The use of Enhanced Vegetation Index for assessing access to different types of green space in epidemiological studies.

BACKGROUND: Exposure to green space can protect against poor health through a variety of mechanisms. However, there is heterogeneity in methodological approaches to exposure assessments which makes creating effective policy recommendations challenging. OBJECTIVE: Critically evaluate the use of a satellite-derived exposure metric, the Enhanced Vegetation Index (EVI), for assessing access to different types of green space in epidemiological studies. METHODS: We used Landsat 5-8 (30 m resolution) to calculate average EVI for a 300 m radius surrounding 1.4 million households in Wales, UK for 2018. We calculated two additional measures using topographic vector data to represent access to green spaces within 300 m of household locations. The two topographic vector-based measures were total green space area stratified by type and average private garden size. We used linear regression models to test whether EVI could discriminate between publicly accessible and private green space and Pearson correlation to test associations between EVI and green space types. RESULTS: Mean EVI for a 300 m radius surrounding households in Wales was 0.28 (IQR = 0.12). Total green space area and average private garden size were significantly positively associated with corresponding EVI measures (ß = < 0.0001, 95% CI: 0.0000, 0.0000; ß = 0.0001, 95% CI: 0.0001, 0.0001 respectively). In urban areas, as average garden size increases by 1 m2, EVI increases by 0.0002. Therefore, in urban areas, to see a 0.1 unit increase in EVI index score, garden size would need to increase by 500 m2. The very small ß values represent no 'measurable real-world' associations. When stratified by type, we observed no strong associations between greenspace and EVI. IMPACT: It is a widely implemented assumption in epidiological studies that an increase in EVI is equivalent to an increase in greenness and/or green space. We used linear regression models to test associations between EVI and potential sources of green reflectance at a neighbourhood level using satellite imagery from 2018. We compared EVI measures with a 'gold standard' vector-based dataset that defines publicly accessible and private green spaces. We found that EVI should be interpreted with care as a greater EVI score does not necessarily mean greater access to publicly available green spaces in the hyperlocal environment.

The nature and timing of coagulation dysfunction in a cohort of trauma patients in the Australian pre-hospital setting.

BACKGROUND: Acute Traumatic Coagulopathy (ATC) is a complex pathological process that is associated with patient mortality and increased blood transfusion requirements. It is evident on hospital arrival, but there is a paucity of information about the nature of ATC and the characteristics of patients that develop ATC in the pre-hospital setting. The objective of this study was to describe the nature and timing of coagulation dysfunction in a cohort of injured patients and to report on patient and pre-hospital factors associated with the development of ATC in the field. METHODS: This was a prospective observational study of a convenience sample of trauma patients. Patients had blood taken during the pre-hospital phase of care and evaluated for derangements in Conventional Coagulation Assays (CCA) and Rotational Thromboelastometry (ROTEM). Associations between coagulation derangement and pre-hospital factors and patient outcomes were evaluated. RESULTS: A total of 216 patients who had either a complete CCA or ROTEM were included in the analysis. One hundred and eighty (83 %) of patients were male, with a median injury severity score of 17 [interquartile range (IQR) 10-27] and median age of 34 years [IQR = 25.0-52.0]. Hypofibrinogenemia was the predominant abnormality seen, (CCA Hypofibrinogenemia: 51/193, 26 %; ROTEM hypofibrinogenemia: 65/204, 32 %). Increased CCA derangement, the presence of ROTEM coagulopathy, worsening INR, worsening FibTEM and decreasing fibrinogen concentration, were all associated with both mortality and early massive transfusion. CONCLUSION: Clinically significant, multifaceted coagulopathy develops early in the clinical course, with hypofibrinogenemia being the predominant coagulopathy. In keeping with the ED literature, pre-hospital coagulation dysfunction was associated with mortality and early massive transfusion. Further work is required to identify strategies to identify and guide the pre-hospital management of the coagulation dysfunction seen in trauma.

The Rural Hand Therapy Project - providing hand therapy services closer to home.

