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Trimethoprim+Sulfamethoxazole Reduces Rates of Melioidosis in High-Risk Hemodialysis Patients
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Melioidosis causes sepsis and death in the Top End of Northern Australia during the monsoonal wet season. Dialysis-dependent adults suffer higher melioidosis rates compared to low rates among renal transplant patients who routinely receive trimethoprim+sulfamethoxazole prophylaxis.
Methods
We performed a prospective interventional study to determine the efficacy and safety of daily trimethoprim+sulfamethoxazole prophylaxis in hemodialysis patients during the wet season, from 1 November 2014 to 30 April 2015. Hemodialysis (for ≥ 3 months) patients ≥ 18 years of age were offered treatment. A total of 269 patients on hemodialysis were eligible. Eight of the 269 patients (3%) were excluded from the analysis for being on melioidosis treatment. In all, 169 of 261 patients (64.8%) received the prophylaxis, and 92 of 261 patients (35.2%) did not, because of allergy history (n = 10), remoteness and logistical reasons (n = 60), poor dialysis attendance (n = 11), and refusal (n = 11). We monitored for clinical side effects 3 times weekly and neutropenia, thrombocytopenia, and liver function monthly throughout treatment and for 2 months posttreatment.
Results
In all, 169 of 261 patients (64.8%) received the prophylaxis. There was no age (years) difference by group (prophylaxis vs. nonprophylaxis, 54.7 [11.3] vs. 54.3 [11.2] [P = 0.751]). Sixteen of 261 patients (6%) had melioidosis. The event frequency was 0% (0/169, prophylaxis, vs. 17.4% [16/92, nonprophylaxis], P < 0.001). Higher thrombocytopenia and neutropenia rates were noted in the prophylaxis group. These did not warrant treatment stoppage. There was no difference in liver function. Three patients (1.8%) withdrew from the treatment because of side effects.
Conclusion
Daily dosing was effective and safe. Posthemodialysis dosing in the subsequent seasons was effective and safer. We recommend this approach in melioidosis-prevalent regions
Contextual factors and clinical reasoning: differences in diagnostic and therapeutic reasoning in board certified versus resident physicians
Get PDFThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background
The impact of context on the complex process of clinical reasoning is not well understood. Using situated cognition as the theoretical framework and videos to provide the same contextual “stimulus” to all participants, we examined the relationship between specific contextual factors on diagnostic and therapeutic reasoning accuracy in board certified internists versus resident physicians.
Methods
Each participant viewed three videotaped clinical encounters portraying common diagnoses in internal medicine. We explicitly modified the context to assess its impact on performance (patient and physician contextual factors). Patient contextual factors, including English as a second language and emotional volatility, were portrayed in the videos. Physician participant contextual factors were self-rated sleepiness and burnout.. The accuracy of diagnostic and therapeutic reasoning was compared with covariates using Fisher Exact, Mann-Whitney U tests and Spearman Rho’s correlations as appropriate.
Results
Fifteen board certified internists and 10 resident physicians participated from 2013 to 2014. Accuracy of diagnostic and therapeutic reasoning did not differ between groups despite residents reporting significantly higher rates of sleepiness (mean rank 20.45 vs 8.03, U = 0.5, p < .001) and burnout (mean rank 20.50 vs 8.00, U = 0.0, p < .001). Accuracy of diagnosis and treatment were uncorrelated (r = 0.17, p = .65). In both groups, the proportion scoring correct responses for treatment was higher than the proportion scoring correct responses for diagnosis.
Conclusions
This study underscores that specific contextual factors appear to impact clinical reasoning performance. Further, the processes of diagnostic and therapeutic reasoning, although related, may not be interchangeable. This raises important questions about the impact that contextual factors have on clinical reasoning and provides insight into how clinical reasoning processes in more authentic settings may be explained by situated cognition theory
‘Sussing that doctor out.’ Experiences and perspectives of people affected by hepatitis C regarding engagement with private general practitioners in South Australia: a qualitative study
Get PDFThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background
Australians with chronic hepatitis C (HCV) can access affordable Direct Acting Antiviral (DAA) treatments with high cure rates (>90%), via General Practitioners (GPs). Benefits from this treatment will be maximised if people with HCV readily disclose and engage with private GPs regarding HCV-related issues. Investigating the perceptions and experiences of people affected by HCV with GPs can allow for this pathway to care for HCV to be improved.
