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Prevention of venous thromboembolism after total hip and knee arthroplasties in Australian hospitals: What are we using?
No full textBackground: Venous thromboembolism (VTE) is a leading cause of preventable morbidity and mortality, with total hip arthroplasty(THA) and total knee arthroplasty (TKA) at the highest risk. Safe and appropriate thromboprophylaxis is essential. However, investigation\u27s into prescribing practices have been limited.
Aim: To describe current VTE prophylaxis regimens in Australian patients following an elective THA/TKA and compare these regimens to an international standard.
Method: A retrospective multisite case series of patients admitted for a THA/TKA in six tertiary hospitals in Queensland, Australia, was conducted over 12 months (1 October 2017–30 September 2018). Patient and medication data were collected following surgery and for 60 days after discharge to determine changes to the patients\u27 thromboprophylaxis regimen. Results were summarised and compared to National Institute for Health and Care Excellence (NICE) guidelines. Ethical approval was granted by the Metro South Human Research Ethics Committee (Reference no: HREC/2018/QMD/46757) and the study conforms to the National Statement on Ethical Conduct in Human Research.
Results: The study included 1011 patients (43.1% THA, 56.9% TKA), and thromboprophylaxis was used in 98.1% of inpatients and in 94.3% of discharge patients for 5.2 (5.2) and 29.2 (15.9) days (standard deviation) respectively. Low-molecular-weight heparins (LMWHs) were the primary drugs for inpatients (71.2%) and aspirin 150 mg for discharge (42.0%), most commonly for 6 weeks(31.8%). Aspirin was used for significantly longer duration than rivaroxaban and LMWH (p \u3c 0.001). A two-staged prophylaxis regimen was implemented, most commonly any anticoagulant as an inpatient; followed by rivaroxaban on discharge (32.7%) or an anti-coagulant as an inpatient with aspirin on discharge (26.4%). Overall, adherence to NICE guidelines was low; THA: 8.7%, TKA: 5.9%.
Conclusion: VTE prophylaxis regimens varied considerably, and consequently, adherence to international guidelines was low. There is a need for local, peer-led guidelines to ensure consistent, safe, and effective prophylaxis
Epistemic hypocrisy and standing to blame
No full textThis paper considers the possibility that ‘epistemic hypocrisy’ could be relevant to our blaming practices. It argues that agents who culpably violate an epistemic norm can lack the standing to blame other agents who culpably violate similar norms. After disentangling our criticism of epistemic hypocrites from various other fitting responses, and the different ways some norms can bear on the legitimacy of our blame, I argue that a commitment account of standing to blame allows us to understand our objections to epistemic hypocrisy. Agents lack the epistemic standing to blame when they are not sufficiently committed to the epistemic norms they are blaming others for violating. This not only gives us a convincing account of epistemic standing to blame, it leaves us with a unified account of moral and epistemic standin
The impact of sedation on the quality of initial skeletal surveys performed for suspected physical abuse in children: A comparative two-centre audit
No full textBACKGROUND: The impact of sedation on the quality of initial skeletal surveys performed for suspected physical abuse in children is not known. OBJECTIVE: To assess whether sedation influenced the number of, reason for and effective dose of repeat radiographs obtained as part of initial skeletal surveys, and their mean examination times.
MATERIALS AND METHODS: One hundred consecutive antemortem initial skeletal survey examinations performed for suspected physical abuse in children \u3c2 years were retrieved from two tertiary paediatric hospitals: Centre 1, where sedation is not used for initial skeletal survey imaging; and Centre 2, where sedation is used routinely.
RESULTS: In total, 4055 radiographic projections were performed, of which 93 (2.3%) were repeats. Comparing centres, there was a significant difference in the total number of repeats (P¼0.001) and the number of repeats in children aged \u3c12 months (P¼0.008). Mean examination times were significantly shorter in unsedated children (P¼0.005), even after outliers were excluded (P¼0.002). There was no significant difference between the number of routine projections (P¼0.587), incompletely imaged body parts (P¼0.254), rotation/suboptimal positioning (P¼0.527), repeats in children aged \u3e12 months (P¼0.089), routine projections in children aged \u3c12 months (P¼0.642) or \u3e12 months (P¼0.979) or the effective doses of repeats (P¼0.286).
CONCLUSION: There were fewer repeat projections in sedated children and those aged \u3c12 months but examination times were significantly longer. There was no difference in the effective doses of repeated projections. The routine use of sedation is not supported whe
Observational evidence linking psychotropic medicines to the dispensing of opioid agents in later life
No full textBackground: The use of opioid medicines is common in developed countries, particularly among older adults and those with mental health disorders. It is unclear if the association between mental disorders and opioid medicines is causal, or is due to reverse causality or confounding.
Methods: We used a 10% random sample of the Australian Pharmaceutical Benefits Scheme (years 2012–2022) to examine the cross-sectional, case– control and longitudinal association between the dispensing of antidepressants, anxiolytics, hypnotics, antipsychotics and lithium, and opioid medicines. We used logistic regression, structural equation models (SEM), and Cox regression to analyze the data. Analyses were adjusted for age (years), sex, and number of non-psychotropic medicines dispensed during the year.
Results: The 2022 file contained 804 334 individuals aged 50 years or over (53.1% women), of whom 181 690 (22.6%) received an opioid medicine. The adjusted odds ratio of being dispensed opioid medicines was 1.44 (99% CI = 1.42–1.46) for antidepressants, 1.97 (99% CI = 1.92–2.03) for anxiolytics, 1.55 (99% CI = 1.51–1.60) for hypnotics, 1.32 (99% CI = 1.27– 1.38) for antipsychotics, and 0.60 (99% CI = 0.53–0.69) for lithium. Similar associations were noticed when we compared participants who were or not dispensed opioid medicines in 2022 for exposure to psychotropic agents between 2012 and 2021. SEM confirmed that this association was not due to reverse causality. The dispensing of antidepressants was associated with increased adjusted hazard (HR) of subsequent dispensing of opioid medicines (HR = 1.29, 99% CI = 1.27–1.30). Similar associations were observed for anxiolytics, hypnotics and antipsychotics, but not lithium.