CONTEXT: Hand therapy optimises functional use of the hand and arm after injury and is an expert area of practice for occupational therapists (OTs) and physiotherapists. In rural Australia, patients frequently travel to metropolitan or larger regional centres for initial hand surgery and rehabilitation. However, rural patients' access to follow-up hand therapy after the initial phase of care is impacted by several factors such as transport options, distance, staff shortages and availability of therapists skilled in hand therapy. To ensure service equity, these challenges require consideration of an alternative model of care that can be provided in rural areas. The aim of this project was to develop a shared care model that would better support rural OTs and rural patients in accessing follow-up hand therapy services closer to home. ISSUE: Two part-time accredited hand therapists (herein referred to as clinical leads) were employed in 2019-2020 to investigate a suitable model of care. Consultation with key stakeholders identified the following core issues: barriers, enablers, processes and intervention, and technology and resources. These findings were combined with recommendations from the literature to develop a model of service delivery: the Rural Hand Therapy Project (RHTP). Under the RHTP, eligible rural patients with complex hand conditions were either seen for their initial appointment, or had their referral screened, by a clinical lead at the regional hospital (Toowoomba Hospital, Queensland). During this process, a detailed handover to the rural OT was completed. Weekly case conferences with a clinical lead were available to all rural clusters. Rural patient cases remained open at the regional hospital for at least 3 months to allow patients to be easily seen by a clinical lead, face to face, or via telehealth (with the rural OT) if needed. The clinical leads also served as the primary contact for any clinical questions from rural OTs. Additionally, the clinical leads provided support and professional development to rural OTs based on the mix of patient cases at the time. LESSONS LEARNED: The RHTP clinical leads were involved in both initial assessment and ongoing intervention for 56% of rural hand therapy patients. The provision of videoconference occasions of service increased from 1% to 8%. Although a low response rate impaired therapist evaluation, an unexpected positive outcome of the RHTP was its flexibility to respond temporarily during rural staff crises and provide vital patient care. The RHTP model of care has shown promise in addressing the challenges faced by rural patients in accessing follow-up hand therapy services closer to home. Further research has been initiated to inform care at a local level. By sharing the model of RHTP, it is hoped that the equity of hand therapy service provision can be increased to improve patient outcomes in other rural and remote localities.

Quality improvement review of O positive blood in emergency transfusion.

BACKGROUND: We recently introduced a policy to use O positive red cells in emergency transfusions for males >16 years of age and females >50 years of age. Here, we investigate changes in emergency transfusion practice and rates of red cell alloimmunization with the use of O positive blood for emergency transfusion. STUDY DESIGN AND METHODS: State-wide retrospective review of emergency transfusions between June 2020 and June 2021. The laboratory information system and patient medical records were used to collect demographic details, indications for transfusion, usage of O positive and O negative blood and rates of alloimmunization. RESULTS: There were 2354 red cell units transfused to 1013 patients (male = 59%, average age = 53 years) during the 12-month period. O positive units accounted for 46.9% (1103 units) of emergency transfusions. However, 726 (30.8%) O negative units were transfused to patients without a mandatory indication for O negative blood. Twenty-eight patients (2.9%) had a red cell alloantibody prior to transfusion including anti-E (n = 10), anti-D (n = 4), and anti-K (n = 4). One patient with prior anti-D had mild delayed hemolysis. There were 19 patients (4.3%, median follow-up 22 days) who developed a red cell alloantibody after emergency transfusion and include anti-E (n = 10), anti-D (n = 7), and anti-C (n = 5). DISCUSSION: The use of O positive blood for emergency transfusion has saved 1103 O negative red cell units with no detriment to patient outcome. There remains potential to optimize use of O positive blood in emergency transfusion and to understand red cell alloimmunization rates in a prospective fashion.

Depression, anxiety, stress, and physical activity of Australian adults during COVID-19: A combined longitudinal and repeated cross-sectional study.

