This study examined the influence of pre-stimulus alpha phase and attention on whether two visual stimuli occurring closely in time were perceived as simultaneous or asynchronous. The results demonstrated that certain phases of alpha in the period immediately preceding stimulus onset were associated with a higher proportion of stimuli judged to be asynchronous. Furthermore, this effect was shown to occur independently of both visuo-spatial attention and alpha amplitude. The findings are compatible with proposals that alpha phase reflects cyclic shifts in neuronal excitability. Importantly, however, the results further suggest that fluctuations in neuronal excitability can create a periodicity in neuronal transfer that can have functional consequences that are decoupled from changes in alpha amplitude. This study therefore provides evidence that perceptual processes fluctuate periodically although it remains uncertain whether this implies the discrete temporal framing of perception.
•Pre-stimulus alpha phase influences the perceived timing of two visual stimuli.•Phase effects were independent of both spatial attention and alpha amplitude.•The results are compatible with the neural excitability hypothesis of alpha phase.
On July 1, 2012 Australia launched a personally controlled electronic health record (PCEHR) designed around the needs of consumers. Using a distributed model and leveraging key component national eHealth infrastructure, the PCEHR is designed to enable sharing of any health information about a patient with them and any other health practitioner involved in their care to whom the patient allows access. This paper discusses the consumer-facing part of the program.
Design of the system was through stakeholder consultation and the development of detailed requirements, followed by clinical design assurance.
Patients are able to access any posted information through a web-accessible ‘consumer portal.’ Within the portal they are able to assert access controls on all or part of their record. The portal includes areas for consumers to record their own personal information.
The PCEHR has the potential to transform the ability of patients to actively engage in their own healthcare, and to enable the emerging partnership model of health and healthcare in medicine. The ability to access health information traditionally kept within the closed walls of institutions also raises challenges for the profession, both in the language clinicians choose and the ethical issues raised by the changed roles and responsibilities.
The PCEHR is aimed at connecting all participants and their interventions, and is intended to become a system-wide activity.
Removal of metal implants is a common procedure that is performed for a variety of indications. However, problems such as a buried screw head may occasionally arise and render hardware removal difficult or even impossible. The problem is further compounded when the initial screw was inserted percutaneously or via a minimally-invasive (MIS) technique. In the present paper, we introduce a novel, minimally invasive technique to remove buried cannulated screws which obviates the need for excessive extension of the skin incision, surgical exploration, soft tissue dissection or excess bone removal, which surgeons may otherwise have to undertake to uncover the buried screw head. This technique is especially useful in removing cannulated screws which have been inserted using small stab incisions and MIS techniques initially. This technique can be applied to the removal of buried cannulated screws which are placed into any bone in the body.
Buried screw; cannulated screw; implant removal
When the head is subject to non-penetrating (blunt) impact, contusion-type injuries are commonly identified beneath the impact site (the coup) and, in some instances, at the opposite pole (the contre-coup). This pattern of injury has long eluded satisfactory explanation and blunt head injury mechanisms in general remain poorly understood. There are only a small number of studies in the open literature investigating the head's response to short duration impacts, which can occur in collisions with light projectiles. As such, the head impact literature to date has focussed almost exclusively on impact scenarios which lead to a quasi-static pressure response in the brain. In order to investigate the response of the head to a wide range of impact durations, parametric numerical studies were performed on a highly bio-fidelic finite element model of the human head created from in vivo magnetic resonance imaging (MRI) scan data with non-linear tissue material properties. We demonstrate that short duration head impacts can lead to potentially deleterious transients of positive and negative intra-cranial pressure over an order of magnitude larger than those observed in the quasi-static regime despite reduced impact force and energy. The onset of this phenomenon is shown to be effectively predicted by the ratio of impact duration to the period of oscillation of the first ovalling mode of the system. These findings point to dramatically different pressure distributions in the brain and hence different patterns of injury depending on projectile mass, and provide a potential explanation for dual coup/contre-coup injuries observed clinically.
