Medicine (RMH) - Theses
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ItemClinical Data Linkage in Spinal Cord Injury( 2019)ABSTRACT Introduction This is the first Australian longitudinal retrospective study on the patients with traumatic Spinal Cord Injury (SCI), over a 14-year period, showing the trends of disease as well as health service utilization. This study involved linking Intensive Care Unit (ICU) datasets with Victorian Admitted Episodes Dataset (VAED) and Victorian Emergency Minimum Dataset (VEMD) from three major hospitals to work out determinants for disability, as well as co-morbidities. From the collected data, the study provides frameworks for chronic disease such as SCI and developed a prototype that can be used to bring the information together to be utilized by clinicians, patients and carers to improve health outcomes. Methods Health administrative datasets with the International Classification of Diseases, 10th revision, Australian Modification (ICD-10-AM) were used to conduct a pilot data linkage study using a unique identifier. A deterministic linkage method was used to link internal datasets from each of three major hospitals to build patient disease profiles and identify comorbidities. An extended Elixhauser comorbidity index (ECI) was used to study risk factors and comorbidities. Results The study identified a lack of coordination between clinical, administrative and statutory data custodians, and issues with coding quality. From the linked datasets from three major hospitals (Alfred Hospital, Royal Melbourne Hospital and Austin Hospital) data on almost 2,629 patients were extracted. The female: male ratio in this cohort was 1:2.9 and the largest proportion of patients was aged between 16 and 30 years. An increase in female admissions was apparent in the last decade. Sixty-six percent of readmissions were for patients from the Melbourne metropolitan area, with much lower proportions in the Gippsland and Hume regions. The three most frequent principal diagnoses were functional level of cervical spinal cord injury (C1-C8), concussion and oedema of thoracic spinal cord and concussion and oedema of cervical spinal cord. The main reasons for readmission were urinary tract infection (UTI), pressure ulcer, mental disorders and respiratory infections. The study of risk factors (alcohol, tobacco and illicit drugs) showed a significant association with overall length of stay in ICU and that males had twice the risk of death than females. Using the linked datasets as backend, a prototype of clinical decision support system (CDSS) was developed. This has scalability and can be improved with the latest technologies such as an ‘alert system’, as well as built-in artificial intelligence (AI) such as an Artificial Neural Network, which can assist clinicians, patients and carers. Conclusion This is the first longitudinal study of SCI, following the e-journey of patients with SCI over 14 years in three major hospitals in Victoria. The lack of coordination between clinical, administrative and statutory data custodians, and issues with coding quality have implications for resource allocation, decision making and planning by health administrators and clinicians. Although the total number of people with spinal cord injury is small, they have prolonged health utilization. This Clinical Data Linkage study has provided unique information about these patients, including the enormous number of readmissions, the reasons for readmission, the exact cost of care at the major Victorian hospitals rather than estimates, and the area of the residence of patients where ongoing care is needed. Ultimately, stratified patient profiles can be used as a backbone for eHealth and a as framework for clinical decision support systems that are known to support self-efficacy for patients with chronic conditions and to improve health outcomes. They may also be used to build a conceptual model for other chronic conditions that have a high number of medical interventions.
