Search

Aims: To determine whether the infestation by the protozoan paramyxean parasite, Marteilia sydneyi, changes the bacterial community of the digestive gland of Sydney rock oysters, Saccostrea glomerata. Methods and Results: Six 16S rDNA clone libraries were established from three M. sydneyi-infected and three un-infected oysters. Restriction enzyme analysis followed by sequencing representative clones revealed a total of 23 different operational taxonomic units (OTUs) in un-infected oysters, comprising the major phyla: Firmicutes, Proteobacteria, Cyanobacteria and Spirocheates, where the clone distribution was 44, 36, 7 and 5%, respectively. Close to half of the OTUs are not closely related to any other hitherto determined sequence. In contrast, S. glomerata infected by M. sydneyi had only one OTU present in the digestive gland. Phylogenetic analysis of the 16S rDNA sequence reveals that this dominant OTU, belonging to the α-Proteobacteria, is closely related to a Rickettsiales-like prokaryote (RLP). Conclusions: The microbiota of the digestive gland of Sydney rock oysters is changed by infection by M. sydneyi, becoming dominated by a RLP, and generally less diverse . The bacterial community of un-infected S. glomerata differs from previous studies in that we identified the dominant taxa as Firmicutes and α-Proteobacteria, rather than heterotrophic γ-Proteobacteria. Significance and Impact of the Study: This is the first culture-independent study of the microbiota of the digestive glands of edible oysters to the species level. The commercial viability of the Sydney rock oyster industry in Australia is currently threatened by Queensland Unknown disease and the changes in the bacterial community of S. glomerata corresponding with infection by M. sydneyi sheds further light on the link between parasite infection and mortality in this economically damaging disease. [ABSTRACT FROM AUTHOR]

Background: Incontinence is common in hospitalised older adults but few studies report new incidence during or following hospitalisation., Objective: To describe prevalence and incidence of incontinence in older inpatients and associations with clinical outcomes., Design: Secondary analysis of prospectively collected data from consecutive consenting inpatients age 65 years and older on medical and surgical wards in four Australian public hospitals., Methods: Participants self-reported urinary and faecal incontinence 2 weeks prior to admission, at hospital discharge and 30 days after discharge as part of comprehensive assessment by a trained research assistant. Outcomes were length of stay, facility discharge, 30-day readmission and 6-month mortality., Results: Analysis included 970 participants (mean age 76.7 years, 48.9% female). Urinary and/or faecal incontinence was self-reported in 310/970 (32.0%, [95% confidence interval (CI) 29.0-35.0]) participants 2 weeks before admission, 201/834 (24.1% [95% CI 21.2-27.2]) at discharge and 193/776 (24.9% [95% CI 21.9-28.1]) 30 days after discharge. Continence patterns were dynamic within the peri-hospital period. Of participants without pre-hospital incontinence, 74/567 (13.1% [95% CI 10.4-16.1) reported incontinence at discharge and 85/537 (15.8% [95% CI 12.8-19.2]) reported incontinence at 30 days follow-up. Median hospital stay was longer in participants with pre-hospital incontinence (7 vs. 6 days, P = 0.02) even in adjusted analyses and pre-hospital incontinence was significantly associated with mortality in unadjusted but not adjusted analyses., Conclusion: Pre-hospital, hospital-acquired and new post-hospital incontinence are common in older inpatients. Better understanding of incontinence patterns may help target interventions to reduce this complication., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Importance: Hospital-associated complications of older people (HAC-OPs) include delirium, hospital-associated disability, incontinence, pressure injuries, and falls. These complications may be preventable by age-friendly principles of care, including early mobility, good nutrition and hydration, and meaningful cognitive engagement; however, implementation is challenging., Objectives: To implement and evaluate a ward-based improvement program ("Eat Walk Engage") to more consistently deliver age-friendly principles of care to older individuals in acute inpatient wards., Design, Setting, and Participants: This cluster randomized CHERISH (Collaboration for Hospitalised Elders Reducing the Impact of Stays in Hospital) trial enrolled 539 consecutive inpatients aged 65 years or older, admitted for 3 days or more to study wards, from October 2, 2016, to April 3, 2017, with a 6-month follow-up. The study wards comprised 8 acute medical and surgical wards in 4 Australian public hospitals. Randomization was stratified by hospital, providing 4 clusters in intervention and in control groups. Statistical analysis was performed from August 28, 2018, to October 17, 2021, on an intention-to-treat basis., Intervention: A trained facilitator supported a multidisciplinary work group on each intervention ward to improve the care practices, environment, and culture to support key age-friendly principles., Main Outcomes and Measures: Primary outcomes were incidence of any HAC-OP and length of stay. Secondary outcomes were incidence of individual HAC-OPs, facility discharge, 6-month mortality, and all-cause readmission. Outcomes were analyzed at the individual level, adjusted for confounders and clustering., Results: A total of 265 participants on 4 intervention wards (124 women [46.8%]; mean [SD] age, 75.9 [7.3] years) and 274 participants on 4 control wards (145 women [52.9%]; mean [SD] age, 78.0 [8.2] years) were enrolled. The composite primary outcome of any HAC-OP occurred for 115 of 248 intervention participants (46.4%) and 129 of 249 control participants (51.8%) (intervention group: adjusted odds ratio, 1.07; 95% CI, 0.71-1.61). The median length of stay was 6 days (IQR, 4-9 days) for the intervention group and 7 days (IQR, 5-10 days) for the control group (adjusted hazard ratio, 0.96; 95% credible interval, 0.80-1.15). The incidence of delirium was significantly lower for intervention participants (adjusted odds ratio, 0.53; 95% CI, 0.31-0.90). There were no significant differences in other individual HAC-OPs, facility discharge, mortality, or readmissions., Conclusions and Relevance: The Eat Walk Engage program did not reduce the composite primary outcome of any HAC-OP or length of stay, but there was a significant reduction in the incidence of delirium., Trial Registration: anzctr.org.au Identifier: ACTRN12615000879561.

