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To describe adults with (non-dialysis) chronic kidney disease (CKD) in nine public renal practice sites in the Australian state of Queensland.7,060 persons were recruited to a CKD Registry in May 2011 and until start of kidney replacement therapy (KRT), death without KRT or June 2018, for a median period of 3.4 years.The cohort comprised 7,060 persons, 52% males, with a median age of 68 yr; 85% had CKD stages 3A to 5, 45.4% were diabetic, 24.6% had diabetic nephropathy, and 51.7% were obese. Younger persons mostly had glomerulonephritis or genetic renal disease, while older persons mostly had diabetic nephropathy, renovascular disease and multiple diagnoses. Proportions of specific renal diagnoses varied2-fold across sites. Over the first year, eGFR fell in 24% but was stable or improved in 76%. Over follow up, 10% started KRT, at a median age of 62 yr, most with CKD stages 4 and 5 at consent, while 18.8% died without KRT, at a median age of 80 yr. Indigenous people were younger at consent and more often had diabetes and diabetic kidney disease and had higher incidence rates of KRT.The spectrum of characteristics in CKD patients in renal practices is much broader than represented by the minority who ultimately start KRT. Variation in CKD by causes, age, site and Indigenous status, the prevalence of obesity, relative stability of kidney function in many persons over the short term, and differences between those who KRT and die without KRT are all important to explore.

Background: Symptom management remains a critical challenge at the end of life. Barriers to symptom relief predominantly focus on perspectives of physicians, patients or care systems but rarely acknowledge the views of nurses. Aim: Examine nurses’ perceptions of barriers to adequate end-of-life symptom relief. Methods: Semi-structured interviews with 25 nurses across different settings who routinely prescribed and/or administered symptom relief to patients near the end of life in Queensland and New South Wales, Australia. Data were analysed using a six-stage hybrid thematic analysis technique. Findings: Nurses identified five barriers to adequate symptom management. Firstly, fears concerning symptom relief such as hastening death, causing addiction, loss of consciousness, and legal/professional repercussions affected clinical practice. Secondly, lack of knowledge, experience and training hindered symptom management. Nurses discussed knowledge gaps regarding medication and palliative care, symptom assessments, recognition of dying and relevant laws. Thirdly, personal, cultural and religious beliefs influenced staff's willingness to offer pain relief, and patients’ and families’ willingness to accept it. Lack of communication between medical teams, patients and families further challenged symptom management. Lastly, institutional barriers played a considerable role as time constraints, insufficient staff support and difficulties accessing resources prevented end-of-life symptom management. Discussion: The identified barriers highlight a substantial need for targeted interventions. Setting-specific challenges such as limited access to medication, staff and palliative care services must be addressed. Conclusions: To provide better end-of-life care, services should acknowledge nurses’ unique insights. Particular attention should be on supporting nurses in aged care facilities, community settings and remote areas.

Background The Queensland Health nurse navigator service is an innovative model that has recently emerged as a way of bridging gaps in care and supporting care coordination for patients with highly complex care needs. The translation of key principles into practice, and how nurse navigators operationalise their role in the care of individual patients in a highly complex health system while engaging a diverse team of health care providers, requires further understanding. Aim To explore how nurse navigators in Queensland operationalise their novel roles. Methods This was a qualitative study involving in-depth interviews with three nurse navigators. To explore interprofessional relationships and modes of operation, an exploratory multiple-case study design was used to produce illustrative case examples of practice. Findings Three main modes of operation were identified and illustrated: the boundary spanner, the problem solver, and the broker. These modes of operation offer important insight into the practices and experiences of nurse navigators. Discussion The ‘problem solver’ demonstrates capacity to instigate system improvements, using patient advocacy as a mechanism for broader systems initiatives. The ‘boundary spanner’ exemplifies how nurse navigators can transcend traditional health system boundaries and build networks across nonhealth settings. The ‘broker’ illustrates the nurse navigator's relational role in forging partnerships with patients, across stakeholders in patient care, and across settings (and beyond the health sector). Conclusion These case examples are demonstrative of how nurse navigators operate across a continuum, delivering holistic and individualised care.

