Better cardiac care - the patient experience - a qualitative study

BACKGROUND

In 2015, a Brisbane tertiary hospital's cardiac unit implemented a new model of multidisciplinary care (Better Cardiac Care (BCC)) for Aboriginal and Torres Strait Islander patients. Since then, clinical indicators for Aboriginal and Torres Strait Islander cardiac patients have improved, but the recipients' voices have not been heard. This research aimed to determine the acceptability and appropriateness, features of value, and opportunities for improvements in this model of care, from the perspective of patients and their family members.

METHODS

This descriptive qualitative study employed a narrative methodology. BCC Health Workers contacted prospective participants; with consent, interested individuals were then contacted by the Aboriginal Research Officer (RO) who arranged yarning sessions and consent. Family members were also invited to share their stories of their loved ones' hospitalisation. Two researchers conducted the interviews, using a yarning approach. Inductive narrative analysis, informed by Aboriginal and Torres Strait Islander ways of Being, Knowing, and Doing, focused on enabling participants' stories to be heard and understood from their perspectives.

RESULTS

Relationality was at the heart of the BCC model of care, particularly between patients and Aboriginal and Torres Strait Islander staff. The relationality included a responsibility for holistic care, extending beyond hospital discharge, although support and handover for family members required improvement. The Aboriginal and Torres Strait Islander staff understood the contextual and structural challenges faced by participants, including the disempowerment and racism experienced in healthcare. This understanding was shared with the BCC team who, in turn, protected, advocated for, and holistically supported participants through their cardiac health journeys.

CONCLUSIONS

Empowering (and employing) Aboriginal and Torres Strait Islander staff, and relating to patients as people, enabled BCC to meet Aboriginal and Torres Strait Islander patient's needs and improve outcomes. The wider health system and health academia could benefit from exploring and valuing Aboriginal and Torres Strait Islander discourses of relationality.

Work-based feedback conversations with GP teachers

INTRODUCTION

Feedback may play out in the general practice workplace less usefully than anticipated by educators. We investigated work-based feedback conversations about directly observed student tasks embedded in the supervisor's clinical consultations with patients.

METHODS

Feedback conversations between GP teachers and medical students and subsequent student reflections were audio-recorded. Student and GP teacher focus groups were also conducted and transcribed professionally. An iterative, qualitative descriptive analysis integrating all transcripts was undertaken. Findings are discussed under the descriptive categories of feedback structure, content and perceived value.

RESULTS

Twenty feedback conversations (total duration of 85 min) between five GP teachers, nine students and 20 student reflections (total duration of 58 min) were analysed. GP teachers actively engaged students in reflection and used balancing scripts and soft correction strategies. Students appeared to have some difficulty steering feedback conversations, which focused more on general skills than case-specific content knowledge. The recorded conversations were fragments of ongoing, in-practice teaching and learning, explicit and implicit. Student reflections suggested that they were able to grasp learning points effectively and identify room for growth. Praise and positive self-feedback appeared to reassure students, particularly when they were disappointed by their performances.

DISCUSSION

Formal 'set-piece' feedback conversations may be a useful opportunity to explicitly surface and/or reinforce previous 'in-practice' reflection and feedback using a systematic structure. They may also reassure and encourage students and foster positive educational alliances. Students value in-practice and on-practice feedback but may prefer more control of the latter conversations.

Systematic scoping review of occupational health injuries and illnesses among Indigenous workers

Indigenous populations in the USA, Australia, New Zealand (NZ) and Canada total more than 13 million, but continue to be marginalised in their respective regions. The goal of this comprehensive review of all studies evaluating adverse occupational health outcomes among Indigenous populations in these countries was to identify gaps in the literature and future research directions. A systematic scoping review of research published between 1970 and 2020 was undertaken using the methodological framework initially proposed by Arksey and O'Malley. Country, Indigenous participants, study type, exposure, adverse health outcome, occupation and industry were identified for each paper. Of the 1272 research papers identified, only 51 articles met the inclusion criteria of this scoping review. Almost half of the studies (n=24, 47.1%) were published after 2010. Only 13 (25.5%) studies specifically focused on Indigenous persons at the time of the study design, and less than half of the studies (47.1%) included more than 100 Indigenous participants. Most studies used the following general terms without mention of specific indigenous groups: Indigenous (Australia), Māori (NZ), Aboriginal (Canada) and American Indian or Alaskan Native (USA). Only one study acknowledged asking respondents their preferred terminology. Over the past 50 years, there has been a paucity of research directly or indirectly evaluating occupational health outcomes of Indigenous populations in these four countries. There is a need for better sampling strategies and inclusion of demographic questions that capture Indigenous status in surveys, workers' compensation data and other commonly used data sources to develop adequate baseline data for targeted future interventions.

