Craig Sinclair

Excitatory and inhibitory processes in primary motor cortex during the foreperiod of a warned reaction time task are unrelated to response expectancy

Reaction time (RT) is shortened when a warning signal precedes the response signal, a finding attributed to response preparation during the foreperiod between the warning and response signals. In a previous experiment, we delivered transcranial magnetic stimulation (TMS) during the short constant foreperiod of a warned RT task and found simultaneous suppression of motor evoked potential (MEP) amplitude and reduction of short-interval intracortical inhibition (SICI) on warned trials (Sinclair and Hammond in Exp Brain Res 186:385–392, 2008). To investigate the extent to which these phenomena are associated with response preparation we measured MEP amplitude and SICI during the foreperiod of a warned RT task in which three different warning signals specified the probability (0, 0.5, or 0.83) of response signal presentation. MEP amplitude was suppressed (Experiment 1) and SICI reduced (Experiment 2) equally in all of the warned conditions relative to when TMS was delivered in the inter-trial interval (ITI) suggesting that the modulation of primary motor cortex excitability during the foreperiod does not depend on momentary response expectancy induced by the warning signal. The reduction of SICI and suppression of MEP amplitude can be explained by assuming that a warning signal induces automatic motor cortical activation which is balanced by a competing inhibition to prevent premature response. A composite measure which weighted both speed and accuracy of response was positively correlated with the MEP amplitude during both the foreperiod and the ITI, suggesting that high motor cortical excitability is associated with optimized preparatory strategies for fast and accurate response.

Diagnosing cancer in the bush: a mixed-methods study of symptom appraisal and help-seeking behaviour in people with cancer from rural Western Australia

BACKGROUND Previous studies have focused on the treatment received by rural cancer patients and have not examined their diagnostic pathways as reasons for poorer outcomes in rural Australia. OBJECTIVES To compare and explore symptom appraisal and help-seeking behaviour in patients with breast, lung, prostate or colorectal cancer from rural Western Australia (WA). METHODS A mixed-methods study of people recently diagnosed with breast, lung, prostate or colorectal cancer from rural WA. The time from first symptom to diagnosis (i.e. total diagnostic interval, TDI) was calculated from interviews and medical records. RESULTS Sixty-six participants were recruited (24 breast, 20 colorectal, 14 prostate and 8 lung cancer patients). There was a highly significant difference in time from symptom onset to seeking help between cancers (P = 0.006). Geometric mean symptom appraisal for colorectal cancer was significantly longer than that for breast and lung cancers [geometric mean differences: 2.58 (95% confidence interval, CI: 0.64-4.53), P = 0.01; 3.97 (1.63-6.30), P = 0.001, respectively]. There was a significant overall difference in arithmetic mean TDI (P = 0.046); breast cancer TDI was significantly shorter than colorectal or prostate cancer TDI [mean difference : 266.3 days (95% CI: 45.9-486.8), P = 0.019; 277.0 days, (32.1-521.9), P = 0.027, respectively]. These differences were explained by the nature and personal interpretation of symptoms, perceived as well as real problems of access to health care, optimism, stoicism, machismo, fear, embarrassment and competing demands. CONCLUSIONS Longer symptom appraisal was observed for colorectal cancer. Participants defined core characteristics of rural Australians as optimism, stoicism and machismo. These features, as well as access to health care, contribute to later presentation of cancer.

Online Mental Health Resources in Rural Australia: Clinician Perceptions of Acceptability