Methods
In 2013–2014, 22 purposively sampled participants from South Australia (SA) were interviewed. They a) had contracted or were at risk of hepatitis C (n = 10), b) were key workers who had clients affected by HCV (n = 6), and c) met both a) and b) criteria (n = 6). The semi-structured interviews were recorded, transcribed and thematically analysed.
Results
People affected by HCV viewed GPs as a source of general healthcare but, due to negative experiences and perceptions, many developed a strategy of “sussing” out doctors before engaging with and disclosing to a GP regarding HCV-related issues. Participants were doubtful about the benefits of engagement and disclosure, and did not assume that they would be provided best-practice care in a non-discriminatory, non-judgemental way. They perceived risks to confidentiality and risks of changes to the care they received from GPs upon disclosure.
Conclusion
GPs may need to act in ways that counteract the perceived risks and persuade people affected by HCV of the benefits of seeking HCV-related care
Characterization of swallow modulation in response to bolus volume in healthy subjects accounting for catheter diameter
Get PDFThis article may be used for non-commercial purposes in accordance With Wiley Terms and Conditions for self-archiving'.
© 2017 John Wiley & Sons, Inc. All rights reserved.
This author accepted manuscript is made available following 12 month embargo from date of publication (August 2017) in accordance with the publisher’s archiving policyObjectives/Hypothesis
Characterization of the pharyngeal swallow response to volume challenges is important for swallowing function assessment. The diameter of the pressure‐impedance recording catheter may influence these results. In this study, we captured key physiological swallow measures in response to bolus volume utilizing recordings acquired by two catheters of different diameter.
Study Design
Ten healthy adults underwent repeat investigations with 8‐ and 10‐Fr catheters. Liquid bolus swallows of volumes 2.5, 5, 10, 20, and 30 mL were recorded. Measures indicative of distension, contractility, and flow timing were assessed.
Methods
Pressure‐impedance recordings with pressure‐flow analysis were used to capture key distension, contractility, and pressure‐flow timing parameters.
Results
Larger bolus volumes increased upper esophageal sphincter distension diameter (P < .001) and distension pressures within the hypopharynx and upper esophageal sphincter (P < .05). Bolus flow timing measures were longer, particularly latency of bolus propulsion ahead of the pharyngeal stripping wave (P < .001). Use of a larger‐diameter catheter produced higher occlusive pressures, namely upper esophageal sphincter basal pressure (P < .005) and upper esophageal sphincter postdeglutitive pressure peak (P < .001).
Conclusions
The bolus volume swallowed changed measurements indicative of distension pressure, luminal diameter, and pressure‐flow timing; this is physiologically consistent with swallow modulation to accommodate larger, faster‐flowing boluses. Additionally, catheter diameter predominantly affects lumen occlusive pressures. Appropriate physiological interpretation of the pressure‐impedance recordings of pharyngeal swallowing requires consideration of the effects of volume and catheter diameter
Age-related impairment of esophagogastric junction relaxation and bolus flow time
Get PDFDistributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/AIM
To investigate the functional effects of abnormal esophagogastric (EGJ) measurements in asymptomatic healthy volunteers over eighty years of age.
METHODS
Data from 30 young controls (11 M, mean age 37 ± 11 years) and 15 aged subjects (9 M, 85 ± 4 years) were compared for novel metrics of EGJ-function: EGJ-contractile integral (EGJ-CI), “total” EGJ-CI and bolus flow time (BFT). Data were acquired using a 3.2 mm, 25 pressure (1 cm spacing) and 12 impedance segment (2 cm) solid-state catheter (Unisensor and MMS Solar GI system) across the EGJ. Five swallows each of 5 mL liquid (L) and viscous (V) bolus were analyzed. Mean values were compared using Student’s t test for normally distributed data or Mann Whitney U-test when non-normally distributed. A P value < 0.05 was considered significant.
RESULTS
EGJ-CI at rest was similar for older subjects compared to controls. “Total” EGJ-CI, measured during liquid swallowing, was increased in older individuals when compared to young controls (O 39 ± 7 mmHg.cm vs C 18 ± 3 mmHg.cm; P = 0.006). For both liquid and viscous bolus consistencies, IRP4 was increased (L: 11.9 ± 2.3 mmHg vs 5.9 ± 1.0 mmHg, P = 0.019 and V: 14.3 ± 2.4 mmHg vs 7.3 ± 0.8 mmHg; P = 0.02) and BFT was reduced (L: 1.7 ± 0.3 s vs 3.8 ± 0.2 s and V: 1.9 ± 0.3 s vs 3.8 ± 0.2 s; P < 0.001 for both) in older subjects, when compared to young. A matrix of bolus flow and presence above the EGJ indicated reductions in bolus flow at the EGJ occurred due to both impaired bolus transport through the esophageal body (i.e., the bolus never reached the EGJ) and increased flow resistance at the EGJ (i.e., the bolus retained just above the EGJ).
