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Introduction: Previous studies have shown that patient-centredness may become eroded as students progress through medical training. The primary objective of this study was to explore the differences in patient-centred attitudes between first- and final-year students in the context of an Australian medical school. The secondary objective was to determine whether student factors such as age, gender, background (rural/urban), discipline of previous degree and specialty of interest were associated with patient-centred attitudes. Methods: This cross-sectional study surveyed 214 first-year and 141 final-year Australian medical students in 2016 and 2017 (total n = 355). Score on the Patient–Practitioner Orientation Scale (PPOS) was the main outcome measure. Results: Anonymous questionnaires were completed by 355 students (76.2%). Mean PPOS score was 4.51 (SD 0.46). Although there was no difference in mean PPOS between first-year and fourth-year students, female respondents were significantly more patient-centred than male respondents (4.58 vs 4.42, p = 0.002). Students with an interest in a surgical specialty had significantly lower patient-centredness than students with a non-surgical specialty of interest (4.36 vs 4.55, p = 0.002). Having general practice intentions was not associated with higher patient-centredness. Students with a previous humanities-based degree had higher patient-centredness than students with previous degrees in different areas (4.67 vs 4.49, p = 0.025). Conclusions: There appears to be no erosion of patient-centredness between first-year and fourth/final-year students. Medical student selection and university culture may have influenced this finding.

There is public concern regarding rural workforce shortages and closure of smaller obstetric centres.To identify whether safety is a concern for Murrumbidgee hospitals that fit primary medical care models and ascertain general practitioner (GP) obstetricians' perspectives regarding the benefits and challenges to practising in the region.Mixed-method retrospective analysis of selected outcomes in the NSW Mothers and Babies Reports 2012-2015 and semi-structured interviews with GP obstetricians.Murrumbidgee Local Health District.Evaluation of the safety of smaller hospitals (i.e. discharge status at birth, neonatal resuscitation and admission to intensive care); and iterative thematic analysis.This study provides evidence that smaller hospitals are providing safe obstetric care. Fewer babies were transferred, with fewer stillbirths, at the smaller hospitals and no difference in newborn deaths. There were more normal vaginal births in the smaller hospitals (70.0%) than in Wagga Wagga Base Hospital (57.2%) or Griffith Base Hospital (58.6%). There were fewer neonatal resuscitations in the smaller hospitals than in Wagga Wagga Base Hospital or Griffith Base Hospital. More than one-quarter of babies were admitted into the special care/neonatal intensive care for both Wagga Wagga and Griffith Base Hospitals; however, the rate was3% in the smaller hospitals (p 0.001). GPs were overwhelmingly positive about the professional rewards of GP obstetric practice and the importance of continuity of care, despite barriers such as workforce shortages, loss of facilities and other staff (midwives and anaesthetists). Possible solutions included fostering support systems, proactive succession planning and improving training support.GP obstetricians are providing a valuable, safe service in MLHD with both personal and community benefits.

Objective Although there is some research on women’s choice of birthplace, most of this research has been conducted overseas. This study explored factors influencing the decision to use public or private maternity services within regional Australia. Methods This cross-sectional study consisted of a community-based, anonymous, online questionnaire focused on factors influencing a woman’s choice of birth location and included adult females who had given birth in the past 2 years within two regional areas. Descriptive statistics were used to analyse demographic characteristics and factors influencing decisions regarding birthplace. Pearson’s Chi-squared test was used to compare public and private births for multiple variables. Binary logistic regression was used to determine the odds ratio for each potential factor based on whether participants with private health insurance (PHI) elected to birth in the public or private regional hospitals. Open coding was used to group responses to open ended questions into themes. Results Data from 510 questionnaires were analysed. The three most frequently reported factors influencing a woman’s decision about birthplace were financial reasons, the ability to choose their doctor and not having PHI. Women with PHI who opted for birth in the public system were almost four-fold more likely to select access to intensive care services and 2.6-fold more likely to select a preference for a low-intervention birth as one of their top five most influential factors. The results highlight that women want access to midwifery continuity of care. Conclusion This study provides insights into the factors influencing a woman’s complex decision about where and with whom to birth and how health insurance affects that decision, an area where there is a paucity of peer-reviewed literature. This research highlights the importance of being able to choose one’s doctor and the desire for access to midwife-led models of care, and provides evidence to advocate for improved access to additional models of care in the private sector. What is already known? The viability of regional private maternity hospitals is in question because, once the birth rate goes below a certain threshold, providing private obstetric service becomes unviable. Closure of regional private hospitals means less choice in regional areas. Minimal information is available about the factors influencing a woman with PHI to give birth in the public system, and much of the evidence is anecdotal. What does this paper add? This study provides insight into how PHI status and other factors influence a woman’s decision to birth in the public versus private sector, an area where there is a paucity of peer-reviewed literature. It also highlights a desire from women for access to midwifery continuity of care in the private system. What are the implications for practitioners? This research provides evidence to advocate for improved access to additional models of care, especially for midwifery-led care in the private sector.

