Functional management of ankle sprains: what volume and intensity of walking is undertaken in the first week postinjury:what volume and intensity of walking is undertaken in the first week postinjury

BACKGROUND: Acute ankle sprains are usually managed functionally, with advice to undertake progressive weight-bearing and walking. Mechanical loading is an important modular of tissue repair; therefore, the clinical effectiveness of walking after ankle sprain may be dose dependent. The intensity, magnitude and duration of load associated with current functional treatments for ankle sprain are unclear.

AIM: To describe physical activity (PA) in the first week after ankle sprain and to compare results with a healthy control group.

METHODS: Participants (16-65 years) with an acute ankle sprain were randomised into two groups (standard or exercise). Both groups were advised to apply ice and compression, and walk within the limits of pain. The exercise group undertook additional therapeutic exercises. PA was measured using an activPAL accelerometer, worn for 7 days after injury. Comparisons were made with a non-injured control group.

RESULTS: The standard group were significantly less active (1.2 ± 0.4 h activity/day; 5621 ± 2294 steps/day) than the exercise (1.7 ± 0 .7 h/day, p=0.04; 7886 ± 3075 steps/day, p=0.03) and non-injured control groups (1.7 ± 0.4 h/day, p=0.02; 8844 ± 2185 steps/day, p=0.002). Also, compared with the non-injured control group, the standard and exercise groups spent less time in moderate (38.3 ± 12.7 min/day vs 14.5 ± 11.4 min/day, p=0.001 and 22.5 ± 15.9 min/day, p=0.003) and high-intensity activity (4.1 ± 6.9 min/day vs 0.1 ± 0.1 min/day, p=0.001 and 0.62 ± 1.0 min/day p=0.005).

CONCLUSION: PA patterns are reduced in the first week after ankle sprain, which is partly ameliorated with addition of therapeutic exercises. This study represents the first step towards developing evidence-based walking prescription after acute ankle sprain.

Scientific revolutions, progess and accounting research

Thomas Kuhn’s concept of a normal science paradigm has been utilised and criticised across a range of social science fields. However, Kuhn’s aim was to argue that science progresses not in an incremental manner but through a series of paradigms that need a revolution in thought to shift from one to the next. This paper addresses Kuhn’s work focusing on the totality of his model, but recognising the ambiguities concerning paradigm shifts that have led to charges of relativism. To address this weakness an argument is advanced for a political economy analysis of the publication process and the development of critical accounting research centred on human emancipation. The paper concludes with some suggested research agendas particularly relevant to the Irish context.

A self-reported work sampling study in community pharmacy practice

Lack of time to implement pharmaceutical care has been cited as a barrier to the routine provision of this extended patient-care service. Using self-reported work sampling methodology, this study investigated how community pharmacists utilise their time. Pharmacists working in community pharmacies in the Greater Belfast area were found to spend approximately 49% of their time engaged in professional activities, 29% in semi-professional activities and 22% involved in non-professional activities. The activity to which pharmacists devoted the majority of their time was product assembly and labelling, this being a task which can be performed by trained technical staff. Only 9.5% of community pharmacists' time was devoted to counselling patients on their prescription medicines. Wide variation in the amount of time apportioned to each activity was observed between the participating community pharmacists (n=30). Staffing levels within the community pharmacy were found to significantly influence pharmacists' involvement in a number of activities, with pharmacists who worked in pharmacies employing multiple pharmacists devoting more time to the assembly and labelling of products and less time to administrative tasks, non-professional encounters and to miscellaneous professional activities. Pharmacists working in pharmacies with a high prescription turnover were found to devote significantly less time to counselling patients regarding OTC products and in responding to patient symptoms.