CONCLUSION
Bolus flow through the EGJ is reduced in asymptomatic older individuals. Both ineffective esophageal bolus transport and increased EGJ resistance contribute to impaired bolus flow
Electron-impact vibrational excitation of the hydroxyl radical in the nighttime upper atmosphere
Get PDF© 2017 Elsevier. This manuscript version is made available under the CC-BY-NC-ND 4.0 license: http://creativecommons.org/licenses/by-nc-nd/4.0/
This author accepted manuscript is made available following 24 month embargo from date of publication (Oct 2017) in accordance with the publisher’s archiving policyChemical processes produce vibrationally excited hydroxyl (OH) in a layer centred at an altitude of about 87 km in the Earth's atmosphere. Observations of this layer are used to deduce temperatures in the mesosphere and to observe the passage of atmospheric gravity waves. Due to the low densities and energies at night of electrons at the relevant altitude, it is not expected that electron-impact excitation of OH would be significant. However, there are unexplained characteristics of OH densities and radiative emissions that might be explained by electron impact. These are measurements of higher than expected densities of OH above 90 km and of emissions at higher energies that cannot be explained by the chemical production processes. This study simulates the role of electron impact in these processes, using theoretical cross sections for electron-impact excitation of OH. The simulations show that electron impact, even in a substantial aurora, cannot fully explain these phenomena. However, in the process of this investigation, apparent inconsistencies in the theoretical cross sections and reaction rates were found, indicating that measurements of electron-impact excitation of OH are needed to resolve these problems and scale the theoretical predictions to allow more accurate simulations
Daytime sleepiness, driving performance, reaction time and inhibitory control during sleep restriction therapy for Chronic Insomnia Disorder
Get PDFCrown Copyright © 2017 Published by Elsevier B.V. This manuscript version is made available under the CC-BY-NC-ND 4.0 license: http://creativecommons.org/licenses/by-nc-nd/4.0/
This author accepted manuscript is made available following 12 month embargo from date of publication (Nov 2017) in accordance with the publisher’s archiving policyBackground
Sleep restriction therapy (SRT) is a largely untested single treatment component of cognitive-behaviour therapy for insomnia. To date, the evidence for contraindications for SRT is limited to very few studies. The present study investigated the objective and subjective daytime consequences during the acute phase of SRT for adults diagnosed with Chronic Insomnia Disorder.
Methods
Sixteen adults (age = 36.3 ± 13.4 yrs, 12 females, 4 males) underwent SRT for their insomnia over a two week period based on recommendations by Miller and colleagues (2014) [6]. Participants completed sleep diaries, self-reported daytime sleepiness (Epworth Sleepiness Scale [ESS]), as well as objective measures of reaction time/inhibition (Go/NoGo task) and driving performance (AusEd driving simulator) at pre-, mid- (ie, after one week of SRT) and post-SRT (after two weeks of SRT).
Results
Sleep diary outcomes indicated participants complied with the restriction of time in bed, and that a similar amount of total sleep time (TST) was maintained from pre-to-post-treatment. There was no significant change in daytime sleepiness, and similarly no significant changes observed in objective performance on the Go/NoGo task and AusEd driving simulator.
