Compliance with recommendations from a screening programme for diabetic retinopathy

METHODS: General practitioner compliance with recommendations for patient follow-up after participation in a screening programme for diabetic retinopathy was assessed. Six months after screening with non-mydriatic retinal photography in four areas of Victoria, the genera practitioner of each participant was surveyed if the participant reported no examination for diabetic retinopathy in the past 2 years and if the results of the screening indicated the need for further assessment. RESULTS: Overall, 208 of 253 (82%) completed questionnaires were analysed. A total of 123 (59%) patients were referred by their doctors for further assessment and 97 (79%) of those referred were reported to have complied with the referral. Of the 85 (41%) patients who were not referred for further assessment, 31 (36%) were reported by their doctors to be already under regular review by an ophthalmologist. CONCLUSIONS: Compliance with genera practitioner referrals suggests that this screening programme was effective and a useful means by which to remind general practitioners of the importance of regular eye examinations for people with diabetes.

How many days of monitoring are needed to reliably assess SenseWear Armband outcomes in primary school-aged children?

OBJECTIVES: To identify the number of hours and days or nights of monitoring required to reliably estimate energy expenditure (EE), steps, waking sedentary time, light- (LPA), moderate- (MPA), vigorous- (VPA), moderate- to vigorous-intensity physical activity (MVPA), time in bed and total sleep time using the SenseWear Armband. DESIGN: Cross-sectional study. METHODS: One hundred and two children (50% boys) aged 8-11 years from six schools wore a SenseWear Armband (BodyMedia Inc, USA) for eight consecutive days (seven consecutive nights). Hourly increments of valid day wear time criteria were examined (days/week; 8h/day-14h/day). Intra-class correlation coefficients estimated the reliability for any individual day for each wear time criteria. The Spearman-Brown prophecy formula was used to determine the number of days/nights of monitoring needed to achieve reliability estimates of 0.7, 0.8 and 0.9. RESULTS: Fewer monitoring days were needed as the valid day criteria became more stringent. For example, at least 12h of wear time on at least 2 days was required to achieve a reliability of 0.7 for EE. In contrast, at least 8h/day on 5 days resulted in reliable estimates (0.7) for MPA, VPA and MVPA. Between 6 and 7 nights of monitoring were required to reliably estimate children's time in bed and total sleep time, respectively. CONCLUSIONS: A 7-day monitoring protocol in primary school-aged children would provide acceptable reliability for the assessment of EE, waking sedentary time, LPA, MPA, VPA, MVPA, time in bed and total sleep time, as assessed by the SenseWear Armband.

Implementing guidelines to routinely prevent chronic vascular disease in primary care: the preventive evidence into practice cluster randomised controlled trial

Objective: To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease. Setting: 32 urban general practices in 4 Australian states. Randomisation: Stratified randomisation of practices. Participants: 122 general practitioners (GPS) and practice nurses (PNs) were recruited at baseline and 97 continued to 12 months. 21 848 patient records were audited for those aged 40-69 years who attended the practice in the previous 12 months without heart disease, stroke, diabetes, chronic renal disease, cognitive impairment or severe mental illness. Intervention: The practice level intervention over 6 months included small group training of practice staff, feedback on audited performance, practice facilitation visits and provision of patient education and referral information. Outcome measures: Primary: 1. Change in proportion of patients aged 40-69 years with smoking status, alcohol intake, body mass index (BMI), waist circumference (WC), blood pressure (BP) recorded and for those aged 45-69 years with lipids, fasting blood glucose and cardiovascular risk in the medical record. 2. Change in the level of risk for each factor. Secondary: change in self-reported frequency and confidence of GPS and PNs in assessment. Results: Risk recording improved in the intervention but not the control group for WC (OR 2.52 (95% CI 1.30 to 4.91)), alcohol consumption (OR 2.19 (CI 1.04 to 4.64)), smoking status (OR 2.24 (1.17 to 4.29)) and cardiovascular risk (OR 1.50 (1.04 to 2.18)). There was no change in recording of BP, lipids, glucose or BMI and no significant change in the level of risk factors based on audit data. The confidence but not reported practices of GPS and PNs in the intervention group improved in the assessment of some risk factors. Conclusions: This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit. Trial registration number: Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000578808, results.