Conclusions: The dispensing of opioid medicines is higher among older individuals exposed to antidepressants, anxiolytics, hypnotics and antipsychotics than those who are not. These associations are not due to reverse causality or study design. Preventive strategies seeking to minimise the risk of inappropriate use of opioid medicines in later life should consider targeting this high-risk population
Development of a value-based healthcare burns core set for adult burn care
No full textBackground: Value-based healthcare (VBHC) is increasingly implemented in healthcare worldwide. Transparent measurement of the outcomes most important and relevant to patients is essential in VBHC, which is supported by a core set of most important quality indicators and outcomes. Therefore, the aim of this study was to develop a VBHC-burns core set for adult burn patients.
Methods: A three-round modified national Delphi study, including 44 outcomes and 24 quality indicators, was conducted to reach consensus among Dutch patients, burn care professionals and researchers. Items were rated on a nine-point Likert scale and selected if ≥ 70% in each group considered an item ‘important’. Subsequently, instruments quantifying selected outcomes were identified based on a literature review and were chosen in a consensus meeting using recommendations from the Dutch consensus-based standard set and the Dutch Centre of Expertise on Health Disparities. Time assessment points were chosen to reflect the burn care and patient recovery process. Finally, the initial core set was evaluated in practice, leading to the adapted VBHC-burns core set.
Results: Twenty-seven patients, 63 burn care professionals and 23 researchers participated. Ten outcomes and four quality indicators were selected in the Delphi study, including the outcomes pain, wound healing, physical activity, self-care, independence, return to work, depression, itching, scar flexibility and return to school. Quality indicators included shared decision-making (SDM), the number of patients receiving aftercare, determination of burn depth, and assessment of active range of motion. After evaluation of its use in clinical practice, the core set included all items except SDM, which are assessed by 9 patient-reported outcome instruments or measured in clinical care. Assessment time points included are at discharge, 2 weeks, 3 months, 12 months after discharge and annually afterwards.
Conclusion: A VBHC-burns core set was developed, consisting of outcomes and quality indicators that are important to burn patients and burn care professionals. The VBHC-burns core set is now systemically monitored and analysed in Dutch burn care to improve care and patient relevant outcomes. As improving burn care and patient relevant outcomes is important worldwide, the developed VBHC-burns core set could be inspiring for other countries
The Fathers of the Church, the Reformation, and the failed attempts at union between the Tübingen Theologians and the Patriarchate of Constantinople: A broad Perspective
No full textThe sixteenth century witnessed dramatic upheavals in Eastern and Western Europe in both the ecclesiastical and political domains. In the previous century, Constantinople had fallen to the Ottoman Turks, meaning that its Eastern Orthodox inhabitants were severed both politically and religiously from their Western Christian neighbors, who were ruled over by sovereigns that derived their spiritual authority from the Papacy. Meanwhile, the Reformation endangered the unity of the political and religious spheres of the Catholic West. As it soon became clear that the mainstream Reformers were neither united nor consistent in their ecclesiological views, one thing remained a constant: a recourse to the Fathers of the Church for the confirmation of Reformed tenets such as sola scriptura and sola fide. The use of Patristic proof texts played an important role in the attempt of the Lutherans to unite with the Orthodox, the former reading the writings of the Fathers in a very different way to the latter. This article analyzes why this attempt at union failed, with specific focus on the correspondence between the Tübingen theologians and the Patriarch of Constantinople, Jeremiah II Tranos, in their respective reading of the Augsburg Confession which represents the main Lutheran articles of faith
Nurses\u27 understanding of their duty of confidentiality to patients in mental health care: A qualitative exploratory study
No full textBackground: There are significant personal repercussions for patients, and professional, legal, financial, or reputational repercussions for stakeholders, when confidential patient information is mishandled by nurses working in mental health care. Education and guidance would be helpful for nurses, to address any knowledge or practice gaps related to their duty of confidentiality to patients, but there is limited empirical literature exploring their understanding of this important area of nursing practice to guide these interventions.
Aim: To explore nurses’ understanding of their duty of confidentiality to patients in mental health care.
Methods: Theoretical thematic analysis employing a deductive approach to coding of interview data. Findings: Nurses have a general knowledge of the concept of confidentiality and its rules, but this knowledge is often incomplete or incorrect. Nonetheless, they recognise and prioritise patients’ interests when considering how confidential information should be handled, whilst also demonstrating awareness of potential risks to patients if their mental health information becomes known to others. Discussion: Nurses’ understanding of their duty of confidentiality is based on information and knowledge that is incomplete or incorrect. However, in general, they are genuinely motivated to protect the interests of patients and other stakeholders. Several key knowledge and practice gaps that would benefit from education and guidance have been identified. Addressing these gaps should lead to improvements in nurses’ handling of confidential patient information.
Conclusion: Confidentiality is an integral element of good mental health care. Findings from this qualitative exploratory study will lead to the development of nurse education and guidance that will assist nurses to thoroughly understand the duty of confidentiality they owe to their patients. Consequently, these findings have the potential to safeguard patients against the mishandling of their personal information by nurses and protect other stakeholders (including nurses) from consequential, personal, professional, legal, or financial repercussions. Further research in this area of practice would also enhance the findings of this study