Interprofessional education in the rural environment to enhance multidisciplinary care in future practice: Breaking down silos in tertiary health education.

OBJECTIVE: Western Sydney University has implemented a rural interprofessional learning programme to promote collaborative care approaches to enhance cross-discipline communications, improve knowledge and clarity of roles and improve patient care and outcomes. DESIGN: Rural interprofessinal learning is an interprofessional educational approach, consisting of simulations of complex health events. Simulation methodology frames the study with a focus on human interaction. A mixed-methods evaluation has been conducted, incorporating pre- and post- event participant surveys along with semi-structured focus groups. SETTING: Simulations are conducted in the rural setting, including community settings, working farms and rural hospitals. MAIN OUTCOME MEASURES: Reflexive thematic analysis was used to identify themes measuring students' perceptions of interdisciplinary care, knowlede of other health discipline roles and skills and how they believe the exercise will influence their future practice. Facilitator feedback regarding the efficacy of the simulations was also recorded and analysed using reflexive thematic analysis. PARTICIPANTS: Care of simulated patient(s)/bystander(s) is primarily provided by paramedicine, nursing and medical students; however, increasing interest has expanded the programme to include students from a range of allied health professions. Simulations are facilitated by a multidisciplinary team of experienced practitioners and specialists. INTERVENTION: Four rural interprofessional learning events have been held. RESULTS: 120 students have participated in the evaluation. Findings include increased understanding of the contributions of other disciplines in enhancing patient care, team approaches, cross-discipline communication and a need to engage in collaborative care in future practice. CONCLUSION: Creating a collaborative learning environment creates a culture of multidisciplinary care, enhancing patient care and improving outcomes. The rural interprofessional learning model is an effective interprofessional educational approach, which can be repeated, refined and improved for continual professional development.

Validity of energy expenditure estimation methods during 10 days of military training.

Wearable physical activity (PA) monitors have improved the ability to estimate free-living total energy expenditure (TEE) but their application during arduous military training alongside more well-established research methods has not been widely documented. This study aimed to assess the validity of two wrist-worn activity monitors and a PA log against doubly labeled water (DLW) during British Army Officer Cadet (OC) training. For 10 days of training, twenty (10 male and 10 female) OCs (mean ± SD: age 23 ± 2 years, height 1.74 ± 0.09 m, body mass 77.0 ± 9.3 kg) wore one research-grade accelerometer (GENEActiv, Cambridge, UK) on the dominant wrist, wore one commercially available monitor (Fitbit SURGE, USA) on the non-dominant wrist, and completed a self-report PA log. Immediately prior to this 10-day period, participants consumed a bolus of DLW and provided daily urine samples, which were analyzed by mass spectrometry to determine TEE. Bivariate correlations and limits of agreement (LoA) were employed to compare TEE from each estimation method to DLW. Average daily TEE from DLW was 4112 ± 652 kcal·day-1 against which the GENEActiv showed near identical average TEE (mean bias ± LoA: -15 ± 851 kcal. day-1 ) while Fitbit tended to underestimate (-656 ± 683 kcal·day-1 ) and the PA log substantially overestimate (+1946 ± 1637 kcal·day-1 ). Wearable physical activity monitors provide a cheaper and more practical method for estimating free-living TEE than DLW in military settings. The GENEActiv accelerometer demonstrated good validity for assessing daily TEE and would appear suitable for use in large-scale, longitudinal military studies.

Carotid artery wall mechanics in young males with high cardiorespiratory fitness.

