A randomized controlled trial of prophylactic intra-aortic balloon counterpulsation in high-risk aneurysmal subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: To assess whether prophylactic postoperative intraaortic balloon counterpulsation (IABC) reduces the risk of poor outcome because of vasospasm following aneurysmal subarachnoid haemorrhage relative to conventional hypervolemic therapy (HT). METHODS: This was a single-center, parallel group randomized controlled trial. Patients suffering a subarachnoid hemorrhage at high risk of vasospasm were eligible. Patients were randomly allocated to receive prophylactic IABC (n=35) or HT (n=36). The primary end point was Glasgow Outcome and SF-36 scores assessed at 6 months by a blinded and independent observer and analyzed by intention to treat. Secondary analysis of physiological parameters was by treatment performed. RESULTS: Twenty-seven patients in each arm had a good outcome (P=0.55). There was no statistical difference in mean SF-36 score (t=0.39, P=0.70). There were no long-term complications secondary to IABC. There were no differences in preload (pulmonary artery wedge pressure, P=0.97) or afterload (mean arterial pressure, P=0.97). IABC was associated with a lower cardiac output (P=0.002) and higher systemic vascular resistance (P=0.005), although for both groups mean cardiac output was >6 L/min. Cerebral blood flow was not different between groups: HT=41.5 (SD 7.2), IABP=44.9 (SD 8.6) mL/100 g/min (P=0.14). CONCLUSIONS: In this study, prophylactic IABC did not improve perfusion indices or confer any clinical benefit following subarachnoid haemorrhage in patients with normal cardiac function. The study was small, however, and cannot be extrapolated to patients with cardiac failure and medically refractory symptomatic cerebral vasospasm. Clinical Trial Registration- This trial was not registered because enrolment began prior to July 1, 2005.

The impact of preparatory activities on medical school selection outcomes: a cross-sectional survey of applicants to the University of Adelaide Medical School in 2007.

BACKGROUND: Selection into medical school is highly competitive with more applicants than places. Little is known about the preparation that applicants undertake for this high stakes process. The study aims to determine what preparatory activities applicants undertake and what difficulties they encounter for each stage of the application process to medical school and in particular what impact these have on the outcome. METHODS: A cross-sectional survey of 1097 applicants who applied for a place in the University of Adelaide Medical School in 2007 and participated in the UMAT (Undergraduate Medicine and Health Sciences Admission Test) and oral assessment components of the selection process. The main outcome measures were an offer of an interview and offer of a place in the medical school and were analysed using logistic regression. RESULTS: The odds of a successful outcome increased with each additional preparatory activity undertaken for the UMAT (odds ratio 1.22, 95% confidence interval 1.11 to 1.33; P < 0.001) and the oral assessment (1.36, 1.19 to 1.55; P < 0.001) stage of selection. The UMAT preparatory activities associated with the offer of an interview were attendance of a training course by a private organisation (1.75, 1.35 to 2.27: P < 0.001), use of online services of a private organisation (1.58, 1.23 to 2.04; P < 0.001), and familiarising oneself with the process (1.52, 1.15 to 2.00; p = 0.021). The oral assessment activities associated with an offer of a place included refining and learning a personal resume (9.73, 2.97 to 31.88; P < 0.001) and learning about the course structure (2.05, 1.29 to 3.26; P = 0.022).For the UMAT, applicants who found difficulties with learning for this type of test (0.47, 0.35 to 0.63: P < 0.001), with the timing of UMAT in terms of school exams (0.48, 0.5 to 0.66; P < 0.001) and with the inability to convey personal skills with the UMAT (0.67, 0.52 to 0.86; P = 0.026) were significantly less likely to be offered an interview. CONCLUSIONS: Medical schools make an enormous effort to undertake a selection process that is fair and equitable and which selects students most appropriate for medical school and the course they provide. Our results indicate that performance in the selection processes can be improved by training. However, if these preparatory activities may be limited to those who can access them, the playing field is not even and increasing equity of access to medical schools will not be achieved.

"Latte rural": the tangible and intangible factors important in the choice of a rural practice by recent GP graduates.

