Evidence based drug therapy : are optimal doses and multiple medication therapies realistic in patients with chronic heart failure

Background: Chronic Heart Failure (CHF) has a high mortality and morbidity. Large scale randomised controlled trials have proven the benefits of beta blockade and ACE inhibitors in reducing mortality in patients with CHF and expert guidelines mandate their use. In spite of these recommendations, important therapies are under-prescribed and under-utilised.

Method: 1015 consecutive patients enrolled in CHF management programs across Australia were surveyed during 2005-2006 to determine prescribing patterns in heart failure medications. These patients were followed-up for a period of 6 months.

Results: The survey revealed that beta blockers were prescribed to 80% of patients (more than 85% were on sub-optimal doses) and 70% were prescribed Angiotensin converting enzyme (ACE) inhibitors (approximately 50% were on sub-optimal dose). 19% of patients were prescribed Angiotensin receptor blockers (ARBs). By 6 months <25% of the patients who were on sub-optimal dose beta blockers or ACE inhibitors at baseline, had been up-titrated to maximum dose (p<0.0001). In CHF programs, were nurses were able to titrate medications, 75% of patients reached optimal dose of beta blockers compared to those programs with no nurse-led medication titration, where only 25% of patients reached optimal dose (p<0.004). When examining optimal dosage for any two of these mandatory medications, less patients were on optimal therapy. Beta blockers and ACE inhibitors, were both prescribed in combination in 60% of patients. While beta blockers and ARBs were prescribed to 15% of patients.

Conclusion: Whilst prescribing rates for a single medication strategy of beta blockers, or ACE inhibitors were greater than 70%, an increase in dosage of these medications and utilisation of proven combination therapy of these medications was poor. It is suggested that clinical outcomes for this cohort of patients could be further improved by adherence to evidence-based practice, ESC guidelines, and optimisation of these medications by heart failure nurses in a CHF program. On the basis of these findings and in the absence of ready access to a polypill, focussing on evidence-based practice to increase utilisation and optimal dosage of combination medication therapy is critical.

What's the difference and where is the evidence? Investigating student teachers learning about literacy in a school based vs university based experience

This paper is in response to increasing national and international interest in the role of university teacher education programs in preparing pre-service  teachers in the area of early years literacy. The most effective manner to  facilitate this learning in teacher education is however not known and much debate exists about the merits of university-based versus school-based  approaches. It is within this context that the authors of this paper conducted a study that investigated student teachers learning about literacy through two different approaches both with distinctive design features. The first approach offered student teachers a school based experience, adopting a two hour micro-teaching model in a preparatory classroom; the other, a mainstream university based approach where students attended a tutorial for two hours. These two approaches were then compared for factors that student teachers articulated through a written survey. In analysing the data, two main findings emerged; firstly from the student teachers’ perspective, choice of approach resulted in improved learning and secondly, from the researchers’ perspective that student teachers placed in the school based approach emerged with a deeper understanding of the complexity of literacy teaching in general.

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.

Health and mortality consequences of abdominal obesity : evidence from the AusDiab study

Objective: To provide an estimate of the morbidity and mortality resulting from abdominal overweight and obesity in the Australian population.

Design and setting: Prospective, national, population-based study (the Australian Diabetes, Obesity and Lifestyle [AusDiab] study).

Participants: 6072 men and women aged ≥ 25 years at study entry between May 1999 and December 2000, and aged ≤ 75 years, not pregnant and for whom there were waist circumference data at the follow-up survey between June 2004 and December 2005.

Main outcome measures: Incident health outcomes (type 2 diabetes, hypertension, dyslipidaemia, the metabolic syndrome and cardiovascular diseases) at 5 years and mortality at 8 years. Comparison of outcome measures between those classified as abdominally overweight or obese and those with a normal waist circumference at baseline, and across quintiles of waist circumference, and (for mortality only) waist-to-hip ratio.

Results: Abdominal obesity was associated with odds ratios of between 2 and 5 for incident type 2 diabetes, dyslipidaemia, hypertension and the metabolic syndrome. The risk of myocardial infarction among obese participants was similarly increased in men (hazard ratio [HR], 2.75; 95% CI, 1.08–7.03), but not women (HR, 1.43; 95% CI, 0.37–5.50). Abdominal obesity-related population attributable fractions for these outcomes ranged from 13% to 47%, and were highest for type 2 diabetes. No significant associations were observed between all-cause mortality and increasing quintiles of abdominal obesity.