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ItemMechanisms Driving Persistent Atrial Fibrillation: Insights from Endocardial-Epicardial Dissociation and Regional High-Density Mapping of the Human Atrium( 2020)Atrial fibrillation (AF) is an extremely common clinical problem with increasing global prevalence. Besides its frequent association with stroke, heart failure and increased mortality, recent data have shown the significant quality of life impairment and psychological distress that results from this arrhythmia. The clinical spectrum of AF can manifest as brief episodic paroxysmal AF or as a sustained arrhythmia in persistent AF in patients with progressive atrial disease. Mechanistically, paroxysmal AF is often triggered by rapidly firing impulses that originate in the pulmonary veins, allowing catheter-mediated elimination of sources, with clinical success rates of 70–85%. However, in persistent AF, the mechanism that sustains the arrhythmia remains incompletely understood and is a topic of ongoing debate. Recent advances in cardiac mapping and computational methods have suggested localised drivers and non-pulmonary vein triggers particularly from the left atrial appendage but there is also accumulating evidence that the atrium frequently functions electrically as a 3-dimensional structure and there exists endocardial-epicardial dissociation in activation during AF. The aims of this thesis are three-fold: Firstly, we review the evidence for the current and expanding indications for catheter ablation in AF and highlight some of the novel tools and technological advancements that have emerged in the recent years for achieving durable pulmonary vein isolation (PVI). Secondly, we investigate the role of some of the novel mechanisms that potentially sustain persistent AF. We addressed this first by systematically reviewing the evidence for a computational mapping technique thought to identify localised sources and then performed a series of cardiac mapping studies in humans. These high-density mapping studies characterised atrial endocardial-epicardial electrical dissociation in the presence of structural heart disease and explored the mechanistic role of localised sources in the left atrium and the left atrial appendage (LAA) in persistent AF. Finally, given the emerging evidence for the mental health effects from AF, we discuss the rationale and methodology of a randomised controlled study comparing catheter ablation with medical therapy on psychological distress and neurocognitive function in patients with AF. Chapter 1 summarizes several aspects of AF including the epidemiology, our current understanding of the classic and novel mechanisms of AF the mechanistic role of risk factors and their implications in remodelling and atrial cardiomyopathy. Chapter 2 reviews the role of catheter ablation in AF and highlights the recent technological advancements. Catheter ablation is a safe and effective rhythm control strategy for symptomatic patients who failed medical therapy or who prefer not to take medications and there is emerging evidence for its role in mortality reduction in AF patients with heart failure. Pulmonary vein isolation is the cornerstone approach and both radiofrequency and cryoablation have similar efficacy. Mounting evidence demonstrates the importance of risk factor management for improving ablation outcomes. In the era of high-density cardiac mapping, FIRM (focal impulse and rotor modulation) emerged as a novel computational mapping technique to identify rotors and focal sources that could potentially be targeted during catheter ablation. Despite early promising results, many studies that followed showed mixed outcomes and indeed, some others showed a pro-arrhythmic consequence. Chapter 3 presents a systematic review and meta-analysis of 11 observational studies and demonstrates the wide variability in the medium-term outcomes of FIRM guided ablation and explores the significant heterogeneity between published studies. Chapters 4 and 5 examine the characteristics of endocardial-epicardial dissociation (EED) in patients with structural heart disease. We performed high-density simultaneous endocardial-epicardial phase mapping of the right atrium in patients undergoing cardiac surgery to study this. In Chapter 3 we report the for the first time, functional EED based on observations of synchronous activation during sinus rhythm and EED in activation timing and wavefront propagation during pacing drive and premature extra-stimulation providing compelling evidence for the functional nature of the atrial substrate. Chapter 4 presents data of phase mapping prolonged persistent AF recordings. The results provide novel evidence for endocardial-epicardial wave front mismatch in AF along with marked EED with temporal heterogeneity. In Chapter 6 we sought to characterise the preferential 3-dimensional nature of sinoatrial conduction in humans using simultaneous endocardial-epicardial mapping of the sinus node region. In intact hearts of patients with structural heart disease, data confirmed the presence of multiple differential endocardial and epicardial sino-atrial exits and hence the redundant structure of the pacemaker complex. This is consistent with data from optical mapping of ex-vivo human hearts and demonstrates that clinical sinus node dysfunction only occurs in the setting of advanced atrial structural remodelling. Recently, data from cohort studies and a randomised controlled trial have shown that LAA isolation improves ablation outcomes in patients undergoing redo ablation for persistent AF. However, there have been concerning reports that such empirical ablation is associated with a heightened risk of LAA thrombus, even in patients who are anticoagulated. Furthermore, data from mapping studies have also shown mixed results on the potential role of LAA as a driver in persistent AF. In Chapter 7 we examine the role of localised sources in the left atrium particularly in the LAA by performing regional high-density mapping of persistent AF. In addition to finding infrequent drivers in the left atrium, this project also showed paucity of triggers from the LAA providing further evidence of its passive role rather than an active driver in persistent AF. Besides physical symptoms that patients with AF experience, recent data has shown the enormity of mental health effects that AF can have that is often underappreciated by clinicians. More importantly, preliminary data from observational studies show the benefits of catheter ablation to improve mental health. Chapters 8 and 9 present the methodology and rationale of a multicentre, randomised controlled trial that assesses the impact of catheter ablation on psychological distress and neurocognitive function in patients with AF. The study has completed recruitment and successfully enrolled 100 participants across the Royal Melbourne and Alfred Hospitals and completion of analysis is expected by March 2022. Chapters 10 and 11 conclude by summarizing the key findings of the studies and their clinical implications. Further, it paves the way for future work that might progress our understanding of AF, especially in light of novel mechanisms
