Retention of physicians and surgeons in rural areas-what works?

BACKGROUND: Causes for health inequity among rural populations globally are multifactorial, and include poorer access to healthcare professionals. This study summarizes the recent literature identifying factors that influence rural doctor retention and analyses strategies implemented to increase retention. Uniquely, this study addresses the importance of context in the planning, implementation and success of these strategies, drawing on literature from high-, middle- and low-income countries. METHODS: A systematic review of the English literature was conducted in two parts. The first identified factors contributing to rural doctor retention, yielding 28 studies (2015-2019). The second identified 19 studies up to 2019 that assessed the outcomes of implemented rural retention strategies. RESULTS: Universal retention factors for health professionals in a rural environment include rural background, positive rural exposure in training or in the early postgraduate years and personal and professional support. Financial incentives were less influential on retention, but results were inconsistent between studies and differed between high-, middle- and low-income nations. Successful strategies included student selection from rural backgrounds into medical school and undergraduate education programs and early postgraduate training in a rural environment. Bundled or multifaceted interventions may be more effective than single factor interventions. CONCLUSION: Rural health workforce retention strategies need to be multifaceted and context specific, and cannot be effective without considering the practitioner's social context and the influence of their family in their decision making. Adequate rural health facilities, living conditions, work-life balance and family, community and professional support systems will maximize the success of implemented strategies and ensure sustainability and continuity of healthcare workforce in rural environments.

Extended Sanitation Intervals for Cage Components and Automated Watering Valves: Validation and Cost Analysis.

Although the Guide suggests changing rodent cage components every 2 wk, it states that "decreased sanitation frequency may be justified if the microenvironment in the cages, under the condition of use ..., is not compromised." The purpose of this study was to evaluate extended sanitation intervals of cage components (automated watering valve, wire bar lid, and filter top) of mouse individually ventilated caging (IVCs) at our institution. We hypothesized that there would be no significant difference in relative light units measured by ATP luminometry of these cage components at the control time point of 14 d as compared with each extended time interval: 28, 56, and 84 d. In addition, for automated watering valves, the study was extended to 168 d. We also hypothesized that time-and-motion studies performed by moving to a sanitation interval of 84 d for all components would result in substantial time and cost savings. The components of a total of 24 cages containing 4 or 5 mice each were swabbed, and an ATP luminometer was used to detect organic matter. We found no significant differences in organic matter load between 14 d and all other time points for all cage components. Our time- and cost-savings analysis found that extending the sanitation interval of cage components from every 2 wk (14 d) to every 3 mo (84 d) for every 10,000 cages would save about 3,000 technician hours annually, for a total annual labor cost savings of about $100,000. This study is the first to validate the extended sanitation interval of automated watering valves and confirms the findings of previous studies that validated the extended sanitation frequency of wire bar lids and filter tops of rodent IVCs. Overall, extending the sanitation frequency of cage components reduces workload of animal care staff without compromising the cage microenvironment.

Royal Australasian College of Surgeons Rural Health Equity Strategic Action Plan: excellence through equity.

Wherever there are people there will be a need for surgical care. Rural people have all kinds of problems and need all kinds of surgeons. The Royal Australasian College of Surgeons (RACS) Rural Health Equity Strategic Action Plan (RHESAP) was endorsed by Council in December 2020. The goal is to increase the rural surgical workforce and increase access to care, through providing motivated surgeons with the training they need to work where they are needed most. The Royal Australasian College of Surgeons Surgical Education and Training Programs (SET) aim to train generalist surgeons across all nine surgical disciplines. To increase the rural surgical workforce and increase access to care, we need to select for rural origin, rural medical school and rural work experience, provide all trainees with the opportunity for positive rural work exposure with an aligned rural curriculum, and we need to support surgeons already living and working in rural areas. In future, with persistent health inequity for underserved populations and the impacts of climate change, we anticipate an increasing need for a culturally and emotionally intelligent, broad-scope surgical workforce, across all surgical disciplines, with the skills, confidence and motivation to work collaboratively and effectively in surgical teams, in areas of need and limited resource environments, including globally.