Effects of Charge Location on the Absorptions and Lifetimes of Protonated Tyrosine Peptides in Vacuo

Nearby charges affect the electronic energy levels of chromophores, with the extent of the effect being determined by the magnitude of the charge and degree of charge-chromophore separation. The molecular configuration dictates the charge chromophore distance. Hence, in this study, we aim to assess how the location of the charge influences the absorption of a set of model protonated and diprotonated peptide ions, and whether spectral differences are large enough to be identified. The studied ions were the dipeptide YK, the tripeptide KYK (Y = tyrosine; K = lysine) and their complexes with 18-crown-6-ether (CE). The CE targets the ammonium group by forming internal ionic hydrogen bonds and limits the folding of the peptide. In the tripeptide, the distance between the chromophore and the backbone ammonium is enlarged relative to that in the dipeptide. Experiments were performed in an electrostatic ion storage ring using a tunable laser system, and action spectra based on lifetime measurements were obtained in the range from 210 to 310 nm. The spectra are all quite similar though there seems to be some changes in the absorption band between 210 and 250 nm, while in the lower energy band all ions had a maximum absorption at similar to 275 nm. Lifetimes after photoexcitation were found to shorten upon protonation and lengthen upon CE complexation, in accordance with the increased number of degrees of freedom and an increase in activation energies for dissociation as the mobile proton model is no longer operative.

Chemical structural effects on γ-ray spectra of positron annihilation in fluorobenzenes

Spectra of ?-ray Doppler shifts for positron annihilation in benzene and its fluoro-derivatives are simulated using low energy plane wave positron (LEPWP) approximation. The results are compared with available measurements. It is found that the Doppler shifts in these larger aromatic compounds are dominated by the contributions of the valence electrons and that the LEPWP model overestimates the measurements by approximately 30%, in agreement with previous findings in noble gases and small molecules. It is further revealed that the halogen atoms not only switch the sign of the charges on carbon atoms that they bond to, but that they also polarize other C-H bonds in the molecule leading to a redistribution of the molecular electrostatic potentials. As a result, it is likely that the halogen atoms contribute more significantly to the annihilation process. The present study also suggests that, while the Doppler shifts are sensitive to the number of valence electrons in the molecules, they are less sensitive to the chemical structures of isomers that have the same numbers and type of atoms and, hence, the same numbers of electrons. Further investigation of this effect is warranted. © EDP Sciences, Società Italiana di Fisica, Springer-Verlag 2012.

The impact of nonadherence to inhaled long-acting β - adrenoceptor agonist/corticosteroid combination therapy on healthcare costs in difficult-to-control asthma

Background: Asthma is a leading, preventable cause of morbidity, mortality and cost. A disproportionate amount of the cost is generated by the 5-10%of patients with difficult-to-control asthma, who are prescribed treatment at step 4/5 of the Global Initiative for Asthma (GINA) guidelines. We have previously demonstrated a high prevalence of nonadherence to inhaled combination therapy (i.e. long-acting ß -adrenoceptor agonist [ß - agonist] and corticosteroid) in this population. The aim of this study was to examine the costs of healthcare utilization in a nonadherent group of patients with difficult-to-control asthma compared with adherent subjects. We also wished to examine potential savings if nonadherence to inhaled combination therapy could be addressed. All costs were measured from the perspective of a publicly funded health service Methods: Adherence was determined through examination of patient prescription refill behaviour and validated with a medical concordance interview. Data on healthcare use were collected from a patient survey and hospital records that included prescribed medicines, hospital admissions, intensive care unit (ICU) admissions and other unscheduled healthcare visits associated with asthma care. Activity was monetized using standard UK references and between-group comparisons based on a series of univariate and multivariate regression analyses. Results: Cost differences were identified for inhaled combination therapy, nebulizer, short acting b2-agonists and hospital costs excluding and including ICU admissions between adherent and nonadherent subjects. Compared with a group who have refractory asthma and who are adherent with medication, additional healthcare costs in nonadherent subjects are offset by the reduction in costs associated with reduced medication utilization. However, if nonadherence can be successfully targeted and hospital admissions avoided in this population, there is a potential $475 ($843-$368) saving per patient, per annum. Conclusion: Nonadherence is an important cause of difficult-to-control asthma. A uniform cost for subjects with difficult-to-control disease can be applied to economic analyses, independent of adherence, as increased healthcare utilization costs are offset by the reduced medication cost due to poor adherence. However, there are substantial potential savings in subjects with difficult-to-control asthma, who are nonadherent to inhaled combination therapy, if cost effective strategies for nonadherence are developed. © 2011 Adis Data Information BV. All rights reserved.