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ItemSuccessful elements of an improved model of care for refugees and immigrants in regional Australia( 2020)Abstract/Overview Australia has benefited from a long history of migration, including accepting refugees and asylum seekers (referred to as refugees within this discussion) from a wide range of countries experiencing conflict and hardship. Multiple health care challenges exist for refugees, including language difficulties, low health literacy, poor mental health and exposure to infectious diseases that may be unfamiliar to Australian health care practitioners. This is exacerbated by the growing numbers of immigrants and refugees settling in regional areas, where there are poorer health outcomes and provision of quality health care is more difficult. The published papers included in this thesis outline a number of the challenges in the provision of high-quality health care to refugees who settle in regional Australia, and some solutions that have been successfully utilised to improve health care provision to this population. The demonstrated solutions used for refugee populations are also valid for other immigrants and locally born Australians living in regional areas. The literature review provides the context and rationale for each of these papers with more specific references included within each paper. The literature review provides an overview of the topic and outlines the importance of the papers in addressing issues previously poorly understood or not considered. Paper one investigates the challenges of identifying appropriate screening for newly arrived immigrants and focuses on the cost effectiveness of screening new arrivals for H pylori. Modelling outlines the situations where a screening program could be considered and highlights the uncertainties that exist within the assumptions used for this modelling. Expanding on specific infectious disease challenges in immigrant populations, paper two examines the genotypes of hepatitis B that are encountered in immigrants from Burma and paper three describes genotypes amongst African immigrants. Papers two and three address the clinical relevance of genotype and country of birth in the management of hepatitis B. The subsequent three papers examine the provision of health care to refugees and immigrants via telehealth. Paper four outlines the development of a tertiary hospital based Infectious Diseases telehealth program. Paper five measures and compares the effectiveness of healthcare delivered to regional areas via telehealth, with a focus on care for individuals with hepatitis C virus. Paper six then describes the extension of the use of telehealth to include the provision of interpreters. The discussion outlines the conclusions that have been drawn from these papers, and then suggests further improvements for the care of refugees and immigrants who settle in regional areas. Reducing the gap in health care outcomes between those who live in large urban centres and those who live in regional areas is relevant to the whole population. Drawing on these findings, recommendations are outlined to reduce this gap.
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ItemUltrasound in the assessment of respiratory function and disease( 2020)This thesis advances the use of clinician-performed ultrasound for two common respiratory presentations; acute respiratory failure, and chronic obstructive pulmonary disease. Ultrasound in acute respiratory failure (ARF) To begin, a narrative review of ultrasound in ARF was undertaken and identified a paucity of evidence for the efficacy of ultrasound in ARF beyond diagnostic accuracy, and consequently a need for studies to examine its impact on clinical management efficacy, and patient and societal outcome efficacy. A prospective study of ultrasound in ARF was undertaken to establish clinical management efficacy. Ultrasound yielded new or additional diagnoses in 34% and enabled multiple clinical diagnoses in individual patients to be rationalised to a single diagnosis in 69%. Clinician diagnostic confidence was increased in 44%. Following ultrasound, patient management was altered in 30%, most frequently in patients with multiple diagnoses on admission. Additionally, a protocol was developed for a randomised controlled trial of ultrasound in ARF. Set in a high-dependency respiratory unit, primary study outcomes will be (i) time to resolution of respiratory failure, representing patient outcome efficacy, and (ii) time to readiness for unit discharge, representing societal outcome efficacy. Ultrasound in chronic obstructive pulmonary disease (COPD) A systematic review of diaphragm and intercostal muscle imaging in COPD was undertaken and included 52 studies. In COPD alterations in diaphragm morphology and function were detected across different imaging modalities, with reduced diaphragm excursion correlated with greater physiological impairment, and diaphragm dysfunction in ICU settings associated with poor outcomes. CT-intercostal muscle area correlated to worse airflow obstruction. Lung volume reduction and physiotherapy were associated with improvements in diaphragm parameters. A prospective study was undertaken in COPD to examine parasternal intercostal muscle thickness and echogenicity in the 2nd and 3rd intercostal spaces by ultrasound. Inter- and intra-rater reliability for thickness was moderate-to-high. Inter-rater measurement of echogenicity was moderate, with moderate-to-high intra-rater reliability. Reduced parasternal intercostal thickness and increased echogenicity (indicative of higher fat content) were both correlated to worse airflow obstruction as measured by FEV1. Finally, parasternal intercostal muscle thickness and echogenicity was studied in COPD patients before and after endobronchial valve (EBV) insertion. There was no change in echogenicity, but there was a strong correlation between reductions in residual volume and increases in parasternal intercostal muscle thickness in the treated hemi-thorax, suggesting length-tension relationships are a key determinant of muscle thickness. Ultrasound is a useful technique in patients presenting with acute respiratory failure and assists clinician decision-making and confidence. Ultrasound measured changes in parasternal intercostal muscles correlate with severity of airflow obstruction in COPD, with strong correlations between change in residual volume and thickness following relief of hyperinflation.
