A systematic review of interventions to enhance medication adherence in children and adolescents with chronic illness

Introduction Poor medication adherence is common in children and adolescents with chronic illness, but there is uncertainty about the best way to enhance medication adherence in this group. The authors conducted a systematic review of controlled trials examining interventions that aim to improve medication adherence. Method A comprehensive literature search was undertaken to locate controlled trials that described specific interventions aiming to improve adherence to long-term medication, where participants were aged 18 years and under, medication adherence was reported as an outcome measure, and which could be implemented by individual health practitioners. Studies were reviewed for quality and outcome. Results 17 studies met inclusion criteria: seven studies examined educational strategies, seven studies examined behavioural interventions and three studies examined educational intervention combined with other forms of psychological therapies. Only two of seven studies reported a clear benefit for education on medication adherence, whereas four of seven trials indicated a benefit of behavioural approaches on medication adherence. One trial reported that combining education with behavioural management may be more effective than education alone. Studies which combined education with other non-medication specific psychological interventions failed to demonstrate a beneficial effect on medication adherence. Only two studies examined adherence-promoting interventions in young people with established adherence problems. Conclusion These findings suggest that education interventions alone are insufficient to promote adherence in children and adolescents, and that incorporating a behavioural component to adherence interventions may increase potential efficacy. Future research should examine interventions in high-risk groups.

Prevalence of diet related risk factors for chronic disease in male prisoners in a high secure prison

BACKGROUND/OBJECTIVES Research on prisoners is limited and demonstrates a group with disproportionate numbers from disadvantaged backgrounds, known to have a high burden of disease, much of which is diet related. The aim of this study was to gauge the presence of markers of chronic disease, as a basis for food and nutrition policy in prisons. METHODS/SUBJECTS A cross-sectional study design was used with a convenience sample of prisoners in a male 945 bed high secure facility. Face to face interviews with physical measures of height, weight, body fat, waist circumference and blood pressure were collected along with fasting bloods. Data was confirmed with facility records, observations and staff interviews. Full ethics approval was obtained. Results were compared with studies of Australian prisoners and the general population. RESULTS The mean age was 35.5 years (n=120). Prevalence rates were: obesity 14%, diabetes 5%, hypertension 26.7% and smoking 55.8%. Self-report of daily physical activity was 84%, with 51% participating ≥two times daily. Standard food provision was consistent with dietary recommendations, except sodium was high. Where fasting bloods were obtained (n=78) dyslipidaemia was 56.4% with the Metabolic Syndrome present in 26%. CONCLUSIONS Prevalence of diabetes and heart disease risk appear similar to the general population, however obesity was lower and smoking higher. The data provides evidence that markers of chronic disease are present, with this the first study to describe the Metabolic Syndrome in prisoners. Food and nutrition policy in this setting is complex and should address the duty of care issues that exist.

Combined pharmacotherapy and psychological therapies for post traumatic stress disorder (PTSD)