Conclusions: Our findings confirm that abdominal obesity confers a considerably heightened risk for type 2 diabetes, the metabolic syndrome (as well as its components) and cardiovascular disease, and they provide important information that enables a more precise estimate of the burden of disease attributable to obesity in Australia.

Range-wide phylogeography of the Little Penguin (Eudyptula minor): evidence of long-distance dispersal

The Little Penguin (Eudyptula minor), a colonial-nesting seabird that is widespread in New Zealand and southern Australia, has high dispersal potential but exhibits regional variation in morphology, coloration, and breeding phenology. We present a distribution-wide survey of mitochondrial DNA variation in the Little Penguin to document phylogeographic relationships and genetic structuring and to test for concordance with intraspecific taxonomy. Phylogeographic structuring was absent among Australian colonies (27 localities, 94 individuals), but the distribution of haplotypes among colonies was significantly nonrandom (ϕST = 0.110, P < 0.01). The Australian individuals exhibited close phylogenetic relationships with a subset of New Zealand birds (4 localities, 22 individuals), whereas the remaining New Zealand birds (20 localities, 106 individuals) were phylogenetically distinct, with ≥7% sequence divergence, and exhibited greater levels of genetic variation and geographic structuring (ϕST = 0.774, P < 0.05). These patterns are consistent with earlier suggestions of an origin in New Zealand followed by recent colonization of Australia and back-dispersal to New Zealand. Extinction and re-establishment processes may have been important factors in the development of genetic structuring across a range of spatiotemporal scales. The genetic data are consistent with suggestions that a single subspecies exists in Australia, but not with the subspecies distributions within New Zealand that have been suggested on the basis of morphology and coloration.

Adaptation to mandated restrictions on smoking in dining areas : results of an Internet survey

Objective : The study aimed to measure changes in dining behaviour associated with the introduction of smoking restrictions on July 1, 2001, to describe strategies adopted by smokers and non-smokers to adapt to the changes, and to describe some of the thoughts, feelings and beliefs underlying the adaptations that people make in response to the introduction of new restrictions.

Method : Data were collected in a longitudinal study with repeated measures of a total of 257 respondents before and after the introduction of the restrictions, using a questionnaire administered via the Internet. Data collection occurred on seven occasions between April 2001 and March 2002. In addition, a series of in-depth telephone interviews was conducted among a group of 31 smokers and non-smokers, who were interviewed once before and twice after the introduction of the bans.

Results : Dining patterns, dining frequency, restaurant choice and expenditure on a meal did not change among either smoking or non-smoking patrons following the introduction of the law. The majority of Victorians approved of smokefree dining legislation before its implementation, and agreement with the law increased sharply and significantly among both smokers and non-smokers immediately following the introduction of the policy, remaining at high levels for the duration of the study period.

Conclusions : These findings suggest there was rapid adaptation to and acceptance of the restrictions among both smokers and non-smokers, and are supported by evidence from other jurisdictions, both interstate and internationally, regarding the introduction of smokefree dining.

Addressing evidence treatment gaps for cardiovascular disease through primary care collaboration

Aims & Rationale/Objectives
The aim is to establish the frequency of counselling by general practitioners (GPs) and community pharmacists (CPs) for patients with uncontrolled CVD risk factors. This will identify conditions for which CPs might collaborate with GPs in addressing evidence-treatment gaps.

Methods
A population survey undertaken in the Wimmera region of Victoria in 2006. 1425 adults aged 25-84 yrs were randomly selected using age/sex stratified electoral role samples. A representative 723 participants were recruited.

Principal Findings
Data on GP and CP visits were available for 694 participants. Overall, participants visited GPs 4.6 times and CPs 6.0 times/annum. However, one third of participants never consulted a pharmacist in 12 months compared to just 11.5% for GPs. Among obese patients (BMI ?? 30), the average number of visits/annum was 4.5 to GPs and 6.8 to CPs. The equivalent numbers were 5.6 and 8.6 respectively for those with systolic BP ?? 140 mmHg; 3.7 and 5.5 for total cholesterol > 5.0 mmol/L; and, 6.7 and 14.6 for patients with random blood glucose concentrations ?? 7.0 mmol/L.