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ItemAn eHealth model of care in the management of chronic disease: Chronic hepatitis C infection( 2020)The rising burden of chronic disease in the developed world has resulted in an increasing accumulation of patients requiring long-term specialist input in care, despite a relatively stagnant specialist capacity in tertiary hospital services. Newer models of care, incorporating specialist input whilst empowering and enabling community-based treatment in a more cost-effective primary care setting are desirable. This thesis details the adaptation, implementation and evaluation of a new model of care that is underpinned by digital technology, using the HealthElink system, in facilitating community and prison-based treatment of chronic hepatitis C virus (HCV). This approach involved establishing outcomes for current treatment models, preliminary system functionality testing and prospective implementation of the eHealth model of care in both community and prison settings throughout Australia. Chronic hepatitis C virus represents a model disease in which rapid treatment advances have allowed care to primarily shift from hospital to community-based treatment. The advent and availability of direct-acting antiviral (DAA) therapy for chronic hepatitis C virus (HCV) in Australia in March 2016 represented a treatment revolution. In effect, HCV became the first chronic viral infection for which a safe, efficacious and permanent cure exists, affording the opportunity to facilitate global eradication programs. The World Health Organisation therefore issued a position paper, calling for the elimination of HCV as a major public health threat by 2030 and ending onward transmission through ‘treatment as prevention’ programs. Owing to the efficacy, ease and safety of DAA therapy, Australia became one of the first jurisdictions to allow any prescriber to use these lifesaving medications. Despite an estimated 80% of patients deemed suitable for treatment by a primary care practitioner, only 18% of prescriptions were from a GP in the first twelve-months. This formed the ideal opportunity to deploy and examine the eHealth model of care. This thesis is built upon the largest prospective clinical study of a novel shared eHealth model of care in Australia. Baseline studies in this thesis established the real-world outcomes of DAA treatment in Australia in the new era of treatment. Failure to test for HCV cure and loss to follow-up were higher than previously reported in controlled trials, particularly in community and prison settings compared to tertiary-based treatment. The eHealth model of care was usable, acceptable and more accurate in treatment selection than the current standard of care in preliminary functionality testing. A quasi-experimental, hybrid implementation-effectiveness study of the eHealth model in both community settings and prisons was undertaken showing similar clinical outcomes to the standard of care, with an improvement in guideline-based quality of care and efficiency. Uptake of the eHealth model was low by general practitioners, likely influenced in part by low HCV screening particularly in regional areas. Integrated hepatitis nurses exhibited high uptake of the system, contrasting with lower usability scores. The electronic patient portal exhibited low utilisation and may hold limited value in the current iteration due to both clinician and patient factors. The clinical decision support system was the most useful component of the eHealth model of care. Integration into existing electronic systems is seen as crucial to future electronic shared care models amongst clinicians. When applied to chronic hepatitis C, the eHealth model is usable and acceptable and demonstrates similar clinical outcomes to the current standard of care. Additional benefits in adherence to guideline-based care and efficiency of care were found. An integrated eHealth model of care for chronic disease, although currently nascent, holds potential to profoundly improve the delivery and quality of care.