The primary health care sector delivers the majority of health care in western countries through small, community-based organizations. However, research into these healthcare organizations is limited by the time constraints and pressure facing them, and the concern by staff that research is peripheral to their work. We developed Q-RARA—Qualitative Rapid Appraisal, Rigorous Analysis—to study small, primary health care organizations in a way that is efficient, acceptable to participants and methodologically rigorous.
Q-RARA comprises a site visit, semi-structured interviews, structured and unstructured observations, photographs, floor plans, and social scanning data. Data were collected over the course of one day per site and the qualitative analysis was integrated and iterative.
We found Q-RARA to be acceptable to participants and effective in collecting data on organizational function in multiple sites without disrupting the practice, while maintaining a balance between speed and trustworthiness.
The Q-RARA approach is capable of providing a richly textured, rigorous understanding of the processes of the primary care practice while also allowing researchers to develop an organizational perspective. For these reasons the approach is recommended for use in small-scale organizations both within and outside the primary health care sector.
Primary health care; Organizations; Qualitative research; Qualitative analysis; Mixed method research
Computerized medical records (CMR) are used in most Australian general practices. Although CMRs have the capacity to amalgamate and provide data to the clinician about their standard of care, there is little research on the way in which they may be used to support clinical governance: the process of ensuring quality and accountability that incorporates the obligation that patients are treated according to best evidence.
The objective of this study was to explore the capability, capacity, and acceptability of CMRs to support clinical governance.
We conducted a realist review of the role of seven CMR systems in implementing clinical governance, developing a four-level maturity model for the CMR. We took Australian primary care as the context, CMR to be the mechanism, and looked at outcomes for individual patients, localities, and for the population in terms of known evidence-based surrogates or true outcome measures.
The lack of standardization of CMRs makes national and international benchmarking challenging. The use of the CMR was largely at level two of our maturity model, indicating a relatively simple system in which most of the process takes place outside of the CMR, and which has little capacity to support benchmarking, practice comparisons, and population-level activities. Although national standards for coding and projects for record access are proposed, they are not operationalized.
The current CMR systems can support clinical governance activities; however, unless the standardization and data quality issues are addressed, it will not be possible for current systems to work at higher levels.
clinical governance; electronic health records; general practice; realist evaluation; quality assurance; health care
There have been concerns about the potential increases in operating time associated with the use of individually wrapped presterilized small orthopaedic implants compared with our traditional method of screw banks. We set out to quantify this theory.
Prospective experimental study.
Orthopaedic Surgical Trainees and Theatre Scrub team.
Main outcome measure
The time taken to complete the operation.
The use of prepacked and sterilized implants added 2 min 56 s to the use of a bank with a full complement of normal screws that required tapping and 3 min 58 s if self-tapping screws were used (P < 0.001).
Using individually wrapped presterilized small orthopaedic implants increases operating time.
Changes to the workforce and organisation of general practice are occurring rapidly in response to the Australian health care reform agenda, and the changing nature of the medical profession. In particular, the last five years has seen the rapid introduction and expansion of a nursing workforce in Australian general practices. This potentially creates pressures on current infrastructure in general practice.
This study used a mixed methods, ‘rapid appraisal’ approach involving observation, photographs, and interviews.
Nurses utilise space differently to GPs, and this is part of the diversity they bring to the general practice environment. At the same time their roles are partly shaped by the ways space is constructed in general practices.
The fluidity of nursing roles in general practice suggests that nurses require a versatile space in which to maximize their role and contribution to the general practice team.
General practice; Private practice nursing; Physicians office; Spatial analysis; Skill mix
Studies of the doctor–patient relationship have focused on the elaboration of power and/or authority using a range of techniques to study the encounter between doctor and patient. The widespread adoption of computers by doctors brings a third party into the consultation. While there has been some research into the way doctors view and manage this new relationship, the behavior of patients in response to the computer is rarely studied. In this paper, the authors use Goffman's dramaturgy to explore patients' approaches to the doctor's computer in the consultation, and its influence on the patient–doctor relationship.