Introduction: Obesity is a major public health concern. Accurate perception of body weight may be critical to the successful adoption of weight loss behavior. The aim of this study was to determine the accuracy of self-perception of BMI class. Methods: Patients admitted to the acute medical service in one regional hospital completed a questionnaire and classified their weight as: “underweight,” “normal,” “overweight,” or “obese.” Reponses were compared to clinically measured BMIs, based on the WHO Classification. Patients were also questioned about health-related behavior. Data were analyzed via Pearson’s Chi-squared test. Results: Almost 70% of the participating patient population (n = 90) incorrectly perceived their weight category, with 62% underestimating their weight. Only 34% of patients who were overweight and 14% of patients with obesity correctly identified their weight status. Two-thirds of patients who were overweight and one-fifth of patients with obesity considered themselves to be “normal” or “underweight.” Patients with obesity were 6.5-fold more likely to misperceive their weight status. Amongst patients with overweight/obesity, those who misperceived their weight were significantly less likely to have plans to lose weight. Almost 60% had not made any recent health behavior changes. This is one of the first regional Australian studies demonstrating that hospitalized patients significantly misperceive their weight. Conclusion: Patients with overweight/obesity had significantly higher rates of weight misperception and the majority had no intention to lose weight or to undertake any health behavior modification. Given the association between weight perception and weight reduction behavior, it introduces barriers to addressing weight loss and reducing the increasing prevalence of obesity in rural Australia. It highlights that doctors have an important role in addressing weight misperception.

ObjectiveAlthough there is some research on women's choice of birthplace, most of this research has been conducted overseas. This study explored factors influencing the decision to use public or private maternity services within regional Australia.MethodsThis cross-sectional study consisted of a community-based, anonymous, online questionnaire focused on factors influencing a woman's choice of birth location and included adult females who had given birth in the past 2 years within two regional areas. Descriptive statistics were used to analyse demographic characteristics and factors influencing decisions regarding birthplace. Pearson's Chi-squared test was used to compare public and private births for multiple variables. Binary logistic regression was used to determine the odds ratio for each potential factor based on whether participants with private health insurance (PHI) elected to birth in the public or private regional hospitals. Open coding was used to group responses to open ended questions into themes.ResultsData from 510 questionnaires were analysed. The three most frequently reported factors influencing a woman's decision about birthplace were financial reasons, the ability to choose their doctor and not having PHI. Women with PHI who opted for birth in the public system were almost four-fold more likely to select access to intensive care services and 2.6-fold more likely to select a preference for a low-intervention birth as one of their top five most influential factors. The results highlight that women want access to midwifery continuity of care.ConclusionThis study provides insights into the factors influencing a woman's complex decision about where and with whom to birth and how health insurance affects that decision, an area where there is a paucity of peer-reviewed literature. This research highlights the importance of being able to choose one's doctor and the desire for access to midwife-led models of care, and provides evidence to advocate for improved access to additional models of care in the private sector.What is already known?The viability of regional private maternity hospitals is in question because, once the birth rate goes below a certain threshold, providing private obstetric service becomes unviable. Closure of regional private hospitals means less choice in regional areas. Minimal information is available about the factors influencing a woman with PHI to give birth in the public system, and much of the evidence is anecdotal.What does this paper add?This study provides insight into how PHI status and other factors influence a woman's decision to birth in the public versus private sector, an area where there is a paucity of peer-reviewed literature. It also highlights a desire from women for access to midwifery continuity of care in the private system.What are the implications for practitioners?This research provides evidence to advocate for improved access to additional models of care, especially for midwifery-led care in the private sector.

