GP perspectives on a psychiatry phone line in Western Australia's Great Southern region: implications for addressing rural GP workload

BACKGROUND

Mental illness is a public health challenge disproportionately affecting rural Australians. GPs provide most of the mental health care, and they report increasing levels of burnout and unsustainable workload in the context of increased patient complexity. This may be more salient in rural settings characterised by resource constraints. In this paper, we use evaluation data from a GP psychiatry phone line established in Western Australia's Great Southern region in 2021 to describe GPs' perspectives on the service and reflect on how it may help alleviate rural GP workload.

METHODS

The sample was recruited among GPs practicing in the region. Data were collected through an online survey and semistructured interviews. Descriptive statistics were used to analyse the survey data. Interview data were subjected to thematic analysis; qualitative survey data were used for triangulation.

RESULTS

A total of 45GPs completed the survey and 14 were interviewed. Interview data yielded three themes: the criticality of timeliness; the building blocks of confidence; and trust. GPs were highly satisfied with the service, and timeliness and trust were the characteristics underpinning its effectiveness. The service built GPs' confidence in managing mental health and alcohol and other drug use issues through strengthening knowledge and providing reassurance.

CONCLUSIONS

Our results suggest that a telephone line operated by trusted, local psychiatrists with knowledge of the local mental health ecosystem of support can reduce rural GP workload through building confidence and strengthening personal agency, helping GPs navigate the ethical and clinical labyrinth of managing patient complexity in rural settings.

Western Australia remote aeromedical substance use disorders outcomes

INTRODUCTION

Substance use disorders (SUDs) cause significant harm to regional Australians, who are more likely to misuse alcohol and other drugs (AODs) and encounter difficulty in accessing treatment services. The primary aims of this study were to describe the demographics of patients aeromedically retrieved from regional locations and compare hospital outcomes with a metropolitan-based cohort.

AIMS

Retrospective case-controlled cohort study. Participants were aeromedically retrieved within Western Australia for SUDs between 1 July 2014 and 30 June 2019. Retrieved patients were case-matched based on age and hospital discharge diagnosis. Descriptive statistics and χ2 analysis were used to summarise the findings.

RESULTS

One hundred thirty-six (91.3%) aeromedical retrievals were found, with the majority being male (n = 95; 69.9%). These were case-matched to 427 metropolitan patients, the majority male (n = 321; 75.2%). Retrieved patients were more likely (all P < 0.05) Indigenous (odds ratio [OR], 9.35 [95% confidence interval (CI), 5.96-14.85]), unemployed (OR, 2.9 [95% CI, 1.41-6.80]), referred to a tertiary hospital (OR, 2.18 [95% CI, 1.24-3.86]) and to stay longer in hospital (OR, 1.08 [95% CI, 1.02-1.14]).

DISCUSSION

Findings highlight that unmarried and/or unemployed males were overrepresented in the retrieval group, with over half identifying as Indigenous. Regional variation in retrievals was noted, while amphetamine-type stimulants featured prominently in the retrieval cohort, who experienced longer hospital stays and more restrictive treatment.

CONCLUSIONS

Comparing clinical outcomes for retrieved regional patients experiencing SUDs, service design and delivery should focus on offering culturally safe care for Indigenous people, catering for regional health care catchment areas, while ideally adopting collaborative and integrated approaches between AODs and mental health services.

The impact of facilitators and rural immersion on medical student engagement during a child and adolescent mental health videoconference workshop

OBJECTIVE

Child and adolescent mental health (CAMH) disorders are a major public health problem in Australia, especially outside metropolitan areas. The issue is compounded by a shortage of child and adolescent psychiatrists (CAPs). CAMH receives minimal coverage in health professional training, training opportunities are scarce, and support for generalist health professionals, who treat most cases, is lacking. Novel approaches to early medical education and teaching are required to strengthen the available skilled workforce in rural and remote settings.

METHOD

This qualitative study explored the factors influencing medical student engagement in a CAMH videoconferencing workshop as part of the Rural Clinical School of WA.

RESULTS

Our results confirm the priority of personal characteristics of medical educators, over clinical and subject matter expertise, on student learning. This research affirms that general practitioners are well-placed to facilitate recognition of learning experiences, especially given that students may not readily recognise exposure to CAMH cases.

CONCLUSION

Our findings support the effectiveness, efficiencies, and benefits of utilising general medical educators in supporting child and adolescent psychiatry expertise in delivering subspecialty training within medical school curricula.

Rurality as a predictor of perinatal mental health and well-being in an Australian cohort

OBJECTIVE

Perinatal emotional well-being is more than the presence or absence of depressive and anxiety disorders; it encompasses a wide range of factors that contribute to emotional well-being. This study compares perinatal well-being between women living in metropolitan and rural regions.

DESIGN

Prospective, longitudinal cohort.

PARTICIPANTS/SETTING

Eight hundred and six women from Victoria and Western Australia recruited before 20 weeks of pregnancy and followed up to 12 months postpartum.

MAIN OUTCOME MEASURES

Rurality was assessed using the Modified Monash Model (MM Model) with 578 in metropolitan cities MM1, 185 in regional and large rural towns MM2-MM3 and 43 in rural to remote MM4-MM7. The Structured Clinical Interview for DSM-IV (SCID-IV) was administered at recruitment to assess depression, and symptoms of depression and anxiety were measured using the Edinburgh Post-natal Depression Scale and the State and Trait Anxiety Scale, respectively. Other measures included stressful events, diet, exercise, partner support, parenting and sleep.

RESULTS

The prevalence of depressive disorders did not differ across rurality. There was also no difference in breastfeeding cessation, exercise, sleep or partner support. Women living in rural communities and who also had depression reported significantly higher parenting stress than metropolitan women and lower access to parenting activities.

