Coherent light scattering from a telecom C-band quantum dot

Quantum networks have the potential to transform secure communication via quantum key distribution and enable novel concepts in distributed quantum computing and sensing. Coherent quantum light generation at telecom wavelengths is fundamental for fibre-based network implementations, but Fourier-limited emission and subnatural linewidth photons have so far only been reported from systems operating in the visible to near-infrared wavelength range. Here, we use InAs/InP quantum dots to demonstrate photons with coherence times much longer than the Fourier limit at telecom wavelength via elastic scattering of excitation laser photons. Further, we show that even the inelastically scattered photons have coherence times within the error bars of the Fourier limit. Finally, we make direct use of the minimal attenuation in fibre for these photons by measuring two-photon interference after 25 km of fibre, demonstrating finite interference visibility for photons emitted about 100,000 excitation cycles apart.

Patient Use, Experience, and Satisfaction With Telehealth in an Australian Population (Reimagining Health Care): Web-Based Survey Study

BACKGROUND

The COVID-19 pandemic triggered a rapid scale-up of telehealth services in Australia as a means to provide continued care through periods of physical restrictions. The factors that influence engagement in telehealth remain unclear.

OBJECTIVE

The purpose of this study is to understand the experience of Australian people who engaged in a telehealth consultation during the pandemic period (2020-2021) and the demographic factors that influence engagement.

METHODS

A web-based survey was distributed to Australians aged over 18 years that included 4 questions on frequency and type of clinical consultation, including with a general practitioner (GP), specialist, allied health, or nurse; 1 question on the experience of telehealth; and 2 questions on the quality of and satisfaction with telehealth. Statistical analysis included proportion of responses (of positive responses where a Likert scale was used) and regression analyses to determine the effect of demographic variables.

RESULTS

Of the 1820 participants who completed the survey, 88.3% (1607/1820) had engaged in a health care consultation of some type in the previous 12 months, and 69.3% (1114/1607) of those had used telehealth. The most common type of consultation was with a GP (959/1114, 86.1%). Older people were more likely to have had a health care consultation but less likely to have had a telehealth consultation. There was no difference in use of telehealth between metropolitan and nonmetropolitan regions; however, people with a bachelor's degree or above were more likely to have used telehealth and to report a positive experience. A total of 87% (977/1114) of participants agreed or strongly agreed that they had received the information they required from their consultation, 71% (797/1114) agreed or strongly agreed that the outcome of their consultation was the same as it would have been face-to-face, 84% (931/1114) agreed or strongly agreed that the doctor or health care provider made them feel comfortable, 83% (924/1114) agreed or strongly agreed that the doctor or health care provider was equally as knowledgeable as providers they have seen in person; 57% (629/1114) of respondents reported that they would not have been able to access their health consultation if it were not for telehealth; 69% (765/1114) of respondents reported that they were satisfied with their telehealth consultation, and 60% (671/1114) reported that they would choose to continue to use telehealth in the future.

CONCLUSIONS

There was a relatively high level of engagement with telehealth over the 12 months leading up to the study period, and the majority of participants reported a positive experience and satisfaction with their telehealth consultation. While there was no indication that remoteness influenced telehealth usage, there remains work to be done to improve access to older people and those with less than a bachelor's degree.

Engagement with healthcare providers and healthcare system navigation among Australians with chronic conditions: a descriptive survey study

OBJECTIVES

With the rate of chronic conditions increasing globally, it is important to understand whether people with chronic conditions have the capacity to find the right care and to effectively engage with healthcare providers to optimise health outcomes.We aimed to examine associations between care navigation, engagement with health providers and having a chronic health condition among Australian adults.

DESIGN AND SETTING

This is a cross-sectional, 39-item online survey including the navigation and engagement subscales of the Health Literacy Questionnaire, completed in December 2018, in Australia. Binary variables (low/high health literacy) were created for each item and navigation and engagement subscale scores. Logistic regression analyses (estimating ORs) determined the associations between having a chronic condition and the navigation and engagement scores, while controlling for age, gender, level of education and income.

PARTICIPANTS

1024 Australians aged 18-88 years (mean=46.6 years; 51% female) recruited from the general population.

RESULTS

Over half (n=605, 59.0%) of the respondents had a chronic condition, mostly back pain, mental disorders, arthritis and asthma. A greater proportion of respondents with chronic conditions had difficulty ensuring that healthcare providers understood their problems (32.2% vs 23.8%, p=0.003), having good discussions with their doctors (29.1% vs 23.5%, p=0.05), discussing things with healthcare providers until they understand all they needed (30.5% vs 24.5%, p=0.04), accessing needed healthcare providers (35.7% vs 29.7%, p=0.05), finding the right place to get healthcare services (36.3% vs 29.2%, p=0.02) and services they were entitled to (48.3% vs 40.6%, p=0.02), and working out what is the best healthcare for themselves (34.2% vs 27.7%, p=0.03). Participants with chronic conditions were 1.5 times more likely to have low scores on the engagement (adjusted OR=1.48, p=0.03, 95% CI 1.05 to 2.08) and navigation (adjusted OR=1.43, p=0.026, 95% CI 1.043 to 1.970) subscales after adjusting for age, gender, income and education.

CONCLUSION

Upskilling in engagement and communication for healthcare providers and people with chronic conditions is needed. Codesigned, clearly articulated and accessible information about service entitlements and pathways through care should be made available to people with chronic conditions. Greater integration across health services, accessible shared health records and access to care coordinators may improve navigation and engagement.