Background Multiparametric magnetic resonance imaging (mpMRI) of the prostate appears to improve prostate cancer detection, but studies comparing mpMRI to histopathology at the time of radical prostatectomy (RP) are lacking. This retrospective study determined the accuracy of mpMRI predicting Gleason score and index lesion location at the time of RP, the current gold standard for diagnosis. Methods Between April 2013 and April 2016, a database of all men aged more than 40 years who underwent RP after positive transrectal ultrasound biopsy by an experienced urological surgeon was collated at a single regional centre. This was cross-referenced with a database of all men who had mpMRIs performed at a single centre and reported according to Prostate Imaging Reporting and Data System (PI-RADS version 1) during this period to generate a sample size of 64 men. A Spearman's rho test was utilized to calculate correlation. Results Median age of patients was 64 years, the median prostate-specific antigen at RP was 6.22 ng/mL. mpMRI was positive (≥PI-RADS 3) in 85.9% of patients who underwent RP. More than 92% of participants had Gleason ≥7 disease. A positive relationship between mpMRI prostate PI-RADS score and RP cancer volume was demonstrated. An anatomical location correlation calculated in octants was found to be 89.1% accurate. Conclusion mpMRI accurately detects prostate cancer location and severity when compared with gold standard histopathology at the time of RP. It thus has an important role in planning for future prostate biopsy and cancer treatment.

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

Although international medical graduates (IMGs) make up a substantial part of the Australian rural general practice workforce, most research on factors associated with rural practice has focused on Australian medical graduates (AMGs). This study aimed to determine whether there were differences between IMGs and AMGs in terms of these factors. Registrars in training and recent fellows (Fellowship of the Royal Australian College of General Practitioners/Fellowship of the Australian College of Rural and Remote Medicine) who participated in training in rural and regional Australia were surveyed about practice models and rural practice. Almost two-thirds of participants were practicing or intending to practice in rural areas, with no difference between AMGs and IMGs. None of the variables associated with rural practice for AMGs was found to be associated with rural practice in IMGs in univariate binary regression analysis. Two key variables that are strongly associated with rural medical practice in the current literature, namely rural background and rural exposure, were not significant predictors of rural practice among IMGs. Due to the significant number of IMGs in regional training programs, any future incentives designed to improve rural recruitment and retention need to address factors relevant to IMGs.

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

Multiparametric magnetic resonance imaging (mpMRI) of the prostate appears to improve prostate cancer detection, but studies comparing mpMRI to histopathology at the time of radical prostatectomy (RP) are lacking. This retrospective study determined the accuracy of mpMRI predicting Gleason score and index lesion location at the time of RP, the current gold standard for diagnosis.Between April 2013 and April 2016, a database of all men aged more than 40 years who underwent RP after positive transrectal ultrasound biopsy by an experienced urological surgeon was collated at a single regional centre. This was cross-referenced with a database of all men who had mpMRIs performed at a single centre and reported according to Prostate Imaging Reporting and Data System (PI-RADS version 1) during this period to generate a sample size of 64 men. A Spearman's rho test was utilized to calculate correlation.Median age of patients was 64 years, the median prostate-specific antigen at RP was 6.22 ng/mL. mpMRI was positive (≥PI-RADS 3) in 85.9% of patients who underwent RP. More than 92% of participants had Gleason ≥7 disease. A positive relationship between mpMRI prostate PI-RADS score and RP cancer volume was demonstrated. An anatomical location correlation calculated in octants was found to be 89.1% accurate.mpMRI accurately detects prostate cancer location and severity when compared with gold standard histopathology at the time of RP. It thus has an important role in planning for future prostate biopsy and cancer treatment.