Identification and Control of an Ornithonyssus Bacoti Infestation in a Rodent Vivarium by Using Molecular Diagnostic Techniques.

Ornithonyssus bacoti, commonly known as the tropical rat mite, is a zoonotic ectoparasite that occasionally infests research rodent colonies. Most infestations have been attributed to wild rodents that harbor the mite and spread it to research animals, often during building construction or other activity that disrupts wild rodent populations. Although infestation may be clinically silent, severe outbreaks have been reported to cause pruritis, dermatitis, decreased reproductive performance, and anemia in rodents. In mid-2020, our institution experienced increased activity of wild mice, which were found to be infested with O. bacoti, diagnosed by microscopic exam and confirmed by fur swab PCR analysis. We elected to add O. bacoti to our quarterly health monitoring exhaust air dust (EAD) testing PCR panel, increase wild mouse control measures, and treat the environment with a sustained-release synthetic pyrethroid spray in an attempt to prevent colony animal infestation. Initial quarterly EAD health monitoring results in September of 2020 were negative for O. bacoti. However, in early 2021, multiple IVC racks tested positive for O. bacoti at quarterly testing. Treatment consisted of providing permethrin-soaked nesting material and surface spray treatment of the room and hallway with a sustained-release synthetic pyrethroid. Historically in the literature, O. bacoti outbreaks of research mice were not identified until mite burden was high enough to cause dermatitis on animal care workers. Due to modern molecular diagnostics and proactive PCR-based health monitoring surveillance, we were able to identify the outbreak earlier than would have otherwise been possible. To the best of our knowledge, this is the first report to successfully identify O. bacoti using environmental health monitoring PCR techniques. This outbreak demonstrates the importance of screening for O. bacoti in facilities with the potential for wild rodent infestation and highlights unique considerations when managing O. bacoti infestations. In addition, a novel permethrin-soaked enrichment item was developed for cage-level treatment.

Characterization of a Jumping Stereotypy in Gerbils (Meriones unguiculatus) and Assessment of Opaque Tubing Enrichment on Stereotypies and Breeding.

Mongolian gerbils can develop stereotypic behaviors, including corner digging. At our institution, gerbils also engage in repetitive corner jumping, which we sought to characterize as a potentially novel stereotypy in gerbils. We then attempted to mitigate this behavior by mimicking the natural habitat by adding intracage environmental complexity. Seventeen gerbil breeding pairs were video recorded in their home cages during the light cycle. Repetitive corner jumping and digging were compared between different times of day to assess when the behaviors occurred and whether they were temporally associated. To determine whether we could reduce the incidence of stereotypic behaviors, we tested a straight tube or 1 of 3 angled opaque tubes in different orientations, which were fitted to the gerbils' preexisting opaque nesting box. Behavior was assessed at baseline and at 1, 4, 8, and 12 wk to evaluate opaque tube placement as an intervention. In addition, breeding efficiency, valuated as the number of gerbil pups born and weaned per breeder pair, was compared with pre- and poststudy data. The number of corner jumps was highest at the end of the light cycle and the majority were associated with corner digging. After placement of the enrichment tubes, an initial increase in corner digging behavior was observed and persisted throughout the study period. The opaque tubes were not associated with significant changes in corner jumping. After adjusting for age, the addition of opaque tubing to gerbil breeding cages was not associated with significant changes in breeding efficiency. The addition of opaque tubing did not effectively address concerns about stereotypic behaviors and was associated with a chronic increase in stereotypic corner digging among breeding gerbil pairs.

'It makes life so much easier'-experiences of users of the MicroGuide™ smartphone app for improving antibiotic prescribing behaviour in UK hospitals: an interview study.

