Dyslipidaemia in rural Australia : the evidence treatment gaps

Aims & rationale/Objectives : Hypercholesterolaemia accounts for 11.6% of total deaths and 6.2% of the disability burden for the Australian population.1 This paper reports population lipid profiles for three rural Australian populations, and assesses evidence-treatment gaps against the most recent (2005-2007) Australian guidelines.

Methods : Three population surveys were undertaken in the Greater Green Triangle. 3,320 adults aged 25-74 yrs were randomly selected using age/gender stratified electoral roll samples and of these 1563 subjects participated in the survey. Anthropometric, clinical and self-administered questionnaire data relating to chronic disease risk were collected in accordance with the WHO MONICA protocol.2 A detailed investigation of dyslipidaemia was included.

Principal findings : All required data was available for 1255 participants. Age-standardised mean total cholesterol (TC), triglycerides, LDL cholesterol and HDL cholesterol concentrations were 5.36 mmol/l, 1.42 mmol/l, 3.23 mmol/l and 1.48 mmol/l, respectively. Amongst those taking lipid-lowering medication, just 11% categorised as secondary prevention/diabetes, and 39% as primary prevention, achieved all lipid targets. In the 20% of untreated participants at high risk of a primary cardiovascular event, 26% were aware of their hypercholesterolaemia and just 2% achieved all lipid targets (2.8% achieved TC?5.5 mmol, 8.5% achieved LDL<3.5 mmol/l). 11.2% of the overall population used lipid-lowering medication (95% was statin monotherapy).

Implications : Most adults do not achieve their target lipid profile. This paper identifies the subpopulations and lipid components which need to be targeted for future interventions. It also identifies substantial evidence-treatment gaps which should be addressed to help improve lipid profiles at a population level.

Quality of reporting of randomized clinical trials in abstracts of the 2005 annual meeting of the American College of Rheumatology.

Objective: To determine the quality of abstracts reporting randomized clinical trials (RCT) at the 2005 Annual Scientific Meeting of the American College of Rheumatology.

Methods: All 2005 abstracts including late-breaking abstracts were assessed. An abstract was deemed to be reporting an RCT if it indicated that participants were randomized in the title or body of the abstract. RCT were excluded if they included only pharmacokinetic data. The CONSORT checklist was applied and relevant data extracted. We defined manufacturer support as acknowledgment of industry support or industry employee as co-author.

Results: Of 2146 abstracts, 143 (6.7%) reported RCT. Of these, 78.3% were drug trials, and 63.6% indicated manufacturer support. Only 30.8% of abstracts used "randomized" in the title, 44.1% did not explicitly state whether blinding was undertaken, and only 7.0% clearly stated who was blinded. Thirty percent of studies did not give an explicit definition of eligibility criteria of participants. While 84.6% explicitly described the experimental intervention, only 37.1% explicitly described the comparator intervention. Only 21% explicitly stated that an intention to treat analysis was performed. Baseline demographic and clinical characteristics were reported in 48.3%. While most abstracts reported summary results for each treatment group, only 35.7% reported effect size with its precision.

Conclusion: The quality of reporting is suboptimal in many RCT abstracts. Abstracts reporting RCT would benefit from a structured approach that ensures more detailed reporting of eligibility criteria, active and comparator interventions, flow of participants, and adequate summary and precision of results.

What determines the size of occupational health services in UK universities?

Background There is wide, largely unexplained, variation in occupational health (OH) provision between UK employers.

Aim To explain the variation in OH provision across the UK university sector.

Methods Analyses of data from a survey of university OH services and from the Higher Education Statistics Agency. The outcome variable was clinical (doctor + nurse) staffing of the university's OH service. The explanatory variables examined were university size, income, research activity score and presence or absence of academic disciplines categorized by an expert panel as requiring a high level of OH provision.

Results All 117 UK universities were included and 93 (79%) responded; with exclusions and incomplete data, between 80 and 89 were included in analyses. There was wide variation in clinical OH staffing (range 0–8.4 full-time equivalents). Number of university staff explained 34% of the variation in OH staffing. After adjusting for other factors, neither the research activity nor the presence of high-needs disciplines appeared to be factors currently used by employers to determine their investment in OH.

Conclusions Government or other guidelines for university employers should take organizational size into account. Employers may need guidance on how to provide OH services proportionate to specific occupational hazards or other OH needs.

Occupational health provision in UK universities

Background Very few studies have been done of occupational health provision across an entire employment sector and universities are particularly understudied. The British government published updated guidance on university occupational health in 2006.