Objective: To determine the prevalence of fundus pathology in metropolitan Australian EDs utilising a non-mydriatic fundus photography screening programme. Secondary objectives include diagnostic accuracy among emergency physicians compared to telehealth ophthalmologist review., Methods: Prospective cross-sectional study investigating non-mydriatic fundus photography as a new diagnostic test in two tertiary Australian EDs. Consecutive adult patients were enrolled if they presented with headache, focal neurological deficit, visual disturbance or diastolic BP >120 mmHg. Diagnostic agreement was determined using kappa statistics and sensitivity and specificity using a reference standard consensus ophthalmology review., Results: A total of 345 consecutive patients were enrolled among whom 56 (16%, 95% confidence interval [CI] 13-21) had urgent fundus pathology. Agreement between emergency physician and ophthalmic assessment of fundus photographs was 74% (kappa = 0.196, P = 0.001). Emergency physicians had 40% sensitivity (95% CI 27-54) and 82% specificity (95% CI 76-86) for detecting urgent pathology on photographs., Conclusions: Fundus photography detects a clinically significant proportion of fundus pathology and urgent diagnoses. Telehealth specialist image review is important to detect some important, time-critical illnesses that can be missed in routine care. This offers an accurate alternative to direct ophthalmoscopy that warrants further research in Australian EDs., (© 2020 Australasian College for Emergency Medicine.)

Objective: The aims of this study were to describe patterns and dose of rehabilitation received following stroke and to investigate their relationship with outcomes., Design: This was a prospective observational cohort study., Setting: A total of seven public hospitals and all subsequent rehabilitation services in Queensland, Australia, participated in the study., Subjects: Participants were consecutive patients surviving acute stroke between July 2016 and January 2017., Methods: We tracked rehabilitation for six months following stroke and obtained 90- to 180-day outcomes from the Australian Stroke Clinical Registry., Measures: Dose of rehabilitation - time in therapy by physiotherapy, occupational therapy and speech pathology; modified Rankin Scale (mRS)- premorbid, acute care discharge and 90- to 180-day follow-up., Results: We recruited 504 patients, of whom 337 (median age = 73 years, 41% female) received 643 episodes of rehabilitation in 83 different services. Initial rehabilitation was predominantly inpatient (260/337, 77%) versus community-based (77/337, 21%). Therapy time was greater within inpatient services (median = 29 hours) compared to community-based (6 hours) or transition care (16 hours). Median (Quartile 1, Quartile 3) six-month cumulative therapy time was 73 hours (40, 130) when rehabilitation commenced in stroke units and continued in inpatient rehabilitation units; 43 hours (23, 78) when commenced in inpatient rehabilitation units; and 5 hours (2, 9) with only community rehabilitation. In 317 of 504 (63%) with follow-up data, improvement in mRS was most likely with inpatient rehabilitation (OR = 3.6, 95% CI = 1.7-7.7), lower with community rehabilitation (OR = 1.6, 95% CI = 0.7-3.8) compared to no rehabilitation, after adjustment for baseline factors., Conclusion: Amount of therapy varied widely between rehabilitation pathways. Amount of therapy and chance of improvement in function were highest with inpatient rehabilitation.

