baseline renal function or functional outcome and correlation between renal functional outcome and proteinuria suggest that renal parenchymal damage is a major determinant of renal dysfunction and outcome in ARVD., (Copyright 2002 by the National Kidney Foundation, Inc.)

At this institution, all non-intensive care unit (ICU)-based patients with acute uremia were previously managed on the general nephrology ward, and there were concerns that these patients may not have been benefiting from optimal management, particularly with regard to nutrition. In 1998, a renal high-dependency care (RHDC) unit was established within the ward, providing opportunity to compare the clinical management and outcomes of acutely uremic patients in 2 annual cohorts that were admitted both before and after implementation of the RHDC unit. Retrospective case reviews complemented data collected prospectively on the unit since 1995. There were 108 patients included from 1995 to 1996 and 86 patients included from 1998 to 1999; no patients were excluded, but a few case records were unobtainable. Both patient groups were demographically similar (median age, 68 years pre-RHDC, 62.5 years with the RHDC unit), and initial illness severity/comorbidity showed no significant differences. Nutritional support increased significantly (P <.05) from 22.4% in 1995 to 1996 to 38.4% of patients in 1998 to 1999, reflecting increased oral supplementation. Dialysis requirements were similar (60.2% v 63.5%). The proportion of patients requiring admission to the ICU (17.6% v 8.1%) and the total number of ICU bed days used (195 v 86) was reduced in 1998 to 1999. Cost analysis showed little overall difference between the 2 cohorts; the actual cost of improved nutritional management was negligible. The RHDC area and its nurse-based protocols have increased nutritional support for acutely uremic patients, allowing a reduction in ICU usage without any worsening in outcomes., (Copyright 2002 by the National Kidney Foundation, Inc.)

Patients with atherosclerotic renal artery occlusion (RAO) effectively have only a single functioning kidney, so they constitute an ideal group in whom to study the relationship of atherosclerotic renovascular disease (ARVD) severity to renal functional outcome. Of 299 patients with ARVD who had presented to a single center over a 12-yr period, 142 (47.5%) patients with RAO were identified. There was no relationship between baseline renal function and contralateral renovascular anatomy. Patients with contralateral normal, insignificant (<50%), or significant (>50%) renal artery stenoses had baseline creatinine of 243 +/- 235, 292 +/- 197, or 210 +/- 102 micromol/L, respectively, but patients with bilateral RAO (creatinine, 540 +/- 304 micromol/L; P < 0.0001) were significantly worse. There were significant correlations between baseline GFR and both proteinuria (r = -0.32; P < 0.01) and contralateral bipolar renal length (r = 0.44; P < 0.0001). Over a mean follow-up period of 31 +/- 21 (2 to 82) mo, the overall rate of progressive renal functional decline was -4.1 ml/min per yr. Nine patients required dialysis at presentation and a further 15 (10.5%) during the course of the study. There were 85 (59.9%) deaths; median survival of the whole group was 25 mo, and 5-yr survival was 31%. Multivariate analysis indicated that low baseline GFR was the chief variable independently associated with increased probability of death or need of dialysis but that renal vascular anatomy had no prognostic impact. This study reinforces the importance of intrarenal vascular and parenchymal disease in the etiology of renal dysfunction in ARVD.