Objective To determine health service managers' (HSMs) recommendations on strengthening the health service response to climate change. Design Self-administered survey in paper or electronic format. Setting Rural south-west of New South Wales. Participants Health service managers working in rural remote metropolitan areas 3–7. Main outcome measures Proportion of respondents identifying preferred strategies for preparation of rural health services for climate change. Results There were 43 participants (53% response rate). Most respondents agreed that there is scepticism regarding climate change among health professionals (70%, n = 30) and community members (72%, n = 31). Over 90% thought that climate change would impact the health of rural populations in the future with regard to heat-related illnesses, mental health, skin cancer and water security. Health professionals and government were identified as having key leadership roles on climate change and health in rural communities. Over 90% of the respondents believed that staff and community in local health districts (LHDs) should be educated about the health impacts of climate change. Public health education facilitated by State or Federal Government was the preferred method of educating community members, and education facilitated by the LHD was the preferred method for educating health professionals. Conclusions Health service managers hold important health leadership roles within rural communities and their health services. The study highlights the scepticism towards climate change among health professionals and community members in rural Australia. It identifies the important role of rural health services in education and advocacy on the health impacts of climate change and identifies recommended methods of public health education for community members and health professionals.

Background Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in orthopaedic surgery. While specific guidelines exist for hip and knee arthroplasty, there is wide variation in VTE prophylaxis in complex spinal surgery. This study sought to determine the incidence of VTE, and risk factors associated with VTE, in patients undergoing elective instrumented posterior lumbar spinal fusion. Methods In a single-centre case series study, 107 consecutive patients undergoing elective lumbar spinal fusion were evaluated for VTE by lower limb duplex ultrasonography and/or clinical observation, and where indicated, computed tomography pulmonary angiogram. The Caprini model for thrombosis risk factor assessment was retrospectively applied to grade levels of VTE risk, which were compared with overall VTE incidence. Results All patients were operated on a spinal frame and received mechanical prophylaxis (thromboembolic deterrent stockings and sequential calf-compression devices). Thirty-seven per cent also received chemoprophylaxis with low-molecular-weight heparin (LMWH). There was no significant relationship between LMWH use and protection from VTE. Risk scores ≥3 (high/highest risk categories) were observed in 96.2% of patients. Four (3.7%) patients encountered a VTE complication (all with no chemoprophylaxis), either deep vein thrombosis (1.9%) or pulmonary embolism (1.9%). No patients sustained an epidural haematoma. Conclusion Although patients undergoing elective instrumental posterior lumbar spinal fusion are at high risk of developing VTE, the actual incidence of VTE in these patients is low. Our data support the use of mechanical prophylaxis with thromboembolic deterrent stockings and sequential calf-compression devices to prevent VTE in these patients.

Objective To determine the knowledge and recommendations of rural general practitioners (GPs) in regard to climate change and the preparedness of rural health services for its health impacts. Design A quantitative descriptive survey distributed in paper-based or electronic form. Setting Rural Southwest of New South Wales. Participants GPs and GP registrars working in Rural Remote Metropolitan Areas (RRMA) 3–7. Main outcome measures Questionnaire responses analysed with descriptive statistics and inferential tests. Results While the majority of respondents agreed with statements supporting climate science and the impact of climate change on health, between 24% and 34% of respondents were unsure or did not agree. Furthermore, between 33% and 44% of GP respondents working in RRMA 5–7 were unsure or did not agree that their health service had the capacity to provide an initial response to an extreme weather event (P = 0.01). Strengthening health service acute disaster capacity response was a preferred adaptation strategy for improving health service preparedness of 61% of participants. A greater proportion of GPs were supportive of their role as advocates on general health issues (80%) compared with extreme weather events (60%) or climate change and health (63.5%) (P ≤ 0.01). For professional development and education, 71% preferred a locally based workshop or seminar. Conclusions The study highlights the need to consider closely the views of GPs when preparing rural communities for the possible health effects of climate change. Findings indicate concern for health service preparedness, particularly in smaller rural communities. Further development of disaster response planning and communication is needed.

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 < 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.