Unlawful assisted dying practices have been reported in Australia for decades. Voluntary assisted dying (VAD) is now lawful in Victoria and Western Australia in limited circumstances and will soon be lawful in a further four Australian States. This article examines nine cases involving unlawful assisted dying practices in Victoria in the 12 months prior to the commencement of the Voluntary Assisted Dying Act 2017 (Vic) in 2019. It explores whether, if that Act had been in operation at the relevant time, these patients would have been eligible to request VAD, having regard to their decision-making capacity and their disease, illness or medical condition. Many of these patients would not have been eligible to request VAD had the legislation been operational, primarily because they lacked decision-making capacity. As VAD is lawful only in a narrow set of circumstances, unlawful assisted deaths may continue to occur in those States where voluntary assisted dying is legal.

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic condition of unknown aetiology associated with a range of disabling symptoms, including post-exertional malaise, chronic fatigue, musculoskeletal pain, orthostatic intolerance, unrefreshing sleep, and cognitive dysfunction. ME/CFS is a heterogeneous disorder, with significant variation in symptom type and severity between individuals, as well as within individuals over time. The diversity of ME/CFS symptom presentation makes management challenging; treatments supported by data from randomised controlled trials may not work for all individuals due to the variability in experienced symptoms. Studies using quantitative N-of-1 observational designs involve repeated outcome measurements in an individual over time and can generate rigorous individual-specific conclusions about symptom patterns and triggers in individuals with ME/CFS. This study aims to explore the feasibility and acceptability of using novel patient-centred N-of-1 observational designs to explore symptom fluctuations and triggers in ME/CFS at the individual level. Individuals with a medical diagnosis of ME/CFS will be recruited through ME/CFS patient organisations to participate in a series of patient-centred N-of-1 observational studies. Using a wrist-worn electronic diary, participants will complete ecological momentary assessments of fatigue, stress, mood, and cognitive demand, three times per day for a period of 6–12 weeks. Personally relevant symptoms and triggers will also be incorporated into the questionnaire design. Physical activity will be objectively measured via an integrated accelerometer. Feasibility and acceptability outcomes will be assessed including the percentage of diary entries completed, as well as recruitment and retention rate, feasibility of analysing and interpreting the data collected, and participant views about participation elicited via a post-study semi-structured interview. This study will assess the feasibility and acceptability of patient-centred N-of-1 observational studies to assess diseases with complex presentations such as ME/CFS, as well as provide individual-level evidence about fluctuations and triggers of ME/CFS symptoms that may aid self-management. Australian and New Zealand Clinical Trials Registry: ACTRN12618001898246. Registered on 22 November 2018.

Background Statistical analysis plans describe the processes of data handling and analysis in clinical trials; by doing so they increase the transparency of the analysis and reporting of studies. This paper reports the planned statistical analysis plan for the Whiplash ImPaCT study. For individuals with whiplash injury, Whiplash ImPaCT aims to assess the effectiveness of a guidelines-based clinical pathway of care compared with usual care. Methods We report the planned procedures, methods, and reporting for the primary and secondary analyses of the Whiplash ImPaCT study. The primary outcomes are Global Recovery and Neck Disability Index at 3 months post-randomisation. Outcomes will be analysed according to the intention to treat principle using linear mixed models. A cost-utility analysis will be conducted to compute the incremental cost-effectiveness of the intervention to usual care. We describe data handling, our analytical approach, assumptions about missing data, and our planned methods of reporting. Discussion This paper will provide a detailed description of the planned analyses for the Whiplash ImPaCT trial.

There are few effective treatments for acute whiplash-associated disorders (WADs). Early features of central sensitisation predict poor recovery. The effect of pregabalin on central sensitisation might prevent chronic pain after acute whiplash injury. This double blind, placebo-controlled randomised controlled trial examined feasibility and potential effectiveness of pregabalin compared with placebo for people with acute WAD. Twenty-four participants with acute WAD (48 hours) and at risk of poor recovery (pain ≥5/10) were recruited from hospital emergency departments in Queensland, Australia, and randomly assigned by concealed allocation to either pregabalin (n = 10) or placebo (n = 14). Pregabalin was commenced at 75 mg bd, titrated to 300 mg bd for 4 weeks, and then weaned over 1 week. Participants were assessed at 5 weeks and 3, 6, and 12 months. Feasibility issues included recruitment difficulties and greater attrition in the placebo group. For the primary clinical outcome of neck pain intensity, attrition at 5 weeks was pregabalin: 10% and placebo: 36% and at 12 months was pregabalin: 10% and placebo: 43%. Pregabalin may be more effective than placebo for the primary clinical outcome of neck pain intensity at 3 months (mean difference: -4.0 [95% confidence interval -6.2 to -1.7]) on an 11-point Numerical Rating Scale. Effects were maintained at 6 months but not 12 months. There were no serious adverse events. Minor adverse events were more common in the pregabalin group. A definitive large randomised controlled trial of pregabalin for acute whiplash injury is warranted. Feasibility issues would need to be addressed with modifications to the protocol.