Rapid review of five years of Aboriginal and Torres Strait Islander health research in Australia - persisting under-representation of urban populations

OBJECTIVE

To review how published Aboriginal and Torres Strait Islander health research reflects the geographical distribution of the Indigenous population of Australia.

METHODS

Rapid review using Lowitja Institute Lit.search tool for PubMed indexed Indigenous health research papers (January 2013 to January 2018). Geographic location, participant age, study type and recruitment site were identified for each paper.

RESULTS

A total of 1,258 research papers were identified: 190 (15%) focused exclusively on Indigenous people living in urban areas; 563 (45%) in rural/remote areas; and 505 (40%) spanned urban and rural/remote areas. Despite similar burdens of disease, three times as many papers were published per 1,000 DALYs for rural/remote areas than urban areas.

CONCLUSIONS

Indigenous health research publications have more than doubled since 2010. However, research focusing on the health needs of urban Indigenous people remains low relative to disease burden and population. Implications for public health: More research to address the health needs of Indigenous people living in urban areas is required although this should not be at the expense of research for rural and remote areas. Increased funding quarantined for Indigenous health research, coupled with self-determination of the research agenda and reporting on the geographic representativeness of research, may help address geographical inequities in research outputs.

The power of talk and power in talk: a systematic review of Indigenous narratives of culturally safe healthcare communication

The study aimed to explore Indigenous narrative accounts of healthcare access within qualitative research papers, to better understand Indigenous views on culturally safe healthcare and health communication represented in that literature. A systematic literature review of peer-reviewed academic qualitative studies identified 65 papers containing Indigenous respondents’ views on accessing healthcare. Analysis included all Indigenous voice (primary quotations) and author findings describing healthcare access across these studies. Healthcare communication, or ‘talk’, emerged as a key theme. Indigenous clients valued talk within healthcare interactions; it was essential to their experience of care, having the power to foster relationships of trust, strengthen engagement and produce positive outcomes. By mediating the power differentials between health professionals and Indigenous clients, talk could either reinforce powerlessness, through judgmental down-talk, medical jargon or withholding of talk, or empower patients with good talk, delivered on the client’s level. Good talk is a critical ingredient to improving Indigenous accessibility and engagement with healthcare services, having the ability to minimise the power differentials between Indigenous clients and the healthcare system.

Yarning about health checks: barriers and enablers in an urban Aboriginal medical service

The annual health check for Aboriginal and Torres Strait Islander People has been welcomed as a means of conducting a comprehensive assessment to address preventive health care delivery, identify new diagnoses and initiate new treatments. Rates of health check uptake across Australia have been poor with less than 12% of the eligible population receiving one during 2009/10. This qualitative study sought to identify barriers and enablers to undertaking health checks in an urban Aboriginal Medical Service through semistructured interviews with 25 clinical staff (doctors, nurses and Aboriginal and Torres Strait Islander health workers). Clinical systems for conducting health checks were unclear to staff, with barriers relating to time pressures for both patients and clinic staff, and lack of clarity about staff responsibilities for initiating and conducting the health check. Additionally some staff perceived some content as sensitive, invasive, culturally inappropriate and of questionable value. Other barriers included concerns about community health literacy, disengagement with preventative health care, and suspicion about confidentiality and privacy. The development of clear service-wide systems that support the conduct of health checks are required to increase uptake, combined with supportive local clinical leadership and audit and feedback systems. Staff training, consideration of culture and roles, and critical review of health check content may improve staff confidence and community acceptance. Community-based health education and promotion is strongly supported by staff to increase client engagement, knowledge and acceptance of the health check.