Background Online mental health resources have been proposed as an innovative means of overcoming barriers to accessing rural mental health services. However, clinicians tend to express lower satisfaction with online mental health resources than do clients. Objective To understand rural clinicians’ attitudes towards the acceptability of online mental health resources as a treatment option in the rural context. Methods In-depth interviews were conducted with 21 rural clinicians (general practitioners, psychologists, psychiatrists, and clinical social workers). Interviews were supplemented with rural-specific vignettes, which described clinical scenarios in which referral to online mental health resources might be considered. Symbolic interactionism was used as the theoretical framework for the study, and interview transcripts were thematically analyzed using a constant comparative method. Results Clinicians were optimistic about the use of online mental health resources into the future, showing a preference for integration alongside existing services, and use as an adjunct rather than an alternative to traditional approaches. Key themes identified included perceptions of resources, clinician factors, client factors, and the rural and remote context. Clinicians favored resources that were user-friendly and could be integrated into their clinical practice. Barriers to use included a lack of time to explore resources, difficulty accessing training in the rural environment, and concerns about the lack of feedback from clients. Social pressure exerted within professional clinical networks contributed to a cautious approach to referring clients to online resources. Conclusions Successful implementation of online mental health resources in the rural context requires attention to clinician perceptions of acceptability. Promotion of online mental health resources to rural clinicians should include information about resource effectiveness, enable integration with existing services, and provide opportunities for renegotiating the socially defined role of the clinician in the eHealth era.

Daily variations in sleep–wake patterns and severity of psychopathology: A pilot study in community-dwelling individuals with chronic schizophrenia

The daily co-occurrence of change in sleep characteristics and psychopathology was examined in six individuals with schizophrenia and seven healthy controls using a prospective assessment of rest-activity patterns conducted in the persons home for up to 28 days. The results provide preliminary evidence that a change in sleep-wake timing is followed by a change in symptom severity.

A public health approach to promoting advance care planning to Aboriginal people in regional communities

OBJECTIVE To explore perceptions of Noongar community members towards advance care planning (ACP), while developing culturally appropriate information resources for use in community and hospital settings. DESIGN Qualitative research methods, combining active health promotion with interviews and group discussions for participant feedback. SETTING Six rural communities across the Great Southern region of Western Australia. PARTICIPANTS Eighteen Noongar community members consented to participate in interviews or group discussions. INTERVENTIONS Community members received information about ACP at community events or home visits, from an Aboriginal health worker and palliative care researcher. MAIN OUTCOME MEASURES Semi-structured interviews and group discussions were thematically analysed using a descriptive, exploratory approach. Research team reflections on community events also constituted data. RESULTS Key themes impacting on perceptions of ACP included cultural approaches to dying, importance of family and kin, and appropriate communication. Participants were satisfied with the information resource and method of community engagement. CONCLUSIONS Culturally appropriate methods of engaging Aboriginal people in ACP discussions should include Aboriginal health workers and take a whole of community approach to awareness raising.

The balancing point: understanding uptake of advance directive forms in a rural Australian community

Objectives The study was conducted in Western Australia, focusing on the attitudes of older, rural, non-hospitalised people towards newly legislated advance care planning (ACP) documents. This study explored baseline awareness and perception of advance directive (AD) forms and factors relevant to their utilisation, using the transtheoretical model as a theoretical framework. Methods Sixty-two adults were recruited from residential aged care facilities, community care organisations, general practice, an oncology service and a law firm. Semi-structured interviews were undertaken. These were transcribed and thematically analysed by the authors. Results Participants gave responses that were consistent with different stages of the transtheoretical model. Perceived susceptibility to the negative consequences of not engaging in AD form utilisation was a trigger for further contemplation. The presence of adequate personal empowerment was important for successful completion of AD forms. There was also qualitative evidence of a negative relationship between perceived susceptibility and empowerment regarding AD form utilisation. Conclusions Promoting balance between a persons perceived susceptibility and empowerment may be an effective method of increasing engagement with AD forms.

Advance care planning uptake among patients with severe lung disease: a randomised patient preference trial of a nurse-led, facilitated advance care planning intervention