Previous research on general practitioners' (GPs') involvement in end-of-life care has largely focused on a specific aspect of care or has provided broad overviews that failed to capture individual variations in patient management. This qualitative study aimed to explore Australian GPs' feedback and reflections on the individual-level care provided for patients in their last year of life. The findings of the study were drawn from a nation-wide survey of GPs' experiences in end-of-life care. We analysed responses from 63 GPs for 267 of the 272 reported deaths. Factors influencing delivery of optimal end-of-life care reported by GPs were categorised into four groups: patient-related factors, carer-related factors, interactions between GPs and patients/carer-related factors and broader health system issues. Each group included both barriers and facilitators. Our study highlighted importance of the emotional dimensions of therapeutic relationships with patients and their family, availability and capacity of family support and smooth communication and continuity of care between GPs and hospitals in delivery of optimal end-of-life care. Lack of these facilitators, misconceptions of palliative care and conflicts on implementing care plans among patients and their family tended to impede delivery of such care. On the basis of our findings in the present study and previous literature, we conclude that improved end-of-life care in general practice requires comprehensive approaches to supporting both the GP and family to provide care in patients' preferred place, such as enhanced palliative care training and improved availability of external support for GPs, higher levels of hospital-based services reaching into community settings and broader community-based resources for families beyond simply the healthcare system.

Residential aged care facilities (RACFs) face severe challenges in the provision of high-quality end of life care. A pilot of a nurse-led end-of-life palliative care consultative service (CiMaS) su...

OBJECTIVE: To explore the general practitioners (GP's) role in providing psychosocial care for cancer survivors through a systematic literature review. METHODS: We searched MEDLINE, EMBASE, PsycINFO, and CINAHL and included the studies that complied with the predefined inclusion and exclusion criteria. At least two independent reviewers performed the quality appraisal and data extraction. RESULTS: We included 33 (five qualitative, 19 observational, and nine intervention) studies; the majority of these studies focused on care for depression and anxiety (21/33). Cancer survivors were more likely to contact their GP for psychosocial problems compared with noncancer controls. Survivors were more likely to use antidepressants compared with controls, although 71% of survivors preferred depression treatment to be "talking therapy only." Overall, GPs and patients mostly agreed that GPs are the preferred healthcare provider to manage psychosocial problems. The major exception is a survivor's fear of recurrence-here, the oncologist was the preferred healthcare provider. Only two interventions effectively decreased depression or anxiety; these studies included patients who had a clinical indication for psychosocial care, were specifically designed for decreasing depression/anxiety, and consisted of a multidisciplinary team approach. The other interventions evaluated GP-led follow-up for cancer survivors and found that this did not impact the patients' levels of anxiety, depression, or distress neither negatively nor positively. CONCLUSIONS: Cancer survivors often prefer psychosocial care by their GP, and GPs generally consider they are well placed to provide this care. Although evidence on the effectiveness of psychosocial care by GPs is limited, an active multidisciplinary team approach seems key. ispartof: PSYCHO-ONCOLOGY vol:30 issue:4 pages:444-454 ispartof: location:England status: published

SUMMARY Palliative care is the province of everyone, particularly people managing older patients. Most people die of multimorbidity, frailty and dementia rather than cancer and will never see a palliative care specialist. People dying from non-malignant disease have symptoms and problems that are usually predictable. Common symptoms like pain and dyspnoea can be anticipated. Planning to prevent them, or for when they occur, is more effective than waiting until they happen. Deprescribing is an effective way of preventing morbidity in this group. Getting to know a few medicines well for each symptom is important when providing palliative care for patients. Starting at low doses and increasing slowly is also key.