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ItemTransforming pre-hospital care of stroke( 2020)Stroke is the second leading cause of death, as well as the second leading cause of disability worldwide. In Australia, the estimated financial burden of stroke on direct healthcare costs and healthy life lost is upwards of $50 billion Australian dollars annually. Highly effective reperfusion therapies exist to improve outcomes for ischaemic stroke but must generally be administered within the first few hours of stroke onset to ensure salvageable tissue is still present. Similarly, most haematoma expansion in intracerebral haemorrhage occurs early and promising interventions are being investigated to potentially reduce growth in this hyperacute period. The journey of a patient from stroke onset through to paramedic management, transport to hospital and eventual treatment is complex, with many workflow steps both in the pre-hospital and in-hospital phases that are susceptible to delays. This means that effective acute interventions in stroke may be delayed or may not be available to a proportion of patients. Historically, much of the effort for improving time to treatment has focussed largely on optimisation of in-hospital workflows. However, the pre-hospital phase may account for up to 50% of the time from stroke recognition to treatment. This is even greater if patients require a secondary inter-hospital transfer, should the initial centre not have capability to provide specialised treatments like endovascular thrombectomy or neurosurgery. This thesis explores two complementary methods of improving pre-hospital care of patients suffering from stroke. The first method is optimising ambulance triage of patients to allow direct transport to specialised stroke centres with advanced treatments. This is achieved through paramedic-led assessment of a clinical severity tool to determine patients likely to benefit from endovascular thrombectomy or neurosurgical services. This thesis studies the feasibility of such a system in metropolitan Melbourne, the design of a new triage tool adapted to local needs and validation of the tool in a real-world pre-hospital cohort of stroke patients. The second method is the use of an Australian-first mobile stroke unit, a custom-built ambulance with on-board computed tomography scanner and multidisciplinary stroke team, that allows pre-hospital assessment, imaging, treatment and triage of stroke patients. This thesis explores the operationalisation of the Melbourne Mobile Stroke Unit, the clinical benefits achieved by the service for treatment of both ischaemic and haemorrhagic stroke and the provision of novel therapies in the pre-hospital setting. Future adoption of the two synergistic pre-hospital strategies on a larger scale is expected to deliver substantial benefits to patients with stroke. Those eligible for time-critical treatment will be able to receive such therapies significantly faster, with expected improvements in longer term health outcomes. Improved pre-hospital management minimises the disadvantage experienced by patients located further away from appropriate stroke services, allowing some mitigation of healthcare inequality. Successful implementation in Melbourne will provide a template for roll-out of the strategies nationally and internationally.
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ItemA 25-year retrospective study of equine abortion in Australia( 2020)Horses (Equus caballus, a subspecies of Equus ferus) have many roles in Australian society and several equine industries contribute greatly to the Australian economy. A recognised major welfare and economic issue to the equine industry is abortion in mares which may be due to infectious or non-infectious causes. Although equine herpesvirus 1 (EHV-1) is considered as a principal cause of infectious abortion in horses, other infectious agents including Chlamydia psittaci, Coxiella burnetii, Toxoplasma gondii, and Leptospira spp. have also been identified as a cause of abortion. Additionally, some of the abortigenic infectious agents are zoonotic, with implications for both human and animal health. The present study investigated abortigenic pathogens in equine abortion cases in Australia using qPCR and metagenomic deep sequencing methods. Using qPCR the prevalence of EHV- 1, C. psittaci, C. burnetii, Leptospira spp. and T. gondii was determined in 600 aborted equine foetal tissues that were submitted from 1994 to 2019 to the diagnostic laboratories at the University of Melbourne.The overall prevalence of C. psittaci and C. burnetii was 6.5% (39/600, 95% CI: 4.7 – 8.8%) and 4% (21/600, 95% CI: 2.2 – 5.3%) respectively. None of the samples were positive for Leptospira spp. and T. gondii. C. psittaci and C. burnetii positive cases were detected in most years that were represented in this study. The prevalence of C. psittaci in Victoria, New South Wales, and South Australia was 7.6% (30/395, 95% CI: 5.4 – 10.6%) and 3.9% (7/182, 95% CI: 1.9 – 7.7%) and 15.4% (2/13, 95% CI: 4.3 – 42.2%) respectively. The prevalence of C. burnetii in Victoria and New South Wales was 3% (10/395, 95% CI: 1 – 5%) and 6% (11/182, 95% CI: 3 – 11%) respectively. These findings highlight the abortigenic potential of these agents in horses across