Aim To describe the occupational health services to all the universities in the UK.

Methods All 117 universities in the UK were included. Detailed surveys were carried out in 2002, 2003 and 2004 requesting self-completed information from each university occupational health service. This paper presents information on general characteristics of the service, staffing, services provided and outcome reporting.

Results There was variation in the type of occupational health provision; half the universities had an in-house occupational health service, 32% used a contractor, 9% relied on the campus primary care or student health service and 9% had ad hoc or no arrangements. In all, 93 of the 117 (79%) universities responded to the detailed questionnaire, the response rate being higher from in-house services and from larger universities. There was a wide variation in staffing levels but the average service was small, staffed by one full-time nurse with one half-day of doctor time per week and a part-time clerical or administrative member of staff. A range of services was provided but, again, there was wide variation between universities.

Conclusions It is unclear if the occupational health provision to universities is proportional to their needs. The wide variation suggests that some universities may have less adequate services than others.

Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry

Objective: To compare the quality and funding source of studies concluding a negative economic impact of smoke-free policies in the hospitality industry to studies concluding no such negative impact.

Data sources: Researchers sought all studies produced before 31 August 2002. Articles published in scientific journals were located with Medline, Science Citation Index, Social Sciences Citation Index, Current Contents, PsychInfo, Econlit, and Healthstar. Unpublished studies were located from tobacco company websites and through internet searches.

Study selection: 97 studies that made statements about economic impact were included. 93% of the studies located met the selection criteria as determined by consensus between multiple reviewers.

Data extraction: Findings and characteristics of studies (apart from funding source) were classified independently by two researchers. A third assessor blind to both the objective of the present study and to funding source also classified each study.

Data synthesis: In studies concluding a negative impact, the odds of using a subjective outcome measure was 4.0 times (95% confidence interval (CI) 1.4 to 9.6; p = 0.007) and the odds of not being peer reviewed was 20 times (95% CI 2.6 to 166.7; p = 0.004) that of studies concluding no such negative impact. All of the studies concluding a negative impact were supported by the tobacco industry. 94% of the tobacco industry supported studies concluded a negative economic impact compared to none of the non-industry supported studies.

Conclusion: All of the best designed studies report no impact or a positive impact of smoke-free restaurant and bar laws on sales or employment. Policymakers can act to protect workers and patrons from the toxins in secondhand smoke confident in rejecting industry claims that there will be an adverse economic impact.

Management of lipids in rural Australia : are the guidelines being followed?

Background: Hypercholesterolaemia is ranked seventh among the major factors contributing to the overall burden of disease in Australia. Guidelines for evidence-based lipid management were released in 2001 and updated in 2005, however little population level data has been published on the current gap between recommended management and actual practice in Australia.

Method: Three population stratified surveys were undertaken in the Greater Green Triangle. Three thousand three hundred and twenty adults aged 25–74 years were randomly selected, stratified by gender and 10-year age groups. Anthropometric, clinical and self-administered questionnaire data relating to cardiovascular disease risk were collected in accordance with the WHO MONICA protocol. Blood samples were collected for lipid profile analysis. Participants were divided into four groups—Group 1: treated, high CVD risk; Group 2: treated, primary prevention; Group 3: untreated, high CVD risk; Group 4: untreated, low CVD risk. For each of these groups we compared cholesterol, HDL cholesterol, triglyceride and LDL cholesterol with targets recommended by the National Heart Foundation's 2005 guidelines.

Results: All lipids were at target in 39.4% of the study population with marked differences between groups: Group 1, 11.2%; Group 2, 38.5%; Group 3, 1.8%; Group 4, 47.6%.

Only 50.8% of the untreated high CVD risk group reported having blood cholesterol measured within the last 12 months.

Conclusion: Current rates of detection and treatment practices in rural Australia are suboptimal. Although one-third of the study population age 25–74 years are at sufficiently high risk to warrant consideration of lipid lowering medication only just over half of these were on treatment at the time of the study. These results suggest that an intensive implementation plan is required for the management of hyperlipidaemia in rural Australia.