CONCLUSIONS

Our study suggests while many of the challenges of the perinatal period were shared between women in all areas, there were important differences in parenting stress and access to activities. Furthermore, these findings suggest that guidelines and interventions designed for perinatal mental health should consider rurality.

Rural workforce challenges: Why not rural psychiatry?

OBJECTIVE

The Australian psychiatry workforce is under-subscribed and highly urbanised. Currently, 90% of psychiatrists work in the cities, and there are significant projected workforce shortages of psychiatrists throughout Australia, particularly in rural and remote locations. This qualitative study explores factors influencing medical students and junior doctors' decisions to pursue a career in rural psychiatry.

METHOD

Using a phenomenological approach, data were collected through semi-structured interviews and focus groups and subjected to thematic analysis.

RESULTS

Sixteen participants were interviewed, 11 interviewees and five participants from two focus groups. This study identified enablers and challenges in pursuing rural psychiatry training in Australia. Clinical exposure to rural psychiatry, personal factors, rural lifestyle and workforce shortage awareness were identified as enablers. The lack of rural infrastructure, the attractiveness of urban psychiatry and the stigma toward rural psychiatry were identified as barriers.

CONCLUSIONS

Australian rural psychiatry workforce remains a complex issue. Reinforcing enablers and addressing barriers identified in this study would benefit future rural workforce initiatives.

Quality improvement through audit: Zuclopenthixol acetate prescribing, monitoring and patient outcomes in a regional health service

OBJECTIVE

Prescribers' expectations of Zuclopethixol Acetate's (ZA) efficacy and tolerability are shaped by clinical experience and organisational culture; however, these expectations may not be consistent with current evidence and best practice.

METHODS

Quality improvement project (QIP) through a process audit of ZA prescribing, monitoring and patient outcomes (adverse events) in order to identify issues requiring intervention to align with service standards and practices.

RESULTS

QIP interventions resulted in a statistically significant shift in psychiatrist oversight, identifying high dose ZA with adverse outcomes and cessation of prescribing/administration within the Emergency Department. Clinically significant changes in patterns of prescribing were observed between pre-post intervention audits.

CONCLUSION

Entrenching an evidence-based QIP approach to clinical practice can effect clinically significant patterns of practice change to improve safe prescribing and drug monitoring.

Remoteness and socioeconomic status reduce access to specialist mental health care across Australia

OBJECTIVE

Estimate impact of socioeconomic factors and remoteness from tertiary hospital on incidence/duration of Australian mental health admissions.

METHODS

Retrospective analysis of incidence/duration of public mental health unit admissions (2018-19). Covariates included Indigenous population, potentially preventable hospitalisations (PPH) and socioeconomic disadvantage.

RESULTS

Regional distance from hospital was correlated with socioeconomic disadvantage (ρ: p < 0.01). Population identifying as Aboriginal or Torres Strait Islander was associated with distance from hospital, socioeconomic disadvantage and PPH (ρ: p < 0.01). Bed days per capita was explained (R²_adj: 0.48) by distance and socioeconomic disadvantage (p < 0.0001). A 1% increase in distance from hospital was associated with a 0.37% decrease in per capita bed days. Admission rate per capita across Queensland and WA was explained (R²_adj: 0.36) by distance, education/occupation and state (p < 0.05). Across Queensland and WA a 1% increase in distance from hospital was associated with a 0.05% decreased incidence of admission.

CONCLUSIONS

Rural Australians face high mental illness burden, socioeconomic disadvantage and limited service provision. Overcoming the additional disadvantages of reduced likelihood of admission to and reduced time in hospital with increasing distance from hospital will require increased outreach proportional to remoteness.

Using social network analysis approach in developing rural psychiatrist workforce

OBJECTIVE

This study examines how rural and remote junior doctors career decisions are influenced by highly connected principles within a discipline.

METHODS

Social network analysis was completed with data collected, by structured interview, with five psychiatry trainees and three early career psychiatrists in a rural location rated MM3 using the Modified Monash Model. UNICET software was used to determine the interactions between individual networks to look for overlap and common influencers.

RESULTS

A single central, highly connected, psychiatrist was found at the core of the entire social network. This connector was instrumental in recruitment and retention in rural psychiatry workforce.

CONCLUSION

Improving the understanding of human capital can encourage innovative solutions in developing sustainable strategies for recruiting and retaining rural psychiatry workforces.

Developing fit-for-purpose funding models for rural settings: Lessons from the evaluation of a step-up/step-down service in regional Australia

INTRODUCTION

Sub-acute mental health community services provide a bridging service between hospital and community care. There is limited understanding of the local factors that influence success, and of the funding implications of delivering services in rural areas.

METHODS

This paper draws from quantitative and qualitative evaluation data from a regional Western Australian service to explore these issues.

RESULTS

Consumers satisfaction with the service was high and, overall, admission to the service resulted in positive outcomes. High re-admission rates may be linked to limited community support services following discharge.

DISCUSSION

Our results suggest that outcomes may be enhanced by implementing flexible approaches that address the resource limitations of the rural context, and that the current funding model for sub-acute mental health services in rural Australian may not be fit for purpose. More needs to be understood about how these services can be better integrated with existing support services, and how they can be better funded.

Remote supervision in psychiatry training: Unlocking capacity and technology

OBJECTIVE

This paper explores the literature regarding remote supervision in the context of training in psychiatry with contemporary pedagogic theory and practice and utilising telephonic and videoconference technologies to enhance education outcomes.

