Clinical tips: The “12 days of Christmas” - surviving and preparing for Christmas as a retailer

“We wish you a Merry Christmas, and a Happy New Year” ... when the Christmas carols start playing in the pharmacy, it is a reminder the silly season has crept up on us. Christmas should be a time of celebration, fun and spending time with loved ones and families. However, if pharmacies are not prepared it can easily turn into the “nightmare before Christmas”. So to make sure everything runs smoothly like Santa’s schedule, we have compiled a few tips to help retailers survive and prepare for Christmas...

Turning up the Heat on Admissions: A Study of the Impacts of Extreme Heat Events on Tasmanian Hospital Admissions 2003-2010

Introduction: Extreme heat events (both heat waves and extremely hot days) are increasing in frequency and duration globally and cause more deaths in Australia than any other extreme weather event. Numerous studies have demonstrated a link between extreme heat events and an increased risk of morbidity and death. In this study, the researchers sought to identify if extreme heat events in the Tasmanian population were associated with any changes in emergency department admissions to the Royal Hobart Hospital (RHH) for the period 2003-2010. Methods: Non-identifiable RHH emergency department data and climate data from the Australian Bureau of Meteorology were obtained for the period 2003-2010. Statistical analyses were conducted using the computer statistical computer software ‘R’ with a distributed lag non-linear model (DLNM) package used to fit a quassi-Poisson generalised linear regression model. Results: This study showed that RR of admission to RHH during 2003-2010 was significant over temperatures of 24 C with a lag effect lasting 12 days and main effect noted one day after the extreme heat event. Discussion: This study demonstrated that extreme heat events have a significant impact on public hospital admissions. Two limitations were identified: admissions data rather than presentations data were used and further analysis could be done to compare types of admissions and presentations between heat and non-heat events. Conclusion: With the impacts of climate change already being felt in Australia, public health organisations in Tasmania and the rest of Australia need to implement adaptation strategies to enhance resilience to protect the public from the adverse health effects of heat events and climate change.

The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

Response: Special communication: Letters to the Editor-in-Chief [Vigorous exercise in clinical practice: balancing risks and benefits]

The effects of different exercise intensities on health have been investigated in several studies in recent years, in which some authors showed greater benefits for vigorous exercise (6) while others did not find any differences (8). An important issue regarding these conflicting results could be the fact that only a few of the studies controlled the effects of different exercise intensities for the overall volume of physical activity, making the evaluation of the available data difficult.

Hospital in the Nursing Home program reduces emergency department presentations and hospital admissions from residential aged care facilities in Queensland, Australia: A quasi-experimental study

Background There has been considerable publicity regarding population ageing and hospital emergency department (ED) overcrowding. Our study aims to investigate impact of one intervention piloted in Queensland Australia, the Hospital in the Nursing Home (HiNH) program, on reducing ED and hospital attendances from residential aged care facilities (RACFs). Methods A quasi-experimental study was conducted at an intervention hospital undertaking the program and a control hospital with normal practice. Routine Queensland health information system data were extracted for analysis. Results Significant reductions in the number of ED presentations per 1000 RACF beds (rate ratio (95 % CI): 0.78 (0.67–0.92); p = 0.002), number of hospital admissions per 1000 RACF beds (0.62 (0.50–0.76); p < 0.0001), and number of hospital admissions per 100 ED presentations (0.61 (0.43–0.85); p = 0.004) were noticed in the experimental hospital after the intervention; while there were no significant differences between intervention and control hospitals before the intervention. Pre-test and post-test comparison in the intervention hospital also presented significant decreases in ED presentation rate (0.75 (0.65–0.86); p < 0.0001) and hospital admission rate per RACF bed (0.66 (0.54–0.79); p < 0.0001), and a non-significant reduction in hospital admission rate per ED presentation (0.82 (0.61–1.11); p = 0.196). Conclusions Hospital in the Nursing Home program could be effective in reducing ED presentations and hospital admissions from RACF residents. Implementation of the program across a variety of settings is preferred to fully assess the ongoing benefits for patients and any possible cost-savings.