OBJECTIVES: To understand the impact on prescribing behaviour of an antimicrobial therapy guidelines smartphone app, in widespread use in hospitals in the UK. METHODS: Twenty-eight doctors and five nurse prescribers from four purposively selected hospitals in the UK participated in behavioural theory-informed semi-structured interviews about their experiences of using the MicroGuide™ smartphone app. Data were analysed using a thematic content analysis. RESULTS: Five themes emerged from the interview data: convenience and accessibility; validation of prescribing decisions; trust in app content; promotion of antimicrobial stewardship; and limitations and concerns. Participants appreciated the perceived convenience, accessibility and timesaving attributes of the app, potentially contributing to more prompt treatment of patients with time-critical illness. The interviewees also reported finding it reassuring to use the app to support decision-making and to validate existing knowledge. They trusted the app content authored by local experts and considered it to be evidence-based and up-to-date. This was believed to result in fewer telephone calls to the microbiology department for advice. Participants recognized the value of the app for supporting the goals of antimicrobial stewardship by promoting the responsible and proportionate use of antimicrobials. Finally, a number of limitations of the app were reported, including the risk of de-skilling trainees, cultural problems with using smartphones in clinical environments and software technical problems. CONCLUSIONS: The MicroGuide app was valued as a means of addressing an unmet need for updated, concise, trustworthy specialist information in an accessible format at the bedside to support safe and effective antimicrobial prescribing.

Telehealth in surgery: an umbrella review.

BACKGROUND: Telehealth use has increased worldwide during the COVID-19 pandemic. However, hands-on requirements of surgical care may have resulted in slower implementation. This umbrella review (review of systematic reviews) evaluated the perceptions, safety and implementation of telehealth services in surgery, and telehealth usage in Australia between 2020 and 2021. METHODS: PubMed was searched from 2015 to 2021 for systematic reviews evaluating real-time telehealth modalities in surgery. Outcomes of interest were patient and provider satisfaction, safety, and barriers and facilitators associated with its use. Study quality was appraised using the AMSTAR 2 tool. A working group of surgeons provided insights into the clinical relevance to telehealth in surgical practice of the evidence collated. RESULTS: From 2025 identified studies, 17 were included, which were of low to moderate risk of bias. Patient and provider satisfaction with telehealth was high. Time savings, decreased healthcare resource use and lower costs were reported as key advantages of the service. Inability to perform comprehensive examinations was noted as the primary barrier. In Australia, peak telehealth usage coincided with the introduction of temporary telehealth services and increased lockdown measures. CONCLUSIONS: Patients and providers are broadly satisfied with telehealth and its benefits. Barriers may be overcome via multidisciplinary collaboration. Telehealth may benefit surgical care long-term if implemented correctly both during and after the COVID-19 pandemic.

Reuse of intermittent catheters: a qualitative study of IC users' perspectives.

OBJECTIVES: To explore the views of intermittent catheter (IC) users regarding the advantages and disadvantages of single-use or reuse of catheters. DESIGN: Qualitative study with semi-structured interviews. The interviews were recorded, transcribed and analysed thematically. SETTING: Participant's own homes in Hampshire and Dorset, UK. PARTICIPANTS: A convenience sample of 39 IC users, aged 23-86 years, using IC for at least 3 months. RESULTS: The analysis revealed four main themes: concerns regarding risk of urinary tract infection (UTI); cleaning, preparation and storage; social responsibility; practicalities and location. The main concern was safety, with the fear that reuse could increase risk of UTI compared with single-use sterile catheters. If shown to be safe then around half of participants thought they might consider reusing catheters. The practicalities of cleaning methods (extra products, time and storage) were considered potentially burdensome for reuse; but for single-use, ease of use and instant usability were advantages. Always having a catheter without fear of 'running out' was considered an advantage of reuse. Some participants were concerned about environmental impact (waste) and cost of single-use catheters. The potential for reuse was usually dependent on location. The analysis showed that often the disadvantages of single-use could be off-set by the advantages of reuse and vice versa, for example, the need to take many single-use catheters on holiday could be addressed by reuse, while the burden of cleaning would be obviated by single-use. CONCLUSIONS: If shown to be safe with a practical cleaning method, some participants would find reuse an acceptable option, alongside their current single-use method. The choice to use a mixture of single-use and reuse of catheters for different activities (at home, work or holiday) could optimise the perceived advantages and disadvantages of both. The safety and acceptability of such an approach would require testing in a clinical trial.