The impact of RICS education reform on building surveying

Purpose – It is of major concern to the surveying profession that the seven years between 1994 and 2001 witnessed a decline in the numbers of UK student surveyors of nearly 50 per cent. This was significant, especially when considered in the context of rising student numbers overall. The RICS decided to implement an education policy with the aim of increasing graduate quality. Changes were introduced in UK universities from September 2001. A number of universities saw their professionally accredited courses withdrawn as the RICS imposed  academic entry standards and research output based on the UK Government's Research Assessment Exercise (RAE) criteria on which to base their “partnership” relationships. Figures released by the RICS in 2003 indicated that surveying student numbers increased by 17 per cent in all areas except building surveying, where they fell by just under 25 per cent to 445 in 2001. The paper seeks to answer a number of questions. Why were building surveying courses failing to recruit students whereas other surveying courses have increased their numbers? If the figures continue to decline or remain at these low levels, what is the future for the BS? In short, could building surveying become an endangered profession?
Design/methodology/approach – All UK university BS course leaders were approached by questionnaire and approximately half responded. The study was partly funded by the RICS Education Trust.
Findings – The small amount of quantitative data collected suggests that recruitment is static at a time when other built environment courses are recruiting well. Course leaders expressed strong views about the impact of the education reforms.
Research limitations/implications – Failure by some BS course leaders to provide some statistical data prevented completion of the quantitative part of the study.
Originality/value – Key recommendations have been made to the BS Faculty Board of the RICS about the future of BS education.

An evaluation of a community aged care nurse practitioner service

Evaluation aims: An evaluation is presented that aimed to augment current understandings of the nurse practitioner role by investigating potential outcomes of a community aged care nurse practitioner (ACNP) service on clients and the health care team.

Background: In Australia, the nurse practitioner role is being implemented in a variety of health care settings and is characterized by extended practice: prescribing of medications, requests for diagnostic investigations, referral to medical specialists and admitting clients to inpatient facilities.

Design: An exploratory qualitative evaluation method through data collection by interview and thematic analysis was undertaken.

Method: All clients referred to the ACNP service between June and August 2003, and a convenience sample of health professionals, were invited to participate in individual semi-structured interviews.

Results: Findings suggested that an ACNP could provide a high quality of holistic nursing care and positively affect clients' physical and psychological symptom management, enhance clients' quality of life, assist with supplies, provide health education and assist with advocacy. Health professionals commented on effective collaboration with the ACNP service during their partnerships in client care provision.

Conclusions: Overall, the positive effects of the ACNP service on clients and the health care team support the full implementation of the role within the community setting.

Relevance to clinical practice: Funding support for the nurse practitioner role is a vital addition to consideration in the development of international policy on advanced practice nursing. Without adequate funding, the full benefits of the nurse practitioner role in clinical practice, as suggested by the findings presented in this evaluation, will be compromised.

Scale development of individual and organisation infrastructure for heart health promotion in regional health authorities

Objective : The purpose of this study was to validate measures of individual and organisational infrastructure for health promotion within Alberta's (Canada) 17 Regional Health Authorities (RHAs).

Design : A series of phases were conducted to develop individual and organisational scales to measure health promotion infrastructure. Instruments were designed with focus groups and then pre-tested prior to the validation study.

Setting : In 1993 all hospitals and Public Health Units in the province of Alberta were regionalised into 17 RHAs, with responsibility for public health, community health, and acute and long-term care. While regionalisation may offer more opportunity for community participation, reorganisation of the public health system may have fragmented and diluted resources and skills for heart health promotion in some RHAs. Infrastructure (for example, human and financial resources), amongst other items, is believed to contribute to the capacity to promote health.

Method : All 17 RHAs participated in the study, yielding a total of 144 individuals (that is board members, senior/middle management, and front line staff). These representative employees completed a self- administered questionnaire on individual- and organisational-level infrastructure measures.

Results : Psychometric analyses of survey data provided empirical evidence for the robustness of the measures. Principal component analyses verified the construct validity of the scales, with alpha coefficients ranging from 0.75 to 0.95.

Conclusion : The scales can be used by health professionals and researchers to assess individual- and organisational-level infrastructure, and tailor interventions to increase infrastructure for health promotion in health organisations.

Quality of life and depression among older patients waiting for joint replacement surgery

Purpose: Older patients waiting for joint replacement surgery in many western countries experience lengthy waits for their surgery. Although these patients suffer with mobility problems the nature of the disability associated with waiting for surgery is unclear. The purpose of this study was to determine health-related quality of life and symptoms of depression in persons waiting for their initial orthopaedic consultation following referral for total knee or total hip replacement surgery.

Methods: All patients who were waiting for an initial orthopaedic consultation for lower-limb joint replacement as at 25 August 2005 were surveyed. Participants were mailed questionnaires concerning demographic information, medical history, health-related quality of life (the Assessment of Quality of Life (AQoL) instrument), and symptoms of depression (Center for Epidemiologic Studies – Depression (CES-D) Scale).