Sonography of paediatric appendicitis and its secondary signs

Sonographic diagnosis of appendicitis in children is an important clinical tool, often obviating the need for potentially harmful ionising radiation from computed tomography (CT) scans and unnecessary appendectomies. Established criteria do not commonly account for the sonographic secondary signs of acute appendicitis as an adjunct or corollary to an identifiably inflamed appendix. If one of, or combinations of these secondary signs are a reliable positive and/or negative indicator of the condition, diagnostic accuracy may be improved. This will be of particular importance in cases where the appendix cannot be easily identified, possibly providing referring clinicians with a less equivocal diagnosis. Acute appendicitis (AA) is the most common emergency presentation requiring surgical intervention among both adults and children. During 2010-11 in Australia 25000 appendicectomies were performed on adults and children, more than double the number of the next most common surgical procedure [1]. Ultrasound has been commonly used to diagnose AA since the 1980s, however the best imaging modality or combination of modalities to accurately and cost-effectively diagnose the condition is still debated. A study by Puylaert advocated ultrasound in all presentations [2], whereas others suggested it only as a first line modality [3–5]. Conversely, York et al state that it is not appropriate as it delays treatment [6]. CT has been shown to more accurately diagnose AA than ultrasound, however its inherent radiation risks warrant cautionary use in children [7]. Improved accuracy in the diagnosis of suspected AA using ultrasound would enable surgeons to make a decision without the need to expose children to the potentially harmful effects of CT. Secondary signs of appendicitis are well established [8], although research into their predictive values has only recently been undertaken [9,10] indicating their potential diagnostic benefit in the absence of an identifiable appendix. The purpose of this review is to examine the history of appendiceal sonography, established sonographic criteria, paediatric specific techniques and the predictive value of secondary signs.

Development and psychometric properties of the DCDDaily: a new test for clinical assessment of capacity in activities of daily living in children with developmental coordination disorder

Objective To develop the DCDDaily, an instrument for objective and standardized clinical assessment of capacity in activities of daily living (ADL) in children with developmental coordination disorder (DCD), and to investigate its usability, reliability, and validity. Subjects Five to eight-year-old children with and without DCD. Main measures The DCDDaily was developed based on thorough review of the literature and extensive expert involvement. To investigate the usability (assessment time and feasibility), reliability (internal consistency and repeatability), and validity (concurrent and discriminant validity) of the DCDDaily, children were assessed with the DCDDaily and the Movement Assessment Battery for Children-2 Test, and their parents filled in the Movement Assessment Battery for Children-2 Checklist and Developmental Coordination Disorder Questionnaire. Results 459 children were assessed (DCD group, n = 55; normative reference group, n = 404). Assessment was possible within 30 minutes and in any clinical setting. For internal consistency, Cronbach’s α = 0.83. Intraclass correlation = 0.87 for test–retest reliability and 0.89 for inter-rater reliability. Concurrent correlations with Movement Assessment Battery for Children-2 Test and questionnaires were ρ = −0.494, 0.239, and −0.284, p < 0.001. Discriminant validity measures showed significantly worse performance in the DCD group than in the control group (mean (SD) score 33 (5.6) versus 26 (4.3), p < 0.001). The area under curve characteristic = 0.872, sensitivity and specificity were 80%. Conclusions The DCDDaily is a valid and reliable instrument for clinical assessment of capacity in ADL, that is feasible for use in clinical practice.

Diabetic charcot neuroarthropathy of the hand: Clinical course, diagnosis, and treatment options

During the treatment of diabetic Charcot neuroarthropathy (CN) of the foot in two young patients, we discovered atypical alterations of their hands with loss of strength and paresthesia combined with atypical and nonhealing bone alterations and instability. Whereas CN of the foot is a serious and well-known complication of diabetes, CN of the hand is only mentioned in four articles (1–4).