Background: Health educators aim to graduate students who are safe, effective and practice evidence-based medicine (EBM). Clinical Practice Guidelines (CPGs) are tools for translating evidence into clinical practice for health professionals and educators who lack time to appraise the evidence. There have been CPGs published for lateral ankle ligament sprains (LALS) for physiotherapists, nurses, and doctors. Clinical decision rules have also been developed for LALS to increase the safety of practice. The Ottawa Ankle Rules (OAR) were developed to screen for the need for an x-ray following an ankle or foot injury., Methods: Educators from the Australasian College of Sports and Exercise Physicians (ACSEP), St John Ambulance first aiders, pharmacy, nursing, and physiotherapy disciplines were participants in this study. Using purposeful sampling with semi-structured questions and a LALS case study, 19 Australian educators were interviewed. Curricula and textbooks were also collected and analysed. Two researchers independently analysed the data using a deductive method., Results: Analysis found that no educator used a CPG to inform their teaching. There was no common LALS curriculum for the five groups studied. There were two approaches: a triage curriculum (St John Ambulance, pharmacy, nursing) and a reflective curriculum (ASCEP and physiotherapy). Textbooks influenced curriculum for physiotherapy, pharmacy and first aid educators. The triage curricula recommend rest, ice, compression and elevation (RICE) alone, while the reflective curricula uses OAR, RICE, immobilisation if the LALS is severe, functional support (brace), exercises and manual therapy. In addition, ACSEP and physiotherapy do not recommend electrotherapy. All five groups were cautious about the use of non-steroidal anti-inflammatory drugs (NSAIDs)., Conclusions: Physiotherapy and ACSEP educators teach OAR. Despite not using the CPGs to inform curriculum, physiotherapy and ACSEP have unintentionally aligned their curriculum with current LALS CPG recommendations. However, nursing, pharmacy and first aid trainers are not teaching OAR or aligned with LALS CPGs. Educators in pharmacy, nursing and first aid should re-examine their curricula and consider possibly teaching OAR and using CPG. Clinical practice guideline developers should consider pharmacists and first aiders as users of their LALS CPGs.

Background: Increases in opioid use and related harms such as mortality are occurring in many high income countries. Community pharmacists are often in contact with patients at risk of opioid-related harm and represent an ideal point for intervention. Best practice in monitoring opioid-related outcomes involves assessing analgesia, pain functioning, mood, risks and harms associated with opioid use. Community pharmacists are well-placed to undertake these tasks., Objectives: Our pilot study will test the implementation of a computer-facilitated screening and brief intervention (SBI). The SBI will support pharmacist identification of opioid-related problems and provide capacity for brief intervention including verbal reinforcement of tailored information sheets, supply of naloxone and referral back to the opioid prescriber. The SBI utilises software that embeds study procedures into dispensing workflow and assesses opioid outcomes with domains aligned with a widely accepted clinical framework., Methods: We will recruit and train 75 pharmacists from 25 pharmacies to deliver the Routine Opioid Outcome Monitoring (ROOM) SBI. Pharmacists will complete the SBI with up to 500 patients in total (20 per pharmacy). Data will be collected on pharmacists' knowledge and confidence through pre- and post-intervention online surveys. Data on feasibility, acceptability and implementation outcomes, including naloxone supply, will also be collected., Project Impact: Our study will examine changes in pharmacists' knowledge and confidence to deliver the SBI. Through the implementation pilot, we will establish the feasibility and acceptability of a pharmacist SBI that aims to improve monitoring and clinical management of patients who are prescribed opioids., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: There is emerging interest in models of care that focus on assessment and brief inpatient treatment (two to three days) including psychiatric emergency care centre units and short-stay units in Australia. We present the development of a functionally integrated Missenden Assessment Unit and six-bed short-stay unit in the new Professor Marie Bashir Centre at Royal Prince Alfred Hospital in inner-city Sydney. The focus was on collaboration between emergency, drug and alcohol and mental-health services in developing the short-stay unit and Missenden Assessment Unit with joint admission and resource use. We outline the models of care and findings from the 2016 evaluation following the initial two years of operation and consider ongoing challenges., Conclusion: The Missenden Assessment Unit provides an alternative point of presentation for mental-health drug and alcohol patients. The short-stay unit provides coordinated, therapeutic interventions. The Missenden Assessment Unit/short-stay unit reduced the burden of presentations to the emergency department while providing the opportunity for training and collaboration. Further refinement of the models of care should occur with policy development and via research.