CONCLUSION

Remote supervision may provide psychiatry trainees with a balance between autonomy and support, promote clinical and professional independence in addition to developing a specific subset of telehealth skills whilst unlocking supervisory capacity to grow the psychiatry workforce, particularly in rural and remote settings.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Meteoroid Fragmentation in the Martian Atmosphere and the Formation of Crater Clusters

The current rate of small impacts on Mars is informed by more than one thousand impact sites formed in the last 20 years, detected in images of the martian surface. More than half of these impacts produced a cluster of small craters formed by fragmentation of the meteoroid in the martian atmosphere. The spatial distributions, number and sizes of craters in these clusters provide valuable constraints on the properties of the impacting meteoroid population as well as the meteoroid fragmentation process. In this paper, we use a recently compiled database of crater cluster observations to calibrate a model of meteoroid fragmentation in Mars' atmosphere and constrain key model parameters, including the lift coefficient and fragment separation velocity, as well as meteoroid property distributions. The model distribution of dynamic meteoroid strength that produces the best match to observations has a minimum strength of 10-90 kPa, a maximum strength of 3-6 MPa and a median strength of 0.2-0.5 MPa. An important feature of the model is that individual fragmentation events are able to produce fragments with a wide range of dynamic strengths as much as 10 times stronger or weaker than the parent fragment. The calibrated model suggests that the rate of small impacts on Mars is 1.5-4 times higher than recent observation-based estimates. It also shows how impactor properties relevant to seismic wave generation, such as the total impact momentum, can be inferred from cluster characteristics.

Dexmedetomidine sedation for a dental extraction in a patient with known difficult airway

Fibrodysplasia ossificans progressiva is an autosomal dominant condition that causes cervical spine fusion and ankylosis of the temporomandibular joint, resulting in anaesthetic challenges. Awake tracheal intubation with flexible bronchoscopy is recommended for general anaesthetics required by patients with this disease. This case report describes the novel approach of using dexmedetomidine sedation in combination with local anaesthesia to allow dental extraction of the fifth and seventh upper left teeth in a patient with fibrodyplasia ossificans progressive, who had a known difficult airway and profound thrombocytopenia. This procedure was not previously tolerated by the patient under local anaesthesia alone. The use of dexmedetomidine was successful in facilitating completion of the procedure with a high degree of patient satisfaction. We discuss the advantages of dexmedetomidine over other sedative agents due to its minimal effects on respiratory drive and airway muscle tone. We highlight the use of dexmedetomidine for complex cases such as this, where tracheal intubation is potentially challenging, but the procedure itself could be managed under sedation and local anaesthesia.

Cohort study comparison of Mental Health and Wellbeing Services delivered by The Royal Flying Doctor Service, across Far North and Central West Queensland

Background

Understanding cultural differences between geographical regions is essential in delivering culturally appropriate healthcare. We aimed to describe the characteristics and outcomes of diverse clients using the Far North Mental Health and Wellbeing Service (FNS) and the Central West Health and Wellbeing Service (CWS).

Methods

We conducted a cohort study within Queensland, Australia, on all clients who received a mental health therapy session at either the FNS or the CWS. Patient data was prospective data collected form July 2019 to December 2020.

Findings

There were1202 clients, with a median number of individual contacts per-client of 3.0 (IQR 2.0-6.0). There was 428 (35.6% 95% CI 32.90-38.39) males and 772 (64.2% 95% CI 61.44-66.94) females with a median age across the genders of 38.0 (IQR 28.0-51.0). There was 505 (42.0% 95% CI 39.20-44.86) identifying as Indigenous and 697 (58.0% 95% CI 55.14-60.80) as non-Indigenous Australians. The FNS had a significantly higher proportion of Indigenous clients (n=484; 54.8% 95% CI 51.46-58.13) as compared to the CWS (n=21; 6.6% 95% CI 4.12-9.89). Of the 1202 clients, 946 (78.7% 95% CI 76.28-80.99) had a socio-economic classification of ‘most disadvantaged’, consisting of 740 (83.8%) clients from the FNS and 206 (64.6%) clients from the CWS. The majority of presentations were for neurotic, stress-related and somatoform disorders (n=568; 47.3%), followed by mood affective disorders (n=310; 25.8%). The overall number of treatments strategies employed was 10798, equalling a median of 6.0 (IQR 4.0-9.0) strategies per-client, with the leading strategies being counselling/psychosocial (n=1394; 12.9%), reflective listening (n=1191; 11.0%), and strengths based reasoning (n=1116; 10.3%). There were 511 (42.5%) clients who completed the Kessler Psychological Distress Scale (K10/K5), with 493 (41.0%) clients not offered as deemed not culturally appropriate by the treating team. The mean initial K10/K5 score was 23.7 (SD 9.4) which significantly decreased (p<0.001) to 18.0 (SD 10.0) at final consultation.

Interpretation

This study highlighted client socioeconomic differences between two geographically remote mental health services. It is essential that services are regionally co-designed to ensure cultural appropriateness.

Funding

No funding to declare.

A rural ecosystem of recovery: Lessons from substance users' experiences of accessing services in Western Australia's South West

INTRODUCTION

Substance use is a public health issue with a greater burden in rural areas. Barriers to accessing services are exacerbated for rural substance users, with confidentiality concerns, longer travel distances, workforce issues and limited availability of services. This paper presents results from a study exploring substance users' experiences of accessing services in Western Australia's South West.

METHODS

This qualitative study was informed by phenomenology, and drew from social determinants and socio-ecological theories. Data were collected through 22 semi-structured telephone interviews with current and past substance users residing in the South West. Interviews were audio-recorded and transcripts were subjected to thematic analysis.

RESULTS

Two themes were identified: readiness to engage as a three-way street; and building an ecosystem of recovery networks. Effective engagement with services required multi-level readiness. Individual readiness was strongly influenced by the social environment, while service readiness required trustworthiness and responsiveness. A number of local access barriers were identified that hindered broader system readiness. Participants experienced recovery as on-going and require an ecosystem of support with peer support at the centre and a network of healthy relationships established through meaningful connections.