BACKGROUND PTSD is an anxiety disorder related to exposure to a severe psychological trauma. Symptoms include re-experiencing the event, avoidance and arousal as well as distress and impairment resulting from these symptoms.Guidelines suggest a combination of both psychological therapy and pharmacotherapy may enhance treatment response, especially in those with more severe PTSD or in those who have not responded to either intervention alone. OBJECTIVES To assess whether the combination of psychological therapy and pharmacotherapy provides a more efficacious treatment for PTSD than either of these interventions delivered separately. SEARCH STRATEGY Searches were conducted on the trial registers kept by the CCDAN group (CCDANCTR-Studies and CCDANCTR-References) to June 2010. The reference sections of included studies and several conference abstracts were also scanned. SELECTION CRITERIA Patients of any age or gender, with chronic or recent onset PTSD arising from any type of event relevant to the diagnostic criteria were included. A combination of any psychological therapy and pharmacotherapy was included and compared to wait list, placebo, standard treatment or either intervention alone. The primary outcome was change in total PTSD symptom severity. Other outcomes included changes in functioning, depression and anxiety symptoms, suicide attempts, substance use, withdrawal and cost. DATA COLLECTION AND ANALYSIS Two or three review authors independently selected trials, assessed their 'risk of bias' and extracted trial and outcome data. We used a fixed-effect model for meta-analysis. The relative risk was used to summarise dichotomous outcomes and the mean difference and standardised mean difference were used to summarise continuous measures. MAIN RESULTS Four trials were eligible for inclusion, one of these trials (n =24) was on children and adolescents. All used an SSRI and prolonged exposure or a cognitive behavioural intervention. Two trials compared combination treatment with pharmacological treatment and two compared combination treatment with psychological treatment. Only two trials reported a total PTSD symptom score and these data could not be combined. There was no strong evidence to show if there were differences between the group receiving combined interventions compared to the group receiving psychological therapy (mean difference 2.44, 95% CI -2.87, 7.35 one study, n=65) or pharmacotherapy (mean difference -4.70, 95% CI -10.84 to 1.44; one study, n = 25). Trialists reported no significant differences between combination and single intervention groups in the other two studies. There were very little data reported for other outcomes, and in no case were significant differences reported. AUTHORS' CONCLUSIONS There is not enough evidence available to support or refute the effectiveness of combined psychological therapy and pharmacotherapy compared to either of these interventions alone. Further large randomised controlled trials are urgently required.

Early maternal deprivation reduces prepulse inhibition and impairs spatial learning ability in adulthood: No further effect of post-pubertal chronic corticosterone treatment

Prolonged maternal deprivation leads to long-term alterations in hypothalamic–pituitary–adrenal (HPA) axis activity, disturbances of auditory information processing and neurochemical changes in the adult brain, some of which are similar to that observed in schizophrenia. Here we report the adult behavioural effects of maternal deprivation (12 h on postnatal days 9 and 11) in Wistar rats on paradigms of auditory information processing (prepulse inhibition), sensitivity to dopamimetics (amphetamine-induced hyper-locomotion) and cognition (T-maze delayed alternation and Morris water-maze). In addition, we examined the long-lasting effect of chronic 21-day corticosterone treatment during the post-pubertal period (i.e., postnatal days 56–76) on each of these behavioural paradigms in maternally deprived and control rats. Behavioural testing commenced 2 weeks after the termination of corticosterone treatment. Maternal deprivation led to a significant reduction in PPI and impaired spatial learning ability in adulthood, but did not affect the behavioural response to amphetamine. Post-pubertal chronic corticosterone treatment did not have any major long-lasting effects on any of the behavioural measures in either maternally deprived or control rats. Our findings further support maternal deprivation as an animal model of specific aspects of schizophrenia.

Exposure to bioaerosols in the school environment in Brisbane, Australia

Introduction: Exposure to bioaerosols in indoor environments has been linked to various adverse health effects, such as airway disorders and upper respiratory tract symptoms. The aim of this study was to assess exposure to bioaerosols in the school environment in Brisbane, Australia. Methods: Culturable fungi and endotoxin measurements were conducted in six schools between October 2010 and May 2011. Culturable fungi (2 indoor air and 1-2 outdoor air samples per school) were assessed using a Biotest RCS High Flow Air Sampler, with a flow rate of either 50L/min or 20L/min. A rose pengar agar was used for recovery, which was incubated prior to counting and partial identification. Endotoxins were sampled (8h, 2L/min) using SKC glass fibre filters (4 indoor air samples per school) and analysed using an endpoint chromogenic LAL assay. Results: The arithmetic mean for fungi concentration in indoor and outdoor air was 710 cfu/m3(125- 1900 cfu/m3) and 524 cfu/m3 (140-1250 cfu/m3), respectively. The most frequently isolated fungal genus from the outdoor air was Cladosporium (over 40 %), followed by isolated Penicillium (21%) and Aspergillus (12%). The percent of Penicillium, Cladosporium and Aspergillus in indoor air samples was 32%, 32% and 8%, respectively. The aritmetic mean of endotoxin concentration was 0.59 EU/m3 (0-2,2 EU/m3). Discussion: The results of the current study are in agreement with previously reported studies, in that airborne fungi and endotoxin concentrations varied extensively, and were mostly dependent on climatic conditions. In addition, the indoor air mycoflora largely reflected the fungal flora present in the outdoor air, with Cladosporium being the most common in both outdoor and indoor (with Penicillium) air. In indoor air, unusually high endotoxin levels, over 1 EU/m3, were detected at 2 schools. Although these schools were not affected by the recent Brisbane floods, persistent rain prior to and during the study perios could explain the results.