ACKNOWLEDGMENTS : The team would like to acknowledge Campotec S.A for the opportunity to produce industrial samples in its installations. The authors acknowledge the support of Fundação para a Ciência e Tecnologia (FCT), through the strategic projects UIDB/04292/2020 and UIDP/04292/2020 granted to MARE, and the grants awarded to Ana Augusto (SFRH/BD/131465/2017) and Andreia Miranda (SFRH\BD\145425\2019). The authors acknowledge the support of the project Alagecoat (POCI-01-0247-FEDER-006392) through the COMPETE-Operational Competitiveness Programme, the European Union through EASME Blue Labs project AMALIA, Algaeto-MArket Lab IdeAs (EASME/EMFF/2016/1.2.1.4/03/SI2.750419), and the ORCHESTRA project (number 70155), co-funded by Centro 2020 program, Portugal 2020, European Union, European Regional Development Fund. Codium tomentosum hydroethanolic extract was obtained using a pilot solid–liquid extractor to validate the anti-browning functionality of the extract under industrial conditions. Fresh-cut apple slices were coated by immersion in: (1) a seaweed extract solution (0.5% w/v) and (2) a commercial coating, and the two sets of samples were compared with a control (immersion in water). Packaged samples were stored, under ambient and modified atmosphere conditions at 4°C. After 30 days of storage, the samples that were coated with the seaweed extract and packaged under modified atmosphere, demonstrated lower peroxidase activity and polyphenol oxidation when compared with the samples treated with the commercial additive. These results confirm, at pilot scale and under industrial production conditions, the efficacy of the seaweed extract as a bio-based substitute for the synthetic coatings, which are currently used to prevent browning in fresh-cut apples. Novelty impact statement Fresh-cut fruits are subjected to processing operations leading to a decrease in nutritional and organoleptic properties. It is therefore necessary to adopt strategies to delay the degradative processes. In this study, the efficacy of a pilot-scale production and industrial application of a coating formulated with Codium tomentosum seaweed extract has been established for the first time. This seaweed extract possesses the potential to prevent browning development in fresh-cut apples under industrial operating conditions. info:eu-repo/semantics/publishedVersion

Objective: To explore the safety, and efficacy of a proprietary hydrolyzed oil extract from seeds of Biota orientalis (hBO/Epiitalis®, Interpath Pty Ltd) in patients with knee pain due to osteoarthritis (OA). Methods: Patients aged 40-65 with X-ray diagnosed knee OA and knee pain > 60 on a 100-point VAS (visual analog scale) were enrolled and randomized into four groups to receive daily hBO for 56 days as high (hBO-HD, 640 mg), mid (hBO-MD, 320 mg) or low (hBO-LD, 160 mg) doses, or a matched placebo oil. The primary outcome was change in VAS knee pain from baseline to 56 days in the mITT (modified intention to treat) population. Exploratory outcomes were the mWOMAC (modified Western Ontario and McMaster Universities Arthritis Index), and the SF-36 QoL (quality of life) questionnaire. The OMERACT-OARSI (Outcome Measures in Arthritis Clinical Trials–Osteoarthritis Research Society International) responder index was also calculated.Results: 223 patients were included in the mITT population. Reductions in VAS scores between baseline and day 56 [LS mean (95% C.I. LS mean)] were 36.4 (31.7 - 41.0), 37.9 (33.2 - 42.7), 35.7 (31.2 - 40.1) and 9.8 (14.5 -15.2) for the hBO-HD, hBO-MD, hBO-LD, and placebo groups respectively. The VAS changes in all hBO groups were significantly different (p < 0.0001) vs. changes in the placebo group. hBO treatment led to similar quantitative beneficial changes in mWOMAC, SF-36 and OMERACT-OARSI responder index. There were no SAEs and no adverse events ascribed to the intervention.Conclusion: In a 56-day trial, hBO was safe, and was efficacious at reducing symptoms in patients with knee OA. Registration: NCT04117490; Oct 7, 2019

Periodontal treatment may be a useful adjunct to medical management of diabetes; however, oral health has not been integrated into multidisciplinary diabetes care in Australia. This study aimed to understand the needs of patients and staff at a diabetes clinic to inform a prototype of integrated dental and diabetes care. Quantitative and qualitative data were collected from patients and staff at West Moreton Diabetes Clinic (WMDC) between September-October 2019. Clinical information, survey responses, and dental screening results were analyzed for 41 patients. Semi-structured interviews were held with six patients and a focus group with seven staff. Most patients (83%) had not seen a dentist in the previous year. Of the 37 patients with remaining natural teeth, 84% required periodontal assessment and 46% had multiple carious lesions. Unmet treatment needs and rates of access were similar for private and public dental patients. Staff and patients reported high levels of support for incorporation of dental care at WMDC. Integrating oral health into diabetes management is well supported by patients and staff to address significant unmet dental needs for both public and private dental patients.Incorporating dental screening/services within diabetes clinics mayincrease uptake and improve awareness of its importance in diabetes management.