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).Retrospective cohort study of 4 months of consecutive ASU admissions, excluding age16, pregnancy, out-of-area transfer and incomplete data. Patients were classified according to World Health Organization WC definitions as high-risk or non-high-risk (increased-risk and no-risk).Of 695 admissions, 512 met the inclusion criteria (47.1% female, average age 52.8 years (SD 22.3)), with 85.1% (P 0.001) of females and 69.4% (P = 0.166) of males 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 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 0.001).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 setting.

A study of orthopedic surgeons in rural and regional Southeast Australia to determine attitudes to investigation and management of osteoporosis found they believe follow-up in regard to osteoporosis after MTF is important; responsibility for follow-up diagnosis and management lies with primary health care and current communication systems are poor. 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 orthopedic surgeons might play in the management of osteoporosis after MTF. The study surveyed orthopedic surgeons in rural and regional Southeast 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. A survey was developed and piloted prior to being posted to 69 orthopedic surgeons asking for their opinions about the general management of osteoporosis, and the roles and responsibilities of health professionals in dealing with osteoporosis following an MTF. 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 coordination 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. This study shows that many rural orthopedic 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.

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

Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in orthopaedic surgery. While specific guidelines exist for hip and knee arthroplasty, there is wide variation in VTE prophylaxis in complex spinal surgery. This study sought to determine the incidence of VTE, and risk factors associated with VTE, in patients undergoing elective instrumented posterior lumbar spinal fusion.In a single-centre case series study, 107 consecutive patients undergoing elective lumbar spinal fusion were evaluated for VTE by lower limb duplex ultrasonography and/or clinical observation, and where indicated, computed tomography pulmonary angiogram. The Caprini model for thrombosis risk factor assessment was retrospectively applied to grade levels of VTE risk, which were compared with overall VTE incidence.All patients were operated on a spinal frame and received mechanical prophylaxis (thromboembolic deterrent stockings and sequential calf-compression devices). Thirty-seven per cent also received chemoprophylaxis with low-molecular-weight heparin (LMWH). There was no significant relationship between LMWH use and protection from VTE. Risk scores ≥3 (high/highest risk categories) were observed in 96.2% of patients. Four (3.7%) patients encountered a VTE complication (all with no chemoprophylaxis), either deep vein thrombosis (1.9%) or pulmonary embolism (1.9%). No patients sustained an epidural haematoma.Although patients undergoing elective instrumental posterior lumbar spinal fusion are at high risk of developing VTE, the actual incidence of VTE in these patients is low. Our data support the use of mechanical prophylaxis with thromboembolic deterrent stockings and sequential calf-compression devices to prevent VTE in these patients.

Objective: To describe the training and certification of physicians who staff small EDs in rural West Virginia. Methods: A survey of rural hospital-based EDs was performed. The authors chose to study all hospitals in counties with populations of

To determine the knowledge and recommendations of rural general practitioners (GPs) in regard to climate change and the preparedness of rural health services for its health impacts.A quantitative descriptive survey distributed in paper-based or electronic form.Rural Southwest of New South Wales.GPs and GP registrars working in Rural Remote Metropolitan Areas (RRMA) 3-7.Questionnaire responses analysed with descriptive statistics and inferential tests.While the majority of respondents agreed with statements supporting climate science and the impact of climate change on health, between 24% and 34% of respondents were unsure or did not agree. Furthermore, between 33% and 44% of GP respondents working in RRMA 5-7 were unsure or did not agree that their health service had the capacity to provide an initial response to an extreme weather event (P = 0.01). Strengthening health service acute disaster capacity response was a preferred adaptation strategy for improving health service preparedness of 61% of participants. A greater proportion of GPs were supportive of their role as advocates on general health issues (80%) compared with extreme weather events (60%) or climate change and health (63.5%) (P ≤ 0.01). For professional development and education, 71% preferred a locally based workshop or seminar.The study highlights the need to consider closely the views of GPs when preparing rural communities for the possible health effects of climate change. Findings indicate concern for health service preparedness, particularly in smaller rural communities. Further development of disaster response planning and communication is needed.

