Non-invasive clinical measurement of the viscoelastic properties of tendon using acoustic wave transmission

Background. In isotropic materials, the speed of acoustic wave propagation is governed by the bulk modulus and density. For tendon, which is a structural composite of fluid and collagen, however, there is some anisotropy requiring an adjustment for Poisson's ratio. This paper explores these relationships using data collected, in vivo, on human Achilles tendon and then compares estimates of elastic modulus and hysteresis against published values from in vitro mechanical tests. Methods. Measurements using conventional B-model ultrasound imaging, inverse dynamics and acoustic transmission techniques were used to determine dimensions, loading conditions and longitudinal speed of sound in the Achilles tendon during a series of isometric plantar flexion exercises against body weight. Upper and lower bounds for speed of sound versus tensile stress in the tendon were then modelled and estimates of the elastic modulus and hysteresis of the Achilles tendon derived. Results. Axial speed of sound varied between 1850 and 2090 ms-1 with a non-linear, asymptotic dependency on the level of tensile stress (5-35 MPa) in the tendon. Estimates derived for the elastic modulus of the Achilles tendon ranged between 1-2 GPa. Hysteresis derived from models of the stress-strain relationship, ranged from 3-11%. Discussion. Estimates of elastic modulus agree closely with those previously reported from direct measurements obtained via mechanical tensile tests on major weight bearing tendons in vitro [1,2]. Hysteresis derived from models of the stress-strain relationship is consistent with direct measures from various mamalian tendon (7-10%) but is lower than previous estimates in human tendon (17-26%) [3]. This non-invasive method would appear suitable for monitoring changes in tendon properties during dynamic sporting activities.

Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy : a systematic review

Background: Charcot Neuro-Arthropathy (CN) is one of the more devastating complications of diabetes. To the best of the authors' knowledge, it appears that no clinical tools based on a systematic review of existing literature have been developed to manage acute CN. Thus, the aim of this paper was to systematically review existing literature and develop an evidence-based clinical pathway for the assessment, diagnosis and management of acute CN in patients with diabetes. Methods: Electronic databases (Medline, PubMed, CINAHL, Embase and Cochrane Library), reference lists, and relevant key websites were systematically searched for literature discussing the assessment, diagnosis and/or management of acute CN published between 2002-2012. At least two independent investigators then quality rated and graded the evidence of each included paper. Consistent recommendations emanating from the included papers were then fashioned in a clinical pathway. Results: The systematic search identified 267 manuscripts, of which 117 (44%) met the inclusion criteria for this study. Most manuscripts discussing the assessment, diagnosis and/or management of acute CN constituted level IV (case series) or EO (expert opinion) evidence. The included literature was used to develop an evidence-based clinical pathway for the assessment, investigations, diagnosis and management of acute CN. Conclusions: This research has assisted in developing a comprehensive, evidence-based clinical pathway to promote consistent and optimal practice in the assessment, diagnosis and management of acute CN. The pathway aims to support health professionals in making early diagnosis and providing appropriate immediate management of acute CN, ultimately reducing its associated complications such as amputations and hospitalisations.

Foot ulcer simulation training (FUST) : are podiatrists FUST with long-term clinical confidence?

Background Foot ulcers are a leading cause of diabetes-related hospitalisations. Clinical training has been shown to be beneficial in foot ulcer management. Recently, improved self-confidence in podiatrists was reported immediately after foot ulcer simulation training (FUST) pilot programs. This study aimed to investigate the longer-term impacts of the FUST program on podiatrists’ self-confidence over 12 months in a larger sample. Methods Participants were podiatrists attending a two-day FUST course comprising web-based interactive learning, low-fidelity part-tasks and high-fidelity full clinical scenarios. Primary outcome measures included participants’ self-confidence measured pre-, (immediately) post-, 6-month post- and 12-month post-course via a purpose designed 21-item survey using a five-point Likert scale (1=Very limited, 5=Highly confident). Participants’ perceptions of knowledge gained, satisfaction, relevance and fidelity were also investigated. ANOVA and post hoc tests were used to test any differences between groups. Results Thirty-four participants completed FUST. Survey response rates were 100% (pre), 82% (post), 74% (6-month post), and 47% (12-month post). Overall mean scores were 3.13 (pre), 4.49 (post), 4.35 (6-month post) and 4.30 (12-month post) (p < 0.05); post hoc tests indicated no differences between the immediately, 6-month and 12-month post group scores (p > 0.05). Satisfaction, knowledge, relevance and fidelity were all rated highly. Conclusion This study suggests that significant short-term improvements in self-confidence to manage foot ulcers via simulation training are retained over the longer term. It is likely that improved self-confidence leads to improved foot ulcer clinical practice and outcomes; although this requires further research.