Ultrafine particle emission of waste incinerators and comparison to the exposure of urban citizens

On the basis of the growing interest on the impact of airborne particles on human exposure as well as the strong debate in Western countries on the emissions of waste incinerators, this work reviewed existing literature to: (i) show the emission factors of ultrafine particles (particles with a diameter less than 100 nm) of waste incinerators, and; (ii) assess the contribution of waste incinerators in terms of ultrafine particles to exposure and dose of people living in the surrounding areas of the plants in order to estimate eventual risks. The review identified only a limited number of studies measuring ultrafine particle emissions, and in general they report low particle number concentrations at the stack (the median value was equal to 5.5×103 part cm-3), in most cases higher than the outdoor background value. The lowest emissions were achieved by utilization of the bag-house filter which has an overall number-based filtration efficiency higher than 99%. Referring to reference case, the corresponding emission factor is equal to 9.1×1012 part min-1, that is lower than one single high-duty vehicle. Since the higher particle number concentrations found in the most contributing microenvironments to the exposure (indoor home, transportation, urban outdoor), the contribution of the waste incinerators to the daily dose can be considered as negligible.

Identifying relationships between symptom clusters and quality of life in adults with chronic mixed venous and arterial leg ulcers

The objective of this study was to identify symptom clusters and their effect on quality of life (QOL) of adults with chronic leg ulcers of mixed venous and arterial aetiology. A secondary analysis of data from four existing prospective longitudinal studies conducted by a wound healing research group in Australia was undertaken. A total of 110 patients who met the inclusion criteria were selected for this study. Exploratory factor analysis (EFA) was used to identify symptom clusters and correlational analyses to examine relationships between the identified symptom clusters and QOL. The EFA identified two distinct symptom clusters: a 'systemic symptom cluster' consisting of pain, fatigue and depressive symptoms; and a 'localised-leg symptom cluster' including pain, fatigue, oedema, lower limb inflammation and exudate. Physical QOL correlated significantly with the systemic symptom cluster (r = -0·055, P < 0·0001) and the localised-leg symptom cluster (r = -0·054, P < 0·0001), whereas mental QOL was associated only with the systemic symptom cluster (r = -0·038, P = 0·01). The results suggest that appropriate intervention strategies targeting specific symptom clusters should be developed. Targeting patients with symptom clusters is particularly important because they are at high risk and the most vulnerable for reduced QOL.

Benefits and barriers to exercise in midlife women undertaking a web-based multi-modal lifestyle intervention for the primary prevention of chronic disease

Chronic diseases are a leading cause of death and disability, largely attributable to modifiable lifestyle risk factors. Many midlife Australian are getting insufficient physical activity for health and face a range of barriers to exercise. Results of this study provide evidence that benefits and barriers are an important predictor of exercise behaviour in midlife women and, that a 12 week nurse led health promotion program can effectively promote benefits and increase physical activity. This study provides evidence about benefits and barriers to exercise that will inform health promotion practice for chronic disease risk factor reduction in midlife women.