NEW FINDINGS: What is the central question of this study? Common carotid artery (CCA) two-dimensional strain imaging detects intrinsic arterial wall properties beyond conventional measures of arterial stiffness, but the effect of cardiorespiratory fitness on two-dimensional strain-derived indices of CCA stiffness is unknown. What is the main finding and its importance? Two-dimensional strain imaging of the CCA revealed greater peak circumferential strain and systolic strain rate in highly fit men compared with their less fit counterparts. Altered CCA wall mechanics might reflect intrinsic training-induced adaptations that help to buffer the increase in pulse pressure and stroke volume during exercise. ABSTRACT: The influence of cardiorespiratory fitness on arterial stiffness in young adults remains equivocal. Beyond conventional measures of arterial stiffness, two-dimensional strain imaging of the common carotid artery (CCA) provides new information related to the intrinsic properties of the arterial wall. Therefore, the aim of this study was to assess the effect of cardiorespiratory fitness on both conventional indices of CCA stiffness and two-dimensional strain parameters, at rest and after a bout of aerobic exercise in young, healthy men. Short-axis ultrasound images of the CCA were recorded in 34 healthy men {22 years old [95% confidence interval (CI), 19, 22]} before and immediately after 5 min of aerobic exercise (40% of maximal oxygen consumption). Images were analysed for arterial diameter, peak circumferential strain (PCS) and peak systolic and diastolic strain rates (S-SR and D-SR). Heart rate, systolic and diastolic blood pressure were simultaneously assessed, and Peterson's elastic modulus (Ep ) and ß-stiffness (ß1 ) were calculated. Participants were separated post hoc into moderate- and high-fitness groups [maximal oxygen consumption, 48.9 (95% CI, 44.7, 53.2) versus 65.6 ml kg-1  min-1 (95% CI, 63.1, 68.1), respectively; P < 0.001]. The Ep and ß1 were similar between groups at baseline (P > 0.13) but were elevated in the moderate-fitness group postexercise (P < 0.04). The PCS and S-SR were elevated in the high-fitness group at both time points [3.0% (95% CI, 1.2, 4.9), P = 0.002, and 0.401 s-1 (95% CI, 0.085, 0.72), P = 0.02, respectively]. No group differences were observed in CCA heart rate, systolic or diastolic blood pressure or D-SR throughout the protocol (P > 0.05). Highly fit individuals exhibit elevated CCA, PCS and S-SR, which might reflect training-induced adaptations that help to buffer the increase in pulse pressure and stroke volume during exercise.

Evidence-based occupational therapy for people with dementia and their families: What clinical practice guidelines tell us and implications for practice.

BACKGROUND/AIM: The first evidence-based Clinical Practice Guidelines and Principles of Care for People with Dementia in Australia have been released. The Guidelines detail a number of important evidence-based recommendations for occupational therapists. The aim of this paper is (1) to provide an overview of Guideline development, and (2) to describe the evidence supporting a recommendation for occupational therapy. Common characteristics of effective occupational therapy programmes for people with dementia are described. METHODS: Guideline development involved adaptation of existing high-quality guidelines developed overseas and 17 systematic reviews to ensure that the most recent high-quality evidence was included. One of the systematic reviews involved examining the evidence for interventions to promote independence in people with dementia. Specifically, we looked at the evidence for occupational therapy and its effect on activities of daily living, quality of life and carer impact. RESULTS: A total of 109 recommendations are included in the Guidelines. Occupational therapy was found to significantly increase independence in activities of daily living and improve quality of life. Effective occupational therapy programmes involve: environmental assessment, problem solving strategies, carer education and interactive carer skills training. CONCLUSION: Occupational therapists working with people with dementia in community settings should ensure that their time is spent on those aspects of intervention that are shown to be effective.

Clinical practice guidelines for dementia in Australia.

About 9% of Australians aged 65 years and over have a diagnosis of dementia. Clinical practice guidelines aim to enhance research translation by synthesising recent evidence for health and aged care professionals. New clinical practice guidelines and principles of care for people with dementia detail the optimal diagnosis and management in community, residential and hospital settings. The guidelines have been approved by the National Health and Medical Research Council. The guidelines emphasise timely diagnosis; living well with dementia and delaying functional decline; managing symptoms through training staff in how to provide person-centred care and using non-pharmacological approaches in the first instance; and training and supporting families and carers to provide care.

Iron supplementation benefits physical performance in women of reproductive age: a systematic review and meta-analysis.