Background: The COVID-19 pandemic has led to a worsening of mental health and health behaviors. While physical activity is positively associated mental health, there is limited understanding of how mental health and physical activity evolve throughout the COVID-19 pandemic. This study aimed to examine changes in depression, anxiety and stress and physical activity, and associations between depression, anxiety, and stress with physical activity in Australian adults across three-time points during the COVID-19 pandemic. Materials and methods: This study collected both longitudinal and cross-sectional data at three-time points during the COVID-19 pandemic in Australia (i.e., April, July/August, and December 2020). Australians aged 18 years and over were invited to complete online surveys hosted on Qualtrics survey platform. Linear mixed models with random subject effect and general linear models were used to analyze the longitudinal and repeated cross-sectional data respectively. Results: The number of participants in cross-sectional surveys and longitudinal surveys was 1,877 and 849, respectively. There was an overall reduction between time 2 vs. time 3 in depression (d = 1.03, 95% CI = 0.20, 1.85), anxiety (d = 0.57, 95% CI = 0.02, 1.12), and stress (d = 1.13, 95% CI = 0.21, 2.04) scores but no significant differences in physical activity across three-time points. On average, participants who met the physical activity guidelines had lower depression (d = -2.08, 95% CI = -2.90, -1.26), anxiety (d = -0.88, 95% CI = -1.41, -0.34), and stress (d = -1.35, 95% CI = -2.13, -0.56) scores compared to those not meeting the guidelines. Conclusion: In the context of the ongoing COVID-19 pandemic, both governments and service providers should continue to provide the public with timely mental health support and promote the benefits of physical activity, as a cost-effective strategy to improve mental health and wellbeing.

Testing the use of translation apps to overcome everyday healthcare communication in Australian aged-care hospital wards-An exploratory study.

AIMS AND OBJECTIVES: To trial three mobile translation apps in the healthcare setting to address language barriers in everyday care between healthcare staff and older people with limited English proficiency (LEP). DESIGN: A mixed-methods exploratory study. METHODS: A two-month trial of three translation apps was conducted across four aged-care hospital wards. Observed interactions during use of translation apps were recorded, and staff surveys regarding the use of translation apps were collected at the end of the trial. Data were analysed using descriptive statistics and thematic content analysis of open-ended responses in the surveys and observations. Findings from the thematic content analysis are reported using the Standards for Reporting of Qualitative Research (SRQR) checklist. RESULTS: Translation apps were mostly used for identifying pain and assisting with activities of daily living. Qualitative findings revealed that translation apps aided staff in providing care and improved rapport; however, practical shortcomings were identified.

Hypofibrinogenaemia and hypocalcaemia in adult trauma patients receiving pre-hospital packed red blood cell transfusions: Potential for supplementary pre-hospital therapeutic interventions.

OBJECTIVE: To report the arrival ionised calcium (iCa) and fibrinogen concentrations in trauma patients treated with packed red blood cells by the road-based high-acuity response units of a metropolitan ambulance service. METHODS: A retrospective review of trauma patients treated with packed red blood cells by high-acuity response units between January 2012 and December 2016. Patients were identified from databases at southeast Queensland adult trauma centres, Pathology Queensland Central Transfusion Laboratory, Gold Coast University Hospital blood bank and the Queensland Ambulance Service. Patient characteristics, results of laboratory tests within 30 min of ED arrival were analysed. RESULTS: A total of 164 cases were analysed. The median injury severity score was 33.5 (interquartile range 22-41), with blunt trauma the commonest mechanism of injury (n = 128, 78.0%). Fifty-eight of the 117 patients (24.4%) with fibrinogen measured had a fibrinogen concentration ≤1.5 g/L; 79 of the 123 patients (64.2%) with an international normalised ratio (INR) measurement had an INR >1.2; 97 of 148 patients (63.8%) with an iCa measured, had an iCa below the Pathology Queensland reference range of 1.15-1.32 mmol/L. Arrival fibrinogen concentration ≤1.5 g/L and arrival iCa ≤1.00 were associated with in-hospital mortality with odds ratio 11.90 (95% confidence interval 4.50-31.65) and odds ratio 4.97 (95% confidence interval 1.42-17.47), respectively. CONCLUSIONS: Hypocalcaemia and hypofibrinogenaemia on ED arrival were common in this cohort. Future work should evaluate whether outcomes improve by correction of these deficits during the pre-hospital phase of trauma care.