Consumer preferences, experiences, and attitudes towards telehealth: Qualitative evidence from Australia

In Australia, telehealth is not new, with several telehealth specialist services being available for those living in rural and remote communities. However, prior to the COVID-19 pandemic, telehealth was not routinely available for primary care or urban specialist appointments. There has been an increased focus in the use of telehealth within primary care, and particularly general practice, but overall, there has been limited research to date to guide telehealth best-practice based on consumer experiences and preferences within these settings. We aimed to capture the consumer experience of telehealth during the COVID-19 pandemic, through a novel Kitchen Table Discussion (KTD) method. This increases access to a broader community consumer cohort, with consumer hosts leading discussions in a safe environment. The KTDs were conducted in May 2021, with 10 community members each hosting a group of up to 10 participants. A total of 90 participants took part from across Australia, with the majority living in major cities, although a significant proportion lived in inner and outer regional areas of Australia, or had experience living in rural, regional or remote areas. Seventy percent of participants reported using telehealth in the past. Data were analysed sequentially using thematic analysis and identified key themes: modality, convenience, access, wait time, existing relationship, communication, connectivity, cost, and privacy. Overall, the future of telehealth looks hopeful from the perspective of the consumer, but significant improvements are required to improve consumer engagement and experience. It is evident that ‘one size does not fit all’, with results suggesting consumers value the availability of telehealth and having choice and flexibility to use telehealth when appropriate, but do not want to see telehealth replacing face-to-face delivery. Participants tended to agree that telehealth was not a preferred method when physical examination was required but would suit certain points of the patient journey.

Creating person‐centred health care value together

In this article we ask: to what extent is person‐centred care truly embedded in our system, and are we making the most of the policy levers that could help?

We describe person‐centred care, shine a light on deficits in the health system, and point to some policy enablers to support person‐centred care.

Cultural change and a commitment to value‐based health care are required. We highlight the merit in adopting and acting on patient‐reported measures as an indicator of what matters to the patient, the need for integrated data systems, and the role of a co‐creation approach. Most importantly, we underscore the importance of funding reform and consumer leadership.

Educational attainment and willingness to use technology for health and to share health information - The reimagining healthcare survey

BACKGROUND

Australia has seen a rapid uptake of virtual care since the start of the COVID-19 pandemic. We aimed to describe the willingness of consumers to use digital technology for health and to share their health information; and explore differences by educational attainment and area of remoteness.

METHODS

We conducted an online survey on consumer preferences for virtual modes of healthcare delivery between June and September 2021. Participants were recruited through the study's partner organisations and an online market research company. Australian residents aged ≥18 years who provided study consent and completed the survey were included in the analysis. We reported the weighted percentages of participants who selected negative response to the questions to understand the size of the population that were unlikely to adopt virtual care. Age-adjusted Poisson regression models were used to estimate the prevalence ratios for selecting negative response associated with education and remoteness.

RESULTS

Of the 1778 participants included, 29% were not aware of digital technologies for monitoring/supporting health, 22% did not have access to technologies to support their health, and 19% were not willing to use technologies for health. Over a fifth of participants (range: 21-34%) were not at all willing to use seven of the 15 proposed alternative methods of care. Between 21% and 36% of participants were not at all willing to share de-identified health information tracked in apps/devices with various not-for-profit organisations compared to 47% with private/for-profit health businesses. Higher proportions of participants selected negative response to the questions in the lower educational attainment groups than those with bachelor's degree or above. No difference was observed between area of remoteness.

CONCLUSIONS

Improving the digital health literacy of people, especially those with lower educational attainment, will be required for virtual care to become an equitable part of normal healthcare delivery in Australia.

Global developments in social prescribing

Social prescribing is an approach that aims to improve health and well-being. It connects individuals to non-clinical services and supports that address social needs, such as those related to loneliness, housing instability and mental health. At the person level, social prescribing can give individuals the knowledge, skills, motivation and confidence to manage their own health and well-being. At the society level, it can facilitate greater collaboration across health, social, and community sectors to promote integrated care and move beyond the traditional biomedical model of health. While the term social prescribing was first popularised in the UK, this practice has become more prevalent and widely publicised internationally over the last decade. This paper aims to illuminate the ways social prescribing has been conceptualised and implemented across 17 countries in Europe, Asia, Australia and North America. We draw from the 'Beyond the Building Blocks' framework to describe the essential inputs for adopting social prescribing into policy and practice, related to service delivery; social determinants and household production of health; workforce; leadership and governance; financing, community organisations and societal partnerships; health technology; and information, learning and accountability. Cross-cutting lessons can inform country and regional efforts to tailor social prescribing models to best support local needs.

Building collaborative leadership: A qualitative evaluation of the Australian Collaborative Pairs trial

The need to reorient the health system to ensure greater involvement of consumers in healthcare has, in recent years, been highlighted as a priority in both literature and policy. This change requires renegotiating power relations among health organisations, health professionals and health consumers. This study presents findings from a trial of a program designed to foster collaborative relationships between clinicians and consumers of health services in the Australian setting. The King's Fund Collaborative Pairs program is a leadership development program that brings together a consumer, patient or community leader to work together in pairs with a service provider clinician or manager to develop new ways of working together. The trial involved 88 participants paired together undertaking one of seven programs conducted from October 2018 to August 2019. Participants were guided through a series of activities in five face-to-face sessions run by facilitators trained by the King's Fund. A qualitative evaluation was undertaken via semi-structured interviews (n = 40) with organisations involved, facilitators and participants. A brief review of program documentation was also included. Thematic analysis was undertaken to evaluate program acceptability, implementation and to identify program impacts. The evaluation, although limited in scope, found the program changed the way some participants understood the nature of consumer and provider relationships and how collaborative working relationships could be developed. The impact of the program on organisations sponsoring participants was less evident as numbers of participants from each organisation were limited and the time required for cultural change to develop is typically longer than the evaluation period allowed for. We highlight key recommendations addressing program recruitment, facilitation and format to inform future iterations of the program.