Engaging patients, clinicians and health funders in weight management: the Counterweight Programme

Background. The Counterweight Programme provides an evidence based and effective approach for weight management in routine primary care. Uptake of the programme has been variable for practices and patients.

Aim. To explore key barriers and facilitators of practice and patient engagement in the Counterweight Programme and to describe key strategies used to address barriers in the wider implementation of this weight management programme in UK primary care.

Methods. All seven weight management advisers participated in a focus group. In-depth interviews were conducted with purposeful samples of GPs (n = 7) and practice nurses (n = 15) from 11 practices out of the 65 participating in the programme. A total of 37 patients participated through a mixture of in-depth interviews (n = 18) and three focus groups. Interviews and focus groups were analysed for key themes that emerged.

Results. Engagement of practice staff was influenced by clinicians’ beliefs and attitudes, factors relating to the way the programme was initiated and implemented, the programme content and organizational/contextual factors. Patient engagement was influenced by practice endorsement of the programme, clear understanding of programme goals, structured proactive follow-up and perception of positive outcomes.

Conclusions. Having a clear understanding of programme goals and expectations, enhancing self-efficacy in weight management and providing proactive follow-up is important for engaging both practices and patients. The widespread integration of weight management programmes into routine primary care is likely to require supportive public policy.

The Counterweight Programme: prevalence of CVD risk factors by body mass index and impact of a 10% weight change

Objectives

To examine relationships between body mass index (BMI), prevalence of physician-recorded cardiovascular disease (CVD) risk factors in primary care, and changes in risk with 10% weight change.

Methods

The Counterweight Project conducted a baseline cross-sectional survey of medical records of 6150 obese (BMI ≥ 30 kg/m2), 1150 age- and sex-matched overweight (BMI 25 to <30 kg/m2), and 1150 age- and sex-matched normal weight (BMI 18.5 to <25 kg/m2) controls, in primary care. Data were collected for the previous 18 months to examine BMI and disease prevalence, and then modelled to show the potential effect of 10% weight loss or gain on risk.

Results

Obese patients develop more CVD risk factors than normal weight controls. BMI ≥ 40 kg/m2 exhibits increased prevalence of type 2 diabetes mellitus (DM), odds ratio (OR) men: 6.16 (p < 0.001); women: 7.82 (p < 0.001) and hypertension OR men: 5.51 (p < 0.001); women: 4.16 (p < 0.001). Dyslipidaemia peaked around BMI 35 to <37.5 kg/m2, OR men: 3.26 (p < 0.001); women 3.76 (p < 0.001) and CVD at BMI 37.5 to <40 kg/m2 in men, OR 4.48 (p < 0.001) and BMI ≥ 40 kg/m2 in women, OR 3.98 (p < 0.001).

A 10% weight loss from the sample mean of 32.5 kg/m2 reduced the OR for type 2 DM by 30% and CVD by 20%, while 10% weight gain increased type 2 DM risk by more than 35% and CVD by 20%.

Conclusion

Obesity plays a fundamental role in CVD risk, which is reduced with weight loss. Weight management intervention strategies should be a public health priority to reduce the burden of disease in the population.

Child obesity prevention in primary health care: the role of practice nurses

Aim

Overweight and obesity affects approximately 20% of Australian pre-schoolers. The general practice nurse (PN) workforce has increased in recent years; however, little is known of PN capacity and potential to provide routine advice for the prevention of child obesity. This mixed methods pilot study aims to explore the current practices, attitudes, confidence and training needs of Australian PNs surrounding child obesity prevention in the general practice setting.

Methods

PNs from three Divisions of General Practice in New South Wales were invited to complete a questionnaire investigating PN roles, attitudes and practices in preventive care with a focus on child obesity. A total of 59 questionnaires were returned (response rate 22%). Semi-structured qualitative interviews were also conducted with a subsample of PNs (n = 10).

