Professional and interprofessional identities: a scoping review.

Identity development within the interprofessional field is an emerging area of research. This scoping review aims to establish how professional and interprofessional identities are defined, conceptualized, theorized and measured within the interprofessional literature. Six databases were systematically searched for papers focusing on professional and/or interprofessional identities in interprofessional healthcare and education using a scoping review methodology. A total of 84 papers were included. Most papers discussed professional identity only; the minority discussed both identities. There were three key findings. First, no universal definition of interprofessional identity exists. Second, there is no shared understanding of interprofessional identity and its relationship with professional identity. Third, poor alignment between definitions, conceptualizations, theories and measures of interprofessional identity exists. The absence of a psychometrically robust instrument that specifically measures interprofessional identity and the short-term focus of current interprofessional identity research further limits understanding. Research that critically examines professional and interprofessional identity development should be underpinned by clear definitions, concepts, theories and measures of both identities. High-quality research will allow greater understanding of interprofessional identity development and its impact on interprofessional practice.

Paraplegia secondary to Burkholderia pseudomallei myelitis: a case report.

Bacterial infection is an uncommon cause of acute paraplegia. A 42-year-old Aboriginal man presented to a remote health clinic in northern Australia with myelitis associated with Burkholderia pseudomallei. He was treated with analgesia and intravenous flucloxacillin, ceftriaxone, and gentamicin and transferred to our hospital, where an urgent T12-L1 laminectomy and decompression was performed. Urine culture confirmed B. pseudomallei infection (melioidosis). Abdominopelvic computed tomography revealed left prostatic lobe and right periprostatic abscesses, which were managed conservatively. The patient was given intravenous ceftazidime (8g/d) for 2 months, followed by oral sulfamethoxazole (1600mg) and trimethoprim (320mg) twice daily for 8 weeks. Magnetic resonance imaging 3 weeks after his admission confirmed transverse myelitis. His rehabilitation was complicated by his difficulty in adjusting to disability, by urinary retention and fecal incontinence, by communication barriers, and his isolation from a culture familiar to him. He returned to his community after 15 weeks, free of infection, with T10-11 paraplegia and an indwelling catheter.

Sleep apnoea related hypoxia is associated with cognitive disturbances in patients with tetraplegia.

Sleep disordered breathing is common in patients with tetraplegia. Nocturnal arterial hypoxemia and sleep fragmentation due to sleep apnoea may be associated with cognitive dysfunction. We therefore studied the influence of sleep disordered breathing on neuropsychological function in 37 representative tetraplegic patients (mean age 34 +/- 9.7 years). Thirty percent (11 of 37 patients) had clinically significant sleep disordered breathing, defined as apnoea plus hypopnoea index (AHI) greater than 15 per hour of sleep. Most apnoeas were obstructive in type. Seven patients (19%) desaturated to < 80% during the night. Neuropsychological variables were significantly correlated with measures of sleep hypoxia, but not with the AHI and the frequency of sleep arousals. The neuropsychological functions most affected by nocturnal desaturation were: verbal attention and concentration, immediate and short-term memory, cognitive flexibility, internal scanning and working memory. There appeared to be a weak association between the presence of severe sleep hypoxia and visual perception, attention and concentration but no association was found between sleep variables and depression scores. We concluded that sleep disordered breathing is common in patients with tetraplegia and may be accompanied with significant oxygen desaturation. The latter impairs daytime cognitive function in these patients, particularly attention, concentration, memory and learning skills. Cognitive disturbances resulting from sleep apnoea might adversely affect rehabilitation in patients with tetraplegia.

Managing chronic back pain: impact of an interdisciplinary team approach.

OBJECTIVE: To evaluate the effectiveness of a six-week outpatient program in pain management for patients with chronic back pain. DESIGN: Retrospective review. SETTING: Rehabilitation Clinical Business Unit, Essendon campus of the Royal Melbourne Hospital. SUBJECTS: 138 consecutive patients who participated in the unit's Chronic Back Pain Programme between 1991 and 1993. INTERVENTION: Multidisciplinary program that promoted pain management rather than "cure", with two six-hour group sessions per week for six weeks. OUTCOME MEASURES: Patient assessments before the program and at program completion and at three months' follow-up, with the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) and a four-minute walk test. RESULTS: At program completion, the WHYMPI showed significant decreases in the amount pain interfered with life and significant increases in patient sense of control and activity level. However, severity of pain remained the same. All these effects were maintained three months later. CONCLUSIONS: A brief outpatient program was effective in improving pain management in a group of chronic back pain sufferers. This seems a useful and relatively inexpensive option in managing this problematic group of patients.

Sleep apnoea in patients with quadriplegia.