Psychological distress and digital health service use during COVID-19: A national Australian cross-sectional survey

BACKGROUND

Previous research suggests that the COVID-19 pandemic caused significant disruption to the lives and mental health of Australians. In response, health services adapted rapidly to digital modes of treatment, prevention and care. Although a large amount of research emerged in the first year of the pandemic, the longer-term mental health impacts, contributing factors, and population-level utilization of digital health services are unknown.

METHODS

A population-based online survey of 5,100 Australians adults was conducted in October 2021. Psychological distress was assessed with the Kessler 6-item Psychological Distress Scale. Additional survey questions included use and satisfaction with digital health services. Where available, data were compared with our previous survey conducted in 2018, permitting an examination of pre- and post-pandemic digital health service utilization.

RESULTS

In 2021, almost a quarter (n = 1203, 23.6%) of respondents reported serious levels of psychological distress; participants with pre-existing health related conditions, of younger age, lower educational attainment, those who lost their job or were paid fewer hours, or living in states with lockdown policies in place were at highest risk of serious psychological distress. Almost half of all respondents (n = 2177, 42.7%) reported using digital health technologies in 2021, in contrast to just 10.0% in 2018. In 2021, respondents with serious psychological distress were significantly more likely to consult with a healthcare professional via telephone/videoconferencing (P < 0.001), access healthcare via a telephone advice line (P < 0.001), or via an email or webchat advice service (P < 0.001) than those with no serious psychological distress. Those with and without psychological distress were highly satisfied with the care they received via digital health technologies in 2021.

CONCLUSION

Rates of serious psychological distress during the second year of the pandemic remained high, providing further evidence for the serious impact of COVID-19 on the mental health of the general population. Those with psychological distress accessed digital mental health services and were satisfied with the care they received. The results highlight the continued need for mental health support and digital health services, particularly for people living with chronic conditions, younger adults and people most impacted by the COVID-19 pandemic, both in the short term and beyond.

462 Empirical Antibiotic Prescribing in General Surgical Patients

Introduction

Prescribing antibiotics is common practice on a standard general surgical take, however incorrect prescribing can result in sub-standard care or even patient harm. This audit loop was conducted to assess the adherence to local antibiotic prescribing guidelines to evaluate and improve practice.

Method

Data was collected prospectively against a pre-designed proforma over a 2-week period. Inclusion criteria were patients admitted on the general surgical take and were prescribed empirical antibiotics. This process was repeated after the first audit and a) a questionnaire on prescribing behaviours b) An educational presentation.

Results

Antibiotic indication and bleep number were generally well documented, above 86% and 77% respectively in both audit cycles. Duration of antibiotic was poorly documented overall and requires further improvement. The most significant improvement was in documentation of signature and a printed name. The questionnaire revealed that 70% of doctors were unaware of the importance of printing name as well as a signature on prescription, after educational intervention the rate of printed and signed scripts improved from 23% to 70%.

Conclusions

Significant improvement was noted in doctors printing their name compared to the initial cycle. These results highlight the importance of informing the junior doctors of the benefits of printing their name on prescriptions.

129 “Pop-Up” Specialist End of Life Ward For COVID-19—The Nottingham Experience

Background

Our hospital trust anticipated an increased need for palliation and end of life care (EoLC) in patients with Covid-19 who were not appropriate for escalation and mechanical ventilation.

Intervention

A dedicated ward was opened as part of the trust-wide Covid-19 admissions pathway, led by geriatricians with palliative care input and staffed by relocated nursing and auxiliary personnel. Retrospective data was collected for consecutive patients admitted to the ward between 3rd April and 26th May 2020 and qualitative data regarding staff experience using a questionnaire.

Result

Of the 168 patients (55% male) admitted, 31.5% came directly from Emergency Department, 17.3% from admission areas and the remainder from inpatient wards. Time spent on the ward ranged from 10 minutes to 17 days (median length of stay 43 hours). 75% had Clinical Frailty Scale score of 6 or more. 150 died with 75% naming Covid-19 as primary cause or contributing factor. Ward staff, who were not palliative care specialists, reported increased confidence in many aspects of palliation including assessing comfort, relieving symptoms, prescribing and administering anticipatory medications and in supporting and communicating with relatives. Staff apprehension about working on a Covid ward eased once the ward was established. Qualitative themes emerging from staff feedback included: professional competency, communication, prioritisation, team work, emotional response, care and consistency in a time of change.

Discussion

The pathway and referral system ensured that our ward cared for appropriate older patients living with frailty. The formation of a specialist unit over a short period of time created a series of logistical and management challenges. The emotional burden felt by staff was also prominent in feedback. These challenges were outweighed by the personal and professional development of staff coupled with the strong sense of teamwork, pride and enthusiasm felt in providing high quality care.

Accessible and affordable healthcare? Views of Australians with and without chronic conditions

Background

With 50% of Australians having chronic disease, health consumer views are an important barometer of the ‘health’ of the healthcare system for system improvement and sustainability.

Aims

To describe the views of Australian health consumers with and without chronic conditions when accessing healthcare.

Methods

A survey of a representative sample of 1024 Australians aged over 18 years, distributed electronically and incorporating standardised questions and questions co‐designed with consumers.

