Standardising practices improves clinical diabetic foot management: the Queensland Diabetic Foot Innovation Project, 2006-09

Objective. The aim of this paper is to report the clinical practice changes resulting from strategies to standardise diabetic foot clinical management in three diverse ambulatory service sites in Queensland, Australia. Methods. Multifaceted strategies were implemented in 2008, including: multidisciplinary teams, clinical pathways, clinical training, clinical indicators, and telehealth support. Prior to the intervention, none of the aforementioned strategies were used, except one site had a basic multidisciplinary team. A retrospective audit of consecutive patient records from July 2006 to June 2007 determined baseline clinical activity (n = 101).Aclinical pathway teleform was implemented as a clinical activity analyser in 2008 (n = 327) and followed up in 2009 (n = 406). Pre- and post-implementation data were analysed using Chi-square tests with a significance level set at P < 0.05. Results. There was an improvement in surveillance of the high risk population of 34% in 2008 and 19% in 2009, and treating according to risk of 15% in 2009 (P < 0.05). The documentation of all best-practice clinical activities performed improved 13–66% (P < 0.03). Conclusion. These findings support the use of multifaceted strategies to standardise practice and improve diabetic foot complications management in diverse ambulatory services.

Standardising practices improves ambulatory diabetic foot management and reduces amputations : the Queensland Diabetic Foot Innovation Project, 2006 – 2009

Background Diabetic foot complications are recognised as the most common reason for diabetic related hospitalisation and lower extremity amputations. Multi-faceted strategies to reduce diabetic foot hospitalisation and amputation rates have been successful. However, most diabetic foot ulcers are managed in ambulatory settings where data availability is poor and studies limited. The project aimed to develop and evaluate strategies to improve the management of diabetic foot complications in three diverse ambulatory settings and measure the subsequent impact on ospitalisation and amputation. Methods Multifaceted strategies were implemented in 2008, including: multi-disciplinary teams, clinical pathways and training, clinical indicators, telehealth support and surveys. A retrospective audit of consecutive patient records from July 2006 – June 2007 determined baseline clinical indicators (n = 101). A clinical pathway teleform was implemented as a clinical record and clinical indicator analyser in all sites in 2008 (n = 327) and followed up in 2009 (n = 406). Results Prior to the intervention, clinical pathways were not used and multi-disciplinary teams were limited. There was an absolute improvement in treating according to risk of 15% in 2009 and surveillance of the high risk population of 34% and 19% in 2008 and 2009 respectively (p < 0.001). Improvements of 13 – 66% (p < 0.001) were recorded in 2008 for individual clinical activities to a performance > 92% in perfusion, ulcer depth, infection assessment and management, offloading and education. Hospitalisation impacts recorded reductions of up to 64% in amputation rates / 100,000 population (p < 0.001) and 24% average length of stay (p < 0.001) Conclusion These findings support the use of multi-faceted strategies in diverse ambulatory services to standardise practice, improve diabetic foot complications management and positively impact on hospitalisation outcomes. As of October 2010, these strategies had been rolled out to over 25 ambulatory sites, representing 66% of Queensland Health districts, managing 1,820 patients and 13,380 occasions of service, including 543 healed ulcer patients. It is expected that this number will rise dramatically as an incentive payment for the use of the teleform is expanded.

Direct fabrication as a patient-targeted therapeutic in a clinical environment

A paradigm shift is taking place in orthopaedic and reconstructive surgery. This transition from using medical devices and tissue grafts towards the utilization of a tissue engineering approach combines biodegradable scaffolds with cells and/or biological molecules in order to repair and/or regenerate tissues. One of the potential benefits offered by solid freeform fabrication (SFF) technologies is the ability to create such biodegradable scaffolds with highly reproducible architecture and compositional variation across the entire scaffold due to their tightly controlled computer-driven fabrication. Many of these biologically activated materials can induce bone formation at ectopic and orthotopic sites, but they have not yet gained widespread use due to several continuing limitations, including poor mechanical properties, difficulties in intraoperative handling, lack of porosity suitable for cellular and vascular infiltration, and suboptimal degradation characteristics. In this chapter, we define scaffold properties and attempt to provide some broad criteria and constraints for scaffold design and fabrication in combination with growth factors for bone engineering applications. Lastly, we comment on the current and future developments in the field, such as the functionalization of novel composite scaffolds with combinations of growth factors designed to promote cell attachment, cell survival, vascular ingrowth, and osteoinduction.