Results

Questionnaire respondent demographics were similar to that of national PN data. PNs described preventive work as enjoyable despite some perceived barriers including lack of confidence. Number of years working in general practice did not appear to strongly influence nurses' perceived barriers. Seventy per cent of PNs were interested in being more involved in conducting child health checks in practice, and 85% expressed an interest in taking part in child obesity prevention training.

Conclusions

Findings from this pilot study suggest that PNs are interested in prevention of child obesity despite barriers to practice and low confidence levels. More research is needed to determine the effect of training on PN confidence and behaviours in providing routine healthy life-style messages for the prevention of child obesity.

We're offering true play-based learning: teacher perspectives on educational dis/continuity in the early years

Educational continuity is a well-documented challenge facing the early childhood field. This research project investigated preschool and primary teachers' perspectives of educational dis/continuity, as they have been under-represented in the literature to date. The inclusion of dual-qualified educators in the sample group provided the counter-perspective of those who have trained and taught in both settings. It was found that teacher perceptions of how preschool and primary school differentiate have historical roots, and are orientated in the belief that the two settings apply incongruent approaches to teaching and learning. It was argued that gaining knowledge and experience in both settings could open up teachers' perceptions and assist them to find opportunities for improving continuity.

Estimating the risk of cardiovascular disease using an obese-years metric

OBJECTIVE: To examine the association between obese-years and the risk of cardiovascular disease (CVD).

STUDY DESIGN: Prospective cohort study.

SETTING: Boston, USA.

PARTICIPANTS: 5036 participants of the Framingham Heart Study were examined.

METHODS: Obese-years was calculated by multiplying for each participant the number of body mass index (BMI) units above 29 kg/m(2) by the number of years lived at that BMI during approximately 50 years of follow-up. The association between obese-years and CVD was analysed using time-dependent Cox regression adjusted for potential confounders and compared with other models using the Akaike information criterion (AIC). The lowest AIC indicated better fit.

PRIMARY OUTCOME CVD RESULTS: The median cumulative obese-years was 24 (range 2-556 obese-years). During 138,918 person-years of follow-up, 2753 (55%) participants were diagnosed with CVD. The incidence rates and adjusted HR (AHR) for CVD increased with an increase in the number of obese-years. AHR for the categories 1-24.9, 25-49.9, 50-74.9 and ≥75 obese-years were, respectively, 1.31 (95% CI 1.15 to 1.48), 1.37 (95% CI 1.14 to 1.65), 1.62 (95% CI 1.32 to 1.99) and 1.80 (95% CI 1.54 to 2.10) compared with those who were never obese (ie, had zero obese-years). The effect of obese-years was stronger in males than females. For every 10 unit increase in obese-years, the AHR of CVD increased by 6% (95% CI 4% to 8%) for males and 3% (95% CI 2% to 4%) for females. The AIC was lowest for the model containing obese-years compared with models containing either the level of BMI or the duration of obesity alone.

CONCLUSIONS: This study demonstrates that obese-years metric conceptually captures the cumulative damage of obesity on body systems, and is found to provide slightly more precise estimation of the risk of CVD than the level or duration of obesity alone.

Indigenous sustainable land management practices: perspectives from Wadawurrung/Wathaurong Country

This paper discusses the role and potential of ethnobotany in Australian Aboriginal plant knowledge in supporting and enabling sustainable land management practices for land use developments. In particular, it draws upon the Wadawurrung / Wathaurong Country knowledge for the greater Geelong region of Australia, summarises recent investigations and research, offers a deeper insight into the risks of indigenous vegetation deterioration and opportunities relating to plant usage, and highlights the importance of this plant knowledge in sustainable land management practice. The focus of this investigation is upon the Wathaurong Country around the City of Greater Geelong, host city for the ISDRS conference, of which there is little published material and oral distillation.
The purpose of this paper is to demonstrate how the Wadawurrung / Wathaurong people survived for over 60,000 years through sustainable land management techniques, caring & healing themselves by holding deep knowledge of the plants available in this region. Ethnoecology is the governing theoretical framework, with ethnobotany being a subset of this and the primary focus of this paper.
Conclusions arising from this research include: there is limited knowledge as a modern colonised nation; what little knowledge there is left is ageing and will disappear; and, there is an urgent need to better understand what still grows in the region prior to further urban applications and this is also compounded by the driving forces of climate change. Accordingly this paper demonstrates the need to urgently undertake this research. The implications for ‘Tipping Points’ is that we are increasingly at the point of no return is when we forget about the indigenous knowledge base and watch the death of the knowledge holders, and their wisdom and its benefits have not been transposed into contemporary society.

