Impact of a general medicine consultant-led ward round in the emergency department.

BACKGROUND: Patients requiring admission to the general medicine wards in a public hospital are usually assessed by a medical registrar. This study is based at a metropolitan public hospital in Melbourne where the majority of general medicine patients in the emergency department (ED) are not seen by a consultant physician until they are transferred to the ward. AIMS: To assess the impact of general medicine consultant-led ward rounds (CWRs) in the ED on patient length of stay (LOS). METHODS: One-month audit was conducted of all patients admitted to general medicine and awaiting transfer to ward from ED at a metropolitan public hospital in Melbourne. A general medicine CWR was then implemented in the ED, followed by another 1-month audit, with the primary outcome being LOS and the secondary outcome being 30-day readmission rate. Additionally, admitting medical registrars were invited to complete a survey before and after the implementation of CWRs to assess satisfaction rate. RESULTS: Data from electronic medical records were analysed for 162 patients (90 preimplementation group and 72 postimplementation group). The median LOS was 6 days in the preimplementation group and 4 days in the postimplementation group (P = 0.014). There was no significant difference in 30-day readmission rates. Surveys showed admitting medical registrars reported a reduced level of stress and fewer barriers to seeking consultant input following implementation. CONCLUSIONS: A CWR in the ED has led to decreased LOS for general medicine patients and improved satisfaction among junior medical staff.

Health System Transformation Playbook and Unified Care Model: an integrated design, systems & complexity thinking approach to health system transformation.

Health system transformation is a complex journey that often results in unintended consequences. Existing methods to drive health system transformation have intrinsic limitations which impede successful implementation in local contexts. The Health System Transformation Playbook is a design-, systems-, and complexity-thinking enabled methodology to systematically design, prioritize and test health system and services transformation actions, anchored on iterative story telling, model building and pathfinding processes that tackles the scale of socially and technologically complex adaptive systems through time. The Unified Care Model and its associated cascade of models are examples of ongoing application of Health System Transformation Playbook in a regional population health system in Singapore. Use of Health System Transformation Playbook enables stewards of health systems to gain a more systematic and coherent understanding of health systems and services planning and organization development, to accelerate transformation towards people-centered, integrated and value-driven health systems.

Tobacco industry strategies for flavour capsule cigarettes: analysis of patents and internal industry documents.

BACKGROUND: The global market for flavour capsule variants (FCVs), cigarettes with a crushable flavour capsule, has grown exponentially. To inform further regulatory efforts, it is important to understand tobacco industry strategies for FCVs. METHODS: Analysis of data from 65 patents and 179 internal tobacco industry documents, retrieved via snowball searches in Patsnap and the Truth Tobacco Industry Documents Library, describing tobacco industry developments related to FCVs. We used an inductive coding method to identify themes relating to FCV features or developments. RESULTS: Tobacco companies were developing FCVs since the 1960s, with little market success until the 2000s following the launch of Camel Crush, a brand which targeted millennials (in their teens or early 20s at the time). Tobacco companies have patented, but not yet marketed, FCVs with microcapsule surface coatings, adjustable or heat-triggered flavour release systems, airflow manipulation features, transparent filters to visualise flavour release, and various flavours and additives for capsules including nicotine/tobacco extracts for an on-demand nicotine hit. Tobacco companies developed FCVs purported to be reduced harm, although their own tests showed that FCVs have higher toxicant concentrations. They have also developed loose flavour capsule units designed to fit into cigarettes, packs, or recessed filters to enable users to customise cigarettes and circumvent tobacco flavour bans. CONCLUSIONS: To prevent tobacco companies from targeting young people and exploiting regulatory loopholes, regulations on tobacco products should ban flavours and consider the broad variety of FCV designs, additives and loose products designed to impart flavour into tobacco products.

Exploring patterns of personal alarm system use and impacts on outcomes.

OBJECTIVES: To describe the patterns of personal emergency response systems (PERS) use in a statewide cohort of older Australians. METHODS: PERS data from clients enrolled in the Personal Alarm Victoria program between January 2014 and June 2017 were analysed. Alarm activation reasons were extracted, and a medical record audit was performed for a sub-cohort of patients admitted to a local hospital following an alarm event. Descriptive statistics were used. RESULTS: There were 42,180 clients enrolled during the study (mean age 80 years, 80% female, 93% living alone). An ambulance attended 44% of the fall-related events and 81% of events coded as unwell. Activation reasons were distributed equally between a fall and feeling unwell, and a repeating pattern of activation reasons was observed. In our sub-cohort (n = 92), the majority of admissions (86%) followed an alarm activation coded as unwell. CONCLUSION: We demonstrated recurring patterns associated with the reasons for alarm use.

Understanding of diagnosis and medications among non-English-speaking older patients.