Background: Family meetings facilitate the exploration of issues and goals of care however, there has been minimal research to determine the benefits and cost implications. Aims: To determine: (1) if family caregivers of hospitalised patients referred to palliative care who receive a structured family meeting report lower psychological distress (primary outcome), fewer unmet needs, improved quality of life; feel more prepared for the caregiving role; and receive better quality of end-of-life care; (2) if outcomes vary dependant upon site of care and; (3) the cost-benefit of implementing meetings into routine practice. Design: Pragmatic cluster randomised trial involving palliative care patients and their primary family caregivers at three Australian hospitals. Participants completed measures upon admission (Time 1); 10 days later (Time 2) and two months after the patient died (Time 3). Regression analyses, health utilisation and process evaluation were conducted. Results: 297 dyads recruited; control ( n = 153) and intervention ( n = 144). The intervention group demonstrated significantly lower psychological distress (Diff: –1.68, p Conclusions: Family meetings may be helpful in reducing family caregiver distress and enhancing their preparedness for the caregiving role and it appears they may be conducted without increased hospital health utilisation impacts; although opportunity costs need to be considered in order to routinely offer these as a standardised intervention. Additional health economic examination is also advocated to comprehensively understand the cost-benefit implications. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12615000200583

Objective:Driving and stopping driving present challenging issues for older people living with memory problems and the family members supporting them. Changes to driving status impact the individual stopping driving and their family members. CarFreeMe is an existing, effective driving cessation program for older people that may be applicable to older people living with dementia. The purpose of this study was to adapt the program and explore feasibility and key stakeholder perspectives.Methods:The Medical Research Council guidelines for conducting research into complex interventions guided the development, acceptability and feasibility piloting. A multidisciplinary approach was taken, and key stakeholders were involved throughout the process. This included an adaptation process, followed by expert reference group feedback and case series pilot study.Results:The background research indicated that some key changes were required to meet the needs of people living with dementia. Aspects of the content, language, format and activities were adapted and an additional module was created for family members – whose involvement was identified as important. A more personalized, flexible approach was recommended. The expert reference group [psychologists (n= 2), occupational therapists (n= 3) and dementia behavior consultants (n= 2)] indicated the program was appropriate and needed, and made recommendations for feasibility. Pilot testing with three families indicated acceptability.Conclusion:A driving cessation program adapted for use with people living with dementia and their families required some changes to meet the needs and situations based on feedback from key stakeholders. Future studies will evaluate implementation outcomes across a range of settings.

OBJECTIVES: To assess the predictive value of the Australian absolute cardiovascular disease risk (ACVDR) calculator and other assessment tools for identifying Australians with family histories of early onset coronary artery disease (CAD) who have coronary artery calcification. DESIGN, SETTING, PARTICIPANTS: People without known CAD were recruited at seven Australian hospitals, October 2016 - January 2019. Participants were aged 40-70 years, had a family history of early onset CAD, and a 5-year ACVDR of 2-15%. MAIN OUTCOME MEASURES: CT coronary artery calcium score greater than zero (any coronary calcification) or greater than 100 (calcification warranting lipid therapy). RESULTS: 1059 participants were recruited; 477 (45%) had non-zero coronary artery calcium scores (median 5-year ACVDR, 4.8% [IQR, 2.9-7.6%]; median coronary artery calcium score, 41.7 [IQR, 8-124]); 582 (55%) did not (median 5-year ACVDR, 3.2% [IQR, 2.0-4.6%]). Of 151 participants with calcium scores of 100 or more, 116 (77%) were deemed to be at low cardiovascular risk by Australian guidelines, while 14 of 75 participants at intermediate risk (19%) had zero calcium scores. The sensitivity of the ACVDR calculator for identifying people with non-zero calcium scores (area under receiver operator curve [AUC], 0.674) was lower than that of the pooled cohort equation (AUC, 0.711; P