New discursive configurations of journalism : Narratives in Rio de Janeiro's favelas [Novas configurações discursivas no jornalismo: narrativas digitais nas favelas do Rio de Janeiro]

Oprincipal objetivo desse artigo é apresentar os resultados parciais de uma pesquisa em andamento sobre o processo de produção de conteúdo do portal Viva Favela, um dos projetos sociais realizados pela organização nãogovernamental Viva Rio. Partindo de uma abordagem conceitual que discute os modos pelos quais a mídia alternativa e o jornalismo público/jornalismo cívico criam as condições de possibilidade para que uma determinada prática jornalística dê ‘voz’ e ‘empodere’ (empower) moradores de periferias e favelas brasileiras, estamos realizando um estudo das rotinas produtivas do Viva Favela e seus ‘correspondentes comunitários’. O conceito sobre voice, de Jo Tacchi, oferece-nos um embasamento teórico adequado para refletirmos sobre o que vem sendo denominado, nos Estados Unidos, de digital storytelling – as narrativas digitais produzidas com as tecnologias de informação e comunicação para “contar estórias” 1, que são criativamente apropriadas, no Brasil, por moradores das favelas e periferias das regiões metropolitanas.

Can a childcare practicum encourage degree qualified staff to enter the childcare workforce?

Concern to ensure that all children have access to high quality educational experiences in the early years of life has instigated moves to increase qualifications of staff in the childcare workforce, in particular to increase the number of degree qualified teachers. However existing data suggest that work in the childcare sector is viewed less favourably by those undertaking early childhood education degrees. For most, childcare is not a preferred place of employment. This study asked whether a practicum in a childcare setting would improve attitudes to childcare and willingness to consider working in childcare settings. In a study of a cohort of Bachelor of Education (Early Childhood) students, measures of attitudes to childcare and willingness to work in childcare were taken before and after practicum. Additionally students provided accounts of their practicum experiences. Results indicate a trend in which there was a group increase in positive attitudes and willingness to consider work in childcare but considerable individual differences influenced by the quality of the practicum experience. The relationship with, and model provided by, centre directors and the group leader in the practicum class was identified as key influencing factors. Results are discussed in term of models of pedagogical leadership.

Using mobile technology and augmented reality to increase data reliability for environmental assessment

Climate change and land use pressures are making environmental monitoring increasingly important. As environmental health is degrading at an alarming rate, ecologists have tried to tackle the problem by monitoring the composition and condition of environment. However, traditional monitoring methods using experts are manual and expensive; to address this issue government organisations designed a simpler and faster surrogate-based assessment technique for consultants, landholders and ordinary citizens. However, it remains complex, subjective and error prone. This makes collected data difficult to interpret and compare. In this paper we describe a work-in-progress mobile application designed to address these shortcomings through the use of augmented reality and multimedia smartphone technology.

The borate mineral jeremejevite Al6(BO3)5(F,OH)3 – A vibrational spectroscopic study

Jeremejevite is a borate mineral of aluminium and is of variable colour, making the mineral and important inexpensive jewel. The mineral contains variable amounts of F and OH, depending on origin. A comparison of the vibrational spectroscopic data is made with the published data of borate minerals. Raman spectra were averaged over a range of crystal orientations. Two intense Raman bands observed at 961 and 1067 cm−1 are assigned to the symmetric stretching and antisymmetric stretching modes of trigonal boron. Infrared spectrum, bands observed at 1229, 1304, 1350, 1388 and 1448 cm−1 are attributed to BOH in-plane bending modes. Intense Raman band found at 372 cm−1 with other bands of significant intensity at 327 and 417 cm−1 is assigned to trigonal borate bending modes. A quite intense Raman band is found at 3673 cm−1 with other sharp Raman bands found at 3521, 3625 and 3703 cm−1 are assigned to the stretching modes of OH. Raman and infrared spectroscopy has been used to assess the molecular structure of the mineral jeremejevite. Such research is important in the study of borate based nanomaterials.

