RESUMO
PURPOSE: To understand how frequently exercise is discussed and/or prescribed as a supportive care measure and the barriers and facilitators to exercise uptake for men with prostate cancer receiving androgen deprivation therapy (ADT) at a regional cancer centre. METHODS: An observational, cross-sectional study was conducted at a regional cancer centre in three stages: (1) Retrospective chart review of men with prostate cancer undergoing ADT to identify the frequency of discussion and/or prescription of supportive care measures; (2) prospective patient survey exploring barriers and facilitators to exercise; and (3) prospective clinician survey exploring barriers, facilitators and awareness of exercise guidelines in men with prostate cancer. RESULTS: Files of 100 men receiving ADT (mean age 73 years; mean ADT duration =12 months) in the medical oncology (n = 50) and radiation oncology (n = 50) clinics were reviewed. Exercise was discussed with 16% of patients and prescribed directly to 5%. Patient survey (n = 49). 44.2% of patients reported participating in exercise at a high level. Common barriers to exercise participation included fatigue (51.0%), cancer/treatment-related weakness (46.9%) and joint stiffness (44.9%). 36.7% of patients reported interest in a supervised exercise program. Clinician survey (n = 22). 36.4% identified one or more exercise guidelines, and 40.9% correctly identified national exercise guidelines. Clinicians reported low knowledge of referral pathways to a supervised exercise program (27.3%). Clinicians believe physiotherapists (95.5%) are most suited to exercise prescription and 72.7% stated that exercise counselling should be part of supportive care. Limited time (63.6%) and patient safety (59.1%) were the two most common barriers to discussing exercise with patients. Clinicians reported that only 21.9% of their patients asked about exercise. The most endorsed facilitators to increase exercise uptake were patient handouts (90.9%) and integration of exercise specialists into the clinical team (86.4%). CONCLUSION: Despite a third of patient respondents indicating an interest in a supervised exercise program, only 16% of patients with prostate cancer undergoing ADT at a regional cancer centre engaged in a discussion about exercise with their treating clinicians. Physical limitations and fatigue were the greatest barriers for patients. Clinicians indicated a need for more clinician education and better integration of exercise specialists into clinical care. A tailored, integrated approach is needed to improve the uptake of exercise in men with prostate cancer.
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Antagonistas de Androgênios , Neoplasias da Próstata , Idoso , Androgênios , Estudos Transversais , Terapia por Exercício , Humanos , Masculino , Estudos Prospectivos , Neoplasias da Próstata/tratamento farmacológico , Estudos Retrospectivos , Inquéritos e QuestionáriosRESUMO
ABSTRACT: A 72-year-old woman with membranous glomerulonephritis and failed renal transplant on peritoneal dialysis presented with bilateral vision loss. She reported several months of diminishing right eye vision that worsened after cataract extraction. On presentation, visual acuity was hand motion in the right and 20/100 in the left eye with a right afferent pupillary defect. Confrontation visual fields were constricted bilaterally. Intraocular pressure was 23 in the right eye, and there was diffuse right eye central corneal opacity with iris neovascularization. Fundus examination revealed bilateral pale optic nerves with cotton wool spot inferior to the left optic disc and diffuse arteriolar whitening with crystalline deposits in the left macula. Given fundus appearance, concurrent ischemic optic neuropathy, and ocular ischemic syndrome, ocular calciphylaxis was suspected. The patient reported development of painful gluteal nodules a month prior, and biopsy revealed calcinosis cutis, a dermatopathologic finding on the spectrum of calcific vasculitides. Her vision continued to decline in both eyes with left eye vision of 20/400. Intravenous sodium thiosulfate through hemodialysis was started with initial improvement in left eye vision to 20/125, but subsequently declined despite treatment. Pathogenesis of systemic calciphylaxis is poorly understood but believed to result from upregulation of osteogenesis and decreased inhibition of vascular calcification in parathyroid axis dyscrasias due to end-stage renal disease. Excess serum calcium-phosphate deposits in blood vessels causing tissue infarction, most commonly in the skin. Prior case reports have described ischemic optic neuropathy mimicking giant cell arteritis and crystalline retinopathy with ocular ischemic syndrome separately. Treatment with empiric intravenous sodium thiosulfate and calcium chelation may preserve vision in some patients.