Is the clinical Queensland High Risk Foot Form valid or reliable for research?

Background High-risk foot complications such as neuropathy, ischaemia, deformity, infections, ulcers and amputations consume considerable health care resources and typically result from chronic diseases. This study aimed to develop and test the validity and reliability of a Queensland High Risk Foot Form (QHRFF) tool. Methods Phase one involved developing a QHRFF using an existing diabetes high-risk foot tool, literature search, expert panel and several state-wide stakeholder groups. Phase two tested the criterion-related validity along with inter- and intra-rater reliability of the final QHRFF. Three cohorts of patients (n = 94) and four clinicians, representing different levels of expertise, were recruited. Validity was determined by calculating sensitivity, specificity and positive predictive values (PPV). Kappa and intra-class correlation (ICC) statistics were used to establish reliability. Results A QHRFF tool containing 46-items across seven domains was developed and endorsed. The majority of QHRFF items achieved moderate-to-perfect validity (PPV = 0.71 – 1) and reliability (Kappa/ICC = 0.41 – 1). Items with weak validity and/or reliability included those identifying health professionals previously attending the patient, other (non-listed) co-morbidity, previous foot ulcer, foot deformity, optimum offloading and optimum footwear. Conclusions The QHRFF had moderate-to-perfect validity and reliability across the majority of items, particularly identifying individual co-morbidities and foot complications. Items with weak validity or reliability need to be re-defined or removed. Overall, the QHRFF appears to be a valid and reliable tool to assess, collect and measure clinical data pertaining to high-risk foot complications for clinical or research purposes.

A 3D virtual medical imaging suite : bridging the academic-clinical training boundary

Aims The Medical Imaging Training Immersive Environment (MITIE) system is a recently developed virtual reality (VR) platform that allows students to practice a range of medical imaging techniques. The aim of this pilot study was to harvest user feedback about the educational value of the application and inform future pedagogical development. This presentation explores the use of this technology for skills training and blurring the boundaries between academic learning and clinical skills training. Background MITIE is a 3D VR environment that allows students to manipulate a patient and radiographic equipment in order to produce a VR-generated image for comparison with a gold standard. As with VR initiatives in other health disciplines (1-6) the software mimics clinical practice as much as possible and uses 3D technology to enhance immersion and realism. The software was developed by the Medical Imaging Course Team at a provider University with funding from a Health Workforce Australia “Simulated Learning Environments” grant. Methods Over 80 students undertaking the Bachelor of Medical Imaging Course were randomised to receive practical experience with either MITIE or radiographic equipment in the medical radiation laboratory. Student feedback about the educational value of the software was collected and performance with an assessed setup was measured for both groups for comparison. Ethical approval for the project was provided by the university ethics panel. Results This presentation provides qualitative analysis of student perceptions relating to satisfaction, usability and educational value as well as comparative quantitative performance data. Students reported high levels of satisfaction and both feedback and assessment results confirmed the application’s significance as a pre-clinical training tool. There was a clear emerging theme that MITIE could be a useful learning tool that students could access to consolidate their clinical learning, either during their academic timetables or their clinical placement. Conclusion Student feedback and performance data indicate that MITIE has a valuable role to play in the clinical skills training for medical imaging students both in the academic and the clinical environment. Future work will establish a framework for an appropriate supporting pedagogy that can cross the boundary between the two environments. This project was possible due to funding made available by Health Workforce Australia.

The impact on clinical practice of a postgraduate clinical pharmacy programme, incorporating competency-based performance evaluation

Background A goal of the postgraduate clinical pharmacy programme (PGCPP) at the University of Queensland is to enhance clinical practice. Aims To evaluate student perceptions of the impact of the PGCPP on practice and the inclusion of a competency-based performance evaluation as a formative component of the curriculum. Method In 2010, students completed a questionnaire to evaluate the impact of the PGCPP. In 2011, formative competency-based performance evaluations were conducted as a component of the course and the questionnaire was repeated. Responses, competency ratings and evaluation feedback were collated. Data were analysed using descriptive statistics. Results 51/57 (89%) of students completed the questionnaire in 2010 and 2011. Over 90% of students agreed or strongly agreed that the PGCPP enhanced practice, knowledge, confidence and contribution to patient care. Responses were similarly positive after the inclusion of the performance evaluation. Conclusion This study demonstrated that the PGCPP is achieving the goal of enhancing the practice of pharmacists.