Animal and human observational studies suggest that iron deficiency impairs physical exercise performance, but findings from randomized trials on the effects of iron are equivocal. Iron deficiency and anemia are especially common in women of reproductive age (WRA). Clear evidence of benefit from iron supplementation would inform clinical and public health guidelines. Therefore, we performed a systematic review and meta-analysis to determine the effect of iron supplementation compared with control on exercise performance in WRA. We searched the Cochrane Central Register of Clinical Trials, MEDLINE, Scopus (comprising Embase and MEDLINE), WHO regional databases, and other sources in July 2013. Randomized controlled trials that measured exercise outcomes in WRA randomized to daily oral iron supplementation vs. control were eligible. Random-effects meta-analysis was used to calculate mean differences (MDs) and standardized MDs (SMDs). Risk of bias was assessed using the Cochrane risk-of-bias tool. Of 6757 titles screened, 24 eligible studies were identified, 22 of which contained extractable data. Only 3 studies were at overall low risk of bias. Iron supplementation improved both maximal exercise performance, demonstrated by an increase in maximal oxygen consumption (VO2 max) [for relative VO2 max, MD: 2.35 mL/(kg ⋅ min); 95% CI: 0.82, 3.88; P = 0.003, 18 studies; for absolute VO2 max, MD: 0.11 L/min; 95% CI: 0.03, 0.20; P = 0.01, 9 studies; for overall VO2 max, SMD: 0.37; 95% CI: 0.11, 0.62; P = 0.005, 20 studies], and submaximal exercise performance, demonstrated by a lower heart rate (MD: -4.05 beats per minute; 95% CI: -7.25, -0.85; P = 0.01, 6 studies) and proportion of VO2 max (MD: -2.68%; 95% CI: -4.94, -0.41; P = 0.02, 6 studies) required to achieve defined workloads. Daily iron supplementation significantly improves maximal and submaximal exercise performance in WRA, providing a rationale to prevent and treat iron deficiency in this group. This trial was registered with PROSPERO (http://www.crd.york.ac.uk/PROSPERO/prospero.asp) as CRD42013005166.

Judicious use of precise fluorescence in situ hybridisation panels guided by population prevalence may assist pragmatic detection of clinically targetable Philadelphia chromosome-like acute lymphoblastic leukaemia fusions: a systematic review.

Diagnosis of Philadelphia chromosome-like acute lymphoblastic leukaemia (Ph-like ALL) in the real-world remains challenging because of definitional complexities, the diverse diagnostic techniques available and the cost, expertise and time involved. We summarise evidence for diagnosis of clinically important Ph-like ALL related genomic lesions using fluorescence in situ hybridisation (FISH) targeting only clinically important and actionable lesions, an accessible and cost-effective diagnostic technique. Electronic databases were interrogated using broad MeSH terms for articles reporting a detailed FISH strategy for diagnosis of Ph-like ALL published since 2014, yielding 653 full text articles and abstracts. We searched the National Library of Medicine Databases including PubMed, Medline, Embase, Cochrane and relevant abstracts. We included studies with a primary aim of determining the utility of FISH for Ph-like ALL diagnosis and studies with broader aims demonstrating Ph-like ALL diagnostic algorithms which partially involved FISH. Nineteen studies met inclusion criteria. Evidence for FISH to detect CRLF2 rearrangements in Ph-like ALL is strongly established and evidence for FISH to detect non-CRLF2 lesions is evolving rapidly. We documented 1620 cases of non-CRLF2 Ph-like lesions diagnosed by FISH. Confirmatory side-by-side methods were applied in six studies (246 samples), four of which demonstrated 100% concordance of FISH results with alternative methods, while two studies demonstrated over 70% sensitivity and specificity. Additional studies demonstrated wide utilisation of FISH in Ph-like ALL classification across diverse geographies and ethnicities, with contrasting prevalence, implicating a need for targeted FISH strategies. In real-world cohorts, it may be clinically useful to prioritise limited early FISH in B-cell ALL (B-ALL) diagnostic algorithms to identify Ph-like abnormalities that respond to locally available kinase inhibitors to promote and prioritise broad access to effective targeted treatment. Additional studies are required to provide adequately powered validations and verifications of targeted Ph-like FISH panels to confirm sensitivity and specificity against side-by-side gold standard methods, and to define optimal local approaches.

Person-centred quality indicators for Australian aged care assessment services: a mixed methods study.