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Calciofilaxia/complicações , Disco Óptico/diagnóstico por imagem , Neuropatia Óptica Isquêmica/etiologia , Doenças Retinianas/etiologia , Calcificação Vascular/complicações , Acuidade Visual , Idoso , Calciofilaxia/diagnóstico , Feminino , Humanos , Pressão Intraocular/fisiologia , Doenças Retinianas/diagnóstico , Síndrome , Calcificação Vascular/diagnósticoRESUMO
BACKGROUND: Allied health services are core to the improvement in health outcomes for remote and rural residents. Substantial infrastructure has been put into place to facilitate rural work-ready allied health practitioners, yet it is difficult to understand or measure how successful this is and how it is facilitated. METHODS: A scoping review and thematic synthesis of the literature using program logic was undertaken to identify and describe the contexts, mechanisms and outcomes of successful models of rural clinical placements for allied health students. This involved all empirical literature examining models of regional, rural and remote clinical placements for allied health students between 1995 and 2019. RESULTS: A total of 292 articles were identified; however, after removal of duplicates and article screening, 18 were included in the final synthesis. Australian papers dominated the evidence base (n = 11). Drivers for rural allied health clinical placements include: attracting allied health students to the rural workforce; increasing the number of allied health clinical placements available; exposing students to and providing skills in rural and interprofessional practice; and improving access to allied health services in rural areas. Depending on the placement model, a number of key mechanisms were identified that facilitated realisation of these drivers and therefore the success of the model. These included: support for students; engagement, consultation and partnership with key stakeholders and organisations; and regional coordination, infrastructure and support. Placement success was measured in terms of student, rural, community and/or program outcomes. Although the strength and quality of the evidence was found to be low, there is a trend for placements to be more successful when the driver for the placement is specifically reflected in the structure of the placement model and outcomes measured. This was seen most effectively in placement models that were driven by the need to meet rural community needs and upskill students in interprofessional rural practice. CONCLUSION: This study identifies the factors that can be manipulated to ensure more successful models of allied health rural clinical placements and provides an evidence based framework for improved planning and evaluation.
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Pessoal Técnico de Saúde/educação , Estágio Clínico , Serviços de Saúde Rural , Austrália , Humanos , Estudantes , Recursos HumanosRESUMO
INTRODUCTION: Longstanding gaps in physiotherapy service delivery exist in rural areas across Australia. In response to this, a large public rural health organisation contracted a private physiotherapy business to implement a public-private partnership (PPP) to supply physiotherapy to hospital inpatients, aged care facility residents and outpatients in four outer regional Australian towns. Treatment rooms were provided by the health organisation for the private physiotherapists to see clients. This study explored how stakeholders defined the success of a PPP model of service delivery in a rural setting and examined if the model was successful according to stakeholder definitions. Barriers and enablers (mechanisms) were identified and linked to stakeholder-defined success measures. METHODS: A qualitative study was conducted using a constructive inquiry design. Participants were purposively recruited, via email invitation and telephone follow-up. Participants comprised managers and clinicians from the rural public health organisation and the private physiotherapy business involved in setting up, working within or alongside the partnership. Semi-structured interviews were undertaken with all participants. Data were transcribed verbatim and analysed using framework analysis. Program logic was used to synthesise all information. RESULTS: Individual interviews were conducted with five staff from each partnering organisation, including managers and clinicians (total n=10). Two main themes and three subthemes were identified. All participants described the model as being successful. Elements of success included improved access to local services, and satisfied stakeholders. There were three mechanisms identified to successfully implement the service delivery model. The first mechanism was the provision of human and several other resources, which included the workforce model and the use of several resources for the partnership. The second mechanism was stakeholder engagement, which included having motivated stakeholders and consistent stakeholders. The third mechanism was streamlined processes, which included the content of the contract and referral schedule, streamlined administration processes for contracting and accounting, having processes for managing private therapists in a public setting as well as processes for communication. CONCLUSION: This study demonstrates that an innovative physiotherapy PPP model of service delivery can be a successful way to improve access to physiotherapy services in rural areas. Success of service models varies depending on the viewpoint of the stakeholder and achieving success for all stakeholders is contingent on mechanisms such as those identified in this study. PPPs have potential to address service gaps in hospitals, residential aged care and primary care in rural areas.