ObjectiveOur aim was to synthesise the available evidence surrounding the structure, processes and outcomes of family meetings in the paediatric palliative care literature.MethodsWe undertook an integrative literature review informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The protocol was registered with PROSPERO (CRD42019138938). Electronic databases were systematically search using keywords and hand searching of reference articles and grey literature was also completed.ResultsTen empirical studies and five theoretical articles were included in the synthesis. Empirical studies provided more information about meeting structure, whereas theoretical articles more frequently described a desired process for planning and undertaking meetings. No articles identified how the success of a meeting was defined or made recommendations for doing so. Despite reports that family meetings are commonly occurring, few articles described outcomes from either the family or clinician perspectives.ConclusionsFamily meetings are essential communication strategies commonly used in paediatric palliative care, yet there is little guidance about how meetings should be organised and conducted, who should participate and when they should occur. The limited data available on the outcomes of family meetings suggest improvements are required to meet the needs of families. We present a framework that synthesises the available evidence. The framework offers an overview of the elements to consider when planning for and undertaking family meetings in paediatric palliative care and may be useful for both clinicians and researchers.

BACKGROUND AND OBJECTIVES: Whole-person care (WPC) is a key characteristic of general practice, but it may not be consistently practised. Previous articles in this series suggest a model of WPC that views patients as multidimensional persons; has length, breadth and depth of scope; is founded on a strong doctor-patient relationship and involves a healthcare team. This article reports factors that general practitioners (GPs) believe affect their provision of WPC. METHOD: Semi-structured interviews were conducted with 20 Australian GPs or general practice registrars and analysed using grounded theory methodology. RESULTS: Participants identified overarching factors (time, perceived value of WPC) and factors related to immediate (interpersonal dynamic), local (practice structure, relationship between care providers) and broader (health system structure) contexts that affect WPC. They volunteered practical suggestions to support WPC. DISCUSSION: GPs believe that multiple factors acting at micro and macro levels affect WPC provision. These findings provide a basis for strategies to support WPC.

Attention deficit/hyperactivity disorder (ADHD) is often accompanied by sleep problems in children. Sleep hygiene is defined as a set of behavioural, environmental, or cognitive modifications to improve sleep, and is routinely clinically utilised as first-line treatment for insomnia in ADHD. The objective of this systematic review of the literature is to evaluate the effectiveness of sleep hygiene interventions for sleep difficulties in children with ADHD. Sixteen relevant articles met the inclusion criteria, involving 1,469 participants, with a mean age of 9.6 years, across 6 countries. Fifteen studies found that sleep hygiene interventions were effective in improving sleep, while one did not show any significant improvement. Definite conclusions on the effectiveness of the interventions are difficult to draw due to the limited number of studies and a high risk of bias. There is growing evidence to support the use of sleep hygiene interventions to improve sleep quality in children with ADHD and sleep disturbance. However, well-conducted clinical trials are required to strengthen the evidence.

Background and objectives Whole-person care (WPC) is a defining feature of general practice, but it may not be consistently implemented. These authors conducted a qualitative study to define WPC and determine factors that influence its provision. Part one of this series suggested a model of WPC. Its foundation is the doctor-patient relationship; this article reports the findings concerning this theme. Method Semi-structured interviews were conducted with 20 Australian GPs or general practice registrars and analysed using grounded theory methodology. Results GPs viewed the doctor-patient relationship as foundational to WPC, facilitating knowledge of the patient, trust and management. Participants' descriptions of the doctor-patient relationship were multidimensional, encompassing interacting professional, personal and business-transactional dimensions. Discussion The results suggest that a multidimensional doctor-patient relationship underpins WPC. It is not adequately described by a consumerist/contractual model; future work could further elucidate its nature. This relationship must be valued to provide quality WPC.

Background: Some patients do not receive adequate pain and symptom relief at the end of life, causing distress to patients, families and healthcare professionals. It is unclear whether undertreatment of symptoms occurs, in part, because of nurses’ concerns about legal and/or disciplinary repercussions if the patient dies after medication is administered. Aim: The aim was to explore nurses’ experiences and knowledge of the law relating to the provision of end-of-life pain and symptom relief. Design: Semi-structured interviews with nurses were assessed using a six-stage hybrid thematic analysis technique. Setting/participants: Four face-to-face and 21 telephone interviews were conducted with nurses who routinely prescribed and/or administered pain and symptom relief to patients approaching the end of their lives in Queensland and New South Wales, Australia. Results: While many nurses had no personal experiences with legal or professional repercussions after a patient had died, the fear of hastening death and being held accountable was frequently discussed and regarded as relevant to the provision of inadequate pain and symptom relief. Concerns included potential civil or criminal liability and losing one’s job, registration or reputation. Two-thirds of participants believed that pain relief was sometimes withheld because of these legal concerns. Less than half of the interviewed nurses demonstrated knowledge of the doctrine of double effect, the legal protection for health professionals who provide end-of-life pain and symptom relief. Conclusion: Education is urgently required to strengthen nurses’ knowledge of the legal protections supporting the provision of appropriate palliative medication, thereby improving their clinical practice with end-of-life patients.