BACKGROUND: Aged Care Assessment Teams are the assessment component of the Australian aged care system. Their purpose is to undertake needs-based assessments to determine an older person's eligibility for, and access to Commonwealth-funded aged care services. There are no measures that tell us if the aged care assessment service is of high quality from the perspective of the person being assessed. Quality measures have been developed and introduced in Australian residential aged care facilities. These however, have not considered the perspectives of those living in this setting. Quality measures for home care services have also been recommended. This research aims to address the gap in person-centred quality measures by asking current and future service users of aged care assessment services to vote on the importance of 24 person-centred quality indicators (PC-QIs), that were developed in a previous study using a modified Delphi method approach supported by engagement with a consumer led Advisory Board. METHODS: This mixed methods study used the RAND/UCLA Appropriateness Method to reach consensus on a final set of PC-QIs. Twenty-five community-dwelling older people in Brisbane, Australia, voted on the importance of 24 PC-QIs using a five-point Likert scale. A consensus statement for PC-QI elimination was determined prior to participants voting. Voting was undertaken with participants individually either face-to-face or via telephone, in their homes. To capture any narrative provided by participants regarding each PC-QI, participant voting sessions were audio-recorded and subsequently transcribed verbatim. Quantitative data from participant votes for each PC-QI were calculated and statistically described by median, interquartile range, consensus met, percentile, percentile rank, rank order, median and standard deviation. PC-QIs were then assessed against the consensus statement for elimination and rank ordered according to importance to participants. Content analysis of qualitative data from audio transcriptions was conducted to determine the presence of certain words supporting participant votes for each PC-QI. RESULTS: No PC-QIs were eliminated during voting. Variation existed among participants' ratings of importance for each PC-QI. Final quality domains, their respective title, quality indicator descriptor and supporting qualitative data are presented. Five PC-QIs had a median of five, no votes recorded below four, an interquartile range of zero, and a rank order score of one, two and four, out of a possible ten, indicating they were of highest importance to participants. CONCLUSION: Participants reached consensus on 24 evidence-based PC-QIs that represent measures of quality of aged care assessment services from the perspectives of current and future service users.

In Australia, people 65 years or over, and Aboriginal and Torres Strait Islander Peoples 50 years or over, can apply to access aged care services funded by the Australian government (Australian Government, Department of Health and Aged Care. 2021-2022 Report on the Operation of the Aged Care Act 1997, 2022). Services the government funds include supporting older people to live at home, residential aged care if the person can't live at home, and short-term rehabilitation (Australian Government, Department of Health and Aged Care. 2021-2022 Report on the Operation of the Aged Care Act 1997, 2022). To access these services, a person needs to fill out an application form and undergo an aged care assessment. Another person can help complete the application. The purpose of the aged care assessment is to assess the person's needs to determine what aged care services they are eligible to access. There are no measures that tell us if the aged care assessment service is of high quality from the perspective of the person being assessed. Twenty-four measures of quality were developed in a previous study with support from a consumer Advisory Board (Smith S, Travers C, Roberts N, Martin­Khan M. Health Expect, 2024). This study asked 25 older people living in Brisbane, the importance of the 24 measures, to decide if any should be eliminated. People were asked to vote using a number scale where number one meant it 'wasn't important', and five meant it was 'extremely important.' A consensus statement was agreed to decide if a measure would be eliminated. All measures were voted as being important with no measure eliminated. Quality Measures voted as being important included receiving assessments from knowledgeable health care staff, who treated them with dignity and respect, adopted a person-centred approach, established a collaborative relationship, and communicated clearly.

Designing an Alternative, Community Integrated Model of Residential Aged Care for People Living with Dementia: Nominal Group Technique and Thematic Analysis.

BACKGROUND: Small-scale models of dementia care are a potential solution to deinstitutionalize residential aged care and have been associated with improved resident outcomes, including quality of life and reduced hospitalizations for people living with dementia. OBJECTIVE: This study aimed to generate strategies and ideas on how homes for people living with dementia in a village setting within a suburban community, could be designed and function without external boundaries. In particular, how could residents of the village and members of the surrounding community access and engage safely and equitably so that interpersonal connections might be fostered? METHODS: Twenty-one participants provided an idea for discussion at three Nominal Group Technique workshops, including people living with dementia, carers or former carers, academics, researchers, and clinicians. Discussion and ranking of ideas were facilitated in each workshop, and qualitative data were analyzed thematically. RESULTS: All three workshops highlighted the importance of a surrounding community invested in the village; education and dementia awareness training for staff, families, services, and the community; and the necessity for adequately and appropriately trained staff. An appropriate mission, vision, and values of the organization providing care were deemed essential to facilitate an inclusive culture that promotes dignity of risk and meaningful activities. CONCLUSION: These principles can be used to develop an improved model of residential aged care for people living with dementia. In particular, inclusivity, enablement, and dignity of risk are essential principles for residents to live meaningful lives free from stigma in a village without external boundaries.