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Fisioterapeutas/organização & administração , Modalidades de Fisioterapia/organização & administração , Parcerias Público-Privadas/organização & administração , Serviços de Saúde Rural/organização & administração , Pessoal Técnico de Saúde/estatística & dados numéricos , Austrália , Feminino , Acessibilidade aos Serviços de Saúde/organização & administração , Humanos , Masculino , Pesquisa Qualitativa , População Rural/estatística & dados numéricosRESUMO
BACKGROUND: There are staff shortages nation-wide in residential aged care, which is only predicted to grow as the population ages in Australia. The aged care staff shortage is compounded in rural and remote areas where the health service workforce overall experiences difficulties in recruitment and retention. There is evidence that nurse practitioners fill important service gaps in aged care and rural health care but also evidence that barriers exist in introducing this extended practice role. METHODS: In 2018, 58 medical and direct care staff participated in interviews and focus groups about the implementation of an older person's nurse practitioner (OPNP) in aged care. All 58 interviewees had previously or currently worked in an aged care setting where the OPNP delivered services. The interviews were analysed using May's implementation theory framework to better understand staff perceptions of barriers and enablers when an OPNP was introduced to the workplace. RESULTS: The major perceived barrier to capacity of implementing the OPNP was a lack of material resources, namely funding of the role given the OPNP's limited ability to self-fund through access to the Medicare Benefits Schedule (MBS). Staff perceived that benefits included timely access to care for residents, hospital avoidance and improved resident health outcomes. CONCLUSION: Despite staff perceptions of more timely access to care for residents and improved outcomes, widespread implementation of the OPNP role may be hampered by a poor understanding of the role of an OPNP and the legislative requirement for a collaborative arrangement with a medical practitioner as well as limited access to the MBS. This study was not a registered trial.
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Enfermagem Geriátrica/métodos , Profissionais de Enfermagem/estatística & dados numéricos , Papel do Profissional de Enfermagem , Serviços de Saúde Rural/normas , Idoso , Estudos de Avaliação como Assunto , Humanos , Entrevistas como Assunto , VitóriaRESUMO
INTRODUCTION: Pierre Robin sequence (PRS) is a rare disorder classically observed as a triad of features including micrognathia, glossoptosis, and upper airway obstruction. It is associated with a syndrome in about 60% of cases. While odontogenic tumors are common findings in patients with familial adenomatous polyposis and nevoid basal cell carcinoma syndromes, PRS has not been found to be consistently associated with any tumors of the jaw. CASE REPORT: The current report aims to describe a patient with PRS who presented with an extensive ameloblastic fibro-odontoma (AFO) of the maxilla. CONCLUSION: Continued observation for odontogenic tumors in PRS is necessary.
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Neoplasias Maxilares/complicações , Odontoma/complicações , Síndrome de Pierre Robin/complicações , Anormalidades Dentárias/complicações , Feminino , Humanos , Adulto JovemRESUMO
OBJECTIVES: To assess patient preferences for different models of care defined by location of care, frequency of care and principal carer within community-based health-care services for older people. DESIGN: Discrete choice experiment administered within a face-to-face interview. SETTING: An intermediate care service in a large city within the United Kingdom. PARTICIPANTS: The projected sample size was calculated to be 200; however, 77 patients were recruited to the study. The subjects had recently been discharged from hospital and were living at home and were receiving short-term care by a publicly funded intermediate care service. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The degree of preference, measured using single utility score, for individual service characteristics presented within a series of potential care packages. RESULTS: Location of care was the dominant service characteristics with care at home being the strongly stated preference when compared with outpatient care (0.003), hospital care (<0.001) and nursing home care (<0.001) relative to home care, although this was less pronounced among less sick patients. Additionally, the respondents indicated a dislike for very frequent care contacts. No particular type of professional carer background was universally preferred but, unsurprisingly, there was evidence that sick patients showed a preference for nurse-led care. CONCLUSIONS: Patients have clear preferences for the location for their care and were able to state preferences between different care packages when their ideal service was not available. Service providers can use this information to assess which models of care are most preferred within resource constraints.