Predicting Liver-Related Outcomes in People With Nonalcoholic Fatty Liver Disease: The Prognostic Value of Noninvasive Fibrosis Tests.

It remains unclear whether screening for advanced fibrosis in the community can identify the subgroup of people with nonalcoholic fatty liver disease (NAFLD) at higher risk for development of liver-related complications. We aimed to determine the prognostic value of baseline noninvasive fibrosis tests for predicting liver-related outcomes and mortality in patients with NAFLD from type 2 diabetes (T2D) clinics or primary care. Patients (n = 243) who were screened for NAFLD with advanced fibrosis by using NAFLD fibrosis score (NFS), fibrosis 4 score (FIB-4), enhanced liver fibrosis (ELF) test, and liver stiffness measurements (LSMs) were followed up for clinical outcomes by review of electronic medical records. During a median follow-up of 50 months, decompensated liver disease or primary liver cancer occurred in 6 of 35 (17.1%) patients with baseline LSM > 13 kPa, 1 of 17 (5.9%) patients with LSM 9.5-13 kPa, and in no patients with LSM < 9.5 kPa. No patient with low-risk NFS developed liver decompensation or liver-related mortality. Following repeat NFSs at the end of follow-up, all patients with a liver-related complication were in the high-risk NFS category. Patients who developed liver-related complications were also more likely to have baseline high-risk FIB-4 scores or ELF test ≥9.8 compared to patients who did not develop liver outcomes. Conclusion: Liver fibrosis risk stratification in non-hepatology settings can identify the subset of patients at risk of liver-related complications. Although the rate of development of a decompensation event or hepatocellular carcinoma was low (2.1% per year) in our patients with compensated cirrhosis (LSM > 13 kPa), these events are projected to lead to a substantial increase in NAFLD-related disease burden over the next decade due to the high prevalence of NAFLD in people with obesity and T2D.

Towards collaborative management of non-alcoholic fatty liver disease: a 'real-world' pathway for fibrosis risk assessment in primary care.

BACKGROUND: The optimal strategy to support primary care practitioners (PCP) to assess fibrosis severity in non-alcoholic fatty liver disease (NAFLD) and thereby make appropriate management decisions remains unclear. AIMS: To examine the feasibility of using a two-step pathway that combined simple scores (NAFLD Fibrosis Score and Fibrosis-4 Index) with transient elastography (FibroScan) to streamline NAFLD referrals from a 'routine' primary care population to specialist hepatology management clinics (HMC). METHODS: The two-step 'Towards Collaborative Management of NAFLD' (TCM-NAFLD) fibrosis risk assessment pathway was implemented at two outer metropolitan primary healthcare practices in Brisbane. Patients aged ≥18 years with a new or established PCP-diagnosis of NAFLD were eligible for assessment. The pathway triaged patients at 'high risk' of clinically significant fibrosis to HMC for specialist review, and 'low risk' patients to receive ongoing management and longitudinal follow up in primary care. RESULTS: A total of 162 patient assessments between June 2019 and December 2020 were included. Mean age was 58.7 ± 11.7 years, 30.9% were male, 54.3% had type 2 diabetes or impaired fasting glucose, and mean body mass index was 34.2 ± 6.9 kg/m2 . A total 122 patients was considered 'low risk' for clinically significant fibrosis, two patients had incomplete assessments and 38 (23.5%) were triaged to HMC. Among 31 completed HMC assessments to date, 45.2% were considered to have clinically significant (or more advanced) fibrosis, representing 9.2% of 153 completed assessments. CONCLUSION: Implementation of the two-step TCM-NAFLD pathway streamlined hepatology referrals for NAFLD and may facilitate a more cost-effective and targeted use of specialist hepatology resources.