DISCUSSION AND CONCLUSIONS

An effective ecosystem of support for alcohol and other drugs users in the South West should include expanded access to health, community and welfare services, with an emphasis on peer-led support programs, and strong cross-sector collaboration to mitigate the access barriers operating at the broader community level. Lessons from our study can inform the development of rural ecosystems of support for alcohol and other drugs users.

Responding to rural adversity: a qualitative study of alcohol and other drug service users' experiences of service response to COVID-19 in Western Australia's Southwest

OBJECTIVE

This study reports on the impact of the COVID-19 pandemic on the lived experiences of people with substance use problems in accessing services in the Southwest region of Western Australia, and its implications for preparedness in a context of rural adversity.

METHOD

This was a qualitative study informed by the principles of phenomenology. Data were collected through semi-structured interviews and subjected to thematic analysis.

RESULTS

Twenty-two participants were interviewed. Two main themes were identified: disruption to supportive connections; and bridging the connection gap: local service response to the COVID-19 pandemic.

CONCLUSIONS

The COVID-19 pandemic restrictions exacerbated social isolation and mental health issues, and disrupted services and treatment in the Southwest. Our results demonstrate that local alcohol and other drug services in rural areas can successfully respond to crises by assertively and flexibly adapting their service provision.

Rethinking Accessibility in Light of the Orange Declaration: Applying a Socio-Ecological Lens to Rural Mental Health Commissioning

The prevalence of mental illness is a critical public health issue. In Australia, the prevalence of mental illness is similar across all settings, however, people living in rural and remote areas experience worse outcomes than their urban counterparts. Access to mental health services is critical, however, the notion of accessibility needs to be understood in the context of the uniqueness and variability of the rural experience. The Orange Declaration on Rural and Remote Mental Health recognized that rural areas face a series of interconnected challenges and called for place-specific responses and new funding models that reward collaboration and local partnerships. In this paper, we argue that recent mental health planning, policy and service development uses a narrow interpretation of the notion of accessibility that is out of step with current thinking on the heterogeneity of the rural experience. We use some examples of our own research and experience in rural Western Australia to argue that the current commissioning model is not aligned with the Orange Declaration, and remains largely metro-centric and reliant on a narrow conceptualization of service accessibility. We argue that what is needed is a dynamic, responsive, context-sensitive understanding of accessibility that is informed by the distinctiveness of rural adversity, and recognizes the heterogeneity and variability of the rural experience whilst acknowledging rural agency and social capital, and we suggest that applying a socio-ecological approach to the development of new commissioning models provides a way forward.

An evaluation of junior doctors' experience in smoking cessation training in a rural mental health setting

INTRODUCTION

Smoking prevalence remains high amongst people with mental illness, however, they are less likely to be screened for tobacco dependence and offered treatment to quit. Smoking cessation and education training are insufficient in medical schools, despite a positive relationship between training and practice once qualified. However, the question as to whether there is adequate skill and expertise to address smoking in people with mental illness within Australian mental health settings is unclear. Furthermore, people living in rural and remote areas smoke at higher rates, quit at lower rates than those in urban areas, and experience limitations in their ability to access smoking cessation supports. The Smokers' Clinic is an initiative established in a rural Australian mental health service offering a smoking cessation service to patients and staff employed by the service.

AIM

This study aims to assess the change in the knowledge and confidence of resident medical officers in their understanding of nicotine dependence, smoking cessation strategies and prescribing nicotine replacement therapy in a community mental health setting. It was hypothesized that providing education and supervised clinical experience would improve knowledge, increasing confidence and motivation in managing smoking cessation in mental health patients. The research was undertaken using data collected through a questionnaire obtained from surveying resident medical officers administering the Smokers' Clinic following a 10-week rural community mental health rotation.

MATERIALS AND METHODS

Twenty resident medical officers completed the 10-week rotation, with 14 completing the questionnaire. Knowledge of tobacco smoking, nicotine dependence and smoking cessation interventions improved with the experience of the Smokers' Clinic during the clinical rotation. Resident medical officers were motivated to spend additional time engaged in self-directed learning and all reported continued use of acquired experience and information in their clinical work after the rotation.

CONCLUSION

This study indicates the utility of a novel approach in delivering education, training, building clinical expertise, and facilitating sustained clinical capacity amongst junior medical staff for smoking cessation in a rural community mental health setting. It offers an efficient approach for mental health services to deliver smoking cessation services to reduce the morbidity and mortality burden associated with tobacco smoking.

Surgical management of complex ileocolonic Crohn's disease: a survey of IBD colorectal surgeons to assess variability in operative strategy

INTRODUCTION

To explore the reported variability in the surgical management of ileocolonic Crohn' s disease and identify areas of standard practice, we present this study which aims to assess how different colorectal surgeons with a subspecialty interest in inflammatory bowel disease (IBD) surgery may act in different clinical scenarios of ileocolonic Crohn's disease.

METHODS

Anonymous videos demonstrating the small bowel walkthrough and anonymised patients' clinical data, imaging and pathological findings were distributed to the surgeons using an electronic tool. Surgeons answered on operative strategy, bowel resections, management of small bowel mesentery, type of anastomosis and use of stomas.

RESULTS

Eight small bowel walkthrough videos were registered and 12 assessors completed the survey with a questionnaire completion rate of 87.5%. There was 87.7% agreement in the need to perform an ileocolonic resection. However, the agreement for the need to perform associated surgical procedures such as strictureplasties or further bowel resections was only 57.4%. When an anastomosis was fashioned, the side to side configuration was the most commonly used. The preferred management of the mesentery was dissection close to the bowel.