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Comportamento de Escolha , Serviços de Saúde Comunitária , Atenção à Saúde/métodos , Preferência do Paciente , Idoso , Idoso de 80 Anos ou mais , Cuidadores , Feminino , Política de Saúde , Serviços de Assistência Domiciliar , Humanos , Instituições para Cuidados Intermediários , Entrevistas como Assunto , Masculino , Reino UnidoRESUMO
OBJECTIVE: This paper explores the impact and mechanisms for successful implementation of a speech language pathology assistant (SLPA) role into a rehabilitation setting using a traineeship approach. METHODS: Multiple data sources were used, including interviews with key stakeholders, documentary evidence and a workload audit. RESULTS: The SLPA role increased clinical service capacity by 28 h per week across the service and required a total of 3 h per week of supervision input (the equivalent of 38 min per speech and language pathologist (SLP)). The SLPA used non-clinical time for training and administration. Mechanisms that facilitated the implementation of the SLPA role were: support for existing staff; formal knowledge and skills in training; consultation and engagement; access to a competency framework; close working with the registered training organisation; clearly defined role and delegation boundaries; clear supervision structures; confidence in own role; supportive organisational culture; vision for expansion of the role; engaging the SLPs in training and development; and a targeted recruitment approach. CONCLUSION: The development and implementation of a new trainee SLPA role using a traineeship approach required a large amount of supervision and training input from the SLPs. However, it was perceived that these efforts were offset by the increased service capacity provided by the introduction of a trainee role and the high levels of satisfaction with the new role.
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Pessoal Técnico de Saúde/educação , Estágio Clínico , Patologia da Fala e Linguagem , Educação , Humanos , Entrevistas como Assunto , Pesquisa Qualitativa , Centros de ReabilitaçãoRESUMO
OBJECTIVE: To identify mechanisms for the successful implementation of support strategies for health-care practitioners in rural and remote contexts. DESIGN: This is an integrative review and thematic synthesis of the empirical literature that examines support interventions for health-care practitioners in rural and remote contexts. RESULTS: This review includes 43 papers that evaluated support strategies for the rural and remote health workforce. Interventions were predominantly training and education programmes with limited evaluations of supervision and mentoring interventions. The mechanisms associated with successful outcomes included: access to appropriate and adequate training, skills and knowledge for the support intervention; accessible and adequate resources; active involvement of stakeholders in programme design, implementation and evaluation; a needs analysis prior to the intervention; external support, organisation, facilitation and/or coordination of the programme; marketing of the programme; organisational commitment; appropriate mode of delivery; leadership; and regular feedback and evaluation of the programme. CONCLUSION: Through a synthesis of the literature, this research has identified a number of mechanisms that are associated with successful support interventions for health-care practitioners in rural and remote contexts. This research utilised a methodology developed for studying complex interventions in response to the perceived limitations of traditional systematic reviews. This synthesis of the evidence will provide decision-makers at all levels with a collection of mechanisms that can assist the development and implementation of support strategies for staff in rural and remote contexts.
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Atenção à Saúde , Pessoal de Saúde , Mentores , Organização e Administração , Serviços de Saúde Rural , População Rural , Necessidades e Demandas de Serviços de Saúde , Humanos , LiderançaRESUMO
Health workforce training in the 21st century is still based largely on 20th century healthcare paradigms that emphasise professionalisation at the expense of patient-focussed care. This is illustrated by the paradox of increased training times for health workers that have corresponded with workforce shortages, the limited career options and pathways for paraprofessional workers, and inefficient clinical training models that detract from, rather than add to, service capacity. We propose instead that a 21st century health workforce training model should be: situated in the clinical setting and supported by outsourced university training (not the other way around); based on the achievement of specific milestones rather than being time-defined; and incorporate para-professional career pathways that allow trainees to 'step-off' with a useable qualification following the achievement of specific competencies. Such a model could be facilitated by existing technology and clinical training infrastructure, with enormous potential for economies of scale in the provision of formal training. The benefits of a clinically based, competency-based model include an increase in clinical service capacity, and clinical training resources become a resource for the delivery of healthcare, not just education. Existing training models are unsustainable, and are not preparing a workforce with the flexibility the 21st century demands.