Rapid Electrochemical Detection of Radiolysis Products in an Aqueous Solution Exposed to Alpha Particle Beams

An electrochemical cell has been developed that allows for the rapid and exhaustive detection of oxygen and/or hydrogen peroxide produced during the radiolysis of aqueous solutions by alpha particle or proton beams. Short, 10–100 s, exposures were sufficient to yield steady-state electrochemical currents proportional to the radiolysisG-factor. The use of thin SiC windows provided a robust means of separating the vacuum environment of the ion-beam accelerator from the aqueous solution at atmospheric pressure with minimal energy loss.

Drug-resistant variants of Escherichia coli thymidylate synthase: effects of substitutions at Pro-254

Drug-resistant variants of thymidylate synthase (TS) can potentially be used in gene therapy applications to decrease the myelosuppressive side effects of TS-directed anticancer agents or to select genetically modified cells in vivo. Mutations of proline 303 of human TS confer resistance to TS-directed fluoropyrimidines and antifolates (). We generated the corresponding variants in Escherichia coli TS (ecTS), position 254, to better understand the mechanism by which mutations at this residue confer resistance. In addition, because ecTS is intrinsically resistant to several antifolates when compared with human TS, we suspected that greater resistance could be achieved with the bacterial enzyme. The P254L enzyme conferred >100-fold resistance to both raltitrexed and 5-fluoro-2'-deoxyuridine (FdUrd) compared with wild-type ecTS. Four additional mutants (P254F, P254S, P254G, and P254D), each of which complemented growth of a TS-deficient cell line, were generated, isolated, and characterized. Steady-state values of K(m) for dUMP and k(cat) were not substantially different among the variants and were comparable with the wild-type values, but K(m) for methylenetetrahydrofolate (CH(2)H(4)PteGlu) was >10-fold higher for P254D. Values of k(on) and k(off) for nucleotide binding, which were obtained by stopped-flow spectroscopy, were virtually unchanged among the mutants. Drastic differences were observed for CH(2)H(4)PteGlu binding, with K(d) values >15-fold higher than observed with the wild-type enzyme; surprisingly, the proposed isomerization reaction that is very evident for the wild-type enzyme is not observed with P254S. The decrease in affinity for CH(2)H(4)PteGlu correlates well with K(i) values obtained for three TS-directed inhibitors. These results show that mutations at Pro-254 specifically affect the initial binding interactions between enzyme and cofactor and also alter the ability of the mutant enzymes to undergo conformational changes that occur on ternary complex formation. The crystal structure of P254S was determined at 1.5 A resolution and is the most precise structure of TS available. When compared with wild-type TS, the structure shows local conformational changes affecting mostly Asp-253; its carbonyl is rotated approximately 40 degrees, and the side chain forms an ion pair with Arg-225.

Percutaneous anterior discectomy under ultrasound guidance

The object of this experiment was to demonstrate that, by using a peritoneal fluid infusion coupled with ultrasound guidance, a safe anterior entry into the L5-S1 disc of the pig could be made. The goal was to develop a procedure with the advantages of a laparoscopic approach to the disc which has been published to allow removal of extruded herniations, that a neurosurgeon could perform without a general surgeon in attendance. The procedure was carried out under general anesthesia and fluoroscopic control. One liter of normal saline was then infused into the abdomen of a pig. Under ultrasound guidance and laparoscopic confirmation, a Nucleotome was placed into the L5-S1 disc and the disc was aspirated. The results showed that the disc was safely entered in all 5 pigs. The disc was successfully removed in 4 of 5 pigs. In all animals the bowel floated out of the pelvis, obviating the need for bowel manipulation. Laparoscopic ultrasound was needed for visualization in 3 pigs, while external ultrasound was used in two. Our conclusion is that peritoneal fluid infusion and ultrasound guidance, when applied to laparoscopic anterior discectomy, eliminates the need for retroperitoneal dissection and bowel manipulation, significantly simplifying the laparoscopic discectomy procedure.

Compliance with tuberculosis treatment in methadone-maintained patients: behavioral interventions

Tuberculosis has increased dramatically in the United States. Noncompliance with treatment is high. The purpose of this investigation was to achieve compliance with prophylactic TB treatment and simultaneously decrease drug use in a high-risk group of intravenous drug users. Two studies were conducted. Study 1: Subjects were 9 chronic opiate users who tested positive for tuberculosis and were placed on isoniazid (INH) and methadone. Methadone was dispensed contingent upon INH ingestion throughout. A within-subject, A-B design with contingency management interventions on drug use was implemented.