CONCLUSIONS

The decision on the main procedure to be performed had a high agreement amongst the different assessors, but the treatment of multifocal disease was highly controversial, with low agreement on the need for associated procedures to treat internal fistulae and the use of strictureplasties. At the same time, there was significant heterogeneity in the decision on when to anastomose and when to fashion an ileostomy.

AB0298 PREGNANCY IN RHEUMATIC DISEASE: A REGION WIDE SURVEY OF CURRENT PRACTICE AMONGST CLINICIANS IN THE WESSEX MULTI-DISCIPLINARY CONNECTIVE TISSUE DISEASE NETWORK

Background:

Rheumatic diseases frequently affect females of child-bearing age, with implications for foetal and maternal outcomes.

Two-thirds (66%) of the women who died in the 2016-18 MBRRACE report were known to have pre-existing medical problems1. The NHS long-term plan supports creation of Maternal Medicine Networks to facilitate access to specialist care and advice in pregnancy.

Guidelines exist for use of disease modifying anti-rheumatic drugs (DMARDs) during pregnancy but other aspects of pregnancy related care in rheumatic disease remain less well defined. The Wessex wide connective tissue disease (CTD) network provides a multi-disciplinary forum to discuss cases, to obtain approval for high cost drugs, to compare practice in multiple hospitals but does not specifically discuss pregnancy related uncertainties.

Objectives:

To survey variations in clinical practice relating to rheumatic disease in pregnancy

Methods:

Following careful project planning with the tertiary referral centre obstetric lead consultant for maternal medicine, several areas of care were identified which were prone to local and individual variation. An anonymous online survey relating to these specific areas of pregnancy related care was circulated amongst members of the CTD network, including rheumatology consultants, rheumatology practitioners and specialist trainees.

Results:

16 responses were obtained across 7 hospital sites; 56% were from rheumatology consultants. 12/16 (75%) reported routinely offering contraceptive advice when prescribing DMARDs. Only 4/16 (25%) were aware of a specific pre-natal obstetric clinic available in their hospital. There was major variation in planned frequency of clinical review. 10/16 would increase frequency of review during pregnancy if a patient’s disease became active or unstable; 6/16 would aim to review patients approximately 3 monthly; 3/16 would not routinely increase frequency of review during pregnancy. Planned post-natal care was equally varied. 3/16 would routinely prescribe aspirin to all lupus women during pregnancy despite this being recommended for all women with SLE for prevention of pre-eclampsia2. Prescription of low molecular weight heparin was variable, and several responses were at odds with the current RCOG guidance on the subject3. 8/16 (50%) would prescribe corticosteroids judiciously in case of an acute disease flare.

Conclusion:

This survey has revealed significant variation in practice relating to rheumatic disease in pregnancy. Integrated care with colleagues from the regional referral centre for maternal medicine is required, in keeping with the recently published NICE guidance on the subject4. Adopting a hub and spoke model, with local centres working closely alongside a tertiary centre, will help optimise peri-partum care and outcome for patients with long-term rheumatic conditions.

References:

[1]Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) Saving Lives, Improving Mothers’ Care Maternal Report (December 2020). Available at https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10.pdf [Accessed 28 January 2021]

[2]National Institute for Health and Care Excellence (2019) Hypertension in pregnancy: diagnosis and management (NICE guideline 133) Available at https://www.nice.org.uk/guidance/ng133 [Accessed 28 January 2021]

[3]Royal College of Obstetricians and Gynaecologists (2015) Reducing the risk of venous thromboembolism during pregnancy and the puerperium (Green-top Guideline Number 37a) Available at https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf [Accessed 5 January 2021]

[4]National Institute for Health and Care Excellence (2019) Intrapartum care for women with existing medical conditions or obstetric complications and their babies (NICE guideline 121) Available at https://www.nice.org.uk/guidance/ng121 [Accessed 5 January 2021]

Disclosure of Interests:

None declared

Mandatory treatment for methamphetamine use in Australia

Background

In 2016, following a flurry of government inquiries and taskforces including calls for mandatory treatment regimes, the Australian community nominated methamphetamine as the drug most likely to be associated as a problem substance. Mandatory treatment for alcohol and other drug problems in Australia consists of broadly two mechanisms compelling a person into treatment: involuntary treatment or civil commitment regimes; and coercive treatment regimes, usually associated with the criminal justice system. This paper aims to provide a review of the evidence for mandatory treatment regimes for people who use methamphetamines.

Methods

Using a narrative review methodology, a comprehensive literature and citation search was conducted. Five hundred two search results were obtained resulting in 41 papers that had cited works of interest.

Results

Small, but robust results were found with coercive treatment programs in the criminal justice system. The evidence of these programs specifically with methamphetamine use disorders is even less promising. Systematic reviews of mandatory drug treatment regimes have consistently demonstrated limited, if any, benefit for civil commitment programs. Despite the growing popular enthusiasm for mandatory drug treatment programs, significant clinical and ethical challenges arise including determining decision making capacity in people with substance use disorders, the impact of self determination and motivation in drug treatment, current treatment effectiveness, cost effectiveness and unintended treatment harms associated with mandatory programs.

Conclusion

The challenge for legislators, service providers and clinicians when considering mandatory treatment for methamphetamines is to proportionately balance the issue of human rights with effectiveness, safety, range and accessibility of both existing and novel mandatory treatment approaches.