wide geographical regions in Australia and underscore the importance of strict adherence to personal protection and biosecurity measures when dealing with cases of equine abortion. Genotyping and phylogenetic analysis performed on the archived C. psittaci positive samples, as well as samples from recent cases of equine reproductive loss in Victoria, revealed that the C. psittaci detected in the equine abortion cases clustered with the parrot-associated 6BC clade (Genotype A/ST24). The findings suggest that infection of horses may be due to spill-over from native Australian parrots. DNA from a total of 49 equine aborted foetal tissues and 8 placentas from normal deliveries were sequenced using next-generation sequencing (NGS) technology. Several potential abortigenic pathogens including Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Streptococcus equi subspecies zooepidemicus, Pantoea agglomerans, Acinetobacter lwoffii, Acinetobacter calcoaceticus, and Chlamydia psittaci were identified at a high level of relative abundance in a number of the abortion cases. No novel potential abortigenic pathogens were identified. Although NGS offers enhanced diagnostic capability, the findings suggest that existing diagnostic methods to detect known pathogens may be appropriate for identifying infectious causes of equine abortion in Australia given some of the current NGS limitations. Improvements in NGS technologies are likely to facilitate the use of NGS for diagnostics in the future. Greater awareness of the different pathogens causing equine abortions in Australia may assist diagnostic accuracy, reduce human infections and limit disease spread and further losses.
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ItemThe Role of Rehabilitation in Disaster Settings( 2020)Disaster may lead to significant economic losses, huge loss of lives, severe traumatic injuries, and psychological consequences which may result in long-term disability, requiring comprehensive multi- or interdisciplinary rehabilitation input for optimisation of physical and functional outcomes. The purpose of this thesis is to address the issues and gaps in knowledge for disaster rehabilitation. This thesis presents a body of work that incorporates five linked studies integrating different methodological models, such as The International Classification of Functioning, Disability and Health (ICF), Priority Sequence Model, The Integrated Care Models and Four-Phase Process by the World Health Organization (WHO), Model of Care for Traumatic Brain Injury (TBI), and Disaster Rehabilitation Continuum Cycle. Studies 1 and 2 are the first reviews to comprehensively evaluate the quality of TBI Clinical Practice Guidelines (CPGs) from a rehabilitative perspective using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool, and summarise recommendations from these relevant CPGs for applicability in disaster settings. The key rehabilitation recommendations for TBI survivors in disaster settings, include: patient/carer education, general physical therapy, practice in daily living activities and safe equipment use, direct cognitive/behavioural feedback, basic compensatory memory/visual and swallowing/communication strategies, and psychological input. Study 3 evaluated functional outcome, quality of life and community re-integration of community-based disaster survivors in Pakistan. The findings suggest that study participants (members of the Pakistani Armed Forces) seemed to have settled well in the community. The severity of impairments (such as walking, self-caring, fatigue, pain etc.) negatively impacted on participants’ community re-integration and in relation to their social roles and productivity. The longer the time since the injury was sustained, the fewer the impairments, and better community re-integration and perceived health status. Study 4 was a pilot study using a structured survey to gain insight from rehabilitation professionals, mainly rehabilitation physicians, regarding their preparedness and willingness for future deployment to disaster settings. Most participants (63%) expressed interest in future deployment to disaster settings, and only 24% had previously received some form of disaster management training. However, the survey provided valuable information on those who responded, including their experience in their respective profession, level of education, and types of preferred disaster management training etc. Study 5 is the first Disaster Rehabilitation Response Plan (DRRP) using a three-tier approach: Tier 1 - Immediate disaster response at a national or international level, Tier 2 - Deployment of rehabilitation medical personnel to the disaster settings, and Tier 3 - Rehabilitation management and community reintegration of disaster survivors. The DRRP can serve as a model for the International Society of Physical and Rehabilitation Medicine (ISPRM) to coordinate and deliver rehabilitation assistance with WHO in future disasters. Findings in this body of work confirm the complexity of disaster rehabilitation and the many challenges for integration of rehabilitation medicine in disaster management. It also supports the view that rehabilitation should be an ongoing process to maintain, restore and maximise function and health status in the long-term.