Collaborating to develop clinical pharmacy teaching in Sri Lanka

Background Bachelor of Pharmacy programs were introduced in 2006 into two Sri Lankan universities - University of Peradeniya and University of Sri Jayewardenepura. Due to minimal clinical pharmacy experience in the country, these universities invited international colleagues to develop and teach the clinical pharmacy course. Aims To describe development, delivery and evaluation of both a clinical pharmacy undergraduate course and a "Train-thetrainer”program provided to local academics delivering undergraduate pharmacy programs. Method In 2009, Australian pharmacist academics developed and piloted an undergraduate clinical pharmacy course at University of Peradeniya. In 2010, this was refined and delivered at University of Sri Jayewardenepura, along with a “train-thetrainer”program for local academics. These were evaluated using surveys. Results Most students considered lecture delivery speed and use of audio visual aids appropriate, and lecture content relevant.Most academics found the “Train-the-Trainer” program increased their knowledge and improved their teaching skills. Conclusion Experienced pharmacist academics can improve the quality of clinical pharmacy teaching in developing countries such as Sri Lanka.

Constructing a clinical decision-making framework for image-guided radiotherapy using a Bayesian Network

A decision-making framework for image-guided radiotherapy (IGRT) is being developed using a Bayesian Network (BN) to graphically describe, and probabilistically quantify, the many interacting factors that are involved in this complex clinical process. Outputs of the BN will provide decision-support for radiation therapists to assist them to make correct inferences relating to the likelihood of treatment delivery accuracy for a given image-guided set-up correction. The framework is being developed as a dynamic object-oriented BN, allowing for complex modelling with specific sub-regions, as well as representation of the sequential decision-making and belief updating associated with IGRT. A prototype graphic structure for the BN was developed by analysing IGRT practices at a local radiotherapy department and incorporating results obtained from a literature review. Clinical stakeholders reviewed the BN to validate its structure. The BN consists of a sub-network for evaluating the accuracy of IGRT practices and technology. The directed acyclic graph (DAG) contains nodes and directional arcs representing the causal relationship between the many interacting factors such as tumour site and its associated critical organs, technology and technique, and inter-user variability. The BN was extended to support on-line and off-line decision-making with respect to treatment plan compliance. Following conceptualisation of the framework, the BN will be quantified. It is anticipated that the finalised decision-making framework will provide a foundation to develop better decision-support strategies and automated correction algorithms for IGRT.

OSCE online : making assessment of clinical competencies transparent, accountable & authentic

Creating an authentic assessment which at once assesses competencies, scene management, communication and overall patient care is challenging in the competitive tertiary education market. Increasing student numbers and the cost of evaluating scenario based competencies serve to ensure the need for consistent objectivity and need for timely feedback to students on their performance. Objective structured clinical examination (OSCE) is currently the most flexible approach to competency based formative and summative assessment and widely used within paramedic degree programs. Students are understandably compelled to perform well and can be frustrated by not receiving timely and appropriate feedback. Increasingly a number of products aimed at providing a more efficient and paperless approach have begun to enter the market. These products, it is suggested are aimed at medicine programs and not at allied health professions and limited to one operating system and therefore ignore issues surrounding equity and accessibility. OSCE Online aims to address this gap in the market and is tailored to these disciplines. The application will provide a service that can be both tailored and standardised from a pre-written bank, depending upon requirement to fit around the needs of clinical competency assessment. Delivering authentic assessments to address student milestones in their training to become paramedics is the cornerstone of OSCE Online. By not being restricted to a specific device it will address issues of functionality, adaptability, accessibility, authenticity and importantly: transparency and accountability by producing contemporaneous data allowing issues to be easily identified and rectified.

Development of reverse phase protein microarrays for clinical applications and patient-tailored therapy

While genomics provide important information about the somatic genetic changes, and RNA transcript profiling can reveal important expression changes that correlate with outcome and response to therapy, it is the proteins that do the work in the cell. At a functional level, derangements within the proteome, driven by post-translational and epigenetic modifications, such as phosphorylation, is the cause of a vast majority of human diseases. Cancer, for instance, is a manifestation of deranged cellular protein molecular networks and cell signaling pathways that are based on genetic changes at the DNA level. Importantly, the protein pathways contain the drug targets in signaling networks that govern overall cellular survival, proliferation, invasion and cell death. Consequently, the promise of proteomics resides in the ability to extend analysis beyond correlation to causality. A critical gap in the information knowledge base of molecular profiling is an understanding of the ongoing activity of protein signaling in human tissue: what is activated and “in use” within the human body at any given point in time. To address this gap, we have invented a new technology, called reverse phase protein microarrays, that can generate a functional read-out of cell signaling networks or pathways for an individual patient obtained directly from a biopsy specimen. This “wiring diagram” can serve as the basis for both, selection of a therapy and patient stratification.