Left ventricular mechanics in humans with high aerobic fitness: adaptation independent of structural remodelling, arterial haemodynamics and heart rate.

Individuals with high aerobic fitness have lower systolic left ventricular strain, rotation and twist ('left ventricular (LV) mechanics') at rest, suggesting a beneficial reduction in LV myofibre stress and more efficient systolic function. However, the mechanisms responsible for this functional adaptation are not known and the influence of aerobic fitness on LV mechanics during dynamic exercise has never been studied. We assessed LV mechanics, LV wall thickness and dimensions, central augmentation index (AIx), aortic pulse wave velocity (aPWV), blood pressure and heart rate in 28 males (age: 21±2 years SD) with a consistent physical activity level (no change>6 months). Individuals were examined at rest and during exercise (40% peak exercise capacity) and separated post hoc into a moderate and high aerobic fitness group (˙V(O2peak): 49 ± 5 and 63 ± 7ml kg−1 min−1, respectively, P <0.0001). At rest and during exercise, there were no significant differences in gross LVstructure, AIx, blood pressure or heart rate (P >0.05).However, for the same AIx, the high ˙V(O2peak) group had significantly lower LV apical rotation (P =0.002) and LV twist (P =0.003) while basal rotation and strain indices did not differ between groups (P >0.05).We conclude that young males with high aerobic fitness have lower LVapical rotation at rest and during submaximal exercise that can occur without changes in gross LV structure, arterial haemodynamics or heart rate. The findings suggest a previously unknown type of physiological adaptation of the left ventricle that may have important implications for exercise training in older individuals and patient populations in which exercise training has previously failed to show clear benefits for LV function.

Toxicity of 6-hydroxydopamine: live cell imaging of cytoplasmic redox flux.

Oxidative stress contributes to several debilitating neurodegenerative diseases. To facilitate direct monitoring of the cytoplasmic oxidation state in neuronal cells, we have developed roTurbo by including several mutations: F223R, A206K, and six of the mutations for superfolder green fluorescent protein. Thus we have generated an improved redox sensor that is much brighter in cells and oxidizes more readily than roGFP2. Cytoplasmic expression of the sensor demonstrated the temporal pattern of 6-hydroxydopamine (6-OHDA) induced oxidative stress in a neuroblastoma cell line (SH-SY5Y). Two distinct oxidation responses were identified in SH-SY5Y cells but a single response observed in cells lacking monoamine transporters (HEK293). While both cell lines exhibited a rapid transient oxidation in response to 6-OHDA, a second oxidative response coincident with cell death was observed only in SH-SY5Y cells, indicating an intracellular metabolism of 6-OHDA, and or its metabolites are involved. In contrast, exogenously applied hydrogen peroxide induced a cellular oxidative response similar to the first oxidation peak, and cell loss was minimal. Glucose deprivation enhanced the oxidative stress induced by 6-OHDA, confirming the pivotal role played by glucose in maintaining a reduced cytoplasmic environment. While these studies support previous findings that catecholamine auto-oxidation products cause oxidative stress, our findings also support studies indicating 6-OHDA induces lethal oxidative stress responses unrelated to production of hydrogen peroxide. Finally, temporal imaging revealed the sporadic nature of the toxicity induced by 6-OHDA in neuroblastoma cells.

Uneven implementation of the National Perinatal Depression Initiative: findings from a survey of Australian women's hospitals.

BACKGROUND: Australia is a leader in recognising that perinatal mental health problems are prevalent and constitute a significant burden of disease among women. In 2009, the Australian government launched the National Perinatal Depression Initiative (NPDI) to address this. AIMS: To investigate implementation of Australia's NPDI. MATERIALS AND METHODS: Data were collected by a structured online survey assessing: screening for depression and depression risk in women receiving antenatal and postnatal care; staff training about perinatal depression; barriers and enablers to implementing the NPDI recommendations. All Australian members of Women's Healthcare Australasia (WHA) were invited to complete the survey in March 2011. RESULTS: Of 30 Australian WHA members, 14 (46.6%) completed the survey. The sample included a representative distribution of small, medium and large hospitals. All respondents had introduced some NPDI recommendations. Most (80%) reported using the Edinburgh Postnatal Depression Scale (EPDS) to screen for antenatal depression and for risk of developing depression but at varied gestational ages, and with differing cut-off scores for follow-up or referral. Only one assessed depression status postpartum. Responsibility for screening and feedback was predominantly assigned to midwives, most of whom were offered <4 h training. Implementation barriers included insufficient personnel; per-client time requirements; insufficient clarity about screening protocols; difficulties modifying the medical record; few referral options and a lack of training resources. CONCLUSIONS: Implementation of the NPDI is uneven among Australian maternity hospitals. Little is known about perinatal mental health screening practices in the private sector and hospitals with <1000 births annually.