Background Rural communities are vulnerable to the health impacts of climate change, particularly in Australia. Rural General Practitioners (GPs) are critical to the development of adaptation strat...

A common method of illegal methamphetamine production uses lead acetate as a reagent. Production errors may result in methamphetamine grossly contaminated with lead. Three reports have documented outbreaks of acute lead poisoning in intravenous methamphetamine users.This study measured blood lead concentrations in intravenous drug users of methamphetamine, cocaine or heroin presenting to the emergency department to determine the prevalence of subclinical lead poisoning in intravenous methamphetamine users.Mean blood leads for methamphetamine users (n = 92) were 6.22 micrograms/dL or 0.30 mumol/L (range 0.10-1.15, SD 0.20) and 7.25 micrograms/dL or 0.35 mumol/L (0.10-0.80, SD 0.15) for the nonmethamphetamine users (n = 53) with no significant difference between groups.The data suggest that previous outbreaks of acute intravenous lead poisoning among methamphetamine users were probably related to episodic contamination of methamphetamine. Subclinical lead poisoning was not found among the methamphetamine users presenting to the emergency department.

The purpose of this pilot study was to investigate whether nurse practitioners are able to provide a level of primary health service applicable to remote/isolated settings in wound management and treatment of blunt limb trauma. It was hypothesized that there would be no significant difference in the quality of care, or the level of client satisfaction, provided by the medical officers and the nurse practitioners in the study. Two groups participated in the study, nurse practitioners and medical officers. The study used a randomized trial design. Data were collected using quantitative and qualitative methods. Two hundred and thirty-two clients participated in the study. Of this number 63 were supervised cases in the pilot trial. In the randomized trial participants were distributed between nurse practitioners and medical officers (n = 169), of which 91 were randomized to medical officers and 78 to nurse practitioners. Telephone interviews were conducted to evaluate client satisfaction. The majority of study participants were surveyed for client satisfaction (n = 132). This represents approximately 78% of the randomized sample and multivariate analysis was carried out on the data. Study results indicate that there were no significant differences between the two groups in relation to client satisfaction. Very positive outcomes of treatment were consistent across groups in the study. The study also found that there was strong support for the role of the nurse practitioner in the rural emergency setting. Recommendations include further research to measure the efficacy of nurse practitioners utilizing the selected competencies in remote/isolated settings.

Propythexedrine is a potent α-adrenergic drug available as a nasal decongestant, which drug abusers sometimes extract and inject into a central vein. A 25-year-old white male presented to a local emergency department 32 h after attempting to inject his right internal jugular vein with “home-made crank.” Following injection, he noted right neck pain, followed by fever and chills. On emergency department admission, he had inspiratory stridor and respiratory distress. Massive edema of his right neck extended from his anterior chest to the right parotid. Neck radiographs showed extensive paracervical swelling with displacement of the trachea. The patient was taken to surgery for nasotracheal intubation with fiberoptic guidance and surgical exploration. The neck contained extensive necrotic tissue that was surgically debrided. In spite of treatment with antibiotics, he developed progressive renal failure and hypotension unresponsive to fluid therapy, followed by cardiopulmonary arrest and death.

The effect has been investigated of the alpha-adrenergic agonist, phenylephrine, on excretion of water and electrolytes (Na, K, and HCO3) by the parotid and mandibular glands of the rat. In the mandibular glands the agonist was as effective as acetylcholine (or parasympathetic nerve stimulation) in stimulating secretion, and the electrolyte excretory patterns seen in the two modes of stimulation were similar. In the parotid gland, phenylephrine was only one-fifth as potent as acetylcholine (or parasympathetic nerve stimulation) in evoking a secretory response but, when due allowance for flow rate differences is made, the electrolyte excretion patterns were similar. In both glands the secretory response to phenylephrine was totally different, in magnitude and in electrolyte excretion pattern, to that evoked by the beta-adrenergic agonist, isoprenaline. It is concluded, as has already been established for secretion of exportable protein, that alpha-adrenergic agonists have very similar effects to muscarinic agonists both on endpiece and on duct cells and that these actions are completely different from those evoked by activation of beta-adrenergic receptors.

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