Bronchoalveolar lavage fluid IMMY Sona Aspergillus lateral-flow assay for the diagnosis of invasive pulmonary aspergillosis: a prospective, real life evaluation

Prompt and reliable diagnosis of invasive pulmonary aspergillosis (IPA) is essential for early initiation of antifungal therapy. We evaluated bronchoalveolar lavage (BAL) fluid IMMY Sona Aspergillus lateral-flow assay (IMMY LFA) in 92 individuals with suspected pulmonary infection. Sensitivity and specificity (vs. host factor but no IPA) of BAL IMMY LFA for diagnosis of IPA in individuals with any European Organisation for Research and Treatment of Cancer-defied "host factor" were 67% and 85%, respectively. Performance appeared better in individuals with renal transplantation (100%, 100%), compared to those with hematological malignancy and/or allogenic stem cell transplantation (70%, 78%). We found BAL IMMY LFA to be a convenient and useful addition to our diagnostic armory for IPA.

LAY ABSTRACT

We evaluated a new test for diagnosing invasive pulmonary aspergillosis from bronchoscopy samples. We tested 92 people and found that it was 67% sensitive and 85% specific (compared to diagnosis according to a set of internationally recognised criteria). We found this test convenient and useful.

Characteristics and in-hospital outcomes of patients requiring aeromedical retrieval for pregnancy, compared to non-retrieved metropolitan cohorts

BACKGROUND

Limited access to obstetrics and gynaecology (O&G) services in rural and remote Australia is believed to contribute to suboptimal birth outcomes.

AIMS

To describe the characteristics of pregnancy aeromedical transfers, in-hospital outcomes, and patient access to O&G services, as compared to whole of Australia data.

MATERIALS AND METHODS

We conducted a cohort study of women who required aeromedical retrieval for pregnancy-related issues between the 1 January 2015 and 31 December 2017.

RESULTS

Hospital outcome data were collected on 2171 (65.2%) mothers and 2438 (100.0%) babies. The leading retrieval reason was threatened preterm labour and delivery (n = 883; 40.7%). Most patients were retrieved from rural and remote areas (n = 2224; 93.0%). Retrieved patients were significantly younger (28.0 vs 30.0 years, 95% CI 27.7-28.3), more likely to be overweight or obese (52.2% vs 45.1%, 95% CI 47.5-56.9) and to have smoked during their pregnancy (14.0% vs 9.9%, 95% CI 12.5-15.5) compared to Australian pregnant women overall. Over one-third of transferred women gave birth by Caesarean section (n = 812; 37.4%); the median gestational age at birth was 33.0 (95% CI 32.7-33.3) weeks. Early gestation is associated with low birth weights (median = 2579.5 g; 95% CI 2536.1-2622.9), neonatal resuscitation (35.4%, 95% CI 33.5-37.3), and special care nursery admission (41.2%, 95% CI 39.3-43.2). There were 42 (1.7%, 95% CI 1.2-2.2) stillbirths, which was significantly higher than seen Australia-wide (n = 6441; 0.7%).

CONCLUSION

This study found that pregnant women retrieved by the Royal Flying Doctor Service were younger, with higher rates of obesity and smoking.

Mental Health Care for Rural and Remote Australians During the Coronavirus Disease 2019 Pandemic

The aims of this article are to comment on pre-coronavirus disease 2019 (COVID-19) mental health activity in rural and remote Australia, including related air medical retrievals; to discuss how the current pandemic is likely to impact on this vulnerable population's mental health; and to provide potential solutions. The COVID-19 pandemic has resulted in significant air medical activity from rural and remote Australia. COVID-19 and the necessary public health and socioeconomic interventions are likely to significantly compound mental health problems for both the general public and the mental health workforce servicing rural and remote communities. However, the COVID-19 crisis provides a window of opportunity to develop, support, and build novel and sustainable solutions to the chronic mental health service vulnerabilities in rural and remote areas in Australia and other countries.

Win Big Fast! An Evaluation of Mobile Applications Available in Australia for Problem Gambling

With the increase in availability of gambling applications (apps) for mobile phones, it has never been easier for individuals to access gaming systems. A proportion of these users will be affected by gambling disorder (GD). Traditional therapies for GD can be geographically and financially difficult to access. Mobile health apps can be useful for other addictions and provide another avenue of treatment for GD. Our objective in this study was to review the features, models of treatment, and aims of apps marketed to assist people in addressing their gambling. We searched the three largest app stores in Australia and performed a descriptive analysis based on the Mobile App Rating Scale of the apps purporting to be of assistance in managing GD or problem gambling. The number of apps available for addressing GD in Australia was vastly outnumbered by the number of apps for gambling or gaming. Apps that met the inclusion criteria most often aimed at total cessation of gambling, but did not use a recognizable therapeutic model. A majority of apps featured a single tool, most often a sober time tracker. Few of the apps were affiliated with existing services, and those that were tended to have a broader range of features and tools. Mobile apps present another way for individuals who are struggling with GD or problem gambling to access treatment. For apps to be effective, more attention needs to be paid to their design in order for them to be both useful and noticeable in the milieu of more invitingly designed apps that promote gambling.RésuméÉtant donné le nombre grandissant d’applications de jeux de hasard pour téléphone mobile, il n’a jamais été aussi facile d’accéder à des systèmes de jeu. Un certain nombre des utilisateurs de ces appareils développeront une dépendance au jeu (DJ). Les thérapies conventionnelles en matière de DJ peuvent être difficiles d’accès en raison de la distance géographique et de leur coût. Les applications mobiles dédiées à la santé, parfois pour traiter d’autres formes de dépendance, pourraient offrir des possibilités de traitement du jeu pathologique. Nous avons analysé les caractéristiques, les modèles de traitement et les objectifs des applications qui prétendent aider les individus à dominer leur DP. Nous avons fouillé les trois principales boutiques d’applications d’Australie à la recherche de tels produits, puis les avons soumis à une analyse descriptive fondée sur un Mobile App Rating Scale [échelle d’évaluation des applications mobiles]. Le nombre d’applications destinées au contrôle de la DJ est largement inférieur à celui des produits dédiés à la pratique des jeux de hasard et des jeux vidéo. Les applications retenues visent pour la plupart l’abandon définitif du jeu, sans reposer sur un modèle thérapeutique reconnaissable. La majorité comporte un seul et unique outil, soit un dispositif de minutage du temps passé sans jouer. Quelques-unes sont jumelées à des services existants; elles tendent à offrir un éventail plus grand de caractéristiques et d’outils. Les applications mobiles offrent aux personnes aux prises avec une dépendance au jeu une autre voie d’accès au traitement. Pour améliorer leur efficacité, toutefois, il faudra accorder une plus grande attention à leur conception et faire en sorte qu’elles se démarquent nettement des applications autrement plus attrayantes qui font la promotion du jeu.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The use of Endo-SPONGE® in rectal anastomotic leaks: a systematic review