Results

Respondents were aged 18–88 years (432 males, 592 females) representing all states and territories, and rural and urban locations. General practices (84.6%), pharmacies (62.1%) and public hospitals (32.9%) were the most frequently accessed services. Most care was received through face‐to‐face consultations; only 16.5% of respondents accessed care via telehealth. The 605 (59.0%) respondents with chronic conditions were less likely to have private health insurance (50.3% vs 57.9%), more likely to skip doses of prescribed medicines (53.6% vs 28.6%), and miss appointments with doctors (15.3% vs 10.1%) or dentists (52.8% vs 40.4%) because of cost. Among 480 respondents without private health insurance, unaffordability (73.5%) or poor value for money (35.3%) were the most common reasons. Most respondents (87.7%) were confident that they would receive high quality and safe care. However, only 57% of people with chronic conditions were confident that they could afford needed healthcare compared with 71.3% without.

Conclusions

Health consumers, especially those with chronic conditions, identified significant cost barriers to access of healthcare. Equitable access to healthcare must be at the centre of health reform.

Changes in public perceptions and experiences of the Australian health-care system: A decade of change

Background

The views and experiences of the Australian public are an important barometer of the health system. This study provides key findings about the changing views held by Australians over time regarding their individual experiences and perceptions of the overall performance of the health system.

Methods

A population‐based online survey was conducted in 2018 (N = 1024). Participants were recruited through market research panels. The results were compared with previous Australian population survey data sets from 2008 (N = 1146), 2010 (N = 1201) and 2012 (N = 1200), each of which used different population samples. The survey included questions consistent with previous surveys regarding self‐reported health status, and questions about use, opinions and experiences of the health system.

Results

Overall, there has been a shift in views from 2008 to 2018, with a higher proportion of respondents now viewing the Australian health‐care system more positively (X² (2, N = 4543) = 96.59, P < .001). In 2018, areas for attention continued to include the following: the need for more doctors, nurses and other health workers (29.0%); lower costs for care or Orion medicines (27.8%); more access to care (13.1%); and enhancements in residential aged care (17.3% rated these services as ‘bad’ or ‘very bad’).

Conclusions

This research suggests that Australians’ perceptions of their health‐care system have significantly improved over the last decade; however, concerns have emerged over access to medicines, inadequate workforce capacity and the quality of aged care facilities. Our study highlights the value of periodically conducting public sentiment surveys to identify potential emerging health system problems.

A major new alliance in Australian healthcare: the Australian consensus framework for ethical collaboration in the healthcare sector

The 'Australian Consensus Framework for Ethical Collaboration in the Healthcare Sector' (ACF) is an Australian initiative aimed at countering dysfunction and growing mistrust in the health sector through the development of a cross-sectoral consensus framework. The development of this framework arose from Australia's involvement in the Asia Pacific Economic Cooperative (APEC) and has since become the largest of its kind internationally, with over 70 signatories representing professional bodies, industry organisations, hospital and health services associations, regulators and patient and advocacy groups. In this article, we describe and critique the framework and outline its implementation.

Oral propranolol in the treatment of proliferating infantile haemangiomas: British Society for Paediatric Dermatology consensus guidelines

BACKGROUND

Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified U.K. guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pretreatment investigations, its use in PHACES (posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe) syndrome and cessation of treatment.

OBJECTIVES

To provide unified guidelines for the treatment of IH with propranolol.

METHODS

This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting.

RESULTS

The expert panel achieved consensus on 47 statements in eight categories, including indications and contraindications for starting propranolol, pretreatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment.

CONCLUSIONS

These consensus guidelines will help to standardize and simplify the treatment of IH with oral propranolol across the U.K. and assist in clinical decision-making.

On the road to value co-creation in health care: the role of consumers in defining the destination, planning the journey and sharing the drive

The role of consumers is now extending beyond being passive health care recipients and even active participants in their own care to involvement in innovation and value co-creation in health care - from being "users and choosers" to becoming "makers and shapers" of services. For active dialogue to occur in co-creation, consumers must become equal partners with health care organisations and providers, with the focus on areas of interest to all parties. The use of value co-creation in health care involves embedding the approach across the whole health care system - from the microsystem level to the mesosystem and the entire macrosystem.

Commissioning: perspectives from the ground

Primary Health Networks (PHNs) have been tasked with two key objectives to be achieved through commissioning. Public value aims can be achieved by developing operational capability in the context of an authorising environment. Public value will need to focus on system level outcomes from multiple perspectives, including a consumer perspective. The authorising environment will require policymakers to allow time for PHNs to mature into their role. It will require an environment of effective collaboration amongst multiple stakeholders including consumers. The operational capability will need to ensure highly competent managers and clinical leadership working in a symbiotic relationship. Although some Medicare Locals demonstrated commissioning capacity and capability, this will need to be scaled up at-pace in the new healthcare landscape in order for PHNs to optimally fulfil their roles.

What skills do primary health care professionals need to provide effective self-management support?Seeking consumer perspectives

This research aimed to identify the skills required by primary health care (PHC) professionals to provide effective chronic condition prevention and self-management support, according to the perceptions of a sample of Australian consumers and carers. Qualitative data were collected and integrated from a focus group, key informant interviews and National Stakeholder meetings and a National Workshop, supported by an extensive literature review. With the exception of health professionals specifically trained or currently working in this area, consumers and carers perceive there is a lack of understanding, competence and practice of chronic condition prevention and self-management support among PHC professionals. The PHC workforce appears not to have the full set of skills needed to meet the growing burden of chronic conditions on the health system. Recommendations include education and training that focuses on improved communication skills, knowledge of community support resources, identification of consumers’ strengths and current capacities, collaborative care with other health professionals, consumers and carers and psychosocial skills to understand the impact of chronic conditions from the person’s perspective.