Background: Emergency department (ED) fast track has been shown to improve patient flow for low complexity presentations.(1) The optimal model of care and service delivery for fast track patients has not been established., Aims: The objective of this pilot study was to compare patient satisfaction using two models of ED fast track - one in a tertiary hospital emergency department staffed by doctors and the other in a nearby urban district hospital staffed by nurse practitioners. We also wanted to determine the proportion of fast track patients who would prefer to see a General Practitioner (GP) instead of presenting to the ED. This pilot study was the foundation for subsequent studies later conducted by Dinh et al.(2,3) METHODS: This was an observational study using a convenience sample of patients. Eligible fast track patients were asked to complete a standardised satisfaction survey. Presenting problems and waiting times of patients were collected using patient information systems. Primary outcome measure was satisfaction rating using a 5-point Likert scale. Secondary outcomes were surrogate satisfaction measures encompassing questions on likelihood of returning to ED. A multivariate analysis was performed to obtain odds ratio for higher satisfaction scores., Results: In total, 353 patients were recruited: 212 patients in the doctor treated group (DR) and 141 were in the nurse practitioner treated group (NP). The two groups had similar baseline characteristics in terms of age, gender, referral source and waiting times. Overall, 320/353(86%) patients rated their care as either very good or excellent, with only 0.6% rating their care as poor. Satisfaction scores in the NP group were higher than those in the DR group (median score 4 vs. 3, p<0.01). A greater proportion of patients in the NP group reported that they would return to the ED for a similar problem (99% vs. 91% p<0.01). Overall, 175/353 (50%) of patients indicated that they would prefer to see a general practitioner for a similar problem if available nearby. These numbers were slightly lower in the NP group (43% vs. 53%, p=0.05)., Conclusions: Most patients were satisfied with ED fast track, irrespective of model of care. Patient satisfaction was greater in the group of patients using the nurse practitioner model of care. Around half of the fast track patients would prefer to see a general practitioner for a similar problem if available nearby., (Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.)

Objective: This study aimed to determine factors associated with length of stay (LOS) for women presenting with early pregnancy complications to a public hospital ED. In particular, we sought to investigate the impact the involvement of the Clinical Midwife Consultant (CMC), specialising in early pregnancy care, had on the ED LOS., Methods: We undertook a retrospective cohort study of women less than 20 weeks pregnant who presented between August 2008 and December 2010 with early pregnancy complications to the ED of the Royal Prince Alfred Hospital in Sydney, Australia and who were then discharged. The main outcome measured was LOS. We performed logistic regression analysis to identify factors significantly associated with this outcome., Results: Data were available for 1739 women. Involvement of the CMC reduced LOS and patients were significantly more likely to be discharged within 4 h or less (OR = 0.47, 95% CI = 0.37-0.60). The factors that increased LOS to over 4 h were arrival after hours (OR = 2.09, 95% CI = 1.66-2.63), being triaged as category 1 to 3 (OR = 1.36, 95% CI = 1.11-1.67) and requiring an ultrasound assessment (OR = 2.44, 95% CI = 1.81-3.28)., Conclusions: This study was able to show factors significantly associated with ED LOS, many of which are not modifiable. The involvement of the CMC reduced LOS, whereas requiring an ultrasound assessment increased LOS. Thus, improvement could be achieved by greater access to a CMC and more rapid access to ultrasound services., (© 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Purpose: To evaluate an emergency department (ED)-based mental health nurse practitioner (MHNP) outpatient service in Sydney, Australia., Data Sources: Data collection incorporated waiting times for follow-up outpatient appointments, two brief self-report measures (the K-10 measure of psychological distress and the General Self-Efficacy Scale), a satisfaction tool, and interviews conducted with a random selection of outpatients and a stratified, purposive sample of ED staff., Conclusions: Over 60% of outpatients were followed up within 5 days of their initial presentation. The mean K-10 score at baseline was 32 (very high psychological distress, n = 101) but this had decreased by two categories to 24 at follow-up (moderate psychological distress, n = 51). There was a modest association between decreased psychological distress and an increase in perceived self-efficacy. Participant satisfaction with aspects of the outpatient service was generally rated as high to very high. Interviewed outpatients (n = 23) were particularly positive about the accessibility, immediacy, and flexibility of the service and overall therapeutic benefits. Emergency staff (n = 20) considered the outpatient service enhanced service provision by facilitating access to a population of patients who were previously underserved., Implications for Practice: The ED-based MHNP role enhances access to specialized mental health care and also supports emergency staff., (©2012 The Author(s) Journal compilation ©2012 American Academy of Nurse Practitioners.)