Patients on H2-receptor antagonists--are we investigating them?

A survey was made of patients receiving H2-receptor antagonists in a group practice serving 8600 patients. Two hundred and twelve patients (2%) who had received at least one prescription for H2 antagonists in a 12 month period were identified. When compared with the practice population, men and patients over 50 years old were more likely to be taking these drugs (P less than 0.01 and P less than 0.001, respectively). One hundred and fifty-seven patients (74%) were investigated before commencing therapy; 114 (73%) of these patients were investigated via the hospital outpatient department, despite the general practitioners having full open access to barium meals. Only 23 (15%) of the patients investigated were found to have no active pathology. Twenty-nine (14%) of the 212 study patients had received one or more gastrointestinal investigations in the 18 months subsequent to starting H2-antagonist therapy. Twenty-five of these patients had also received an investigation before starting therapy. One hundred and eleven patients (52%) had had their H2 antagonist therapy initiated by their general practitioner.

Repeat prescribing of non-steroidal anti-inflammatory drugs excluding aspirin:how careful are we?

About 5% of all National Health Service prescriptions in Britain and a quarter of reports of suspected adverse reactions are accounted for by non-steroidal anti-inflammatory drugs. Their prescription was investigated in two computerised group practices serving 11850 patients. Altogether 198 patients receiving repeat prescriptions of non-steroidal anti-inflammatory drugs were identified and relevant clinical details extracted from their notes. Of these patients, 119 were over 65 years old; 172 were receiving one of six different non-steroidal anti-inflammatory drugs; and 76 were taking drugs that can interact with non-steroidal anti-inflammatory drugs. Ninety one patients had one or more medical conditions that may be aggravated by non-steroidal anti-inflammatory drugs, and 36 had experienced side effects important enough for their treatment to be changed. A questionnaire to assess opinions and knowledge of non-steroidal anti-inflammatory drugs was given to 42 general practitioners and 26 rheumatologists. Although the two groups showed a comparable knowledge of the properties and costs of non-steroidal anti-inflammatory drugs, they differed significantly in their views on the circumstances under which these drugs should be used. Clear guidelines on the prescription of these drugs would indicate when careful monitoring is essential for patients to benefit from them safely.

Economic aspects of pharmacotherapy for chronic constipation

Constipation is one of the most common digestive complaints. It is a symptom, not a disease. The subjectivity that this involves means that assessments of clinical epidemiology, socioeconomic costs and pharmacotherapy are difficult, since there is no definition of 'normal' bowel habit. Although constipation can affect all ages, the problem increases with age, and is of particular concern for those who are frail and in long term care. Cultural influences may affect the prevalence in older people. Drug therapy of constipation cannot be considered in isolation, since there are issues in the prevention of constipation and the principles of good management that also apply. Furthermore, some consideration of the pathophysiology and diagnosis is important. This is because a number of remediable causes can be identified, and the diagnostic process involves patient education, which in turn may be effective in reducing costs. It is the complaint of constipation which leads either to self-medication or to consultation with the medical profession. Both of these courses of action have a significant influence on utilisation of laxatives (cathartics), obtained both over-the-counter and by prescription. Although there are a large number of laxative preparations available, therapy has changed little in half a century. Costs may vary considerably, and with such a significant problem there is a need for comparative studies. However, study methodologies are difficult, and a significant placebo response may be found. Education and preventive measures have been shown to reduce laxative use and costs in institutions. Unfortunately, there are few comparative studies of individual laxatives and even fewer cost-effectiveness studies. Those that there are have been based in institutions, and so extrapolation to other situations may be difficult. In general, little attention is given to constipation. It is, however, an area with significant resource implications in which education and preventive measures have been shown to be beneficial. Even so, there is still a need for good comparative studies, particularly where cost effectiveness is concerned.