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Pessoal Técnico de Saúde/educação , Educação Baseada em Competências/organização & administração , Austrália , Humanos , Modelos TeóricosRESUMO
BACKGROUND: Access to appropriate healthcare is essential for children's healthy development. This is lacking in rural and remote areas, impacting health outcomes. Despite efforts to improve access for these communities, to date, no review has systematically mapped the literature on allied health models of care for children with developmental needs. This scoping review seeks to address this knowledge gap. METHODS: Adhering to the PRISMA-ScR and Joanna Briggs Institute guidelines, a systematic search was conducted. A total of 8 databases (from inception to May 2023) and 106 grey literature sources were searched. Two reviewers independently undertook a two-stage screening process. Data were extracted using customised tools and narratively synthesised utilising the Institute of Medicine's quality domains. This review is registered a priori via Open Science Framework. RESULTS: Twenty-five citations were identified within the literature. Varied models of care were reported from five mostly Western countries. Models of care identified in these areas were classified as screening services, role substitution, consultative services, or online-based services. Positive impacts on quality of healthcare were reported across all quality domains (apart from safety) with the domain of effectiveness being the most commonly reported. CONCLUSIONS: Multiple models of care are currently in operation for children with developmental needs in rural and remote areas and appear to improve the quality of care. Due to complexities within, and limitations of, the evidence base, it is unclear if one model of care is superior to another. This review provides a basis for further research to explore why some models may be more effective than others.
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Deficiências do Desenvolvimento , População Rural , Humanos , Criança , Deficiências do Desenvolvimento/terapia , Pré-Escolar , Adolescente , Lactente , Acessibilidade aos Serviços de SaúdeRESUMO
The National Disability Insurance Scheme (NDIS) ushered in a transformative era in disability services in Australia, requiring new workforce models to meet evolving participant needs. Therapy Assistants are utilised to increase the capacity of therapy services in areas of workforce shortage. The governance arrangements required to support this emergent workforce have received limited attention in the literature. This review examined the key components and contextual factors of governance in rural settings, specifically focusing on therapy support workers under the guidance of allied health professionals in rural and remote areas. Guided by the social model of disability and the International Classification of Functioning, Disability and Health, a realist perspective was used to analyse 26 papers (after deduplication), mostly Australian and qualitative, with an emphasis on staff capabilities, training, and credentialling. Success measures were often vaguely defined, with most papers focusing on staff improvement and few focusing on client or organisational improvement. Consistent staffing, role clarity, community collaboration, and supportive leadership were identified as enabling contexts for successful governance of disability therapy support workers in rural areas. Investment in capability (soft skills) development, tailored training, competency assessment, credentialling, and supervision were identified as key activities that, when coupled with the identified enabling contexts, were likely to influence staff, client and organisational outcomes. Further research is warranted to explore long-term impacts of governance arrangements, educational program accountability, and activities targeted at enhancing staff capabilities.
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Pessoas com Deficiência , Humanos , Austrália , Serviços de Saúde Rural/organização & administração , População Rural , Pessoal Técnico de SaúdeRESUMO
BACKGROUND: Increasingly, health workforces are undergoing high-level 're-engineering' to help them better meet the needs of the population, workforce and service delivery. Queensland Health implemented a large scale 5-year workforce redesign program across more than 13 health-care disciplines. This study synthesized the findings from this program to identify and codify mechanisms associated with successful workforce redesign to help inform other large workforce projects. METHODS: This study used Inductive Logic Reasoning (ILR), a process that uses logic models as the primary functional tool to develop theories of change, which are subsequently validated through proposition testing. Initial theories of change were developed from a systematic review of the literature and synthesized using a logic model. These theories of change were then developed into propositions and subsequently tested empirically against documentary, interview, and survey data from 55 projects in the workforce redesign program. RESULTS: Three overarching principles were identified that optimized successful workforce redesign: (1) drivers for change need to be close to practice; (2) contexts need to be supportive both at the local levels and legislatively; and (3) mechanisms should include appropriate engagement, resources to facilitate change management, governance, and support structures. Attendance to these factors was uniformly associated with success of individual projects. CONCLUSIONS: ILR is a transparent and reproducible method for developing and testing theories of workforce change. Despite the heterogeneity of projects, professions, and approaches used, a consistent set of overarching principles underpinned success of workforce change interventions. These concepts have been operationalized into a workforce change checklist.