OBJECTIVE: To determine whether non-English-speaking background (NESB) patients had a poorer understanding of diagnosis and medications compared to English-speaking background (ESB) patients. METHODS: English-speaking background and NESB patients admitted to inpatient geriatric evaluation and management (GEM) unit were asked standardised questions about their admission diagnosis, reason for GEM admission and medications. Accuracy of answers, as compared to medical notes, ranked as 'full credit', 'partial credit' or 'no credit'. RESULTS: Of the 66 patients recruited (30 NESB), understanding of diagnosis and purpose of GEM admission was good. There was no difference between ESB and NESB patients. Understanding of medications taken prior to admission was poor, with 67% of overall patients scoring 'no credit'. NESB patients were more likely to score 'no credit' compared to ESB (80% vs 56%, P = 0.036). CONCLUSION: Reassuringly, patients had a reasonable understanding of diagnosis and purpose of GEM admission. Lack of understanding of medications, especially among NESB patients, should be improved.

Mechanical Robustness of Graphene on Flexible Transparent Substrates.

This study reports on a facile and widely applicable method of transferring chemical vapor deposited (CVD) graphene uniformly onto optically transparent and mechanically flexible substrates using commercially available, low-cost ultraviolet adhesive (UVA) and hot-press lamination (HPL). We report on the adhesion potential between the graphene and the substrate, and we compare these findings with those of the more commonly used cast polymer handler transfer processes. Graphene transferred with the two proposed methods showed lower surface energy and displayed a higher degree of adhesion (UVA: 4.40 ± 1.09 N/m, HPL: 0.60 ± 0.26 N/m) compared to equivalent CVD-graphene transferred using conventional poly(methyl methacrylate) (PMMA: 0.44 ± 0.06 N/m). The mechanical robustness of the transferred graphene was investigated by measuring the differential resistance as a function of bend angle and repeated bend-relax cycles across a range of bend radii. At a bend angle of 100° and a 2.5 mm bend radius, for both transfer techniques, the normalized resistance of graphene transferred on polyethylene terephthalate (PET) was around 80 times less than that of indium-tin oxide on PET. After 10(4) bend cycles, the resistance of the transferred graphene on PET using UVA and HPL was found to be, on average, around 25.5 and 8.1% higher than that of PMMA-transferred graphene, indicating that UVA- and HPL-transferred graphene are more strongly adhered compared to PMMA-transferred graphene. The robustness, in terms of maintained electrical performance upon mechanical fatigue, of the transferred graphene was around 60 times improved over ITO/PET upon many thousands of repeated bending stress cycles. On the basis of present production methods, the development of the next-generation of highly conformal, diverse form factor electronics, exploiting the emerging family of two-dimensional materials, necessitates the development of simple, low-cost, and mechanically robust transfer processes; the developed UVA and HPL approaches show significant potential and allow for large-area-compatible, near-room temperature transfer of graphene onto a diverse range of polymeric supports.

Toward 300 mm wafer-scalable high-performance polycrystalline chemical vapor deposited graphene transistors.

The largest applications of high-performance graphene will likely be realized when combined with ubiquitous Si very large scale integrated (VLSI) technology, affording a new portfolio of "back end of the line" devices including graphene radio frequency transistors, heat and transparent conductors, interconnects, mechanical actuators, sensors, and optical devices. To this end, we investigate the scalable growth of polycrystalline graphene through chemical vapor deposition (CVD) and its integration with Si VLSI technology. The large-area Raman mapping on CVD polycrystalline graphene on 150 and 300 mm wafers reveals >95% monolayer uniformity with negligible defects. About 26,000 graphene field-effect transistors were realized, and statistical evaluation indicates a device yield of ∼ 74% is achieved, 20% higher than previous reports. About 18% of devices show mobility of >3000 cm(2)/(V s), more than 3 times higher than prior results obtained over the same range from CVD polycrystalline graphene. The peak mobility observed here is ∼ 40% higher than the peak mobility values reported for single-crystalline graphene, a major advancement for polycrystalline graphene that can be readily manufactured. Intrinsic graphene features such as soft current saturation and three-region output characteristics at high field have also been observed on wafer-scale CVD graphene on which frequency doubler and amplifiers are demonstrated as well. Our growth and transport results on scalable CVD graphene have enabled 300 mm synthesis instrumentation that is now commercially available.

Isotretinoin and night blindness.

Isotretinoin is an effective and increasingly popular treatment for acne vulgaris. There have been reports of night blindness as a side-effect of treatment although the evidence does not demonstrate a clear causal relationship between isotretinoin therapy and the risk of night blindness. Nevertheless, considering the lack of evidence in this area, it is important to educate patients about this potential consequence, which may become longstanding and even irreversible, and encourage them to promptly report changes in their night vision.

The pectoralis major myocutaneous flap.