Behavioural and biochemical responses to morphine associated with its motivational properties are altered in adenosine A(2A) receptor knockout mice

BACKGROUND AND PURPOSE

The purinergic system through the A(2A) adenosine receptor regulates addiction induced by different drugs of abuse. The aim of the present study was to investigate the specific role of A(2A) adenosine receptors (A(2A)Rs) in the behavioural and neurochemical responses to morphine associated with its motivational properties.

EXPERIMENTAL APPROACH

Mice lacking A(2A)Rs (A(2A) knockout (KO) mice) and wild-type littermates were used to evaluate behavioural responses induced by morphine. Antinociception was assessed using the tail-immersion and the hot-plate tests. Place-conditioning paradigms were used to evaluate the rewarding effects of morphine and the dysphoric responses of morphine withdrawal. Microdialysis studies were carried out to evaluate changes in the extracellular levels of dopamine in the nucleus accumbens of A(2A) KO mice after morphine administration.

KEY RESULTS

The acute administration of morphine induced a similar enhancement of locomotor activity and antinociceptive responses in both genotypes. However, the rewarding effects induced by morphine were completely blocked in A(2A) KO mice. Also, naloxone did not induce place aversion in animals lacking the A(2A)Rs.

CONCLUSIONS AND IMPLICATIONS

Our findings demonstrate that the rewarding and aversive effects associated with morphine abstinence were abolished in A(2A) KO mice, supporting a differential role of the A(2A) adenosine receptor in the somatic and motivational effects of morphine addiction. This study provides evidence for the role of A(2A)Rs as general modulators of the motivational properties of drugs of abuse. Pharmacological manipulation of these receptors may represent a new target in the management of drug addiction.

Models in the delivery of depression care: a systematic review of randomised and controlled intervention trials

Background

There is still debate as to which features, types or components of primary care interventions are associated with improved depression outcomes. Previous reviews have focused on components of collaborative care models in general practice settings. This paper aims to determine the effective components of depression care in primary care through a systematic examination of both general practice and community based intervention trials.

Methods

Fifty five randomised and controlled research trials which focused on adults and contained depression outcome measures were identified through PubMed, PsycInfo and the Cochrane Central Register of Controlled Trials databases. Trials were classified according to the components involved in the delivery of treatment, the type of treatment, the primary focus or setting of the study, detailed features of delivery, and the discipline of the professional providing the treatment. The primary outcome measure was significant improvement on the key depression measure.

Results

Components which were found to significantly predict improvement were the revision of professional roles, the provision of a case manager who provided direct feedback and delivered a psychological therapy, and an intervention that incorporated patient preferences into care. Nurse, psychologist and psychiatrist delivered care were effective, but pharmacist delivery was not. Training directed to general practitioners was significantly less successful than interventions that did not have training as the most important intervention. Community interventions were effective.

Conclusion

Case management is important in the provision of care in general practice. Certain community models of care (education programs) have potential while others are not successful in their current form (pharmacist monitoring).

General Practice Based Multidisciplinary Care Teams in Australia: Still some unanswered questions. A discussion paper from the Australian General Practice Network

Evidence indicates that general practice-based multidisciplinary teams can offer a means of addressing some of the key issues currently facing Western health systems, especially workforce and chronic disease management. Elements of team-working have been addressed in research and policy initiatives both overseas and in Australia, yet some important aspects of primary health care multidisciplinary team-working still remain unclear in the Australian context. This discussion paper has been developed by the Australian General Practice Network (AGPN) to raise awareness of and promote thought on four questions relating to multidisciplinary team-working that AGPN considers important but that, as yet, have not been fully addressed. (Except where indicated, it is not a position statement about AGPN's views on this matter.) Questions considered are: Who is in the team? What makes a successful team? How should teams be funded in Australia? Who coordinates the team? Each question broadly considers what is already known about the area through purposeful literature reviews of the published and grey literature, current policy impacting on the area, and suggested areas for policy development in the context of Australian general practice and primary care.

Older immigrant Tamil women and their doctors: attitudes toward breast cancer screening

Cultural beliefs have been hypothesized to be powerful barriers to breast cancer screening in minority women and physician recommendation is consistently reported to be the strongest incentive. This study investigated (1) beliefs regarding breast cancer and (2) the perception of barriers to mammography and clinical breast examination in a sample of immigrant Tamil women, as well as in a sample of primary care physicians. Three focus groups, each consisting of 10 immigrant Tamil women from Sri Lanka aged 50 years or over were conducted and 52 primary care physicians who serve this population completed mailed surveys. The most common barriers to screening reported by the women were (1) lack of understanding of the role of early detection in medical care, (2) religious beliefs and, (3) fear of social stigmatization. Physicians reported the most common barriers to their screening recommendations for this group of women to be (1) women's episodic care, (2) unrelated presenting problems and, (3) women refusing to be screened. Interventions to increase screening in this and other minority groups requires an elaborated understanding of utilization barriers for both women and their doctors.