Implications
People with suboptimal status for most common CVD risk factor are counselled frequently by CPs. A coordinated approach with GPs to the delivery of cardiovascular health promotion could provide valuable reinforcement of key messages and offers greater opportunity to identify at-risk individuals. Acknowledgements: KM is a pharmacist-academic at Greater Green Triangle UDRH, a position funded by the Department of Health and Ageing through the Rural and Remote Pharmacy Workforce Development Program

Internationalization and alliance formation : evidence from Turkish SMEs

This study explores the issue of internationalization through forming alliances with foreign capital in the small business sector in Turkey. Using a sample of 257 SMEs from this emerging market economy, collected via a field study, it finds that Turkish SMEs would like to form alliances with foreign capital for expanding their production capacity and accessing to world markets. Multivariate multinomial logit models are employed to analyse the survey data econometrically. Size-specific, sector-specific and management-specific factors are identified in the alliance motivation. The `market' and `finance' aspects of alliances prevail in the multivariate analysis with significant implications. There is also evidence that some conditional relationships offered by multivariate analysis differ from unconditional associations found in the survey, which implies that alliance motivation is partly a product of multidimensional decision-making process on behalf of SMEs.

Prevalence, awareness, treatment, and control of hypertension in China data from the China National Nutrition and Health Survey 2002

Background— The present article aims to provide accurate estimates of the prevalence, awareness, treatment, and control of hypertension in adults in China.

Methods and Results— Data were obtained from sphygmomanometer measurements and an administered questionnaire from 141 892 Chinese adults 18 years of age who participated in the 2002 China National Nutrition and Health Survey. In 2002, 153 million Chinese adults were hypertensive. The prevalence was higher among men than women (20% versus 17%; P<0.001) and was higher in successive age groups. Overall, the prevalence of hypertension was higher in urban compared with rural areas in men (23% versus 18%; P<0.01) and women (18% versus 16%; P<0.001). Of the 24% affected individuals who were aware of their condition, 78% were treated and 19% were adequately controlled. Despite evidence to suggest improved levels of treatment in individuals with hypertension over the past decade, compared with estimates from 1991, the ratio of controlled to treated hypertension has remained largely unchanged at 1:4.

Conclusions— One in 6 Chinese adults is hypertensive, but only one quarter are aware of their condition. Despite increased rates of blood pressure–lowering treatment, few have their hypertension effectively controlled. National hypertension programs must focus on improving awareness in the wider community, as well as treatment and control, to prevent many tens of thousands of cardiovascular-related deaths.

Australia's strengths and weaknesses in technology transfer and R&D exploitation : GEM survey "experts" views compared with public policy and other published data

There has been increasing public debate in Australia in recent years about research culture in universities and other publicly funded research agencies such as CSIRO and its impact on Australia's performance in generating economic, social and environmental benefits to the Australian community from the large amount of public funding for R&D. This is the supply side issue. On the demand side there is equally concern about the technology absorptive capacity of Australian. business as illustrated by the low proportion of gross business research expenditure (GERD) spent by business (BERD). Against this background, this paper has explored the views of abut 100 "experts" interviewed in the Australian Global Entrepreneurship Monitor (GEM) studies in the years 2000, 2001, 2002 and 2003 on the issues, strengths and weaknesses of Australia's technology transfer performance as it applies to new technology small firms. The paper has also explored evidence for any longitudinal change over this period.

Audit committee characteristics, internal auditors' contribution to financial statement audits and audit fees : Malaysian evidence

This paper provides empirical evidence on the impact of audit committee characteristics on the extent of internal auditor’s contribution to financial statement audits in an emerging economy. Using a cross-sectional regression model, based on Felix, Gramling and Maletta’s (2001) study, it provides evidence of a positive relationship between internal auditor contribution to financial statement audits and three dimensions of audit committee characteristics: the proportion of independent audit committee members; the extent of audit committee members’ knowledge and experience in auditing, accounting, and finance; and the extent of audit committee review of IA proposal related to program, budget and coordination. A second model examines a relationship between internal audit contribution to financial statement audits and audit fees. However, the results did not yield a significant relationship between the two variables. These results are based on a unique data set comprised of publicly available data matched with survey data from chief internal auditors or financial controllers of 90 firms listed on the Kuala Lumpur Stock Exchange (KLSE).