The effect of project information on the accuracy of building price forecasts

A fundamental proposition is that the accuracy of the designer's tender price forecasts is positively correlated with the amount of information available for that project. The paper describes an empirical study of the effects of the quantity of information available on practicing Quantity Surveyors' forecasting accuracy. The methodology involved the surveyors repeatedly revising tender price forecasts on receipt of chunks of project information. Each of twelve surveyors undertook two projects and selected information chunks from a total of sixteen information types. The analysis indicated marked differences in accuracy between different project types and experts/non-experts. The expert surveyors' forecasts were not found to be significantly improved by information other than that of basic building type and size, even after eliminating project type effects. The expert surveyors' forecasts based on the knowledge of building type and size alone were, however, found to be of similar accuracy to that of average practitioners pricing full bills of quantities.

Institutional specifics and unemployment insurance eligibility in Canada : how sensitive are employment duration effects?

The paper examines the influence of unemployment insurance on the duration of employment spells in Canada using the 1988–90 Labour Market Activity Survey. The primary focus of the paper is to evaluate whether estimated UI effects are sensitive to the degree to which institutional rules and regulations governing UI eligibility and entitlement are explicitly modelled. The key result of the paper is that it is indeed important to allow for institutional detail when estimating unemployment insurance effects. Estimates using simple proxies for eligibility indicate small, often insignificant UI effects. The size and significance of the effects rise as more realistic versions of the variables are adopted. The estimates using the eligibility variables incorporating the greatest level of institutional detail suggest that a jump in the hazard rate by a factor of 2.3 may not be an unreasonable estimate of the effect.

Genetic investigation of methylenetetrahydrofolate reductase (MTHFR) and catechol-O-methyl transferase (COMT) in multiple sclerosis

Multiple sclerosis (MS) is a chronic neurological disease characterized by central nervous system (CNS) inflammation and demyelination. The C677T substitution variant in the methylenetetrahydrofolate reductase (MTHFR) gene has been associated with increased levels of circulating homocysteine and is a mild risk factor for vascular disease. Higher blood levels of homocysteine have also been reported in MS. Thus, the C677T mutation of the MTHFR gene may influence MS susceptibility. Noradrenaline, a neurotransmitter believed to play an immunosupressive role in neuroinflammatory disorders, is catabolized by catechol-O-methyl transferase (COMT). The COMT G158A substitution results in a three- to four-fold decreased activity of the COMT enzyme, which may influence CNS synaptic catecholamine breakdown and could also play a role in MS inflammation. We tested DNA from Australian MS patients and unaffected control subjects, matched for gender, age and ethnicity. Specifically, we genotyped the MTHFR C677T and the COMT G158A mutations. Genotype distributions showed that the homozygous mutant MTHFR genotype (T/T) and the COMT (H/H) genotype were slightly over-represented in the MS group (16% versus 11% and 24% versus 19%, respectively), but both variations failed to reach statistical significance (P=0.15 and P=0.32, respectively). Hence, results from the present study do not support a major role for either functional gene mutation in MS susceptibility.