Integrated reporting and directors’ concerns about personal liability exposure: Law reform options

Integrated reporting () holds significant promise as a new reporting paradigm that is holistic, strategic, responsive, material, and relevant across multiple time frames. However, its uptake in Australia is being hampered by directors’ concerns about personal liability exposure, particularly for forward-looking statements that subsequently prove to be unfounded. This article seeks to illuminate the bases for these liability concerns by outlining the similarities between and the operating and financial review requirements under the Corporations Act 2001 (Cth), and the relevant grounds for liability for misleading and deceptive disclosures, and breach of directors’ duties. In light of this discussion, this article proposes four possible reform options, ranging from minor adaptations to the Framework to far-reaching reforms of the Corporations Act. As assurance is desirable to ensure that reliance can be placed on integrated reports, the development of a legal safe harbour for auditors of forward-looking information is also canvassed.

General practice coordinated chronic disease management to reduce avoidable hospital admission

Chronic disease accounts for about 80 per cent of the total disease burden in Australia, and its management accounts for 70 per cent of all current health expenditure.1 Effective prevention and management of chronic disease requires a coordinated approach between primary health care, acute care services, and the patients.2 However, what is not clear is whether improvements in primary healthcare management can have a clear benefit in the cost of care of patients with chronic disease. We recently completed a pilot study in rural Western Australia to ascertain the feasibility of a coordinated general practice-based approach to managing chronic respiratory and cardiovascular conditions, and to determine the direct cost savings to the public insurer through reduction in avoidable hospital admission. The aim of this correspondence is to share our preliminary findings and encourage debate on how such a project may be scaled up or adapted to other primary healthcare settings.

The optimal frequency of aquatic physiotherapy for individuals with chronic musculoskeletal pain: a randomised controlled trial

Purpose: To establish whether there was a difference in health-related quality of life (HRQoL) in people with chronic musculoskeletal disorders (PwCMSKD) after participating in a multimodal physiotherapy program (MPP) either two or three sessions a week. Methods: Total of 114 PwCMSKD participated in this prospective randomised controlled trial. An individualised MPP, consisting of exercises for mobility, motor-control, muscle strengthening, cardiovascular training, and health education, was implemented either twice a week (G2: n = 58) or three times a week) (G3: n = 56) for 1 year. Outcomes: HRQoL physical and mental health state (PHS/MHS), Roland Morris disability Questionnaire (RMQ), Neck-Disability-Index (NDI) and Western Ontario and McMaster Universities’ Arthritis Index (WOMAC) were used to measure outcomes of MPP for people with chronic low back pain, chronic neck pain and osteoarthritis, respectively. Measures were taken at baseline, 8 weeks (8 w), 6 months (6 m), and 1 year (1 y) after starting the programme. Results: No statistically significant differences were found between the two groups (G2 and G3), except in NDI at 8 w (−3.34, (CI 95%: −6.94/0.84, p = 0.025 (scale 0–50)). All variables showed improvement reaching the following values (from baseline to 1 y) G2: PHS: 57.72 (baseline: 41.17; (improvement: 16.55%), MHS: 74.51 (baseline: 47.46, 27.05%), HRQoL 0.90 (baseline: 0.72, 18%)), HRQoL-VAS 84.29 (baseline: 58.04, 26.25%), RMQ 4.15 (baseline: 7.85, 15.42%), NDI 3.96 (baseline: 21.87, 35.82%), WOMAC 7.17 (baseline: 25.51, 19.10%). G3: PHS: 58.64 (baseline: 39.75, 18.89%), MHS: 75.50 (baseline: 45.45, (30.05%), HRQoL 0.67 (baseline: 0.88, 21%), HRQoL-VAS 86.91 (baseline: 52.64, 34.27%), RMQ 4.83 (baseline: 8.93, 17.08%), NDI 4.91 (baseline: 23.82, 37.82%), WOMAC 6.35 (baseline: 15.30, 9.32%). Conclusions: No significant differences between the two groups were found in the outcomes of a MPP except in the NDI at 8 weeks, but both groups improved in all variables during the course of 1 year under study.