Results: The 84 respondents (response rate 64%) had a mean age of 68.3 (SD 11.5 years), and 60% or respondents were women. Respondents reported an average of 1.6 (SD 0.9) medical conditions, and 85% reported osteoarthritis.} The average health-related quality of life was low (mean AQoL 0.38; SD 0.27), and near death-equivalent or worse than death-equivalent health-related quality of life (AQoL<0.1 of a maximum possible 1.0) was reported by 23% of the participants.The mean depression scale score was 16.5 (SD 11.1), and symptoms of depression (CES-D>16 of a maximum possible 60) were reported by 35% of the sample. There was a strong correlation between health-related quality of life and depression (r=–0.6).

Conclusions: Almost a third of patients waiting to see an orthopaedic surgeon about joint replacement surgery for their hip or knee had symptoms of depression. Geriatric rehabilitation services often provide interventions to these patients. The very poor quality of life reported suggests that more than exercise and strengthening will be needed to reduce disability.

A low intensity, community based lifestyle programme to prevent weight gain in women with young children : cluster randomised controlled trial

Objective To develop and evaluate the effectiveness of a community behavioural intervention to prevent weight gain and improve health related behaviours in women with young children.
Design Cluster randomised controlled trial.
Setting A community setting in urban Australia. 
Participants 250 adult women with a mean age of 40. 39 years (SD 4.77, range 25-51) and a mean body mass index of 27.82 kg/m2 (SD 5.42, range 18-47) were recruited as clusters through 12 primary (elementary) schools. Intervention Schools were randomly assigned to the intervention or the control. Mothers whose schools fell in the intervention group (n=127) attended four interactive group sessions that involved simple health messages, behaviour change strategies, and group discussion, and received monthly support using mobile telephone text messages for 12 months. The control group (n=123)
attended one non-interactive information session based on population dietary and physical activity guidelines. 
Main outcome measures The main outcome measures were weight change and difference in weight change between the intervention group and the control group at 12 months. Secondary outcomes were changes in serum concentrations of fasting lipids and glucose, and changes in dietary behaviours, physical activity, and self management behaviours.
Results All analyses were adjusted for baseline values and the possible clustering effect. Women in the control group gained weight over the 12 month study period (0.83 kg, 95% confidence interval (CI) 0.12 to 1.54), whereas those in the intervention group lost weight (−0.20 kg, −0.90 to 0.49). The difference in weight change between the intervention group and the control group at 12 months was −1.13 kg (−2.03 to −0.24 kg; P<0.05) on the basis of observed values and −1.11 kg (−2.17 to −0.04) after multiple imputation to account for possible bias created by missing values. Secondary analyses after multiple imputation showed a difference in the intervention group compared with the control group for total cholesterol concentration (−0.35 mmol/l, −0.70 to −0.001), self management behaviours (diet score 0.18, 0.13 to 0.33; physical activity score 0.24, 0.05 to 0.43), and confidence to control weight (0.40, 0.11 to 0.69). Regular self weighing was associated with weight loss in the intervention group only (−1.98 kg, −3.75 to −0.23).
Conclusions Weight gain in women with young children could be prevented using a low intensity self management intervention delivered in a community setting. Self management of health behaviours improved with the intervention. The response rate of 12%, although comparable with that in other community studies, might limit the ability to generalise to other populations.    
Trial registration Australian New Zealand Clinical Trials Registry number ACTRN12608000110381.

Muscle determinants of bone mass, geometry and strength in prepubertal girls

Purpose: The aim of this study was to compare the relative contribution of peak muscle force (isokinetic peak torque) with surrogate estimates of muscle force, including leg lean tissue mass (LTM) and vertical jump height (VJH), on bone mass, geometry and strength in healthy prepubertal girls (n = 103).

Methods: Total leg and FN BMC and leg LTM were measured by DXA; the hip strength analysis program was used to assess FN diameter, cross-sectional area (CSA) and section modulus (Z). Isokinetic peak torque of the knee extensors and flexors (60°·s-1) were used as direct measures of peak muscle force. VJH was measured as an estimate of neuromuscular function. Total leg length or femoral length was used as a surrogate measure of moment arm length.