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Pessoal Técnico de Saúde/organização & administração , Atenção à Saúde , Reforma dos Serviços de Saúde/organização & administração , Pessoal Técnico de Saúde/provisão & distribuição , Humanos , Modelos Organizacionais , Queensland , Recursos HumanosRESUMO
Traumatic aneurysms, pseudoaneurysms, and arteriovenous (AV) fistulas of the superficial temporal artery (STA) are uncommon, accounting for only 0.5% to 2.0% of all aneurysms subjected to surgery. In the literature that relates to the STA, the general term "aneurysm following traumatic injury" often includes a wide array of pathologic entities, including proper aneurysms, pseudoaneurysms, and AV fistulas. In 75% of cases, such aneurysms are due to blunt trauma. Within this group, STA AV fistulas constitute an exceedingly rare subset. The case presents the occurrence of a traumatic AV fistula of the STA following blunt trauma (karate kick) and provides the first description of the histologic appearance of this lesion.
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Malformações Vasculares do Sistema Nervoso Central/diagnóstico , Doenças Arteriais Cerebrais/diagnóstico , Traumatismos Craniocerebrais/diagnóstico , Artes Marciais/lesões , Artérias Temporais/patologia , Malformações Vasculares do Sistema Nervoso Central/etiologia , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Doenças Arteriais Cerebrais/etiologia , Doenças Arteriais Cerebrais/cirurgia , Traumatismos Craniocerebrais/etiologia , Traumatismos Craniocerebrais/cirurgia , Procedimentos Endovasculares , Humanos , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-IdadeRESUMO
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by the presence of circulating autoantibodies against phospholipid-binding plasma proteins, leading to an increased risk of thrombosis and pregnancy loss. The most common manifestation of lung disease in APS is pulmonary embolism, which may often be the presenting symptom. We present a 30-year-old man with probable primary APS (with no history of thromboses) presenting with diffuse alveolar hemorrhage, an uncommon presentation. He was also found to have severe mitral valve regurgitation and during valve replacement surgery had cardiac vegetations compatible with a presentation of Libman-Sacks endocarditis. There are only 21 other reported cases of diffuse alveolar hemorrhage occurring as a result of APS. This is the first case of Libman-Sacks endocarditis in the setting of probable APS and alveolar hemorrhage.Diffuse alveolar hemorrhage should be considered as a nonthrombotic manifestation of APS, even in the absence of known thromboses, and may be the presenting symptom.
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Síndrome Antifosfolipídica/diagnóstico , Endocardite não Infecciosa/diagnóstico , Hemorragia/diagnóstico , Pneumopatias/diagnóstico , Insuficiência da Valva Mitral/diagnóstico , Alvéolos Pulmonares , Adulto , Síndrome Antifosfolipídica/tratamento farmacológico , Ecocardiografia , Implante de Prótese de Valva Cardíaca , Hemoptise/etiologia , Humanos , Masculino , Valva Mitral/patologia , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Tomografia Computadorizada por Raios XRESUMO
PURPOSE: Individuals have multiple intersecting identities, unique perspectives, and experiences which provide opportunities for new ways to interact, support inclusion and equity, and address the Sustainable Development Goals (SDGs). This commentary explores the diversity of the speech-language pathology workforce in Australia. RESULT: A survey of Australian speech-language pathologists (SLPs; n = 1,638) distributed in November and December 2021 explored personal characteristics and experiences of the workforce. Almost 30% of SLPs who responded reported having experiences or perspectives that were relevant to service users and a quarter described other lived experiences, which included disability, cultural and linguistic background, mental health, caring responsibilities, neurodiversity, and being LGBTQI+. CONCLUSION: This commentary affirms the value of diversity among allied health professions to enrich practice with individuals and communities. By understanding the diversity of the speech-language pathology workforce and perspectives of historically marginalised or invisible groups, the profession can introduce strategies to more meaningfully engage and support people with diverse backgrounds and perspectives in the workforce and enhance service equity and accessibility for people with communication and swallowing disabilities. This commentary focusses on SDG 3, SDG 4, SDG 8, SDG 10.