Residential schools in a first-year undergraduate engineering programme

BACKGROUND OR CONTEXT: For over 20 years, Deakin University has delivered an accredited undergraduate engineering course by means of distance education. Prior to 2004, off-campus students were not required to attend classes in person on campus. The course was designed so that the off campus students were able to undertake all study and assessment tasks remotely from the university campus. Offering accredited domestic undergraduate engineering courses via distance education has been seen as an important strategy for helping to provide graduate domestically educated engineers to meet Australia’s current and future needs. From 2000 the Australian accreditation management system for professional engineers, as managed by Engineers Australia, has increased its scrutiny of accredited domestic undergraduate engineering courses that were provided in distance-education mode. This led to a series of policies and recommendations for Australian universities that offer accredited engineering courses in distance-education mode: one of the recommendations was that off campus
enrolled engineering students should periodically attend some campus-based activities throughout the course. During the 2004 accreditation review of engineering courses at Deakin University, the
accreditation panel requested that mandatory campus-based activities be incorporated into the accredited undergraduate engineering course. Specifically the request was that Deakin mandate that all off-campus students enrolled in an accredited undergraduate engineering course provided by university attend in person a residential school at least once during every year of equivalent full-time study load. The accreditation panel suggested a program model for the residential school component of the course as developed by the University of Southern Queensland.
PURPOSE OR GOAL: This paper describes the development of the mandatory residential school component of accredited distance education undergraduate engineering courses at Deakin University with
a particular focus on how the residential school program is implemented at level 1 (first-year full-time equivalent level) of the courses.
APPROACH: To be compliant with accreditation requirements, since 2005 Deakin has conducted residential schools for off-campus students at its Geelong Waurn Ponds Campus. Initially the schools were conducted annually over two-weeks during the first semester, and have transitioned to the current mode where the residential school is conducted as a one week programme in each of the trimesters. During these schools, activities are organised around the respective engineering-course units undertaken by students during the trimester.
DISCUSSION: The minimum requirements for the on-campus components of distance-education-mode accredited engineering courses were developed by Engineers Australia in consultation with members of the Washington Accord (International Education Alliance) and at the time of development, generated considerable debate (Palmer, 2005, 2008). The intended purpose of residential schools was for off-campus enrolled students to have reasonable exposure to a typical “on-the-campus” student experience periodically throughout the course. Elements considered suitable and worthwhile for inclusion in residential school programs included:
• in person engagement with their academic lecturers,
• presentations and interaction with guest speakers from industry,
• industry-based site visits,
• engagement in sole and group-based learning and assessment activities on campus, and
• social interaction with other students.
RECOMMENDATIONS/IMPLICATIONS/CONCLUSION: We have found that advantages to the students who attends a residential school include completing real practical work without the need to assemble their own materials at home, and social engagement with staff and students. Off-campus students leave the residential school with a sense of belonging to a “community”, “one of many doing the same and not the only one”. They have the opportunity to share their often significant professional experience with the generally younger and less experienced on-campus student colleagues. Through this interaction between on-campus and off-campus students, the on-campus students benefit as much as the off-campus students. The disadvantages to the off-campus students is the requirement to travel to Geelong for an extended time, which costs the students both money and time away from work and family. From our experience, we recommend to other institutions starting residential schools of their own that they exploit the mandatory on-campus-presence requirement to enhance learning outcomes, well publicised timetables be available to students before trimester begins (certainly before census date), a standardised academic week during trimester be set for all residential schools, encourage student feedback on the program, and apply a practice of uniformity and consistency in how the programme is managed, especially mandated student attendance. Our residential schools for off-campus-mode students have been running for over 10 years. We have found that the educational and social advantages to the student outweigh the disadvantages.