The Utility of Fractional Exhaled Nitric Oxide Suppression in the Identification of Nonadherence in Difficult Asthma

Rationale: Nonadherence to inhaled corticosteroid therapy (ICS) is a major contributor to poor control in difficult asthma, yet it is challenging to ascertain. Objectives: Identify a test for nonadherence using fractional exhaled nitric oxide (FENO) suppression after directly observed inhaled corticosteroid (DOICS) treatment. Methods: Difficult asthma patients with an elevated FENO (>45 ppb) were recruited as adherent (ICS prescription filling >80%) or nonadherent (filling <50%). They received 7 days of DOICS (budesonide 1,600 µg) and a test for nonadherence based on changes in FENO was developed. Using this test, clinic patients were prospectively classified as adherent or nonadherent and this was then validated against prescription filling records, prednisolone assay, and concordance interview. Measurements and Main Results: After 7 days of DOICS nonadherent (n = 9) compared with adherent subjects (n = 13) had a greater reduction in FENO to 47 ± 21% versus 79 ± 26% of baseline measurement (P = 0.003), which was also evident after 5 days (P = 0.02) and a FENO test for nonadherence (area under the curve = 0.86; 95% confidence interval, 0.68-1.00) was defined. Prospective validation in 40 subjects found the test identified 13 as nonadherent; eight confirmed nonadherence during interview (three of whom had excellent prescription filling but did not take medication), five denied nonadherence, two had poor inhaler technique (unintentional nonadherence), and one also denied nonadherence to prednisolone despite nonadherent blood level. Twenty-seven participants were adherent on testing, which was confirmed in 21. Five admitted poor ICS adherence but of these, four were adherent with oral steroids and one with omalizumab. Conclusions: FENO suppression after DOICS provides an objective test to distinguish adherent from nonadherent patients with difficult asthma. Clinical trial registered with www.clinicaltrials.gov (NCT 01219036). Copyright © 2012 by the American Thoracic Society.

Effect of preventive primary care outreach on health related quality of life among older adults at risk of functional decline: Randomised controlled trial

Objective: To evaluate the impact of a provider initiated primary care outreach intervention compared with usual care among older adults at risk of functional decline. Design: Randomised controlled trial. Setting: Patients enrolled with 35 family physicians in five primary care networks in Hamilton, Ontario, Canada. Participants Patients: were eligible if they were 75 years of age or older and were not receiving home care services. Of 3166 potentially eligible patients, 2662 (84%) completed the validated postal questionnaire used to determine risk of functional decline. Of 1724 patients who met the risk criteria, 769 (45%) agreed to participate and 719 were randomised. Intervention: The 12 month intervention, provided by experienced home care nurses in 2004-6, consisted of a comprehensive initial assessment using the resident assessment instrument for home care; collaborative care planning with patients, their families, and family physicians; health promotion; and referral to community health and social support services. Main outcome measures: Quality adjusted life years (QALYs), use and costs of health and social services, functional status, self rated health, and mortality. Results: The mean difference in QALYs between intervention and control patients during the study period was not statistically significant (0.017, 95% confidence interval -0.022 to 0.056; P=0.388). The mean difference in overall cost of prescription drugs and services between the intervention and control groups was not statistically significant, (-$C165 (£107; €118; $162), 95% confidence interval -$C16 545 to $C16 214; P=0.984). Changes over 12 months in functional status and self rated health were not significantly different between the intervention and control groups. Ten patients died in each group. Conclusions: The results of this study do not support adoption of this preventive primary care intervention for this target population of high risk older adults. Trial registration: Clinical trials NCT00134836.