Changes in disability, physical/mental health states and quality of life during an 8-Week multimodal physiotherapy programme in patients with chronic non-specific neck pain: A prospective cohort study

Aim The aim of this study was to analyse the effect of an 8-week multimodal physiotherapy programme (MPP), integrating physical land-based therapeutic exercise (TE), adapted swimming and health education, as a treatment for patients with chronic non-specific neck pain (CNSNP), on disability, general health/mental states and quality of life. Methods 175 CNSNP patients from a community-based centre were recruited to participate in this prospective study. Intervention: 60-minute session (30 minutes of land-based exercise dedicated to improving mobility, motor control, resistance and strengthening of the neck muscles, and 30 minutes of adapted swimming with aerobic exercise keeping a neutral neck position using a snorkel). Health education was provided using a decalogue on CNSNP and constant repetition of brief advice by the physiotherapist during the supervision of the exercises in each session. Study outcomes: primary: disability (Neck Disability Index); secondary: physical and mental health states and quality of life of patients (SF-12 and EuroQoL-5D respectively). Differences between baseline data and that at the 8-week follow-up were calculated for all outcome variables. Results Disability showed a significant improvement of 24.6% from a mean (SD) of 28.2 (13.08) at baseline to 16.88 (11.62) at the end of the 8-week intervention. All secondary outcome variables were observed to show significant, clinically relevant improvements with increase ranges between 13.0% and 16.3% from a mean of 0.70 (0.2) at baseline to 0.83 (0.2), for EuroQoL-5D, and from a mean of 40.6 (12.7) at baseline to 56.9 (9.5), for mental health state, at the end of the 8-week intervention. Conclusion After 8 weeks of a MPP that integrated land-based physical TE, health education and adapted swimming, clinically-relevant and statistically-significant improvements were observed for disability, physical and mental health states and quality of life in patients who suffer CNSNP. The clinical efficacy requires verification using a randomised controlled study design.

Pedestrian Crashes in Ethiopia: Identification of contributing factors through modelling of exposure and road environment variables

Pedestrian safety is a critical issue in Ethiopia. Reports show that 50 to 60% of traffic fatality victims in the country are pedestrians. The primary aim of this research was to examine the possible causes of and contributing factors to crashes with pedestrians in Ethiopia, and improve pedestrian safety by recommending possible countermeasures. The secondary aim was to develop appropriate pedestrian crash models for two-way two-lane rural roads and roundabouts in the capital city of Ethiopia. This research uses quantitative methods throughout the process of the investigation. The research has applied various statistical methods. The results of this research support the idea that geometric and operational features have significant influence on pedestrian safety and crashes. Accordingly, policies and strategies are needed to safeguard pedestrians in Ethiopia.

Biomonitoring of polycyclic aromatic hydrocarbons exposure in small groups of residents in Brisbane, Australia and Hanoi, Vietnam, and those travelling between the two cities

Exposure to polycyclic aromatic hydrocarbons (PAHs) has been associated with adverse health outcomes. Concentrations of urinary PAH metabolites (OH-PAHs) provide an integrated measure of human exposure to PAHs but measurement of urinary OH-PAHs has not been done in Australia and rarely in Vietnam, where air pollution is of concern. In this study, we assessed exposure to PAHs in 16 participants living in Brisbane, Australia and Hanoi, Vietnam, with 4 participants travelling between the two cities during the monitoring period. A total of 312 first morning urine samples were collected over 10 weeks and were analysed for nine OH-PAHs. Concentrations of the urinary OH-PAHs were 2–10 times higher in participants from Hanoi than those from Brisbane. For example, the median concentrations of 1-hydroxypyrene were 292 pg/mL in Hanoi, compared to 64 pg/mL in Brisbane. For participants travelling from Brisbane to Hanoi and back, differences in exposure to PAHs in these two cities resulted in corresponding changes of urinary OH-PAH concentrations, demonstrating that the more polluted environment in Hanoi was likely the source for higher PAH exposure there.