Effects of an intradialytic resistance training programme on physical function: a prospective stepped-wedge randomized controlled trial

BACKGROUND: Intradialytic exercise programmes are important because of the deterioration in physical function that occurs in people receiving haemodialysis. Unfortunately, exercise programmes are rarely sustained in haemodialysis clinics. The aim of this study was to determine the efficacy of a sustainable resistance exercise programme on the physical function of people receiving haemodialysis. METHODS: A total of 171 participants from 15 community satellite haemodialysis clinics performed progressive resistance training using resistance elastic bands in a seated position during the first hour of haemodialysis treatment. We used a stepped-wedge design of three groups, each containing five randomly allocated cluster units allocated to an intervention of 12, 24 or 36 weeks. The primary outcome measure was objective physical function measured by the 30-s sit-to-stand (STS) test, the 8-foot timed up and go (TUG) test and the four-square step test. Secondary outcome measures included quality of life, involvement in community activity, blood pressure and self-reported falls. RESULTS: Exercise training led to significant improvements in physical function as measured by STS and TUG. There was a significant average downward change (β = -1.59, P < 0.01) before the intervention and a significant upward change after the intervention (β = 0.38, P < 0.01) for the 30-s STS with a similar pattern noted for the TUG. CONCLUSION: Intradialytic resistance training can improve the physical function of people receiving dialysis.

A mobile phone intervention increases physical activity in people with cardiovascular disease: Results from the HEART randomized controlled trial.

AIM: To determine the effectiveness and cost-effectiveness of a mobile phone intervention to improve exercise capacity and physical activity behaviour in people with ischaemic heart disease (IHD).

METHODS AND RESULTS: In this single-blind, parallel, two-arm, randomized controlled trial adults (n = 171) with IHD were randomized to receive a mobile phone delivered intervention (HEART; n = 85) plus usual care, or usual care alone (n = 86). Adult participants aged 18 years or more, with a diagnosis of IHD, were clinically stable as outpatients, able to perform exercise, able to understand and write English, and had access to the Internet. The HEART (Heart Exercise And Remote Technologies) intervention involved a personalized, automated package of text messages and a secure website with video messages aimed at increasing exercise behaviour, delivered over 24 weeks. All participants were able to access usual community-based cardiac rehabilitation, which involves encouragement of physical activity and an offer to join a local cardiac support club. All outcomes were assessed at baseline and 24 weeks and included peak oxygen uptake (PVO2; primary outcome), self-reported physical activity, health-related quality of life, self-efficacy and motivation (secondary outcomes). Results showed no differences in PVO2 between the two groups (difference -0.21 ml kg(-1)min(-1), 95% CI: -1.1, 0.7; p = 0.65) at 24 weeks. However significant treatment effects were observed for selected secondary outcomes, including leisure time physical activity (difference 110.2 min/week, 95% CI: -0.8, 221.3; p = 0.05) and walking (difference 151.4 min/week, 95% CI: 27.6, 275.2; p = 0.02). There were also significant improvements in self-efficacy to be active (difference 6.2%, 95% CI: 0.2, 12.2; p = 0.04) and the general health domain of the SF36 (difference 2.1, 95% CI: 0.1, 4.1; p = 0.03) at 24 weeks. The HEART programme was considered likely to be cost-effective for leisure time activity and walking.

CONCLUSIONS: A mobile phone intervention was not effective at increasing exercise capacity over and above usual care. The intervention was effective and probably cost-effective for increasing physical activity and may have the potential to augment existing cardiac rehabilitation services.

Impact of nurse-mediated management on achieving blood pressure goal levels in primary care: insights from the Valsartan intensified primary carE reduction of blood pressure study

BACKGROUND: Blood pressure targets in individuals treated for hypertension in primary care remain difficult to attain.

AIMS: To assess the role of practice nurses in facilitating intensive and structured management to achieve ideal BP levels.