BACKGROUND

The aim of this study was to assess the efficacy of an endoluminal vacuum device (Endo-SPONGE^®) in the treatment of rectal anastomotic leaks.

METHODS

All studies looking at endoluminal vacuum therapy with Endo-SPONGE^® in the treatment of rectal anastomotic leaks were included. A comprehensive search was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Primary outcome was defined as the rate of total anastomotic salvage, with secondary outcomes including rate of ileostomy closure, additional transrectal closures and functional outcomes RESULTS: Sixteen studies met the inclusion criteria. There was a significant publication bias (z = 3.53, p = 0.0004). Two hundred sixty-six patients were identified. The median treatment failure rate was 11.8% (range 0-44%), with random effects model of 0.17 (95% CI 0.11-0.22). There was improvement with early therapy start (OR 3.48) and negative correlation with neoadjuvant radiotherapy (OR 0.56). Fifty-one percent of all diverting stomas were closed at the end of treatment period and 12.8% of patients required an additional trans-rectal closure of the abscess cavity.

CONCLUSIONS

Endo-SPONGE^® seems to be a useful method of rectal anastomotic leak treatment in selected group of patients; however, the quality of available data is poor and it is impossible to draw a final conclusion. There is unexpected high rate of permanent ileostomy. There is a need for further assessment of this therapy with well-designed randomised or cohort studies.

Video-laparoscopic assessment of the small bowel in Crohn's disease: a comparative study to evaluate surgeons' inter-observer variability

BACKGROUND

Assessment of the entire small bowel is advocated during Crohn's disease (CD) surgery, as intraoperative detection of new lesions may lead to change in the planned procedure. The aim of this study was to evaluate the inter-observer variability in the assessment of extent and severity of CD at the small bowel laparoscopic "walkthrough".

METHODS

A survey on laparoscopic assessment of the small bowel in patients with CD, including items adapted from the MREnterography or ultrasound in Crohn's disease (METRIC) study and from the classification of severity of mesenteric disease was developed by an invited committee of colorectal surgeons. Anonymous laparoscopic videos demonstrating the small bowel "walkthrough" in ileocolonic resection for primary and recurrent CD were distributed to the committee members together with the anonymous survey. The primary outcome was the rate of inter-observer variability on assessment of strictures, dilatations, complications and severity of mesenteric inflammation.

RESULTS

12 assessors completed the survey on 8 small bowel walkthrough videos. The evaluation of the small bowel thickening and of the mesenteric fat wrapping were the most reliable assessments with an overall agreement of 87.1% (k = 0.31; 95% CI - 0.22, 0.84) and 82.7% (k = 0.35; 95% CI - 0.04, 0.73), respectively. The presence of strictures and pre-stenotic dilatation demonstrated agreement of 75.2% (k = 0.06: 95% CI - 0.33, 0.45) and 71.2% (k = 0.33; 95% CI 0.15, 0.51), respectively. Evaluation of fistulae had an overall agreement of 75.3%, while there was a significant variation in the evaluation of mild, moderate and severe mesenteric disease with overall agreement ranging from 33.3 to 100%.

CONCLUSION

Laparoscopic assessment of the small bowel thickening and of the presence of mesenteric fat wrapping is reliable for the intraoperative evaluation of CD with high inter-rater agreement. There is significant heterogeneity in the assessment of the severity of the mesenteric disease involvement.

Extending a Conceptual Framework for Junior Doctors' Career Decision Making and Rural Careers: Explorers versus Planners and Finding the 'Right Fit'

This study uses data from a Rural Clinical School of Western Australia (RCSWA) and WA Country Health (WACHS) study on rural work intentions among junior doctors to explore their internal decision-making processes and gain a better understanding of how junior doctors make decisions along their career pathway. This was a qualitative study involving junior doctor participants in postgraduate years (PGY) 1 to 5 undergoing training in Western Australia (WA). Data was collected through semi-structured telephone interviews. Two main themes were identified: career decision-making as an on-going process; and early career doctors’ internal decision-making process, which fell broadly into two groups (‘explorers’ and ‘planners’). Both groups of junior doctors require ongoing personalised career advice, training pathways, and career development opportunities that best “fit” their internal decision-making processes for the purposes of enhancing rural workforce outcomes.