Background and objectives: Whole-person care (WPC) is a core value of general practice and is particularly relevant with increasing population multimorbidity. However, WPC has lacked consensus definition, and some argue that it is not consistently practised. The aim of this study was to determine Australian general practitioners’ (GPs’) understanding of WPC and factors affecting its provision. This article (the first in a three-part series) describes GPs’ understanding of WPC. Methods: Semi-structured interviews were conducted with 20 Australian GPs or general practice registrars and analysed using grounded theory methodology. Results: Four themes encapsulated GPs’ understanding of WPC: 1) treats patients as multidimensional persons; 2) length, breadth and depth of scope; 3) based on the foundation of a doctor–patient relationship; and 4) may involve team-based care. Discussion: WPC encompasses several defining characteristics of generalism. Previous evidence supports the efficacy of several of its dimensions. The current findings provide a basis for education, self-reflection and assessment of implementation and outcomes of WPCs.

Background Prognostic uncertainty and the need for proxy decision-making owing to cognitive impairment in advanced dementia, adds complexity to end-of-life care planning within the long-term care setting. Case conferences provide a structure to facilitate difficult conversations and an opportunity for family and clinicians to engage in prospective planning, and reach agreement on goals of end-of-life care. Objective To explore interactions between multidisciplinary healthcare clinicians and families during facilitated case conferences on end-of-life care for residents with advanced dementia. Methods A qualitative approach was used. Transcripts of audio-recorded case conferences facilitated by a trained registered nurse were coded by two independent researchers and analysed inductively. Transcripts were selected from an available pool until thematic saturation was reached. Emerging themes were confirmed with the wider research group. Results Thematic saturation was reached after 25 transcripts. An overarching theme concerned the ways in which clinicians and families bridged medical and person-centred perspectives. Subthemes included: details of day-to-day care versus establishing overall goals of care; expression of emotion versus retreat from emotion; and missed opportunities versus expressed cues. Successful facilitation served to ‘bridge the gap’ between family and clinicians. Conclusion Facilitation of case conferences for residents with advanced dementia should focus on ensuring that: clinicians do not miss opportunities to discuss end-of-life care; discussions on the minutiae of care regularly return to the resident’s broader goals of care; and information on dementia and treatments provided by clinicians is integrated with advice by family members regarding the resident’s premorbid values and likely preferences.

Liquid crystal polymers, through covalent bonding, combine the spontaneous long range orientational order of the liquid crystal state with the entropically driven random coil configurations of the skeletal polymer chains in a single material [1]. [...] info:eu-repo/semantics/publishedVersion

ObjectivesTo describe general practitioners’ (GPs) involvement in end-of-life care, continuity and outcomes of care, and reported management challenges in the Australian context.MethodsSixty-three GPs across three Australian states participated in a follow-up survey to report on care provided for decedents in the last year life using a clinic-based data collection process. The study was conducted between September 2018 and August 2019.ResultsApproximately one-third of GPs had received formal palliative care training. Practitioners considered themselves as either the primary care coordinator (53.2% of reported patients) or part of the management team (40.4% of reported patients) in the final year of care. In the last week of life, patients frequently experienced reduced appetite (80.6%), fatigue (77.9%) and psychological problems (44.9%), with GPs reporting that the alleviation of these symptoms were less than optimal. Practitioners were highly involved in end-of-life care (eg, home visits, consultations via telephone and family meetings), and perceived higher levels of satisfaction with communication with palliative care services than other external services. For one-third of patients, GPs reported that the last year of care could potentially have been improved.ConclusionThere are continuing needs for integration of palliative care training into medical education and reforms of healthcare systems to further support GPs’ involvement in end-of-life care. Further, more extensive collection of clinical data is needed to evaluate and support primary care management of end-of-life patients in general practice.