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Transtornos da Comunicação , Patologia da Fala e Linguagem , Humanos , Desenvolvimento Sustentável , Austrália , Recursos HumanosRESUMO
Background: Potentially avoidable hospitalisations (PAHs) are proxy measures of effective primary care at a population level. PAHs are higher in rural and disadvantaged areas. This qualitative study sought a deeper understanding of PAHs for chronic health conditions in a rural context from the perspectives of patients and health professionals, and aimed to develop a logic model for rural health services to identify intervention targets. Methods: Patients with chronic obstructive pulmonary disease, congestive cardiac failure or type 2 diabetes, admitted to a rural hospital in Australia and local health professionals were invited to participate in interviews in late 2019. Semistructured interviews were recorded, transcribed verbatim and thematically analysed. Themes were mapped against a programme logic model developed in a similar study. Results: patients and 16 health professionals participated. The logic model encompassed patient level (knowledge, skills, health status), provider level (workforce availability, attributes) and system level (clinical pathways) contexts. These contexts influenced key mechanisms of relationships, continuity of care and capacity to offer services. Outcomes included responsive and timely access to care, improved clinical outcomes and resource use. Themes that did not readily map to the logic model included socioeconomic disadvantage and healthcare costs, which influenced affordability and equity of access. Conclusion: Patients' complex health and social circumstance, health service access and unclear care pathways were strong themes associated with PAH in this rural context. Patient, provider and system contexts influencing key mechanisms and outcomes need to be understood when designing solutions to address PAHs in rural settings. Ideally, interventions should address the cost of healthcare alongside interventions to enhance relationships, continuity of care and capacity to offer services.
RESUMO
Rare in occurrence, the following case of intrapulmonary lipoma is only the fifth known case in a female patient reported in the literature. Importantly, the incorporation of this lesion into the differential diagnosis during frozen section of a predominantly adipocytic lesion limited the extent of surgical intervention and provided the patient with an optimal standard of care.
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Lipoma/patologia , Neoplasias Pulmonares/patologia , Adulto , Feminino , Humanos , Lipoma/cirurgia , Neoplasias Pulmonares/cirurgiaRESUMO
Xanthomas are benign lesions frequently described in the upper gastrointestinal tract, most commonly in the stomach. In the stomach, these lesions are usually associated with chronic gastritis, intestinal metaplasia, H. pylori infection and duodenogastric reflux following gastric surgery, but are otherwise indolent. Xanthomas in the upper gastrointestinal tract occur in a broad age range, 45-82 years (mean: 65 years). Rare cases have also been described in the esophagus, duodenum, small intestine, colon and rectum. Rectosigmoid location of xanthomas have been described in rare cases. We present a case of polypoid xanthoma in the rectosigmoid colon occurring in a 70-year-old female with a history of hyperplastic polyps.
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Gastrite , Pólipos , Feminino , Infecções por Helicobacter , Humanos , XantomatoseRESUMO
This paper explores the compatibility of the recently modernized NHS pay structure, "Agenda for Change" (AfC) with the workforce flexibilities arising within intermediate care services in the NHS in England. The findings reported here were an unanticipated outcome of a larger, Department of Health (England) study which explored the impact of workforce flexibility on the costs and outcomes of older peoples' community-based services. The research coincided with the introduction of AfC, and, as such pay modernization was a strongly emergent theme from focus groups that involved 11 teams as part of the larger study. In principle, it appears that both intermediate care and AfC should support the concepts of interprofessional working, blurring of role boundaries and role substitution, however the findings from this study suggest otherwise. In particular, intermediate care was described as a largely non-hierarchical service structure where staff roles expand horizontally to take on a broad plethora of generic tasks. In contrast, AfC promotes a hierarchical framework for career progression that recognizes and rewards defined skills, expertise and responsibility. From this perspective, AfC was seen to reward specialization rather than skill sharing, and had difficulty differentiating between and rewarding staff with broad generalist roles.