Aim: This paper reports a study investigating the continuity of care and general wellbeing of patients with comorbidities who required an elective total hip or knee joint replacement. Background: Advances in medical science and improved lifestyles have reduced mortality rates in most western countries. As a result, there is an ageing population with a concomitant growth in the number of people who are living with chronic illnesses. Indeed a significant number of people will experience multiple chronic illnesses (comorbidities). Osteoarthritis is a common comorbidity and joint replacement surgery is frequently performed in people who have comorbidities that may require joint replacement surgery to relieve symptoms, creating a blend of acute and chronic needs. Method: A purposive sample of twenty participants with multiple comorbidities who required joint replacement surgery were recruited to obtain survey, interview and medical record audit data. Data was analysed for descriptive statistics and Ritchie and Spencer’s a theoretical method of qualitative analysis (Ritchie & Spencer, 1994). Findings: The findings demonstrate that the participants did not receive co-ordinated, continuity of care of their comorbidities prior to having surgery, during the acute care stay and following surgery. The acute care setting was primarily concerned with patient throughput following joint replacement surgery according to a prescribed clinical pathway. Pain, fatigue, insomnia and alterations in urinary elimination were chief sources of discomfort from preadmission to eight weeks postdischarge. Conclusion: These findings have implications for a comprehensive and coordinated approach to patients with comorbidities in need of acute care, in particular, joint replacement. Acute care, clinical pathways, and the specialisation of medicine and nursing, subordinated the general problem of patients with comorbidities. Models of chronic illness management and systems designed to integrate and co-ordinate chronic illness care had limited application in the acute care setting. A multidisciplinary, holistic approach is required. Recommendations for further research conclude this paper.

Background. Advances in medical science and improved lifestyles have reduced mortality rates in Australia and most Western countries. As a result, there is an ageing population with a concomitant growth in the number of people living with chronic illnesses. Indeed, a significant number of people will experience multiple chronic illnesses (comorbidities) and may require admission to hospital for acute care that is superimposed on their chronic illnesses. Aim. The aim of this study was to investigate perceptions of quality of care by patients experiencing comorbidities who required an acute hospital stay. Method. A qualitative descriptive design was adopted, informed by Colaizzi’ sphenomenological method. Single semi-structured interviews were conducted with12 patients within 14 days of being discharged home after an acute illness episode. Findings. Data analysis revealed three themes: poor continuity of care for comorbidities, the inevitability of something going wrong during acute care and chronic conditions persisting after discharge. Combinations of chronic illnesses and treatments affected these patients’ experiences of acute care and recovery postdischarge. Medicalized conceptualizations of comorbidity failed to capture the underlying health care needs of these patients. Limitations. No generalizations can be drawn because the findings and conclusions were derived from a purposive sample of patients who agreed to participate. Conclusion. These findings have implications for a comprehensive and co-ordinated approach to this group of patients, and inform the body of nursing knowledge about how patients with comorbidities experience nursing care.

OBJECTIVE: The authors describe a novel peer-peer learning activity with medical students, encompassing a specialist psychiatrist-general practitioner (GP) dyadic interchange of letters, and a group discussion facilitated by a GP and a psychiatrist to enhance students' appreciation of the complexities of psychiatric assessment and formulation, emphasize the importance of the GP in the comprehensive longitudinal care of people with a mental illness, and improve students' written communication skills. METHODS: Quantitative and qualitative methods were employed to evaluate the activity. RESULTS: Twenty-eight fifth-year medical students undertook the learning activity; of these, 20 completed the questionnaires and 18 participated in the focus groups. Quantitative feedback was good, with most agreeing or strongly agreeing that the activity met the learning objectives. The qualitative outcomes suggested the students found the exercise relevant and useful in clarifying their communication style regarding a patient with a psychiatric problem. CONCLUSIONS: The use of peer-peer learning using a "GP letter" can go some way towards meeting a number of teaching and learning challenges pertinent to psychiatry.