INTRODUCTION: A large of amount of literature exists on the factors that influence the recruitment and retention of rural general practitioners (GPs) in Australia and other countries. The selection of a rural practice location is known to be influenced by professional, personal and family, community and economic factors. Most of this research has been undertaken on the either the baby boomer generation or their predecessors, and this is likely to have influenced the responses gained. Generation X and Y doctors are known to have a different perception regarding workload, lifestyle and the support required to practise. The aim of this study was to explore, from a Generation X perspective, factors deemed important by general practice graduates in selecting a rural practice at completion of their training. The study also aimed to identify the process general practice graduates use to identify a potential rural practice, and when they commence this process. METHODS: Semi-structured interviews were held with 15 rural pathway general practice registrars in their final year of training with 2 regional training providers in South Australia. The interview topics included source of information on potential practices, their ideal rural practice and community, the process used to select a practice, and when they commenced this process. Phenomenological hermeneutic thematic analysis of interview transcripts was undertaken to identify themes and sub-themes. RESULTS: For an ideal rural practice, registrars wished to work in a practice with a friendly atmosphere, good business structure, support from senior GPs and in close proximity to a hospital. They also wanted reasonable on-call arrangements, the chance to develop further skills (such as anaesthetics or obstetrics) and the freedom to practise according to their interests. They also emphasised the importance of a good team and an ethical practice. In terms of community, registrars wanted a positive living place, access to amenities such as childcare, good schools and the opportunity of work for their spouses. They also appreciated attractions such as the beach, or green farmland. Word of mouth, referrals by colleagues and experience of a practice were the most common approaches to finding a suitable rural practice. The majority of the registrars commenced selection of a rural practice in their last 6 months of training. CONCLUSIONS: Many of the factors identified by the Generation X registrars were similar to those identified by the previous generation. However, they also identified factors such as a positive team environment and practice with good ethics as important. The results can be used to tailor the marketing of rural practices to Generation X general practice registrars.

Synthesis and evaluation of hydroxyazolopyrimidines as herbicides; the generation of amitrole in planta.

BACKGROUND: Exploiting novel herbicidal modes of action is an important method to overcome the challenges faced by increasing resistance and regulatory pressure on existing commercial herbicides. Recent reports of inhibitors of enzymes in the non-mevalonate pathway of isoprenoid biosynthesis led to the design of a novel class of azolopyrimidines which were assessed for their herbicidal activity. Studies were also undertaken to determine the mode of action responsible for the observed herbicidal activity. RESULTS: In total, 30 novel azolopyrimidines were synthesised and their structures were unambiguously determined by 1 H NMR, mass spectroscopy and X-ray crystallographic analysis. The herbicidal activity of this new chemical class was assessed against six common weed species, with compounds from this series displaying bleaching symptomology in post-emergence tests. A structure-activity relationship for the novel compounds was determined, which showed that only those belonging to the hydroxytriazolopyrimidine subclass displayed significant herbicidal activity. Observed similarities between the bleaching symptomology displayed by these herbicides and amitrole suggested that hydroxytriazolopyrimidines could be acting as elaborate propesticides of amitrole, and this was subsequently demonstrated in plant metabolism studies using Amaranthus retroflexus. It was shown that selected hydroxytriazolopyrimidines that displayed promising herbicidal activity generated amitrole, with peak concentrations of amitrole generally being observed 1 day after application. Additionally, the herbicidal activity of selected compounds was profiled against tobacco plants engineered to overexpress 4-diphosphocytidyl-2C-methyl-d-erythritol synthase (IspD) or lycopene ß-cyclase, and the results suggested that, where significant herbicidal activity was observed, inhibition of IspD was not responsible for the activity. Tobacco plants overexpressing lycopene ß-cyclase showed tolerance to amitrole and the two most herbicidally active triazolopyrimidines. CONCLUSIONS: Inhibition of IspD leading to herbicidal activity has been ruled out as the mode of action for the hydroxytriazolopyrimidine class of herbicides. Additionally, tobacco plants overexpressing lycopene ß-cyclase showed tolerance to amitrole, which indicates that this is the main herbicidal mode of action for amitrole. Results from the metabolic fate study of selected hydroxytriazolopyrimidines suggested that the herbicidal activity displayed by these compounds is due to amitrole production, which was confirmed when tobacco plants overexpressing lycopene ß-cyclase also showed tolerance towards two triazolopyrimidines from this study. © 2016 Society of Chemical Industry.

The utility and futility of non-invasive ventilation in non-designated areas: can critical care outreach nurses influence practice?

OBJECTIVE: To explore the practice of delivering non-invasive ventilation (NIV) in non-designated areas within a large university teaching hospital by critical care outreach nurses. METHODS: Local audit was prospectively conducted over a five-month period of all patients commenced on NIV in non-designated areas. The audit was repeated a year later and again four years later. MAIN OUTCOME MEASURES: Documentation of patient diagnosis and management plan including whether they were suitable for attempted cardiopulmonary resuscitation and endotracheal intubation as per British Thoracic Society guidelines (2002). Patient outcome (to hospital discharge) and arterial blood gas results pre and post commencement of NIV. RESULTS: 115 patients received NIV for the treatment of acute respiratory failure. The mortality rate for the first 2 years data combined (n75) was 57% and attributed to the fact that patients were elderly, acidotic and had diagnoses associated with a poor response to NIV. 86% of patients had a documented resuscitation status and management plan. Resuscitation status (p=0.01) and arterial blood gas improvement within two hours of therapy had a significant effect on patient outcome (p=0.001). Four years later the mortality rate had reduced to 35% possibly due to appropriate patient selection. More patients were deemed suitable for resuscitation, were transferred to designated areas and electively ventilated. CONCLUSION: Inappropriate use of NIV in non-designated areas is associated with a high mortality. Critical care outreach nurses can play a pivotal role in influencing appropriate patient selection for NIV.