Developing a Culture of Support to Advance and Accelerate Nursing Innovation.

Nurses everywhere are called to seek new and better ways of providing care in the complex and dynamic environments where they practise. The core of innovation is the creation of new ideas and use of existing ideas in new ways or in new settings. Today, innovation and fresh thinking are more important than ever as the world is changing rapidly and complexity is the norm. Nurse leaders are called to action to create the insights, cultures, structures and methodologies needed to promote the development and uptake of innovative ideas in nursing practice and interdisciplinary team work. This paper highlights three successful examples of nursing leadership in the development of a culture of innovation at the national (SE Health), provincial (Registered Nurses Foundation of Ontario's Nurse Innovator Awards) and local (Sinai Health) levels. The goal of these initiatives is to cultivate innovation as a way of being, thinking and doing, ensuring that it is inherent in nursing culture and visible in nursing practice, education and research that enhances patients' and care partners' experiences.

Basal thumb arthritis: Treatment strategies for managing pain.

BACKGROUND: The carpometacarpal joint of the thumb is one of the joints most commonly affected by arthritis. The dominant hand is involved in 60-65% of cases, with a higher prevalence among women. The condition results in significant disability of the hand, which affects activities of daily living. Management is dependent on both the clinical stage of the disease and patient expectations and demands. OBJECTIVE: The aim of this article is to review the current non-operative and operative modalities in managing pain symptoms, and explore evidence for the use of these modalities. DISCUSSION: Basal thumb arthritis is a very common condition encountered by the general practitioner. Treatment must focus on functional expectations and demands of the patient, and individualised treatment plans need to be tailored to the patient. Hand therapy in addition to patient education and use of an orthosis has been shown to be very effective in management of the early stages of basal thumb arthritis. With more advanced disease, surgical modalities provide better symptomatic control.

The perceptions of translation apps for everyday health care in healthcare workers and older people: A multi-method study.

AIMS AND OBJECTIVES: To understand the attitudes and perceptions of older people with limited English proficiency (LEP) and healthcare workers to using mobile translation technology for overcoming language barriers in the healthcare setting. BACKGROUND: Australia's cohort of people aged 65 and over has a sizeable population with LEP. In healthcare settings, difficulties with communication may potentially result in inadequate care. Mobile language translation applications have been identified as a potential way to improve communication between patients and healthcare staff when used as an adjunct to professional interpreters in low-risk scenarios; however, the perceptions of the use of mobile translation applications for such communication is unknown. METHODS: A multi-method design was used. Focus group discussions were conducted with older people from culturally and linguistically diverse (CALD) backgrounds and nursing and allied health professionals to understand their perceptions of translation technology. Qualitative data were analysed using inductive content analysis. Qualitative findings were reported using the Standards for Reporting of Qualitative Research (SRQR) checklist. Participants also appraised three existing translation apps via survey and results were analysed using descriptive statistics. RESULTS: Overall, older people from CALD backgrounds (n = 12) and healthcare staff (n = 17) agreed that translation technology could play a role in reducing communication barriers. There was enthusiasm amongst older people to learn and use the technology, while healthcare staff saw the potential to address communication barriers in their own work. Barriers identified by older people and healthcare staff included: accuracy of translation and phrases, possible technological learning curves, risk of mistranslation in high-risk conversation and inability to check accuracy of translation. Fixed-phrase translation apps were seen as more favourable than real-time voice-to-voice mobile translation applications. CONCLUSIONS: Older people from CALD backgrounds and healthcare staff were open to the use of mobile translation applications for everyday healthcare communications. RELEVANCE TO CLINICAL PRACTICE: Translation applications may have a role in reducing language barriers in everyday healthcare communication but context, accuracy and ease of use need to be considered.

Language Translation Apps in Health Care Settings: Expert Opinion.