Who makes prescribing decisions in hospital inpatients?:An observational study

Errors involving drug prescriptions are a key target for patient safety initiatives. Recent studies have focused on error rates across different grades of doctors in order to target interventions. However, many prescriptions are not instigated by the doctor who writes them. It is important to clarify how often this occurs in order to interpret these studies and create interventions. This study aimed to provisionally quantify and describe prescriptions where the identity of the decision maker and prescription writer differed.

Magnetic instability in a dilute circular rarefaction wave

The growth of magnetic fields in the density gradient of a rarefaction wave has been observed in simulations and in laboratory experiments. The thermal anisotropy of the electrons, which gives rise to the magnetic instability, is maintained by the ambipolar electric field. This simple mechanism could be important for the magnetic field amplification in astrophysical jets or in the interstellar medium ahead of supernova remnant shocks. The acceleration of protons and the generation of a magnetic field by the rarefaction wave, which is fed by an expanding circular plasma cloud, is examined here in form of a 2D particle-in-cell simulation. The core of the plasma cloud is modeled by immobile charges, and the mobile protons form a small ring close to the cloud's surface. The number density of mobile protons is thus less than that of the electrons. The protons of the rarefaction wave are accelerated to 1/10 of the electron thermal speed, and the acceleration results in a thermal anisotropy of the electron distribution in the entire plasma cloud. The instability in the rarefaction wave is outrun by a TM wave, which grows in the dense core distribution, and its magnetic field expands into the rarefaction wave. This expansion drives a secondary TE wave. (C) 2012 American Institute of Physics. [http://dx.doi.org/10.1063/1.4769128]

Medicalization, markets and consumers.

This paper examines the impact of changes in the medical marketplace on medicalization in U.S. society. Using four cases (Viagra, Paxil, human growth hormone and in vitro fertilization), we focus on two aspects of the changing medical marketplace: the role of direct-to-consumer advertising of prescription drugs and the emergence of private medical markets. We demonstrate how consumers and pharmaceutical corporations contribute to medicalization, with physicians, insurance coverage, and changes in regulatory practices playing facilitating roles. In some cases, insurers attempt to counteract medicalization by restricting access. We distinguish mediated and private medical markets, each characterized by differing relationships with corporations, insurers, consumers, and physicians. In the changing medical environment, with medical markets as intervening factors, corporations and insurers are becoming more significant determinants in the medicalization process.

Trends in the use of psychotropic medications among adolescents, 1994 to 2001

Objectives: Few psychotropic medications are approved for use among children younger than 18 years. Yet previous studies have shown an increase in the use of psychotropic medications among school-age children and adolescents. Most previous studies examined data only up to 1997; therefore, the results predate any impact of changing federal policies and newly marketed medications. This study examined trends in the prescription of psychotropic medications to adolescents aged 14 to 18 years in office-based care in the United States from 1994 to 2001. Methods: Data from the National Ambulatory Medical Care Survey (NAMCS) were used to determine visit rates and prescribing patterns from 1994 to 2001 for psychotropics that were prescribed in office-based treatment settings to adolescents aged 14 to 18 years. Rates of visits that resulted in a prescription for psychotropic medication were calculated for two-year periods. Analyses were conducted by type of medication, gender, and the prescribing physician's specialty. Results: Rates of visits that resulted in a psychotropic prescription increased from 3.4 percent in 1994-1995 to 8.3 percent in 2000-2001. These trends were evident for males and females. The average annual growth rates for psychotropic prescriptions were much higher after 1999. Trends were also significant across drug classes. By 2001, one out of ten office visits by adolescent males resulted in a prescription for a psychotropic medication. Conclusions: Average annual growth rates for the prescription of psychotropics to adolescents increased from 1994 to 2001, with especially rapid acceleration after 1999. This increase may be associated with changing thresholds of diagnosis and treatment, availability of new medications, and changes in federal regulatory policies concerning promotion of medications by the pharmaceutical industry.