RESULTS

Compliance with INH was 100% in 8 patients. Cocaine use remained high. Study 2: Two patients, meeting same criteria as Study 1, participated in a within-subject A-B multiple baseline design. Methadone was dispensed contingent upon INH ingestion throughout. Successive decreases in cocaine use were reinforced in the contingent phase.

RESULTS

Compliance with INH was high. During contingency, both patients had over 40% cocaine-free urine samples compared with 0% at baseline. This investigation serves as a model for achieving compliance with TB treatment in opiate users.

Acute phase reactants in neonatal bacterial infection

The C-reactive protein (CRP) level was evaluated in 142 infants requiring investigation for suspected infection. After excluding two neonates because of incomplete data, there remained 140 neonates, of whom 16 had septicemia. Fifteen of 16 had increased CRP levels. The CRP value was not elevated in any baby (n = 5) who had positive blood cultures for Staphylococcus epidermidis, all of whom had an uneventful clinical course. The CRP level was elevated in all six babies with meconium-aspiration syndrome, but was normal in five infants whose viral cultures were positive. Ninety-nine percent of uninfected babies had normal CRP values. Overall, CRP was a valuable test for diagnostic confirmation of bacterial infection. Elevated CRP level was always accompanied by at least one abnormality in the other tests performed. Although the study was not intended to predict clinical onset of bacterial disease, our results suggest that the CRP level, because of a high negative predictive value, may be useful in ruling out bacterial infection.

The hemodynamic effects of Cremophor-EL

A problem associated with parenteral cyclosporine has been the increased incidence of renal toxicity. Cremophor-EL, the vehicle for parenteral cyclosporine has been associated with massive histamine release and anaphylaxis in certain animal models. We investigated the effects of Cremophor-EL on the cardiac output (CO); mean arterial pressure (MAP); and hepatic, renal and pancreatic blood flow in the anesthesized canine model. Doppler flow probes were utilized to calculate individual organ blood flow. Profound adverse affects were noted on the CO, MAP, and hepatic blood flow. There were negative trends noted in the renal and splenic arterial flow that did not reach statistical significance. It was noted that the changes in organ blood flow were partially independent on MAP and the total dose of Cremophor-EL. We therefore conclude that it is prudent to consider the possible adverse hemodynamic role of Cremophor-EL in canine allograft dysfunction.

The use of glass capillary columns for food and essential oil analysis

Foods and essential oils represent complex mixtures whose components frequently embrace a wide range of functional groups and volatilities. The analyst concerned with these products may be interested in overall separation or "fingerprinting," in correlating the amount of individual compounds with specific flavor notes, in the detection and measurement of specific substances such as nitrosamines or pesticides, or in following the progress of a biochemical reaction. Analytical speed and the sensitivity of the method may also be important, as well as the ability of reactive compounds to survive the analysis. Toward all of these goals, glass capillary gas chromatography offers distinct advantages.

The significance of lowered jejunal disaccharidase levels

Disaccharidase estimations on 115 consecutive jejunal biopsies are reported. The patients were divided into four groups: 1. Normal jejunal biopsy light microscopy, not milk intolerant, 82 cases. 2. Normal jejunal biopsy light microscopy, milk intolerant, eight cases. 3. Patients with giardiasis, 11 cases. 4. Coeliac disease patients, 14 cases. The lowest disaccharidase levels were found in coeliac disease, with giardiasis cases showing intermediate levels. Poor correlation of lactase levels with milk intolerance was found. Three cases in Group 1 showing lowered lactase levels were given metronidazole and showed remission of clinical symptoms, raising the possibility that they had undiagnosed infections with Giardia lamblia.

The diagnosis of giardiasis

Four methods of diagnosing giardiasis are compared. Examination of smear preparations made from the jeunal biopsy specimen showed positive results in all of the 20 consecutive cases of giardiasis reported. The test was more reliable than examination of histological sections of the jejunal biopsy, wet preparations of jejunal aspirate, or faecal smears.