BACKGROUND: This study was undertaken to establish the prevalence of, and the factors contributing towards, sleep disordered breathing in patients with quadriplegia. METHODS: Forty representative quadriplegic patients (time since injury > 6 months, injury level C8 and above, Frankel category A, B, or C; mean (SE) age 35.0 (1.7) years) had home sleep studies in which EEG, EOG, submental EMG, body movement, nasal airflow, respiratory effort, and pulse oximetry (SpO2) were measured. Patients reporting post traumatic amnesia of > 24 hours, drug or alcohol abuse or other major medical illness were excluded from the study. A questionnaire on medications and sleep was administered and supine blood pressure, awake SpO2, spirometric values, height, and neck circumference were measured. RESULTS: A pattern of sustained hypoventilation was not observed in any of the patients. Sleep apnoeas and hypopnoeas were, however, common. Eleven patients (27.5%) had a respiratory disturbance index (RDI, apnoeas plus hypopnoeas per hour of sleep) of > or = 15, with nadir SpO2 ranging from 49% to 95%. Twelve of the 40 (30%) had an apnoea index (AI) of > or = 5 and, of these, nine (75%) had predominantly obstructive apnoeas-that is, > 80% of apnoeas were obstructive or mixed. This represents a prevalence of sleep disordered breathing more than twice that observed in normal populations. For the study population RDI correlated with systolic and diastolic blood pressure and neck circumference. RDI was higher in patients who slept supine compared with those in other postures. Daytime sleepiness was a common complaint in the study population and sleep architecture was considerably disturbed with decreased REM sleep and increased stage 1 non-REM sleep. CONCLUSIONS: Sleep disordered breathing is common in quadriplegic patients and sleep disturbance is significant. The predominant type of apnoea is obstructive. As with non-quadriplegic patients with sleep apnoea, sleep disordered breathing in quadriplegics is associated with increased neck circumference and the supine sleep posture.

Hypoxia episodes during sleep in high tetraplegia.

To determine whether oxygen desaturation occurs during sleep in high tetraplegics, 10 neurologically stable male patients (aged 17 to 55 years) with complete motor lesions (C4 to C6) had continuous pulse oximetry recordings and sleep observations on two nights. The patients were studied during admissions for nonrespiratory problems (eg, pressure sores, urinary infection, respite). Lung function tests and daytime arterial blood gases were also measured. Mean forced vital capacity was 46% of predicted, but mean awake PaO2 and PaCO2 were normal (95.0 mmHg and 42.8 mmHg, respectively). Three subjects showed severe nocturnal oxygen desaturation spending greater than 10% of the time overnight with arterial oxyhaemoglobin saturation (SaO2) levels of less than 90%. For the group as a whole, the percentage of time spent under 90% SaO2 correlated with body mass index. Mean overnight SaO2 correlated inversely with body mass index and directly with maximal expiratory pressure, a measure of respiratory muscle strength. Low overnight SaO2 was also associated with higher levels of injury. The pattern of nocturnal oxygen desaturation observed was episodic and was suggestive of obstructive sleep apnoea during rapid eye movement (REM) sleep. Levels of nocturnal oxygen desaturation similar to those observed in the three most severely affected patients have been shown, in other disorders, to be associated with cognitive impairment, cardiovascular disease and increased mortality. Our results suggest up to a third of high tetraplegics may be at risk of potentially serious nocturnal hypoxic episodes.

Failure to prevent nicotine addition in young people with diabetes.

The habit of smoking is usually acquired at a young age and it is particularly undesirable in individuals with diabetes. A study was carried out to assess objectively the prevalence of smoking in young patients with diabetes and whether younger age at onset of diabetes (implying exposure to health education) reduced the incidence of smoking. Ninety nine young adults with diabetes attending the routine clinic were studied using a structured interview and assay of a urinary nicotine metabolite (cotinine). Forty eight percent of the cohort were smoking (raised urinary cotinine), although only 31% admitted to smoking. Thirty eight percent of the patients with childhood onset diabetes, 56% of the adolescent onset, and 47% of the young adult onset patients were smoking. Smoking was not related to glycaemic control or body mass index. In conclusion, smoking is common in young patients with diabetes and is often denied. Conventional health education does not appear to prevent children and adolescents with diabetes from starting to smoke. Anti-smoking policies and health education must therefore be reinforced and improved.

How accurate is the smoking history in newly diagnosed diabetic patients?

A smoking history was obtained from 94 consecutive newly diagnosed diabetic patients referred to an adult diabetic clinic. The smoking load was measured using urinary cotinine/creatinine ratios (COT/Cr). Fifty-six patients (60%) claimed to be non-smokers, but COT/Cr suggested active smoking in five of these. The patients who admitted to smoking were given standardised anti-smoking advice. At 3 months, 32 smoking patients were reviewed and 21 (66%) claimed to have reduced or stopped smoking. However, the median COT/Cr in the 32 patients showed no significant reduction (11.15 vs. 9.30 micrograms/mg). Urinary COT/Cr indicated that 6 patients had stopped smoking (median COT/Cr 6.98 fell to 0.97 micrograms/mg), but several patients had a marked rise in COT/Cr, demonstrating that their smoking habit had increased considerably. Therefore the smoking history obtained from new diabetic patients can be very misleading. An objective measure of smoking habits in the initial assessment and follow-up of diabetes may be worthwhile. Anti-smoking counselling at diagnosis of diabetes may persuade some smokers to stop.

Temperament in infants born prematurely.

The temperament of infants born prematurely was studied to examine further the notion that prematurity may be a risk factor for an infant's subsequent social interaction. The Infant Temperament Questionnaire of Carey and McDevitt was revised and revalidated for an Australian population and sent to mothers of infants who had been born prematurely (36 weeks or less) and who were aged 4 to 8 months (corrected for prematurity). Two hundred and twenty-six questionnaires were distributed and 110 (49%) returned. There were no differences between respondents and nonrespondents with respect to gestational age, birth weight, method of delivery, Apgar scores, or perinatal complications. When compared to a control group (N = 240) of infants born at term and who came from families with similar demographic characteristics, infants born prematurely did not differ significantly on any of the nine temperament dimensions. Both groups had similar proportions of "easy," "difficult," and "slow to warm up" infants, and there were no significant differences in maternal global ratings of temperament between the two groups. Comparisons of infants of less than 33 weeks gestation gave results similar to those reported above. These data indicate that infants born prematurely have temperament profiles at 4 to 8 months similar to infants born at term.