Bridging the divide: a survey of nurses' opinions regarding barriers to, and facilitators of, research utilization in the practice setting

Background. Many researchers have explored the barriers to research uptake in order to overcome them and identify strategies to facilitate research utilization. However, the research–practice gap remains a persistent issue for the nursing profession.

Aims and objectives. The aim of this study was to gain an understanding of perceived influences on nurses' utilization of research, and explore what differences or commonalities exist between the findings of this research and those of studies that have been conducted in various countries during the past 10 years.

Design. Nurses were surveyed to elicit their opinions regarding barriers to, and facilitators of, research utilization. The instrument comprised a 29-item validated questionnaire, titled Barriers to Research Utilisation Scale (BARRIERS Scale), an eight-item scale of facilitators, provision for respondents to record additional barriers and/or facilitators and a series of demographic questions.

Method. The questionnaire was administered in 2001 to all nurses (n = 761) working at a major teaching hospital in Melbourne, Australia. A 45% response rate was achieved.

Results. Greatest barriers to research utilization reported included time constraints, lack of awareness of available research literature, insufficient authority to change practice, inadequate skills in critical appraisal and lack of support for implementation of research findings. Greatest facilitators to research utilization reported included availability of more time to review and implement research findings, availability of more relevant research and colleague support.

Conclusion. One of the most striking features of the findings of the present study is that perceptions of Australian nurses are remarkably consistent with reported perceptions of nurses in the US, UK and Northern Ireland during the past decade.

Relevance to clinical practice. If the use of research evidence in practice results in better outcomes for our patients, this behoves us, as a profession, to address issues surrounding support for implementation of research findings, authority to change practice, time constraints and ability to critically appraise research with conviction and a sense of urgency.

An exploratory survey of Australia's informal venture capitalists : a predicate to theory building in the context of international angel research

In Australia, as it is all over the world, finding and acquiring equity capital is one of the major problems facing entrepreneurs who are starting or growing entrepreneurial ventures. The informal venture capital market, made up of high net worth non-institutional private equity investors (or ‘business Angels’) provides risk capital directly to new and growing businesses and has been shown to be considerably more significant than institutional providers as a source of finance for entrepreneurial businesses. Building upon and comporting with Angel research undertaken overseas, this study generated and evaluated data resulting from an investigation of Australian business Angels which focused upon three primary research questions: (i) Who are Australia's Informal Venture Capitalists (Business Angels)? (ii) How do they behave? (iii) What are their investment criteria? Analysis of answers resulting from a survey of 36 carefully screened respondents produced a descriptive profile, depicted in twelve key graphs, of Australian Angels' identifying characteristics, patterns of investment behaviour and investment criteria. The study initiates Australian Angel research into the developing international continuum of formal Angel research and can serve as the generator of empirically sensible hypotheses for future research and theory development.

Evidence-based development of school-based and family-involved prevention of overweight across Europe : the ENERGY-project's design and conceptual framework

Background
There is an urgent need for more carefully developed public health measures in order to curb the obesity epidemic among youth. The overall aim of the "EuropeaN Energy balance Research to prevent excessive weight Gain among Youth" (ENERGY)-project is the development and formative evaluation of a theory-informed and evidence-based multi-component school-based and family-involved intervention program ready to be implemented and evaluated for effectiveness across Europe. This program aims at promoting the adoption or continuation of health behaviors that contribute to a healthy energy balance among school-aged children. Earlier studies have indicated that school and family environments are key determinants of energy-balance behaviors in schoolchildren. Schools are an important setting for health promotion in this age group, but school-based interventions mostly fail to target and involve the family environment.

Methods
Led by a multidisciplinary team of researchers from eleven European countries and supported by a team of Australian experts, the ENERGY-project is informed by the Environmental Research Framework for Weight gain Prevention, and comprises a comprehensive epidemiological analysis including 1) systematic reviews of the literature, 2) secondary analyses of existing data, 3) focus group research, and 4) a cross European school-based survey.

Results and discussion
The theoretical framework and the epidemiological analysis will subsequently inform stepwise intervention development targeting the most relevant energy balance-related behaviors and their personal, family-environmental and school-environmental determinants applying the Intervention Mapping protocol. The intervention scheme will undergo formative and pilot evaluation in five countries. The results of ENERGY will be disseminated among key stakeholders including researchers, policy makers and the general population.

Conclusions
The ENERGY-project is an international, multidisciplinary effort to develop and test an evidence-based and theory-informed intervention program for obesity prevention among school-aged children.