BACKGROUND: Currently, over 300 languages are spoken in Australian homes. People without proficient English from non-English speaking countries may not receive equitable care if their health care workers do not speak their primary language. Use of professional interpreters is considered the gold standard; however, for a variety of reasons, it is often limited to key aspects of care such as diagnosis and consent. With the emergence of mobile technologies, health care workers are increasingly using digital translation tools to fill this gap. However, many of these technologies have not been developed for health care settings and their use has not been evaluated. OBJECTIVE: This study aimed to evaluate iPad-compatible language translation apps to determine their suitability for enabling everyday conversations in health care settings. METHODS: Translation apps were identified by searching the Apple iTunes Store and published and grey literature. Criteria for inclusion were that the apps were available at no cost, able to translate at least one of the top 10 languages spoken in Australia, and available for use on iPad. Apps that met inclusion criteria were reviewed in 2 stages. Stage 1 was the feature analysis conducted by 2 independent researchers, where apps were evaluated for offline use, input and output methods, and number of languages. Stage 2 was the analysis of suitability for everyday communication in the health care setting, conducted by 2 independent professionals with expertise in translation and cross-cultural communication. Apps that enabled key aspects of care normally within the realm of professional interpreters, such as assessment, treatment and discharge planning, and seeking consent for medical treatments, were considered unsuitable. RESULTS: In total, 15 apps were evaluated. Of these, 8 apps contained voice-to-voice and voice-to-text translation options. In addition, 6 apps were restricted to using preset health phrases, whereas 1 app used a combination of free input and preset phrases. However, 5 apps were excluded before stage 2. In addition, 6 of the 10 remaining apps reviewed in stage 2 were specifically designed for health care translation purposes. Of these, 2 apps were rated as suitable for everyday communication in the health care setting-culturally and linguistically diverse Assist and Talk To Me. Both apps contained simple and appropriate preset health phrases and did not contain conversations that are normally within the realm of professional interpreters. CONCLUSIONS: All iPad-compatible translation apps require a degree of caution and consideration when used in health care settings, and none should replace professional interpreters. However, some apps may be suitable for everyday conversations, such as those that enable preset phrases to be translated on subject matters that do not require a professional interpreter. Further research into the use of translation technology for these types of conversations is needed.

Older people and knowledge of epilepsy: GPs can help.

BACKGROUND: Epilepsy is a common neurological disease with a high prevalence in people aged 65 years or older. Therefore, an understanding of the disease is important. The objective of this article was to determine older people's knowledge of epilepsy. METHODS: Electronic or paper-based surveys were completed by people aged 65 years and older. RESULTS: Five hundred and seventy-two surveys were completed, including 100 from people with epilepsy. Those with epilepsy had relatively poor knowledge of their condition, but they answered some questions significantly more correctly than participants without epilepsy. The main predictor of knowledge was clear information from a health professional. Two-thirds of those with epilepsy had their condition managed by a general practitioner. DISCUSSION: Older people with epilepsy need more information on their condition to facilitate better care management.

The feasibility of civilian prehospital trauma teams carrying and administering packed red blood cells.

OBJECTIVE: To evaluate the feasibility, limitations and costs involved in providing prehospital trauma teams with packed red blood cells (pRBCs) for use in the prehospital setting. METHODS: A retrospective cohort study, examining 18 months of historical data collated by the Queensland Ambulance Service Trauma Response Team (TRT) and the Pathology Queensland Central Transfusion Laboratory was undertaken. RESULTS: Over an 18-month period (1 January 2011-30 June 2012), of 500 pRBC units provided to the TRT, 130 (26%) were administered to patients in the prehospital environment. Of the non-transfused units, 97.8% were returned to a hospital blood bank and were available for reissue. No instances of equipment failure directly contributed to wastage of pRBCs. The cost of providing pRBCs for prehospital use was $A551 (£361) for each unit transfused. CONCLUSIONS: It is feasible and practical to provide prehospital trauma teams with pRBCs for use in the field. Use of pRBCs in the prehospital setting is associated with similar rates of pRBC wastage to that reported in emergency departments.

Characteristics and outcomes of patients administered blood in the prehospital environment by a road based trauma response team.