METHODS: We analysed outcome data from the Valsartan Intensified Primary carE Reduction of Blood Pressure Study. Patients were randomly allocated (2:1) to the study intervention or usual care. Within both groups, a practice nurse mediated the management of blood pressure for 439 patients with endpoint blood pressure data (n=1492). Patient management was categorised as: standard usual care (n=348, 23.3%); practice nurse-mediated usual care (n=156, 10.5%); standard intervention (n=705, 47.3%) and practice nurse-mediated intervention (n=283, 19.0%). Blood pressure goal attainment at 26-week follow-up was then compared.

RESULTS: Mean age was 59.3±12.0 years and 62% were men. Baseline blood pressure was similar in practice nurse-mediated (usual care or intervention) and standard care management patients (150 ± 16/88 ± 11 vs. 150 ± 17/89 ± 11 mmHg, respectively). Practice nurse-mediated patients had a stricter blood pressure goal of ⩽125/75 mmHg (33.7% vs. 27.3%, p=0.026). Practice nurse-mediated intervention patients achieved the greatest blood pressure falls and the highest level of blood pressure goal attainment (39.2%) compared with standard intervention (35.0%), practice nurse-mediated usual care (32.1%) and standard usual care (25.3%; p<0.001). Practice nurse-mediated intervention patients were almost two-fold more likely to achieve their blood pressure goal compared with standard usual care patients (adjusted odds ratio 1.92, 95% confidence interval 1.32 to 2.78; p=0.001).

CONCLUSION: There is greater potential to achieve blood pressure targets in primary care with practice nurse-mediated hypertension management.

Primary tumor resection and overall survival in patients with metastatic colorectal cancer treated with palliative intent

The survival impact of primary tumor resection in patients with metastatic colorectal cancer (mCRC) treated with palliative intent remains uncertain. In the absence of randomized data, the objectives of the present study were to examine the effect of primary tumor resection (PTR) and major prognostic variables on overall survival (OS) of patients with de novo mCRC. Patients and Methods: Consecutive patients from the Australian 'Treatment of Recurrent and Advanced Colorectal Cancer' registry were examined from June 2009 to March 2015. Univariate and multivariate Cox proportional hazards regression analyses were used to identify associations between multiple patient or clinical variables and OS. Patients with metachronous mCRC were excluded from the analyses. Results: A total of 690 patients de novo and 373 metachronous mCRC patients treated with palliative intent were identified. The median follow-up period was 30 months. The median age of de novo patients was 66 years; 57% were male; 77% had an Eastern Cooperative Oncology Group performance status of 0 to 1; and 76% had a colon primary. A total of 216 de novo mCRC patients treated with palliative intent underwent PTR at diagnosis and were more likely to have a colon primary (odds ratio [OR], 15.4), a lower carcinoembryonic antigen level (OR, 2.08), and peritoneal involvement (OR, 2.58; P < .001). On multivariate analysis, PTR at diagnosis in de novo patients was not associated with significantly improved OS (hazard ratio [HR], 0.82; 99% confidence interval [CI], 0.62-1.09; P = .068). PTR at diagnosis did not correlate with outcome in de novo patients with a colon primary (HR, 0.74; 99% CI, 0.54-1.01; P = .014) or a rectal primary (HR, 0.81; 99% CI, 0.27-2.44; P = .621). Conclusion: For de novo mCRC patients treated with palliative intent, PTR at diagnosis does not significantly improve OS when adjusting for known major prognostic factors. The outcomes of randomized trials examining the survival impact of PTR are awaited.

Developing primary pre-service teachers' mathematical content knowledge during practicum teaching

While it is recognised that a teachers' mathematical content knowledge (MCK) is crucial for teaching, less is known about when different categories of MCK develop during teacher education. This paper reports on two primary pre-service teachers, whose MCK was investigated during their practicum experiences in first, second and fourth years of a four-year Bachelor of Education program. The results identify when and under what conditions pre-service teachers' developed different categories of their MCK during practicum. Factors that assisted pre-service teachers to develop their MCK included program structure providing breadth and depth of experiences; sustained engagement for learning MCK; and quality of pre-service teachers' learning experiences.