Understanding the Factors Influencing Junior Doctors' Career Decision-Making to Address Rural Workforce Issues: Testing a Conceptual Framework

Medical graduates’ early career is known to be disorienting, and career decision-making is influenced by a complex set of factors. There is a strong association between rural background and rural undergraduate training and rural practice, and personal and family factors have been shown to influence workplace location, but the interaction between interest, training availability, and other work-relevant factors has not yet been fully explored. A qualitative study conducted by the Rural Clinical School of Western Australia (RCSWA) and WA Country Health Service (WACHS) explored factors influencing the decision to pursue rural work among junior doctors. Data collection and analysis was iterative. In total, 21 junior doctors were recruited to participate in semi-structured telephone interviews. Two main themes relating to the systems of influence on career decision-making emerged: (1) The importance of place and people, and (2) the broader context. We found that career decision-making among junior doctors is influenced by a complex web of factors operating at different levels. As Australia faces the challenge of developing a sustainable rural health workforce, developing innovative, flexible strategies that are responsive to the individual aspirations of its workforce whilst still meeting its healthcare service delivery needs will provide a way forward.

The Youth Stream: evaluating the transition to a new model of care at a regional health service

OBJECTIVE

To determine what benefits and challenges are associated with a cost-neutral organisational change within a rural Community Mental Health Service from a Traditional Care model to a Youth Stream model.

METHOD

Retrospective descriptive analysis of the last 18 months of the Traditional Care model and first 18 months of the Youth Stream model.

RESULTS

There was a 17% increase in the number of referrals once the service moved to a Youth Stream model. The increased referral numbers did not lead to a proportionate increase in the number of service contacts, but rather more single assessments were performed. The increased engagement was not reflected across all demographics, with vulnerable youth groups continuing to have below average engagement. Key aspects of data that would allow for further analysis by diagnosis and illness severity were missing from the dataset.

CONCLUSIONS

Cost-neutral changes to services can create change, if that change is based on need identified within the service. As much care needs to be taken with data entry and evaluation if the service is aiming to perform a retrospective analysis.

Paleo-Rock-Hosted Life on Earth and the Search on Mars: A Review and Strategy for Exploration

Here we review published studies on the abundance and diversity of terrestrial rock-hosted life, the environments it inhabits, the evolution of its metabolisms, and its fossil biomarkers to provide guidance in the search for life on Mars. Key findings are (1) much terrestrial deep subsurface metabolic activity relies on abiotic energy-yielding fluxes and in situ abiotic and biotic recycling of metabolic waste products rather than on buried organic products of photosynthesis; (2) subsurface microbial cell concentrations are highest at interfaces with pronounced chemical redox gradients or permeability variations and do not correlate with bulk host rock organic carbon; (3) metabolic pathways for chemolithoautotrophic microorganisms evolved earlier in Earth's history than those of surface-dwelling phototrophic microorganisms; (4) the emergence of the former occurred at a time when Mars was habitable, whereas the emergence of the latter occurred at a time when the martian surface was not continually habitable; (5) the terrestrial rock record has biomarkers of subsurface life at least back hundreds of millions of years and likely to 3.45 Ga with several examples of excellent preservation in rock types that are quite different from those preserving the photosphere-supported biosphere. These findings suggest that rock-hosted life would have been more likely to emerge and be preserved in a martian context. Consequently, we outline a Mars exploration strategy that targets subsurface life and scales spatially, focusing initially on identifying rocks with evidence for groundwater flow and low-temperature mineralization, then identifying redox and permeability interfaces preserved within rock outcrops, and finally focusing on finding minerals associated with redox reactions and associated traces of carbon and diagnostic chemical and isotopic biosignatures. Using this strategy on Earth yields ancient rock-hosted life, preserved in the fossil record and confirmable via a suite of morphologic, organic, mineralogical, and isotopic fingerprints at micrometer scale. We expect an emphasis on rock-hosted life and this scale-dependent strategy to be crucial in the search for life on Mars.

Macro-to-nanoscale investigation of wall-plate joints in the acorn barnacle Semibalanus balanoides: correlative imaging, biological form and function, and bioinspiration

Correlative imaging combines information from multiple modalities (physical-chemical-mechanical properties) at various length scales (centimetre to nanometre) to understand the complex biological materials across dimensions (2D-3D). Here, we have used numerous coupled systems: X-ray microscopy (XRM), scanning electron microscopy (SEM), electron backscatter diffraction (EBSD), optical light microscopy (LM) and focused ion beam (FIB-SEM) microscopy to ascertain the microstructural and crystallographic properties of the wall-plate joints in the barnacle Semibalanus balanoides. The exoskeleton is composed of six interlocking wall plates, and the interlocks between neighbouring plates (alae) allow barnacles to expand and grow while remaining sealed and structurally strong. Our results indicate that the ala contain functionally graded orientations and microstructures in their crystallography, which has implications for naturally functioning microstructures, potential natural strengthening and preferred oriented biomineralization. Elongated grains at the outer edge of the ala are oriented perpendicularly to the contact surface, and the c-axis rotates with the radius of the ala. Additionally, we identify for the first time three-dimensional nanoscale ala pore networks revealing that the pores are only visible at the tip of the ala and that pore thickening occurs on the inside (soft bodied) edge of the plates. The pore networks appear to have the same orientation as the oriented crystallography, and we deduce that the pore networks are probably organic channels and pockets, which are involved with the biomineralization process. Understanding these multiscale features contributes towards an understanding of the structural architecture in barnacles, but also their consideration for bioinspiration of human-made materials. The work demonstrates that correlative methods spanning different length scales, dimensions and modes enable the extension of the structure-property relationships in materials to form and function of organisms.

Time to end the drought in the bush

OBJECTIVE

This paper outlines the current psychiatry workforce shortages experienced by rural and remote communities in Australia and argues that postgraduate training in psychiatry may play a role in rectifying these healthcare access inequities.

CONCLUSION

Funding for postgraduate medical specialist training in Australia is undergoing a shift away from solely metropolitan-centric training schemes, based on substantial evidence over the past two decades in undergraduate medical training. Psychiatry is well placed to lead the development of dedicated postgraduate rural training pathways to enhance recruitment and retention of an urgently required rural and remote psychiatry workforce.