INTRODUCTION: The pectoralis major myocutaneous flap (PMMF) is a workhorse flap for head and neck reconstruction and a flap of choice for anterior chest wall reconstruction. METHODS: A thorough review of the literature was undertaken, exploring the full range of designs, variations, indications, and outcomes of the PMMF. RESULTS: Numerous modifications have been documented since it was first described in 1968. Complication rates vary greatly in the literature, but most institutions describe significant success with the PMMF. It is fast, versatile, reliable, and a good alternative when microsurgical flap failure occurs. A classification system of skin paddles is presented. CONCLUSION: In the era of free tissue transfer, the PMMF still has its advantages and continues to command an important place in the reconstructive surgeon's armamentarium.

Rotatory subluxation of the metacarpophalangeal index finger joint: a case report.

We report a case of rotatory subluxation of the metacarpophalangeal joint (MCPJ) of the finger. A 40-year-old man sustained an open injury to his index finger following an explosive injury. Radiographs showed rotatory subluxation of the index finger MCPJ. The index finger extensor digitorium was found interposed in the MCPJ, with a complete tear of the radial collateral ligament. Treatment was by open reduction and repair of the collateral ligament and the extensor tendon. A high level of clinical suspicion is needed to diagnose this entity.

Asplenic fulminant sepsis secondary to a dog bite complicated by toxic epidermal necrolysis/Stevens-Johnson syndrome.

We report a case of asplenic fulminant sepsis in Australia following a dog bite which was complicated by toxic epidermal necrolysis/Stevens-Johnson syndrome (TENS/SJS). Capnocytophaga canimorsus, the infective organism, is a rare cause of septicaemia: a high degree of suspicion of this unusual organism and its early aggressive management is paramount. The diagnostic and management difficulties of TENS/SJS in the context of a patient with fulminant sepsis, DIC and on inotropes are also highlighted.

Characterization of a liquid crystal microlens array using multiwalled carbon nanotube electrodes.

Reconfigurable liquid crystal microlenses employing arrays of multiwalled carbon nanotubes (MWNTs) have been designed and fabricated. The cells consist of arrays of 2 microm high MWNTs grown by plasma-enhanced chemical vapor deposition on silicon with a top electrode of indium tin oxide coated glass positioned 20 microm above the silicon and the gap filled with the nematic liquid crystal BLO48. Simulations have found that, while its nematic liquid crystal aligns with MWNTs within a distance of 10nm, this distance is greatly enhanced by the application of an external electric field. Polarized light experiments show that light is focused with focal lengths ranging from approximately 7 microm to 12 microm.

Transformation of unipolar single-walled carbon nanotube field effect transistors to ambipolar induced by polystyrene nanosphere assembly.

We have fabricated single-walled carbon nanotube (SWNT) field effect transistors (FETs) with molybdenum source and drain contacts. Normally, these devices operate only as p-channel transistors, however, after polystyrene latex nanospheres were attached to the nanotubes close to the contacts, they changed to ambipolar operation. This strategy provides a simple method to modify the electrical behavior of unipolar SWNT-FETs by influencing the gate-channel electric field distribution and offset charge, so enabling complementary circuits to be fabricated.

On the suitability of carbon nanotube forests as non-stick surfaces for nanomanipulation.

A carbon nanotube forest provides a unique non-stick surface for nanomanipulation, as the nanostructuring of the surface allows micro- and nanoscale objects to be easily removed after first being deposited via a liquid dispersion. A common problem for smooth surfaces is the strong initial stiction caused by adhesion forces after deposition onto the surface. In this work, carbon nanotube forests fabricated by plasma-enhanced chemical vapour deposition are compared to structures with a similar morphology, silicon nanograss, defined by anisotropic reactive ion-etching. While manipulation experiments with latex microbeads on structured as well as smooth surfaces (gold, silicon, silicon dioxide, Teflon, diamond-like carbon) showed a very low initial stiction for both carbon nanotube forests and silicon nanograss, a homogeneous distribution of particles was significantly easier to achieve on the carbon nanotube forests. Contact-angle measurements during gradual evaporation revealed that the silicon nanograss was superhydrophic with no contact-line pinning, while carbon nanotube forests in contrast showed strong contact-line pinning, as confirmed by environmental scanning electron microscopy of microdroplets. As a consequence, latex microbeads dispersed on the surface from an aqueous solution distributed evenly on carbon nanotube forests, but formed large agglomerates after evaporation on silicon nanograss. Lateral manipulation of latex microbeads with a microcantilever was found to be easier on carbon nanotube forests and silicon nanograss compared to smooth diamond-like carbon, due to a substantially lower initial stiction force on surfaces with nanoscale roughness. Nanomanipulation of bismuth nanowires, carbon nanotubes and organic nanofibres was demonstrated on carbon nanotube forests using a sharp tungsten tip. We find that the reason for the remarkable suitability of carbon nanotube forests as a non-stick surface for nanomanipulation is indeed the strong contact-line pinning in combination with the nanostructured surface, which allows homogeneous dispersion and easy manipulation of individual particles.