Results: All estimates of muscle function, except VJH, were positively associated with leg BMC (r = 0.72 - 0.90) and FN BMC, geometry and strength (r = 0.35-0.65) (all, P < 0.001). Multiple linear regression analyses revealed that leg LTM and isokinetic peak torque were independently and equally predictive of leg BMC and FN BMC, bone geometry and strength, explaining 8 to 28% of the variance in each of the bone traits after accounting for moment arm length. When isokinetic peak torque was corrected for both leg LTM and moment arm length, it remained an independent predictor of BMC, CSA and Z, but only accounted for an additional 2 to 5% of the variance.

Conclusion: These data suggest that DXA-derived leg LTM can be used as a reasonable surrogate for isokinetic peak muscle forces when assessing bone strength in relation to muscular function in healthy pre-pubertal girls.

The validity of the 21-item version of the depression anxiety stress scales as a routine outcome measure

Objective: This study aimed to test the validity of the 21-item Depression Anxiety Stress Scales (DASS-21) as a routine clinical outcome measure in the private in-patient setting. We hypothesized that it would be a suitable routine outcome instrument in this setting.

Method: All in-patients treated at a private psychiatric hospital over a period of 24 months were included in the study. Data were collected on demographics, service utilization, diagnosis and a set of four routine measures both at admission and discharge. These measures consisted of the Clinical Global Impressions (CGI) scales, Health of the Nation Outcome Scales (HoNOS), the Mental Health Questionnaire (MHQ-14) and DASS-21. The results of these measures were compared.

Results: Of 786 admissions in total, the number of fully completed (ie paired admission and discharge) data sets for the DASS-21 depression, anxiety and stress subscales were 337, 328 and 347, respectively. All subscales showed statistically significant reductions in mean scores from admission to discharge (P < 0.001) and were significantly correlated with all MHQ-14 subscales and significantly related to CGI scale categories. The total DASS-21 and total HoNOS scores were also significantly correlated.

Conclusions: The findings from the present study support the validity of DASS-21 as a routine clinical outcome measure in the private in-patient setting.

Regulation of human pregnane X receptor and its target gene cytochrome P450 3A4 by Chinese herbal compounds and a molecular docking study

1. The pregnane X receptor (PXR) plays a critical role in the regulation of human cytochrome P450 3A4 (CYP3A4) gene. In this study, we investigated the effect of an array of compounds isolated from Chinese herbal medicines on the activity of PXR using a luciferase reporter gene assay in transiently transfected HepG2 and Huh7 cells and on the expression of PXR and CYP3A4 in LS174T cells. Furthermore, molecular docking was performed to investigate the binding modes of herbal compounds with PXR.

2. Praeruptorin A and C, salvianolic acid B, sodium danshensu, protocatechuic aldehyde, cryptotanshinone, emodin, morin, and tanshinone IIA significantly transactivated the CYP3A4 reporter gene construct in either HepG2 or Huh7 cells. The PXR mRNA expression in LS174T cells was significantly induced by physcion, protocatechuic aldehyde, salvianolic acid B, and sodium danshensu. However, epifriedelanol, morin, praeruptorin D, mulberroside A, tanshinone I, and tanshinone IIA significantly down-regulated the expression of PXR mRNA in LS174T cells.

3. All the herbal compounds tested can be readily docked into the ligand-binding cavity of PXR mainly through hydrogen bond and aromatic interactions with Ser247, Gln285, His407, and Arg401.

4. These findings suggest that herbal medicines can significantly regulate PXR and CYP3A4 and this has important implication in herb–drug interactions.

Socioeconomic status and risk factors for obesity and metabolic disorders in a population-based sample of adult females

Objectives : The association between lower socioeconomic status (SES), obesity, lifestyle choices and adverse health consequences are well documented, however to date the relationship between these variables and area-based SES (equivalised for advantage and disadvantage) has not been examined simultaneously in one population or with more than tertiary divisions of SES. We set out to examine the risk factors for obesity and metabolic disorders in the same population across quintiles of area-based SES.

Methods : We performed a descriptive cross-sectional study using existing data from a population-based random selection of women aged 20–92 years (n = 1110) recruited from the Barwon Statistical Division, South Eastern Australia.

Results : All measures of adiposity were inversely associated with SES, and remained significant after adjusting for age. Lifestyle choices associated with adiposity and poorer health, including smoking, larger serving sizes of foods, and reduced physical activity, were significantly associated with individuals from lower SES groups.

Conclusions : Greater measures of adiposity and less healthy lifestyle choices were observed in individuals from lower SES. Significant differences in body composition were identified between quintiles 1 and 5, whereas subjects in the mid quintiles had relatively similar measures. The inverse relationship between SES, obesity and less healthy lifestyle underscores the possibility that these associations may be causal and should be investigated further.