BACKGROUND: As older patients' health care needs become more complex, they often experience challenges with managing medications across transitions of care. Families play a major role in older patients' lives. To date, there has been no review of the role of families in older people's medication management at transitions of care. This systematic review aimed to examine family involvement in managing older patients' medications across transitions of care. METHODS: Five databases were searched for quantitative, qualitative and mixed methods empirical studies involving families of patients aged 65 years and older: Cumulative Index to Nursing and Allied Health Literature Complete, Medline, the Cochrane Central Register of Controlled Trials, PsycINFO, and EMBASE. All authors participated independently in conducting data selection, extraction and quality assessment using the Mixed Methods Appraisal Tool. A descriptive synthesis and thematic analysis were undertaken of included papers. RESULTS: Twenty-three papers were included, comprising 17 qualitative studies, 5 quantitative studies and one mixed methods study. Families participated in information giving and receiving, decision making, managing medication complexity, and supportive interventions in regard to managing medications for older patients across transitions of care. However, health professionals tended not to acknowledge the medication activities performed by families. While families actively engaged with older patients in strategies to ensure safe medication management, communication about medication plans of care across transitions tended to be haphazard and disorganised, and there was a lack of shared decision making between families and health professionals. In managing medication complexity across transitions of care, family members perceived a lack of tailoring of medication plans for patients' needs, and believed they had to display perseverance to have their views heard by health professionals. CONCLUSIONS: Greater efforts are needed by health professionals in strengthening involvement of families in medication management at transitions of care, through designated family meetings, clinical bedside handovers, ward rounds, and admission and discharge consultations. Future work is needed on evaluating targeted strategies relating to family members' contribution to managing medications at transitions of care, with outcomes directed on family understanding of medication changes and their input in preventing and identifying medication-related problems.

UNLABELLED: BACKGROUND: Mental health related presentations are common in Australian Emergency Departments (EDs). We sought to better understand ED staff knowledge and levels of confidence in treating people with mental health related problems using qualitative methods. METHODS: This was a qualitative learning needs analysis of Australian emergency doctors and nurses regarding the assessment and management of mental health presentations. Participants were selected for semi-structured telephone interview using criterion-based sampling. Recruitment was via the Australasian College for Emergency Medicine and College of Emergency Nursing Australasia membership databases. Interviews were audio-recorded and transcribed verbatim. Thematic framework analysis was used to identify perceived knowledge gaps and levels of confidence among participants in assessing and managing patients attending EDs with mental health presentations. RESULTS: Thirty-six staff comprising 20 doctors and 16 nurses consented to participate. Data saturation was achieved for four major areas where knowledge gaps were reported. These were: assessment (risk assessment and assessment of mental status), management (psychotherapeutic skills, ongoing management, medication management and behaviour management), training (curriculum and rotations), and application of mental health legislation. Participants' confidence in assessing mental health patients was affected by environmental, staff, and patient related factors. Clinicians were keen to learn more about evidence based practice to provide better care for this patient group. Areas where clinicians felt the least confident were in the effective assessment and management of high risk behaviours, providing continuity of care, managing people with dual diagnosis, prescribing and effectively managing medications, assessing and managing child and adolescent mental health, and balancing the caseload in ED. CONCLUSION: Participants were most concerned about knowledge gaps in risk assessment, particularly for self-harming patients, violent and aggressive patients and their management, and distinguishing psychiatric from physical illness. Staff confidence was enhanced by better availability of skilled psychiatric support staff to assist in clinical decision-making for complex cases and via the provision of a safe ED environment. Strategies to enhance the care of patients with mental health presentations in Australian emergency departments should address these gaps in knowledge and confidence.

BACKGROUND: Drug repositioning is the process of identifying new uses for existing drugs. Computational drug repositioning methods can reduce the time, costs and risks of drug development by automating the analysis of the relationships in pharmacology networks. Pharmacology networks are large and heterogeneous. Clustering drugs into small groups can simplify large pharmacology networks, these subgroups can also be used as a starting point for repositioning drugs. In this paper, we propose a two-tiered drug-centric unsupervised clustering approach for drug repositioning, integrating heterogeneous drug data profiles: drug-chemical, drug-disease, drug-gene, drug-protein and drug-side effect relationships. RESULTS: The proposed drug repositioning approach is threefold; (i) clustering drugs based on their homogeneous profiles using the Growing Self Organizing Map (GSOM); (ii) clustering drugs based on drug-drug relation matrices based on the previous step, considering three state-of-the-art graph clustering methods; and (iii) inferring drug repositioning candidates and assigning a confidence value for each identified candidate. In this paper, we compare our two-tiered clustering approach against two existing heterogeneous data integration approaches with reference to the Anatomical Therapeutic Chemical (ATC) classification, using GSOM. Our approach yields Normalized Mutual Information (NMI) and Standardized Mutual Information (SMI) of 0.66 and 36.11, respectively, while the two existing methods yield NMI of 0.60 and 0.64 and SMI of 22.26 and 33.59. Moreover, the two existing approaches failed to produce useful cluster separations when using graph clustering algorithms while our approach is able to identify useful clusters for drug repositioning. Furthermore, we provide clinical evidence for four predicted results (Chlorthalidone, Indomethacin, Metformin and Thioridazine) to support that our proposed approach can be reliably used to infer ATC code and drug repositioning. CONCLUSION: The proposed two-tiered unsupervised clustering approach is suitable for drug clustering and enables heterogeneous data integration. It also enables identifying reliable repositioning drug candidates with reference to ATC therapeutic classification. The repositioning drug candidates identified consistently by multiple clustering algorithms and with high confidence have a higher possibility of being effective repositioning candidates.