Observational study of Australian general practice. 141 consultations from 20 general practitioners were videotaped and analyzed using a hermeneutic framework.
Patients negotiated the relationship between themselves, the doctor, and the computer demonstrating two themes: dyadic (dealing primarily with the doctor) or triadic (dealing with both computer and doctor). Patients used three signaling behaviors in relation to the computer on the doctor's desk (screen watching, screen ignoring, and screen excluding) to influence the behavior of the doctor. Patients were able to draw the doctor to the computer, and used the computer to challenge doctor's statements.
This study demonstrates that in consultations where doctors use computers, the computer can legitimately be regarded as part of a triadic relationship. Routine use of computers in the consultation changes the doctor–patient relationship, and is altering the distribution of power and authority between doctor and patient.
Physician patient relationship; medical informatics; qualitative research; office visits; computers; patient-centered medicine
We report the case of a 14-year-old boy who sustained a displaced triplane fracture of the distal radius. This was treated with closed reduction and application of a cast with good clinical and radiological results. We discuss (for the first time) the reasons for the rarity of this fracture at the distal radius compared to the distal tibia.
triplane; fracture; distal radius; paediatric.
Participants read aloud swear words, euphemisms of the swear words, and neutral stimuli while their autonomic activity was measured by electrodermal activity. The key finding was that autonomic responses to swear words were larger than to euphemisms and neutral stimuli. It is argued that the heightened response to swear words reflects a form of verbal conditioning in which the phonological form of the word is directly associated with an affective response. Euphemisms are effective because they replace the trigger (the offending word form) by another word form that expresses a similar idea. That is, word forms exert some control on affect and cognition in turn. We relate these findings to the linguistic relativity hypothesis, and suggest a simple mechanistic account of how language may influence thinking in this context.
The study was undertaken to evaluate the contribution of a process which uses clinical trial data plus linked de-identified administrative health data to forecast potential risk of adverse events associated with the use of newly released drugs by older Australian patients.
The study uses publicly available data from the clinical trials of a newly released drug to ascertain which patient age groups, gender, comorbidities and co-medications were excluded in the trials. It then uses linked de-identified hospital morbidity and medications dispensing data to investigate the comorbidities and co-medications of patients who suffer from the target morbidity of the new drug and who are the likely target population for the drug. The clinical trial information and the linked morbidity and medication data are compared to assess which patient groups could potentially be at risk of an adverse event associated with use of the new drug.
Applying the model in a retrospective real-world scenario identified that the majority of the sample group of Australian patients aged 65 years and over with the target morbidity of the newly released COX-2-selective NSAID rofecoxib also suffered from a major morbidity excluded in the trials of that drug, indicating a substantial potential risk of adverse events amongst those patients. This risk was borne out in post-release morbidity and mortality associated with use of that drug.
Clinical trial data and linked administrative health data can together support a prospective assessment of patient groups who could be at risk of an adverse event if they are prescribed a newly released drug in the context of their age, gender, comorbidities and/or co-medications. Communication of this independent risk information to prescribers has the potential to reduce adverse events in the period after the release of the new drug, which is when the risk is greatest.
Note: The terms 'adverse drug reaction' and 'adverse drug event' have come to be used interchangeably in the current literature. For consistency, the authors have chosen to use the wider term 'adverse drug event' (ADE).
Across the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate.
This three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies.
Despite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice.
Interprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice.
Nine Staphylococcus capitis isolates from blood cultures of newborns were examined for resistance to vancomycin. MICs were within the susceptible range, but population profiling revealed a resistant subpopulation. Only isolates with the largest subpopulation were identified as heteroresistant to vancomycin by Etest. This finding may have therapeutic implications.