(Re)presenting Masculinity: A theatre director's critical observations of, and theatrical experimentation with, (re)presentations of masculinity in selected works of contemporary Australian theatre

Health professionals, academics, social commentators and the media are increasingly sending the same message – Australian men are in crisis. This message has been supported by documented rises in alcoholism, violence, depression, suicide and crime amongst men in Australia. A major cause of this crisis, it can be argued, is an over-reliance on the out-dated and limited model of hegemonic masculinity that all men are encouraged to imitate in their own behaviour. This paper, as part of a larger study, explores representations of masculinity in selected works of contemporary Australian theatre in order to investigate the concept of hegemonic masculinity and any influence it may have on the perceived ‘crisis of masculinity’. Theatre is but one of the artistic modes that can be used to investigate masculinity and issues associated with identity. The Australia Council for the Arts recognises theatre, along with literature, dance, film, television, inter-arts, music and visual arts, as critical to the understanding and expression of Australian culture and identity. Theatre has been chosen in this instance because of the opportunities available to this study for direct access to specific theatre performances and creators and, also, because of the researcher’s experience, as a theatre director, with the dramatic arts. Through interviews with writers, directors and actors, combined with the analysis of scripts, academic writings, reviews, articles, programmes, play rehearsals and workshops, this research utilises theatre as a medium to explore masculinity in Australia.

A randomised controlled clinical trial of a post-discharge, nurse-led educational intervention to reduce anxiety and enhance self-efficacy in percutaneous coronary intervention (PCI) patients within the first week post-discharge: A pilot study

This research investigated the efficacy of a post-discharge nurse-led clinic, for patients who underwent a cardiovascular interventional procedure in Australia. A randomised controlled clinical trial measured the effects of the clinic on patient confidence to self-manage and minimise psychological distress given the strong link between anxiety, depression and coronary heart disease. Hospitalisation for the procedure is short and stressful, and patients may wait up to 7-64 days for post-discharge review. This study provides preliminary quantitative and qualitative evidence that nurse-led clinics undertaken within the first week post-percutaneous coronary intervention may fill a much-needed gap for patients during a potentially vulnerable period.

Blended learning in medical imaging pre-clinical skills training – does it work?

Undergraduate Medical Imaging (MI)students at QUT attend their first clinical placement towards the end of semester two. Students undertake two (pre)clinical skills development units – one theory and one practical. Students gain good contextual and theoretical knowledge during these units via a blended learning model with multiple learning methods employed. Students attend theory lectures, practical sessions, tutorial sessions in both a simulated and virtual environment and also attend pre-clinical scenario based tutorial sessions. The aim of this project is to evaluate the use of blended learning in the context of 1st year Medical Imaging Radiographic Technique and its effectiveness in preparing students for their first clinical experience. It is hoped that the multiple teaching methods employed within the pre-clinical training unit at QUT builds students clinical skills prior to the real situation. A quantitative approach will be taken, evaluating via pre and post clinical placement surveys. This data will be correlated with data gained in the previous year on the effectiveness of this training approach prior to clinical placement. In 2014 59 students were surveyed prior to their clinical placement demonstrated positive benefits of using a variety of learning tools to enhance their learning. 98.31%(n=58)of students agreed or strongly agreed that the theory lectures were a useful tool to enhance their learning. This was followed closely by 97% (n=57) of the students realising the value of performing role-play simulation prior to clinical placement. Tutorial engagement was considered useful for 93.22% (n=55) whilst 88.14% (n=52) reasoned that the x-raying of phantoms in the simulated radiographic laboratory was beneficial. Self-directed learning yielded 86.44% (n=51). The virtual reality simulation software was valuable for 72.41% (n=42) of the students. Of the 4 students that disagreed or strongly disagreed with the usefulness of any tool they strongly agreed to the usefulness of a minimum of one other learning tool. The impact of the blended learning model to meet diverse student needs continues to be positive with students engaging in most offerings. Students largely prefer pre -clinical scenario based practical and tutorial sessions where 'real-world’ situations are discussed.