Clinical perceptions of radiation therapy undergraduate competency standards

Introduction The multifactorial nature of clinical skills development makes assessment of undergraduate radiation therapist competence level by clinical mentors challenging. A recent overhaul of the clinical assessment strategy at Queensland University of Technology has moved away from the high-stakes Observed Structured Clinical Examination (OSCE) to encompass a more continuous measure of competence. This quantitative study aimed to gather stakeholder evidence to inform development of standards by which to measure student competence for a range of levels of progression. Methods A simple anonymous questionnaire was distributed to all Queensland radiation therapists. The tool asked respondents to assign different levels of competency with a range of clinical tasks to different levels of student. All data were anonymous and was combined for analysis using Microsoft Excel. Results Feedback indicated good agreement with tasks that specified amount of direction required and this has been incorporated into the new clinical achievements record that the students need to have signed off. Additional puzzling findings suggested higher expectations with planning tasks than with treatment-based tasks. Conclusion The findings suggest that the amount of direction required by students is a valid indicator of their level and has been adopted into the clinical assessment scheme. Further work will build on this to further define standards of competency for undergraduates.

Australia’s first Allied Health Prescribing Program – exploring participants' understanding and confidence in clinical therapy choices for patient management

BACKGROUND Globally there are emerging trends for non-medical health professionals to expand their scope of practice into prescribing. The NPS Prescribing Competencies Framework and the Health Professionals Prescribing Pathway Program are recent initiatives to assist with implementation of prescribing for allied health professionals (AHPs). For AHPs to become prescribers, training programmes must be designed to extend their knowledge of medicines information and medicine management principles with the aim of optimising medicines related outcomes for patients. AIM To explore the understanding and confidence in clinical therapeutic choices for patient management of those AHPs enrolled in the Allied Health Prescribing Training Program Module One: Introduction to clinical therapeutics for prescribers, delivered by Queensland University of Technology, Brisbane. METHOD A pre-post survey was developed to explore key themes around understanding and confidence in selecting therapeutic choices for patients with varying complexities of conditions. Data were collected from participants in week one and 13 of the module via an online survey using a five-point Likert scale (1 = Strongly Agree (SA) to 5 = Strongly Disagree (SD)). RESULTS In the pre-Module survey the AHPs had a limited degree (D/SD) of understanding and confidence regarding the safe and effective use of medicines and appropriate therapeutic choices for managing patients, particularly with complex patients. This improved significantly in the post Module survey (A/SA).

Quantification of functional hand grip using electromyography and inertial sensor-derived accelerations: Clinical implications

Background Assessing hand injury is of great interest given the level of involvement of the hand with the environment. Knowing different assessment systems and their limitations generates new perspectives. The integration of digital systems (accelerometry and electromyography) as a tool to supplement functional assessment allows the clinician to know more about the motor component and its relation to movement. Therefore, the purpose of this study was the kinematic and electromyography analysis during functional hand movements. Method Ten subjects carried out six functional movements (terminal pinch, termino-lateral pinch, tripod pinch, power grip, extension grip and ball grip). Muscle activity (hand and forearm) was measured in real time using electromyograms, acquired with the Mega ME 6000, whilst acceleration was measured using the AcceleGlove. Results Electrical activity and acceleration variables were recorded simultaneously during the carrying out of the functional movements. The acceleration outcome variables were the modular vectors of each finger of the hand and the palm. In the electromyography, the main variables were normalized by the mean and by the maximum muscle activity of the thenar region, hypothenar, first interosseous dorsal, wrist flexors, carpal flexors and wrist extensors. Conclusions Knowing muscle behavior allows the clinician to take a more direct approach in the treatment. Based on the results, the tripod grip shows greater kinetic activity and the middle finger is the most relevant in this regard. Ball grip involves most muscle activity, with the thenar region playing a fundamental role in hand activity. Clinical relevance Relating muscle activation, movements, individual load and displacement offers the possibility to proceed with rehabilitation by individual component.