Asymptomatic hypoechoic regions on patellar tendon ultrasound : a 4-year clinical and ultrasound followup of 46 tendons

Patellar tendon ultrasound appearance is commonly used in clinical practice to diagnose patellar tendinopathy and guide management. Using a longitudinal study design we examined whether or not the presence of a hypoechoic ultrasonographic lesion in an asymptomatic patellar tendon conferred a risk for developing jumper's knee compared with a tendon that was ultrasonographically normal. Ultrasonographic, symptomatic and anthropometric assessment was completed at baseline and followup. Magnetic resonance imaging was performed on four tendons that resolved ultrasonographically in the study period. Forty-six patellar tendons were followed over 47 ± 11.8 months. Eighteen tendons were hypoechoic at baseline and 28 were ultrasonographically normal. Five tendons resolved ultrasonographically in the study period. Magnetic resonance imaging in four of these tendons was normal. Seven normal patellar tendons at baseline developed a hypoechoic area but only two became symptomatic. Analysis of ultrasonography at baseline and clinical outcome with Fisher's exact test shows there is no association between baseline ultrasound changes and symptoms at followup. In this study there is no statistically significant relationship between ultrasonographic patellar tendon abnormalities and clinical outcome in elite male athletes. Management of jumper's knee should not be solely based on ultrasonographic appearance; clinical assessment remains the cornerstone of appropriate management.

Intercultural residential care in New Zealand

Along with other Organization for Economic Cooperation and Development (OECD) countries, New Zealand’s society is aging such that an increase in the number of older people requiring residential care is predicted. What cannot be foreseen is how culturally defined health beliefs affect the care given to older people in residential care. In this article, the authors describe and discuss the culturally based health beliefs of some Pacific Islands caregivers and predominately European (Pakeha) older people resident at one long-term care facility in Auckland, New Zealand. The delivery of care is influenced by culturally related beliefs about “being old.” Racism is evident in residential care, and the authors discuss the reactions of caregivers, residents, and management. This research extends the discussion of caregiving and receiving into the cross-cultural setting, and the findings highlight a number of elements in cultural differences between carer and cared-for that might affect care practices at the residential facility studied.

Auto-inhibition of hydrogen gas evolution on gold in aqueous acid solution

It was demonstrated recently that dramatic changes in the redox behaviour of gold/aqueous solution interfaces may be observed following either cathodic or thermal electrode pretreatment. Further work on the cathodic pretreatment of gold in acid solution revealed that as the activity of the gold surface was increased, its performance as a substrate for hydrogen gas evolution under constant potential conditions deteriorated. The change in activity of the gold atoms at the interface, which was attributed to a hydrogen embrittlement process (the occurrence of the latter was subsequently checked by surface microscopy), was confirmed, as in earlier work, by the appearance of a substantial anodic peak at ca. 0.5 V (RHE) in a post-activation positive sweep. Changes in the catalytic activity of a metal surface reflect the fact that the structure (or topography), thermodynamic activity and electronic properties of a surface are dependent not only on pretreatment but also, in the case of the hydrogen evolution reaction, vary with time during the course of reaction. As will be reported shortly, similar (and often more dramatic) time-dependent behaviour was observed for hydrogen gas evolution on other metal electrodes.

An outbreak of salmonellosis linked to a marine turtle

In September 1998, an outbreak of gastroenteritis occurred in a coastal Aboriginal community in the Northern Territory over a seven day period. An investigation was conducted by the Center for Disease Control, Territory Health Services. Thirty-six cases were detected and 17% (n=6) were hospitalized. Salmonella chester was isolated from eight of nine stool specimens. Sixty-two percent of cases interviewed (n=28) reported consumption of a green turtle (Chelonia mydas) within a median of 24 hours prior to onset of illness. Of the remainder, all but two were contacts of other cases. Salmonella chester was isolated from a section of partially cooked turtle meat. There are no previous published reports of salmonellosis associated with consumption of sea turtles despite them being a popular food source in coastal communities in the Pacific.

Chemotherapy for upper gastrointestinal tumours

The aim of this review is to identify current chemotherapy treatment for tumours of the oesophagus, stomach, pancreas, and liver. The role of both neoadjuvant, adjuvant, and palliative chemotherapy regimens will be discussed. This review will be of interest to oncologists in clarifying current issues regarding chemotherapy, and to physicians in other medical specialties, to increase their general understanding of benefits and drawbacks of chemotherapy in this patient group.