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ItemMedications and oral restrictions( 2020)Many patients presenting for a procedure/surgery take long-term oral medications. Many of these medications are omitted inappropriately during the fasting period, which can put patients at risk of undesirable complications. The PhD took a qualitative-quantitative approach to explore potential causes, solutions, implementation considerations and impact of strategies to improve medication management in patients with oral intake restrictions, such as when fasting before a procedure/surgery. Four studies were conducted: The first identified barriers to managing medications appropriately, while the second investigated barriers and enablers to implementation of improvement initiatives. The third was a focus group exploring the perceptions and experiences of surgical nurses operating the initiatives. This was followed by a retrospective interrupted time series analyses of medications omitted inappropriately and overall omissions in patients fasting before a procedure/surgery, pre- and post-implementation of improvement strategies in Medical and Surgical areas of one hospital. The barriers analysis indicated confusion about how to manage medications when patients have oral intake restrictions. This was exacerbated by lack of a standardised approach, leadership and using fasting and nil by mouth interchangeably. These findings supported development of improvement strategies that provide clarity and guidance for staff; specifically, clear definitions for fasting and nil by mouth in relation to medication administration and decision aids to highlight these instructions at the frontline. This was the basis of the Medications and Oral Restrictions Policy (the Policy). Resource and infrastructure, staff interpretation of their roles and the perceived applicability and credibility of the Policy were common themes for both barriers and enablers to policy implementation. Challenging barriers included variability in the communication structure, differing interpretation of responsibility and staff movement and turnover. Despite a considered implementation approach, the enablers and strategies employed were insufficient to manage the barriers. The focus group findings corroborated those from the medication management barriers analysis and barriers and enablers to policy implementation. Surgical nurses concurred about the confusion and lack of guidance pre-policy introduction; however, although the Policy offered clarity, guidance and context for managing medications for some, limitations in the Policy’s reach and individual staff interpretation of its messages and inherent decision-making process meant it was unhelpful for others. The interrupted time series study suggested a moderate but statistically significant reduction in inappropriate and overall medication omissions in patients fasting before a procedure/surgery following policy implementation, especially in Medical areas. Surgical baseline omissions were lower than Medical’s, which contrasted evidence from the literature and requires exploration. In summary, a pragmatic approach to medication management was associated with a moderate reduction in inappropriate and overall dose omissions in patients fasting before a procedure/surgery. The Policy provided clarity and guidance for some: Those who understood the context found the Policy helpful to their practice. Nonetheless, insufficient resources to provide context, ensure adequate uptake and sustainability affected wider policy impact. Existing systems that do not require ongoing staff effort to sustain, that are relatively impervious to staff movement, such as the electronic prescribing platform, should be capitalised on to improve the reach and uptake of the Policy.
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ItemDuloxetine for pain in Parkinsons disease( 2020)Pain in Parkinsons disease is common and poorly managed. The body of literature showing that pain adversely impacts on the quality of life of Parkinsons disease patients is overwhelming. Different strategies have been adopted to address pain in Parkinsons disease but results have been mixed. The pathophysiology of pain in Parkinsons disease is thought to involve dopaminergic and extra-dopaminergic factors. Duloxetine, a serotonin and noradrenaline reuptake inhibitor has been used for pain in multiple sclerosis and painful diabetic peripheral neuropathy. We embarked on a project to explore the role of duloxetine in Parkinsons disease patients with pain in a randomized double blind placebo controlled trial using validated pain questionnaires, pain sensitivity measurements and functional imaging techniques. We showed a statistically significant improvement in the pain scores of the affective component of the Short-Form McGill Questionnaire and a trend towards improvement in pain tolerance following evoked pressure stimulus in the duloxetine group as compared to the placebo group. Additionally, the changes were not associated with changes in the affective states of the participants, as measured by the Geriatric Depression Scale and Positive Affect and Negative Affect Schedule. We did not find any statistically significant difference in the task-based fMRI and the resting state fMRI between the groups. In conclusion, our study showed that duloxetine may be most effective in addressing symptoms arising from the affective dimension of pain in Parkinsons disease patients.