Background As doctors who provide care across the life-course, general practitioners (GPs) play a key role in initiating timely end-of-life discussions. Nonetheless, these discussions are often not initiated until close to death. Given the ageing of the population, GPs will be confronted with end-of-life care more often, and this needs to become a core skill for all GPs. Objective To describe GPs’ approach to initiating end-of-life discussions. Methods Fifteen GPs or GP trainees from South-East Queensland, Australia, were purposively recruited to participate in a semi-structured interview. We analysed transcripts using a thematic analysis. Results GPs’ approach to initiating end-of-life discussions was summarized by four themes: (1) Preparing the ground; (2) finding an entry point; (3) tailoring communication and (4) involving the family. Conclusions Emphasis on the doctor–patient relationship; assessing patient readiness for end-of-life discussions; and sensitive information delivery is consistent with factors previously reported to be important to both GPs and patients in this context. Our findings provide a framework for GPs initiating end-of-life discussions, which must be tailored to patient and GP personality factors. Further research is required to evaluate its outcomes.

BACKGROUND AND OBJECTIVES: Commitment to providing whole-person care (WPC) is a core value of general practice. The current Health Care Homes (HCHs) trial reforms Australian primary care with the aim of improving complex and chronic disease care. The aim of this study was to clarify how Australian general practitioners (GPs) anticipate the government's HCHs will affect WPC. METHOD: Qualitative semi-structured interviews with 20 Australian GPs and general practice registrars were conducted between May and November 2018. RESULTS: GPs supported the principles underlying the Medical Home concept, believing these could assist WPC by facilitating flexibility, continuity and scope of care and team involvement. However, many had serious misgivings about the government's HCH trial, believing that aspects of capitation funding and limitation of the trial to chronic disease management may impede WPC. They also reported practical struggles with the trial. DISCUSSION: GPs anticipate a mixed impact of HCHs on WPC and potentially on the therapeutic relationship underlying WPC. They identified practical struggles previous literature anticipated. These findings provide on-the-ground evidence of GPs' views about HCHs and WPC, which stakeholders planning the ongoing direction of Australian primary care should carefully consider.

This work focuses on understanding the action of a novel seaweed extract with anti-browning functionality in fresh-cut apples. Organic fresh-cut apples were coated by immersion in an aqueous Codium tomentosum seaweed extract (0.5 % w/v), packaged under ambient atmospheric conditions in plastic bags, and stored at 4 ˚C for 15 days. Browning-related enzymatic activities, as well as targeted gene expression related to superficial browning, were monitored immediately after coating and followed at five-day intervals, until a final storage period of 15 days. Gene expression was particularly affected one hour after coating application (day 0), with no expression registered for peroxidase (mdPOD) and phenylalanine ammonia-lyase (mdPAL) genes in the coated samples. A reduction in polyphenol oxidase expression levels was also observed. After 15 days of storage, the coated samples developed lower browning levels and presented distinctly lower activities of polyphenol oxidase and peroxidase - the oxidative enzymes predominantly involved in enzymatic browning. The observed post-coating suppression of mdPAL and mdPOD expression, and reduction in mdPPO expression, suggest that the seaweed C. tomentosum extract delays the activation of these genes, and decreases enzymatic activity, which in turn accounts for the coating's anti-browning effect.

Psychological therapies combined with medication are effective treatments for depression and anxiety in patients with cancer. However, the psycho-oncology workforce is insufficient to meet patient need and is hard to access outside of the major cities. To bridge this gap, innovative models of care are required. Implementation of a new model of care requires attention to the facilitators and barriers. The aim of this study was to explore stakeholders' attitudes to the feasibility and acceptability of a community-based, shared care model for the treatment of depression and anxiety.Semi-structured interviews were conducted with community-based clinical psychologists (n = 10), general practitioners (n = 6), and hospital-based psychologists working in psycho-oncology (n = 9). Framework analysis was conducted to identify key themes.All stakeholders perceived the model as feasible and acceptable. Potential barriers/facilitators to implementation were summarised under six key themes: (a) initiative, ownership, and autonomy; (b) resources; (c) pathway establishment; (d) support; (e) skill acquisition; and (f) patient engagement. Facilitators included quality communication between health professionals across primary and tertiary care and appropriate education and support for community-based clinicians.This in-depth exploration of Australian health professionals' perceptions of the feasibility and acceptability of a community-based model of psycho-oncology care revealed that most clinicians were willing to adopt the proposed changes into practice. An RCT of a shared care intervention for depressed patients with cancer is needed.