Conclusions
These preliminary results suggest SRT during the acute phase does not appear to place insomnia patients at risk of significant impairments in sleepiness and reaction times. We note these findings can only be translated into clinical practice when sleep duration remains relatively unchanged. Future studies using objective measures of sleep and a control group are recommended
Mainland Chinese students’ self-appraisals of their psychological dispositions at school
No full text‘This is the peer reviewed version of the following article: Askell-Williams, H., Skyrzypiec, G., Zhao, X. et al. Soc Psychol Educ (2018) 21: 139. https://doi.org/10.1007/s11218-017-9404-zwhich is available at Springer via: https://doi.org/10.1007/s11218-017-9404-z
This author accepted manuscript is made available following 12 month embargo from date of publication (Oct 2017) in accordance with the publisher’s archiving policyThis paper reports mainland Chinese students’ self-appraisals about their psychological dispositions whilst at school. Increasing interest has turned to factors such as resilience, wellbeing, flourishing, happiness and satisfaction, which in turn are predicted to be associated with factors such as emotional stability, achieving personal goals, social fulfilment and quality of life. Such psychological dispositions are developed in conjunction with the influences of social systems such as schools. Although a number of researchers have collaborated with schools to investigate students’ dispositions in English speaking countries, similar research in mainland China is in its infancy. This is particularly the case for studies that seek students’ own perspectives. We administered a questionnaire about resilience, flourishing, wellbeing, self-concept, school satisfaction, mental health, and happiness at school to 2756 students in Years 5–9 in mainland China. As expected with a non-clinical population, most students reported positively across the various scales. However, dividing the sample into subgroups enabled the creation of stratified visual profiles that showed significant differences between students with different backgrounds, such as gender, age, and mental health. This study illustrates the importance of subgroup analyses to identify potential areas of concern for different types of students, which in turn may inform differentiated school-based intervention programs to support students to flourish
Contribution of Discretionary Foods and Drinks to Australian Children’s Intake of Energy, Saturated Fat, Added Sugars and Salt
Get PDF© 2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).Interventions are required to reduce children’s consumption of discretionary foods and drinks. To intervene we need to identify appropriate discretionary choice targets. This study aimed to determine the main discretionary choice contributors to energy and key nutrient intakes in children aged 2–18 years. Secondary analyses were performed with population weighted, single 24 h dietary recall data from the 2011–2012 National Nutrition and Physical Activity Survey. Cakes, muffins, and slices; sweet biscuits; potato crisps and similar snacks; and, processed meats and sugar-sweetened drinks were relatively commonly consumed and were within the top three to five contributors to per capita energy, saturated fat, sodium, and/or added sugars. Per consumer intake identified cereal-based takeaway foods; cakes, muffins and slices; meat pies and other savoury pastries; and, processed meats as top contributors to energy, saturated fat, and sodium across most age groups. Subgroups of sugar-sweetened drinks and cakes, muffins and slices were consistently key contributors to added sugars intake. This study identified optimal targets for interventions to reduce discretionary choices intake, likely to have the biggest impact on moderating energy intake while also reducing intakes of saturated fat, sodium and/or added sugars
What enables and constrains the inclusion of the social determinants of health inequities in government policy agendas? A narrative review
Get PDFPublished by Kerman University of Medical Sciences. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.Background
Despite decades of evidence gathering and calls for action, few countries have systematically attenuated health inequities (HI) through action on the social determinants of health (SDH). This is at least partly because doing so presents a significant political and policy challenge. This paper explores this challenge through a review of the empirical literature, asking: what factors have enabled and constrained the inclusion of the social determinants of health inequities (SDHI) in government policy agendas?
Methods
A narrative review method was adopted involving three steps: first, drawing upon political science theories on agenda-setting, an integrated theoretical framework was developed to guide the review; second, a systematic search of scholarly databases for relevant literature; and third, qualitative analysis of the data and thematic synthesis of the results. Studies were included if they were empirical, met specified quality criteria, and identified factors that enabled or constrained the inclusion of the SDHI in government policy agendas.
Results
A total of 48 studies were included in the final synthesis, with studies spanning a number of country-contexts and jurisdictional settings, and employing a diversity of theoretical frameworks. Influential factors included the ways in which the SDHI were framed in public, media and political discourse; emerging data and evidence describing health inequalities; limited supporting evidence and misalignment of proposed solutions with existing policy and institutional arrangements; institutionalised norms and ideologies (ie, belief systems) that are antithetical to a SDH approach including neoliberalism, the medicalisation of health and racism; civil society mobilization; leadership; and changes in government.
Conclusion
A complex set of interrelated, context-dependent and dynamic factors influence the inclusion or neglect of the SDHI in government policy agendas. It is better to think about these factors as increasing (or decreasing) the ‘probability’ of health equity reaching a government agenda, rather than in terms of ‘necessity’ or ‘sufficiency.’ Understanding these factors may help advocates develop strategies for generating political priority for attenuating HI in the future.This work was supported by the NHMRC Centre of Research
Excellence on the Social Determinants of Health Equity:
Policy research on the social determinants of health equity
(APP1078046)