Cholinergic and dopaminergic interactions alter attention and response inhibition in Long-Evans rats performing the 5-choice serial reaction time task.

Acetylcholine (ACh) neurotransmission is important for attention, while dopamine (DA) signaling modulates impulsive behavior. Prior studies have established an existing relationship between ACh and DA that mediates dopamine release in the prefrontal cortex of the brain in rats performing the 5-choice serial reaction time task (5-CSRTT). This study is aimed to identify cholinergic and dopaminergic interactions that govern attention and impulsive behavior, using adult Long-Evans rats of both sexes and a 5-CSRTT, with variable short and long cue delays. In Experiment 1, the effects of single cholinergic and dopaminergic drugs were evaluated on 5-CSRTT performance. Drugs like nicotinic ACh receptor (nAChR) agonist nicotine, amphetamine, and GBR12909 that increase the synaptic levels of ACh and DA respectively all increased impulsive behavior. In addition, amphetamine and GBR 12909 decreased attention while nicotine had no effect on attention. The antagonists mecamylamine, a general nAChR antagonist, flupenthixol a DA 1/2 receptor antagonist, and SCH 23390 a DA 1 receptor antagonist, all decreased impulsive behavior, with mixed effects on attention. In contrast, dihydro-ß-erythroidine hydrobromide (DHBE), an α4ß2 subunit-specific nAChR antagonist, had no significant effects on attention or impulsivity across doses administered. Eticlopride, a DA 2 receptor antagonist, decreased attention at the shortest cue delay but did not affect impulsivity. The acetylcholinesterase inhibitor donepezil decreased both attention and impulsive behavior. Subsequently in Experiment 2, effects of nicotine and amphetamine were determined after pretreatment with SCH 23390 or eticlopride. SCH 23390 attenuated the effects of nicotine and amphetamine to increase impulsivity, while eticlopride only attenuated the effect of nicotine on impulsivity. Minimal effects were seen on attention in the combination trials. This study confirms that dopamine D1 receptor plays an essential role in modulation of impulsive behavior, as measured by the 5-CSRTT. More importantly, it establishes that impulsive behavior is altered by interactions between cholinergic and dopaminergic neurotransmission.

Intermittent catheter users' symptom identification, description and management of urinary tract infection: a qualitative study.

OBJECTIVES: To elucidate the views of intermittent catheter (IC) users regarding urinary tract infection (UTI) symptom presentation, terminology for describing signs and symptoms, the cause of UTI and management strategies. DESIGN: Qualitative study with semi-structured interviews. The transcribed text was analysed thematically. SETTING: 12 general practitioner (GP) surgeries in Hampshire and Dorset, UK. PARTICIPANTS: A convenience sample of 30 IC users, aged over 18, using IC for at least 3 months who had at least one self-reported UTI since starting IC. RESULTS: Participants reported a variety of signs and symptoms, such as urine cloudiness and smell, as indicators of UTI. The terms used often differed from those in the modified National Institute on Disability and Rehabilitation Research (NIDRR) symptom set. IC users had difficulty distinguishing possible UTI symptoms from those of their comorbidities. They expressed uncertainty about the cause of UTI, often attributing it to poor hygiene and lifestyle behaviours. Whereas some viewed UTI as an expected consequence of IC use that could be self-managed, others felt more concerned and were more reliant on their GP for support. A range of management strategies was described, including drinking more fluids, increased attention to personal hygiene and self-medicating with antibiotics. CONCLUSIONS: There is uncertainty among IC users about UTI signs and symptoms and when to seek help. Individual accounts of UTI fitted generally within the modified NIDRR descriptors but adopted less technical and more 'lay' language. IC users' descriptions of UTI signs and symptoms can lack precision, owing partly to the presence of underlying health conditions. This, together with differing levels of concern about the need to seek help and self-medication with antibiotics, presents challenges for the GP. This study provides the basis for developing a self-help tool which may aid identification of UTI and enhance communication with healthcare professionals.