Women's experiences of care and their concerns and needs following a significant primary postpartum hemorrhage.

BACKGROUND: In the context of rising rates of postpartum hemorrhage and little data about its effect on women, this study aimed to describe the experiences of care, and the concerns and needs of women after a significant postpartum hemorrhage. METHODS: A cohort of 206 women with a primary postpartum hemorrhage of 1,500 mL or more and/or a peripartum fall in hemoglobin concentration to 7 g/dL or less and/or of 4 g/dL or more was recruited from 17 major hospitals in Australasia. Women rated their satisfaction with care and provided written responses to questions in postpartum questionnaires completed in the first week and at 2 and 4 months postpartum. RESULTS: In relation to care in hospital, consistently over 20 percent women responded that their needs for information, acknowledgment, and reassurance were only met sometimes, rarely, or never. Sixty-two percent reported that they were given adequate information about their likely physical recovery, and 48 percent about their likely emotional recovery. Four major themes were identified in response to the open-ended questions: adequacy of care, emotional responses to the experience, implications for the future, and concerns for their baby. CONCLUSIONS: This study is an important step in identifying the negative impact of experiencing a significant postpartum hemorrhage during childbirth for women who survive. Our results suggest that health professionals should pay greater attention to these women's informational and emotional needs.

Emotional and physical health outcomes after significant primary post-partum haemorrhage (PPH): a multicentre cohort study.

BACKGROUND: Post-partum haemorrhage (PPH) rates are rising; however, data on the health impact on women are lacking. AIMS: To describe the emotional and physical health outcomes for women following PPH. METHODS: A cohort of 206 women with primary PPH of 1500 mL or more, and/or peripartum fall in haemoglobin concentration to 7 g/dL or less, and/or of 4 g/dL or less, was recruited from 17 Australian/New Zealand hospitals. Women completed questionnaires in the first week, and at two and four months post-partum. Obstetric details came from hospital records. Outcomes were anxiety; post-natal depression (PND); fatigue; post-traumatic stress disorder (PTSD); general health (SF-36); physical health problems; post-natal bleeding duration; hospital readmission. RESULTS: Eighty-three percent completed the two-month and 81% the four-month questionnaires; 28% reported bleeding continuously for more than six weeks; 10% required hospital readmission within two months. Anxiety scores were in the medium range; 11 and 13% were at risk of PND at two and four months, respectively; median total fatigue scores were 17 at two and 15 at four months; 5% showed evidence of PTSD at two and 3% at four months; women scored highly in most SF-36 categories and showed improvements over time in all but general and mental health. Physical health concerns were comparable to those reported for general post-natal populations, with the exception of uterine infection (6% at two months). CONCLUSIONS: In a cohort of women experiencing PPH, emotional and physical health outcomes were similar to those reported in general post-natal populations, with the exception of post-natal bleeding duration, uterine infection and hospital readmission.

Early Implementation and Evaluation of StepUp for Dementia Research: An Australia-Wide Dementia Research Participation and Public Engagement Platform.

Recruiting participants for dementia research takes time. For those who are interested, opportunities to participate can be ad hoc. Delays in finding the right participants can result in studies taking longer to deliver, often requiring funding extensions, and ultimately increasing the cost and limiting the effectiveness of research and evaluation. To address these issues, a digital platform, StepUp for Dementia Research, was developed in 2019 and evaluated through ongoing data analytics, researcher feedback and annual volunteer surveys in 2019 and 2021. Using innovative matching technology, StepUp provides volunteers with an opt-in, secure way of registering interest in dementia studies and allows researchers to access matched volunteers in Australia. As of June 2021, 1070 volunteers registered (78% female), and 25 organizations became 'champions' for StepUp promotion. Of 122 registered researchers, 90 completed training. Forty studies from 17 research/health institutions recruited participants using StepUp. The evaluation demonstrated program feasibility and recruitment efficiency with a high level of satisfaction from users. Evaluation outcomes highlighted disparities in public participation in dementia research (e.g., gender, education and race/ethnicity) and provided valuable insights for further enhancements of StepUp. A concerted and strategic effort is needed by leading registries such as StepUp to ensure narrowing volunteer participation gaps in dementia research.