A role for N-acetylglucosamine as a nutrient sensor and mediator of insulin resistance

The ability to regulate energy balance at both the cellular and whole body level is an essential process of life. As western society has shifted to a higher caloric diet and more sedentary lifestyle, the incidence of type 2 diabetes (non-insulin-dependent diabetes mellitus) has increased to epidemic proportions. Thus, type 2 diabetes has been described as a disease of 'chronic overnutrition'. There are abundant data to support the relationship between nutrient availability and insulin action. However, there have been multiple hypotheses and debates as to the mechanism by which nutrient availability modulates insulin signaling and how excess nutrients lead to insulin resistance. One well-established pathway for nutrient sensing is the hexosamine biosynthetic pathway (HSP), which produces the acetylated aminosugar nucleotide uridine 5'-diphospho-N-acetylglucosamine (UDP-Glc-NAc) as its end product. Since UDP-GlcNAc is the donor substrate for modification of nucleocytoplasmic proteins at serine and threonine residues with N-acetylglucosamine (O-GlcNAc), the possibility of this posttranslational modification serving as the nutrient sensor has been proposed. We have recently directly tested this model in adipocytes by examining the effect of elevated levels of O-GlcNAc on insulin-stimulated glucose uptake. In this review, we summarize the existing work that implicates the HSP and O-GlcNAc modification as nutrient sensors and regulators of insulin signaling.

Influences on breast cancer screening behaviors in Tamil immigrant women 50 years old and over

OBJECTIVE

To investigate, using the Health Belief Model as a theoretical framework, the incentives and barriers to breast cancer screening in a recent immigrant group, older Tamil women from Sri Lanka.

METHOD

Tamil women who had had a mammogram and Tamil women who had never had a mammogram were compared on the following variables: socio-demographics, personal risk estimates for breast cancer, risk-reduction expectancies, beliefs and knowledge about breast cancer and screening recommendations, and acculturation.

RESULTS

Groups differed significantly in terms of education, years living in North America, acculturation, and beliefs/knowledge about breast cancer. When education and acculturation were controlled, perceived barriers to mammography were most predictive of mammography utilization.

DISCUSSION

Results are discussed with a view to developing culture-appropriate educational campaigns.

Nucleocytoplasmic O-glycosylation: O-GlcNAc and functional proteomics

The molecular complexity that defines different cell types and their biological responses occurs at the level of the cell's proteome. The recent increase in availability of genomic sequence information is a valuable tool for the field of proteomics. While most proteomic studies focus on differential expression levels, post-translational modifications such as phosphorylation, glycosylation, and acetylation, provide additional levels of functional complexity to the cell's proteome. The reversible post-translational modification O-linked beta-N-acetylglucosamine (O-GlcNAc) is found on serines and threonines of nuclear and cytoplasmic proteins. It appears to be as widespread as phosphorylation. While phosphorylation is recognized as a fundamental mechanism for controlling protein function, less is known about the specific roles of O-GlcNAc modification. However, evidence is building that O-GlcNAc may compete with phosphate at some sites of attachment. Aberrant O-GlcNAc modification has been linked to several disease states, including diabetes and Alzheimer's disease. Regulated enzymes catalyzing the addition (O-GlcNAc transferase, OGT) and removal (O-GlcNAcase) of the modification have been cloned and OGT is required for life at the single cell level. Here we review the properties of O-GlcNAc that suggest it is a regulatory modification analogous to phosphorylation. We also discuss the use of comparative functional proteomics to elucidate functions for this ubiquitous intracellular carbohydrate modification.

Characterization of a mouse monoclonal antibody specific for O-linked N-acetylglucosamine

beta-O-linked N-acetylglucosamine (O-GlcNAc) is an abundant posttranslational modification of resident nuclear and cytoplasmic proteins in eukaryotes. Increasing evidence suggests that O-GlcNAc plays a regulatory role in numerous cellular processes. Here we report on the production and characterization of a highly specific mouse monoclonal antibody, MAb CTD110.6, that specifically reacts with O-GlcNAc. The antibody recognizes O-GlcNAc in beta-O-glycosidic linkage to both serine and threonine. We could detect no cross-reactivity with alpha-linked Ser/Thr-O-GlcNAc, alpha-linked Ser-O-linked N-acetylgalactosamine (O-GalNAc), or N-linked oligosaccharides on ovalbumin and immunoglobulin G. The monosaccharide GlcNAc, but not GalNAc, abolishes immunoreactivity, further demonstrating specificity toward O-GlcNAc. Furthermore, galactose capping of O-GlcNAc sites also inhibits CTD110.6 immunoreactivity. Enrichment of GlcNAc-containing glycoproteins using the lectin wheat germ agglutinin dramatically enriches for CTD110.6-reactive proteins. The antibody reacts with a large number of proteins from cytoplasmic and nuclear extracts and readily detects in vivo changes in O-GlcNAc modification. These studies demonstrate that CTD110.6 is highly specific toward O-GlcNAc, with no cross-reactivity toward similar carbohydrate antigens or toward peptide determinants.

Kingella kingae endocarditis in a sixteen-month-old-child

We report the case of a child with acute neurologic symptoms who was found to have bacterial endocarditis caused by Kingella kingae. The case alerts microbiologists and pediatricians to an organism that has rarely been reported to cause endocarditis in children.