Objective Advance care planning (ACP) clarifies goals for future care if a patient becomes unable to communicate their own preferences. However, ACP uptake is low, with discussions often occurring late. This study assessed whether a systematic nurse-led ACP intervention increases ACP in patients with advanced respiratory disease. Design A multicentre open-label randomised controlled trial with preference arm. Setting Metropolitan teaching hospital and a rural healthcare network. Participants 149 participants with respiratory malignancy, chronic obstructive pulmonary disease or interstitial lung disease. Intervention Nurse facilitators offered facilitated ACP discussions, prompted further discussions with doctors and loved ones, and assisted participants to appoint a substitute medical decision-maker (SDM) and complete an advance directive (AD). Outcome measures The primary measure was formal (AD or SDM) or informal (discussion with doctor) ACP uptake assessed by self-report (6 months) and medical notes audit. Secondary measures were the factors predicting baseline readiness to undertake ACP, and factors predicting postintervention ACP uptake in the intervention arm. Results At 6 months, formal ACP uptake was significantly higher (p<0.001) in the intervention arm (54/106, 51%), compared with usual care (6/43, 14%). ACP discussions with doctors were also significantly higher (p<0.005) in the intervention arm (76/106, 72%) compared with usual care (20/43, 47%). Those with a strong preference for the intervention were more likely to complete formal ACP documents than those randomly allocated. Increased symptom burden and preference for the intervention predicted later ACP uptake. Social support was positively associated with ACP discussion with loved ones, but negatively associated with discussion with doctors. Conclusions Nurse-led facilitated ACP is acceptable to patients with advanced respiratory disease and effective in increasing ACP discussions and completion of formal documents. Awareness of symptom burden, readiness to engage in ACP and relevant psychosocial factors may facilitate effective tailoring of ACP interventions and achieve greater uptake. Trial registration number ACTRN12614000255684.

Negative emotional processing induced by spoken scenarios modulates corticospinal excitability

Emotion is assumed to facilitate the preparation of behavioral responses to environmental stimuli. In the present study, we examined whether emotional processing induced by spoken scenarios of positive and negative content, related to the self or to other people, modulates corticospinal excitability. Motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation (TMS) in 20 volunteers indicated that processing of negative emotional content increased MEP amplitude, regardless of the perspective taken in the scenario. By contrast, positive emotional processing did not reliably alter MEP amplitude. These results provide the first TMS evidence that the auditory processing of emotionally negative information triggers action preparation.

Positive community responses to an arts–health program designed to tackle diabetes and kidney disease in remote Aboriginal communities in Australia: a qualitative study

Objective: The Western Desert Kidney Health Project (WDKHP) is an innovative clinical screening, arts–health and community development program, staffed by Aboriginal health workers. The WDKHP is aimed at prevention and early detection, improving the chance of better management of kidney disease among people in 10 predominantly Aboriginal communities in rural Western Australia. This paper aimed to understand community responses to the WDKHP in three of these communities.

When paperwork does not represent the patient's wishes for surrogate decision-making

We read with interest the article by Cheang et al. in the October 2014 issue of the Internal Medicine Journal. Their work in Royal North Shore Hospital highlighted one of the practical issues that has arisen as legislation supporting advance care planning and traditional hospital ways of doing business diverge. They found that in 27% of reviewed cases the ‘person responsible’ nominated by elderly inpatients to provide medical decision-making on their behalf was not the same person as the ‘next of kin’ or ‘emergency contact’ documented in the paper medical record. This is a significant challenge to hospital admission processes. We work in Albany Health Campus, a 130-bed regional hospital in Western Australia, servicing approximately 50 000 people. In December 2014, the team engaged in improving advance care planning processes in the hospital explored this question as part of a quality improvement initiative. The ward clerk in the day procedure unit completed the usual admission paperwork for the front of the medical record, including next-of-kin details. Following this, she went on to ask ‘Who is the person you would like to speak on your behalf when making a medical decision if you were unable to do so yourself?’ Two hundred and seventytwo people participated, and 270 people were able to answer the follow-up question. Ten per cent (n = 27) identified someone other than the next-of-kin. Cheang et al. propose that appropriate screening questions may contribute to the routine prompting of advance care planning in hospital settings. We suggest the use of such a question in the admission or pre-admission process may stimulate discussion and, for some, nomination of an enduring guardian (Western Australia terminology for a legally authorised person responsible). This initial work suggests that a pre-admission clinic may be an appropriate setting for such a screening question to be asked. The capacity for patients to complete such questions in a private setting, or using self-administered paper documents, may reduce the risk of them feeling pressured to nominate a particular family member. Further work must be done to ensure that accurate information is routinely recorded and updated in paper and electronic records.