How, why and under what circumstances does a quality improvement collaborative build knowledge and skills in clinicians working with people with dementia? A realist informed process evaluation.

In increasingly constrained health and aged care services, strategies are needed to improve quality and translate evidence into practice. In dementia care, recent failures in quality and safety have led the WHO to prioritise the translation of known evidence into practice. While quality improvement collaboratives have been widely used in healthcare, there are few examples in dementia care.We describe a recent quality improvement collaborative to improve dementia care across Australia and assess the implementation outcomes of acceptability and feasibility of this strategy to translate known evidence into practice. A realist-informed process evaluation was used to analyse how, why and under what circumstances a quality improvement collaborative built knowledge and skills in clinicians working in dementia care.This realist-informed process evaluation developed, tested and refined the programme theory of a quality improvement collaborative. Data were collected pre-intervention and post-intervention using surveys and interviews with participants (n=28). A combined inductive and deductive data analysis process integrated three frameworks to examine the context and mechanisms of knowledge and skill building in participant clinicians.A refined program theory showed how and why clinicians built knowledge and skills in quality improvement in dementia care. Six mechanisms were identified: motivation, accountability, identity, collective learning, credibility and reflective practice. These mechanisms, in combination, operated to overcome constraints, role boundaries and pessimism about improved practice in dementia care.A quality improvement collaborative designed for clinicians in different contexts and roles was acceptable and feasible in building knowledge, skills and confidence of clinicians to improve dementia care. Supportive reflective practice and a credible, flexible and collaborative process optimised quality improvement knowledge and skills in clinicians working with people with dementia.Trial registration numberACTRN12618000268246.

The adrenal medulla in cardiovascular medicine: an untold story.

Unlike noradrenaline, the sympathetic neurotransmitter which overflows to the circulation, adrenaline (ADR) is a secreted hormone, with a low plasma concentration, and plasma concentration for biological action a log order lower than that of noradrenaline. The venous drainage of the left adrenal medulla into the left renal vein does expose this vein to uniquely high plasma ADR concentrations and possible risk of thrombosis at high rates of ADR secretion. There is typically a different timeframe for adrenal medullary and sympathetic nervous system responses: ADR release is short term in contrast with sympathetic activation persisting for years in heart failure and hypertension. The historic view of Walter Cannon, subject to recent review, that the sympathoadrenal system is a unified biological system, was deconstructed further with demonstration of frequent mismatching of adrenal medullary and sympathetic nervous responses. Under gravity stimulation with standing, there is prompt sympathetic activation without ADR release. In many diseases, notably obesity, hypertension, heart failure and depressive illness, an activated sympathetic nervous system and silent adrenal medulla coexist. The therapeutic corollary of this is that ADR blockade is much less commonly needed clinically than pharmacological antagonism of the sympathetic nervous system.

Mitogen-inducible gene 6 is an endogenous inhibitor of HGF/Met-induced cell migration and neurite growth.

Hepatocyte growth factor (HGF)/Met signaling controls cell migration, growth and differentiation in several embryonic organs and is implicated in human cancer. The physiologic mechanisms that attenuate Met signaling are not well understood. Here we report a mechanism by which mitogen-inducible gene 6 (Mig6; also called Gene 33 and receptor-associated late transducer) negatively regulates HGF/Met-induced cell migration. The effect is observed by Mig6 overexpression and is reversed by Mig6 small interfering RNA knock-down experiments; this indicates that endogenous Mig6 is part of a mechanism that inhibits Met signaling. Mig6 functions in cells of hepatic origin and in neurons, which suggests a role for Mig6 in different cell lineages. Mechanistically, Mig6 requires an intact Cdc42/Rac interactive binding site to exert its inhibitory action, which suggests that Mig6 acts, at least in part, distally from Met, possibly by inhibiting Rho-like GTPases. Because Mig6 also is induced by HGF stimulation, our results suggest that Mig6 is part of a negative feedback loop that attenuates Met functions in different contexts and cell types.