OBJECTIVE: To describe the characteristics, clinical interventions and the outcomes of patients administered packed red blood cells (pRBCs) by a metropolitan, road based, doctor-paramedic trauma response team (TRT). METHODS: A retrospective cohort study examining 18 months of historical data collated by the Queensland Ambulance Service TRT, the Pathology Queensland Central Transfusion Laboratory, the Royal Brisbane and Women's Hospital and the Princess Alexandra Hospital Trauma Services was undertaken. RESULTS: Over an 18-month period (1 January 2011 to 30 June 2012), 71 trauma patients were administered pRBCs by the TRT. Seven patients (9.9%) died on scene and 39 of the 64 patients (60.9%) transported to hospital survived to hospital discharge. 57 (89.1%) of the transported patients had an Injury Severity Score (ISS) > 15, with a mean ISS, Revised Trauma Score (RTS) and Trauma-Injury Severity Score of 32.11, 4.70 and 0.57, respectively. No patients with an RTS < 2 survived to hospital discharge. 53 patients (82.8%) received additional pRBCs in hospital with 17 patients (26.6%) requiring greater than 10 units pRBCs in the first 24 h. 47 patients (73.4%) required surgical or interventional radiological procedures in the first 24 h. CONCLUSIONS: There is a potential role for prehospital pRBC transfusions in an integrated civilian trauma system. The RTS calculated using the initial set of observations may be a useful tool in determining in which patients the administration of prehospital pRBC transfusions would be futile.

Fatal toxic leukoencephalopathy secondary to overdose of a new psychoactive designer drug 2C-E ("Europa").

We present a case of a fatal toxic leukoencephalopathy following ingestion of a new psychoactive designer drug known as 2C-E or "Europa." Recreational drugs, particularly hallucinogenic substances, appear to be growing in popularity, with increasing amounts of information available via the Internet to entice potential users. In addition, some newer "designer" psychoactive substances are available for purchase online without adverse legal consequences, therefore adding to their popularity. We describe magnetic resonance imaging (MRI) findings to include selective diffuse toxic injury of the cerebral white matter with sparing of the cortex and most of the deep gray nuclei. To our knowledge, this is the first reported description of cerebral findings on MRI that are likely related to a lethal ingestion of 2C-E.

Improving attendance for cardiovascular risk assessment in Australian general practice: an RCT of a monetary incentive for patients.

BACKGROUND: Preventive health care is an important part of general practice however uptake of activities by patients is variable. Monetary incentives for doctors have been used in the UK and Australia to improve rates of screening and immunisation. Few studies have focussed on incentives for patients to attend preventive health care examinations. Our objective was to investigate the use of a monetary incentive to increase patient attendance with their general practitioner for a cardiovascular risk assessment (CVRA). METHODS: A pragmatic RCT was conducted in two Australian general practices. Participating GPs underwent academic detailing for cardiovascular risk assessment. 301 patients aged 40-74, who did not have cardiovascular disease, were independently randomised to receive a letter inviting them to a no cost cardiovascular risk assessment with their GP, or the same letter plus an offer of a $25 shopping voucher if they attended. An audit of patient medical records was also undertaken and a patient questionnaire administered to a sub sample of participants. Our main outcome measure was attendance for cardiovascular risk assessment. RESULTS: In the RCT, 56/301(18.6%) patients attended for cardiovascular risk assessment, 29/182 (15.9%) in the control group and 27/119 (22.7%) in the intervention group. The estimated difference of 6.8% (95% CI: -2.5% to 16.0%) was not statistically significant, P = 0.15. The audit showed that GPs may underestimate patients' absolute cardiovascular risk and the questionnaire that mailed invitations from GPs for a CVRA may encourage patients to attend. CONCLUSIONS: A small monetary incentive does not improve attendance for cardiovascular risk assessment. Further research should be undertaken to determine if there are other incentives that may increase attendance for preventive activities in the general practice setting. CLINICAL TRIALS REGISTRATION: ACTRN12608000183381.