Clinical relevance of MTHFR, eNOS, ACE, and ApoE gene polymorphisms and serum vitamin profile among Malay patients with ischemic stroke

Background The purpose of this study was threefold. First, it was to determine the relationship between serum vitamin profiles and ischemic stroke. The second purpose was to investigate the association of methylenetetrahydrofolate reductase (MTHFR), endothelial nitric oxide synthase (eNOS), angiotensin converting enzyme (ACE), and apolipoprotein-E (ApoE) gene polymorphisms with ischemic stroke and further correlate with serum vitamin profiles among ischemic stroke patients. The third purpose of the study was to highlight the interaction of MTHFR and eNOS haplotypes with serum vitamin profiles and ischemic stroke risks. Methods Polymorphisms of these genes were analyzed in age-, sex-, and ethnicity-matched case–controls (n = 594); serum vitamin profiles were determined using immunoassays. Results The MTHFR 677C>T, 1298A>C, eNOS intron 4a/b, and ApoE polymorphisms were significantly associated with the increased risk of ischemic stroke. Elevated serum homocysteine and vitamin B12 levels were associated with MTHFR 677C>T and eNOS intron 4a/b polymorphisms. The ApoE and eNOS −786T>C polymorphisms were associated with increased serum vitamin B12 levels. However, none of the polymorphisms influenced serum folate levels except for the MTHFR 1298A>C. Different patterns of MTHFR and eNOS haplotypes tend to affect serum vitamin profiles to different degrees, which contribute to either different susceptibility risk or protective effect on ischemic stroke. Overall, increased levels of serum homocysteine and vitamin B12 levels were associated with higher risk of ischemic stroke in the investigated population. Conclusions The present study suggests that the genotypes and haplotypes of MTHFR 677C>T and eNOS intron 4a/b polymorphisms are potential serum biomarkers in the pathophysiological processes of ischemic stroke, by modulating homocysteine and vitamin B12 levels.

Nutrition during noninvasive ventilation: clinical determinants and key practical recommendations

Malnutrition and poor nutritional intake have been identified as key issues associated with poorer clinical outcomes in chronic obstructive pulmonary disease (COPD) patients. There is strong evidence showing nutritional support is effective in treating malnutrition in stable COPD, but there is only limited research regarding nutritional status in patients treated with noninvasive ventilation (NIV). The impact of NIV during acute exacerbations of respiratory disease on nutritional status requires further investigation.

Deregulation of miR-126 expression in colorectal cancer pathogenesis and its clinical significance

In this study, we investigated the expression profiles and clinicopathological significance of miR-126 in large cohort of patients with colorectal cancers as well the cellular repercussions of miR-126 in colon cancer cells along with its targets in-vitro. Down regulation of miR-126 expression was associated with histological subtypes, peri-neural tumour infiltration, microsatellite instability and pathological staging of colorectal cancers (p<0.05). Low miR-126 expression was also associated with poorer survival in patients with colorectal cancer. Analysis of matched tissues from the same patient revealed that approximately 70% of the tested patients had similar levels of expression of miR-126 in primary cancer and cancer metastases in both lymph node and distant metastases. In addition, induced overexpression of miR-126 showed reduced cell proliferation, increased apoptosis and decreased accumulation of cells in the G0-G1 phase of the colon cancer cells. Furthermore, SW480(+miR-126) cells showed reduced BCL-2 and increased P53 protein expression. To conclude, deregulation of miR-126 in colorectal cancer at the tissue and cellular levels as well as its correlation with various clinicopathological parameters confirm the cancer suppressive role of miR-126 in colorectal cancer.