Dynamic O-glycosylation of nuclear and cytosolic proteins: cloning and characterization of a neutral, cytosolic beta-N-acetylglucosaminidase from human brain

Dynamic modification of cytoplasmic and nuclear proteins by O-linked N-acetylglucosamine (O-GlcNAc) on Ser/Thr residues is ubiquitous in higher eukaryotes and is analogous to protein phosphorylation. The enzyme for the addition of this modification, O-GlcNAc transferase, has been cloned from several species. Here, we have cloned a human brain O-GlcNAcase that cleaves O-GlcNAc off proteins. The cloned cDNA encodes a polypeptide of 916 amino acids with a predicted molecular mass of 103 kDa and a pI value of 4.63, but the protein migrates as a 130-kDa band on SDS-polyacrylamide gel electrophoresis. The cloned O-GlcNAcase has a pH optimum of 5.5-7.0 and is inhibited by GlcNAc but not by GalNAc. p-Nitrophenyl (pNP)-beta-GlcNAc, but not pNP-beta-GalNAc or pNP-alpha-GlcNAc, is a substrate. The cloned enzyme cleaves GlcNAc, but not GalNAc, from glycopeptides. Cell fractionation suggests that the overexpressed protein is mostly localized in the cytoplasm. It therefore has all the expected characteristics of O-GlcNAcase and is distinct from lysosomal hexosaminidases. Northern blots show that the transcript is expressed in every human tissue examined but is the highest in the brain, placenta, and pancreas. An understanding of O-GlcNAc dynamics and O-GlcNAcase may be key to elucidating the relationships between O-phosphate and O-GlcNAc and to the understanding of the molecular mechanisms of diseases such as diabetes, cancer, and neurodegeneration.

Glycosylation of nucleocytoplasmic proteins: signal transduction and O-GlcNAc

The dynamic glycosylation of serine or threonine residues on nuclear and cytosolic proteins by O-linked beta-N-acetylglucosamine (O-GlcNAc) is abundant in all multicellular eukaryotes. On several proteins, O-GlcNAc and O-phosphate alternatively occupy the same or adjacent sites, leading to the hypothesis that one function of this saccharide is to transiently block phosphorylation. The diversity of proteins modified by O-GlcNAc implies its importance in many basic cellular and disease processes. Here we systematically examine the current data implicating O-GlcNAc as a regulatory modification important to signal transduction cascades.

Covalent heterogeneity of the human enzyme galactose-1-phosphate uridylyltransferase

Galactose-1-phosphate uridylyltransferase (GALT) acts by a double displacement mechanism, catalyzing the second step in the Leloir pathway of galactose metabolism. Impairment of this enzyme results in the potentially lethal disorder, galactosemia. Although the microheterogeneity of native human GALT has long been recognized, the biochemical basis for this heterogeneity has remained obscure. We have explored the possibility of covalent GALT heterogeneity using denaturing two-dimensional gel electrophoresis and Western blot analysis to fractionate and visualize hemolysate hGALT, as well as the human enzyme expressed in yeast. In both contexts, two predominant GALT species were observed. To define the contribution of uridylylated enzyme intermediate to the two-spot pattern, we exploited the null allele, H186G-hGALT. The Escherichia coli counterpart of this mutant protein (H166G-eGALT) has previously been demonstrated to fold properly, although it cannot form covalent intermediate. Analysis of the H186G-hGALT protein demonstrated a single predominant species, implicating covalent intermediate as the basis for the second spot in the wild-type pattern. In contrast, three naturally occurring mutations, N314D, Q188R, and S135L-hGALT, all demonstrated the two-spot pattern. Together, these data suggest that uridylylated hGALT comprises a significant fraction of the total GALT enzyme pool in normal human cells and that three of the most common patient mutations do not disrupt this distribution.

Determining structure/function relationships for sarcomeric myosin heavy chain by genetic and transgenic manipulation of Drosophila

Drosophila melanogaster is an excellent system for examining the structure/function relationships of myosin. It yields insights into the roles of myosin in assembly and stability of myofibrils, in defining the mechanical properties of muscle fibers, and in dictating locomotory abilities. Drosophila has a single gene encoding muscle myosin heavy chain (MHC), with alternative RNA splicing resulting in stage- and tissue-specific isoform production. Localization of the alternative domains of Drosophila MHC on a three-dimensional molecular model suggests how they may determine functional differences between isoforms. We are testing these predictions directly by using biophysical and biochemical techniques to characterize myosin isolated from transgenic organisms. Null and missense mutations help define specific amino acid residues important in actin binding and ATP hydrolysis and the function of MHC in thick filament and myofibril assembly. Insights into the interaction of thick and thin filaments result from studying mutations in MHC that suppress ultrastructural defects induced by a troponin I mutation. Analysis of transgenic organisms expressing engineered versions of MHC shows that the native isoform of myosin is not critical for myofibril assembly but is essential for muscle function and maintenance of muscle integrity. We show that the C-terminus of MHC plays a pivotal role in the maintenance of muscle integrity. Transgenic studies using headless myosin reveal that the head is important for some, but not all, aspects of myofibril assembly. The integrative approach described here provides a multi-level understanding of the function of the myosin molecular motor.

Subcellular localization of galactose-1-phosphate uridylyltransferase in the yeast Saccharomyces cerevisiae

The enzyme galactose-1-phosphate uridylyltransferase (GALT) catalyzes the second step of the Leloir pathway of galactose metabolism, following galactokinase (GALK) and preceding UDP-galactose-4-epimerase (GALE). Impairment of GALT in humans results in the potentially lethal disorder classic galactosemia. Standard lysis protocols of bacteria, yeast, or mammalian cells release all three Leloir enzymes in the soluble fraction, leading to the historical assumption that all three function as free cytosolic enzymes. We have tested this assumption with regard to GALT in vivo using the yeast Saccharomyces cerevisiae, by linking a GFP-tag onto the amino terminus of Gal7p, the endogenous yeast GALT. We find clear evidence of localization of the fusion protein to discrete spots in the cytoplasm of the majority of cells expressing all three Leloir enzymes, although GFP alone appears freely cytosolic. In contrast, yeast expressing GFP-Gal7p but lacking Gal1p (GALK), Gal10p (GALE), or both do not demonstrate spots in the majority of cells, implicating a role, either direct or indirect, for these other Leloir proteins in the Gal7p localization process. Preliminary truncation experiments reveal that amino acids 1-134 of Gal7p are sufficient to drive localization of the fusion protein, while amino acids 1-66 are not. Finally, GFP-tagged human GALT expressed in yeast also localizes to spots, demonstrating that at least some of the intrinsic determinants of localization have been conserved. These observations raise the intriguing possibility that GALT may function in a sequestered rather than a freely diffusible state, and that this subcellular organization may have been conserved through evolution.