Although primary health care, and in particular, general practice will be at the frontline in the response to pandemic influenza, there are no frameworks to guide systematic planning for this task or to appraise available plans for their relevance to general practice. We aimed to develop a framework that will facilitate planning for general practice, and used it to appraise pandemic plans from Australia, England, USA, New Zealand and Canada.
We adapted the Haddon matrix to develop the framework, populating its cells through a multi-method study that incorporated the peer-reviewed and grey literature, interviews with general practitioners, practice nurses and senior decision-makers, and desktop simulation exercises. We used the framework to analyse 89 publicly-available jurisdictional plans at similar managerial levels in the five countries. The framework identifies four functional domains: clinical care for influenza and other needs, public health responsibilities, the internal environment and the macro-environment of general practice. No plan addressed all four domains. Most plans either ignored or were sketchy about non-influenza clinical needs, and about the contribution of general practice to public health beyond surveillance. Collaborations between general practices were addressed in few plans, and inter-relationships with the broader health system, even less frequently.
This is the first study to provide a framework to guide general practice planning for pandemic influenza. The framework helped identify critical shortcomings in available plans. Engaging general practice effectively in planning is challenging, particularly where governance structures for primary health care are weak. We identify implications for practice and for research.
The iterative development of the Falls Risk Assessment and Management System (FRAMS) drew upon research evidence and early consumer and clinician input through focus groups, interviews, direct observations, and an online questionnaire. Clinical vignettes were used to validate the clinical model and program logic, input, and output. The information model was developed within the Australian General Practice Data Model (GPDM) framework. The online FRAMS implementation used available Internet (TCP/IP), messaging (HL7, XML), knowledge representation (Arden Syntax), and classification (ICD10-AM, ICPC2) standards. Although it could accommodate most of the falls prevention information elements, the GPDM required extension for prevention and prescribing risk management. Existing classifications could not classify all falls prevention concepts. The lack of explicit rules for terminology and data definitions allowed multiple concept representations across the terminology–architecture interface. Patients were more enthusiastic than clinicians. A usable standards-based online-distributed decision support system for falls prevention can be implemented within the GPDM, but a comprehensive terminology is required. The conceptual interface between terminology and architecture requires standardization, preferably within a reference information model. Developments in electronic decision support must be guided by evidence-based clinical and information models and knowledge ontologies. The safety and quality of knowledge-based decision support systems must be monitored. Further examination of falls and other clinical domains within the GPDM is needed.
Objective: To evaluate group B streptococcus (GBS) detection in an in vitro setting, using a low and controlled
inoculum from swabs directly inoculated into a selective medium, as compared to delayed inoculation following
a period in a commercial Amies transport medium with charcoal (Venturi Transystem™
Study design: Clinical isolates of GBS (n = 103), were inoculated into the Amies transport medium with charcoal
in a concentration of 100 colony-forming units (cfu)/ml (10 cfu/swab). Swabs were then transferred to an
enrichment broth (NPC) at time intervals of 0, 2, 4, 6 and 24 hours. Broths were then incubated for 18–24 hours
at 35°C in air, before being transferred to New Granada Medium Modified (NGM) for GBS detection and incubated
for a further 18–24 hours at 35°C in air. If the characteristic orange pigmented colonies were observed after
this period, the specimen was recorded as + (1–10 colonies) or ++ (more than 10 colonies).
Results: Overall 92.2% (95/103) of isolates were detected in all tubes and at all times. An additional two isolates
were non-hemolytic, non-pigment forming GBS. Of note, 3.9% (4/103) were negative until 2 hours delayed
inoculation and 1.9% (2/103) gave inconsistent results, likely due to the low inoculum used.
Conclusion: Delayed inoculation into selective enrichment broth following a period in transport medium,
even with a low inoculum, gave a similar and acceptable GBS detection rate to direct inoculation. Hence,
Amies transport medium with charcoal is an appropriate transport medium to use, where it is not practical for
clinical specimens to be directly inoculated into selective enrichment broth and as endorsed in the Centers
for Diseases Control (CDC) Guidelines, 2002.