Functional consequence of substitutions at residue 171 in human galactose-1-phosphate uridylyltransferase

Impairment of the human enzyme galactose-1-phosphate uridylyltransferase (hGALT) results in the potentially lethal disorder classic galactosemia. Although a variety of naturally occurring mutations have been identified in patient alleles, few have been well characterized. We have explored the functional significance of a common patient mutation, F171S, using a strategy of conservative substitution at the defined residue followed by expression of the wild-type and, alternatively, substituted proteins in a null-background strain of yeast. As expected from patient studies, the F171S-hGALT protein demonstrated <0.1% wild-type levels of activity, although two of three conservatively substituted moieties, F171L- and F171Y-hGALT, demonstrated approximately 10% and approximately 4% activity, respectively. The third protein, F171W, demonstrated severely reduced abundance, precluding further study. Detailed kinetic analyses of purified wild-type, F171L- and F171Y-hGALT enzymes, coupled with homology modeling of these proteins, enabled us to suggest that the effects of these substitutions resulted largely from altering the position of a catalytically important residue, Gln-188, and secondarily, by altering the subunit interface and perturbing hexose binding to the uridylylated enzyme. These results not only provide insight into the functional impact of a single common patient allele and offer a paradigm for similar studies of other clinically or biochemically important residues, but they further help to elucidate activity of the wild-type human GALT enzyme.

The continuing fall in incidence of hypoxic-ischaemic encephalopathy in term infants

OBJECTIVE

To examine trends in incidence of hypoxic-ischaemic encephalopathy in term infants over a twenty-one year period.

DESIGN

A retrospective analysis of medical records of all term infants admitted to a neonatal unit with hypoxic-ischaemic encephalopathy during the years 1992-1996 (period C) and a comparison with data from the years 1976-1980 (period A) and 1984-1988 (period B) from the same unit (previously published).

SETTING

A District Health Authority in Central England serving a population of about 450,000.

SAMPLE

All term infants admitted with clinical features of hypoxic-ischaemic encephalopathy.

MAIN OUTCOME MEASURES

Incidence of three grades of hypoxic-ischaemic encephalopathy, disability and mortality.

RESULTS

In each five year period there were similar numbers of births. Over the time-span of this study the stillbirth rate and neonatal mortality rate has consistently fallen. The overall incidence of hypoxic-ischaemic encephalopathy in term infants was significantly lower (P < 0.001; OR 0.42 CI 0.29-0.59) in the present study period (C) compared with the earlier study period B (1.9 vs 4.6 per 1,000 total live births). The fall in moderately and severely affected infants between the present and the first study period was significant (1.2 vs 2.6 per 1,000 total live births, P < 0.001: OR 0.46 CI 0.29-0.72). The number of deaths and the incidence of cerebral palsy in survivors fell progressively over the 21 years spanned by this study.

CONCLUSION

This study shows that the incidence of hypoxic-ischaemic encephalopathy and its sequelae in term infants has fallen significantly. The use of cardiotocography and caesarean section rates have risen but the relative contributions of changes in clinical practice are uncertain.

Ondansetron/promethazine combination or promethazine alone reduces nausea and vomiting after middle ear surgery

STUDY OBJECTIVES

To determine the incidence of postoperative nausea and vomiting when a combination of ondansetron and promethazine is given prophylactically, and to ascertain the effect of postoperative nausea and vomiting on recovery room duration and patient satisfaction.

DESIGN

Prospective, randomized, placebo-controlled, double-blind study.

SETTING

University-affiliated tertiary-care hospital.

PATIENTS

87 ASA physical status I and II adult patients scheduled for middle ear surgery.

INTERVENTIONS

Patients were randomly assigned to receive one of the following interventions intravenously: ondansetron 4 mg (Group 1), promethazine 25 mg (Group 2), ondansetron 2 mg plus promethazine 12.5 mg (Group 3, combination), or placebo (Group 4).

MEASUREMENTS AND MAIN RESULTS

Independent, study blinded observers recorded complaints of nausea and number of episodes of vomiting for 24 hours following the patient's first response to commands. All patients were contacted the day after discharge to inquire about nausea and vomiting. The awakening time, postanesthesia care unit and day surgery unit durations, opioid use, and side effects were recorded. At the end of the 24-hour period, the study blinded observers asked patients for an overall assessment of their global anesthesia experience using an 11-point scale. During the 24-hour period, the incidence of postoperative nausea and vomiting was reduced from 74% (placebo) to 39% (promethazine; p = 0.03) and 29% (combination; p = 0.003). Compared with placebo, the severity of vomiting was significantly less in the combination group (p = 0.04). The number of very satisfied patients correlated negatively with the incidence of postoperative nausea and vomiting (p < 0.0001) and with the severity of vomiting (p = 0.003).

CONCLUSION

The prophylactic use of an antiemetic with middle ear surgery may reduce postoperative nausea and vomiting over 24 hours, and the ondansetron/promethazine combination or promethazine alone are cost-effective choices. Finally, the combination reduced significantly the severity of vomiting.