New regimen for eccentric calf-muscle training in patients with chronic insertional achilles tendinopathy : results of a pilot study

Background: Chronic painful insertional Achilles tendinopathy is seen in both physically active and non-active individuals. Painful eccentric training, where the patients load the Achilles tendon into full dorsiflexion, has shown good results in patients with mid-portion Achilles tendinosis. However, only 32% of patients with insertional Achilles tendinopathy had good clinical results with that type of eccentric training regimen.

Aim: To investigate whether a new model of painful eccentric training had an effect on chronic painful insertional Achilles tendinopathy.

Patients and methods: 27 patients (12 men, 15 women, mean age 53 years) with a total of 34 painful Achilles tendons with a long duration of pain (mean 26 months), diagnosed as insertional Achilles tendinopathy, were included. The patients performed a new model of painful eccentric training regimen without loading into dorsiflexion. This was done as 3x15 reps, twice a day, 7 days/week, for 12 weeks. Pain during Achilles-tendon-loading activity (VAS) and patient’s satisfaction (back to previous activity) were evaluated.

Results: At follow-up (mean 4 months) 18 patients (67%, 23/34 tendons) were satisfied and back to their previous tendon-loading activity. Their mean VAS had decreased from 69.9 (SD 18.9) to 21 (SD 20.6) (p<0.001). Nine patients (11 tendons) were not satisfied with the treatment, although their VAS was significantly reduced from 77.5 (8.6) to 58.1 (14.8) (p<0.01).

Conclusion: In this short-term pilot study this new model of painful eccentric calf-muscle training showed promising clinical results in 67% of the patients.

A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy

Objectives: This non-randomised pilot study investigated the effect of eccentric quadriceps training on 17 patients (22 tendons) with painful chronic patellar tendinopathy.

Methods: Two different eccentric exercise regimens were used by subjects with a long duration of pain with activity (more than six months). (a) Nine consecutive patients (10 tendons; eight men, one woman; mean age 22 years) performed eccentric exercise with the ankle joint in a standard (foot flat) position. (b) Eight patients (12 tendons; five men, three women; mean age 28 years) performed eccentric training standing on a 25° decline board, designed to increase load on the knee extensor mechanism. The eccentric training was performed twice daily, with three sets of 15 repetitions, for 12 weeks. Primary outcome measures were (a) 100 mm visual analogue scale (VAS), where the subject recorded the amount of pain during activity, and (b) return to previous activity. Follow up was at 12 weeks, with a further limited follow up at 15 months.

Results: Good clinical results were obtained in the group who trained on the decline board, with six patients (nine tendons) returning to sport and showing a significantly reduced amount of pain over the 12 week period. Mean VAS scores fell from 74.2 to 28.5 (p = 0.004). At 15 months, four patients (five tendons) reported satisfactory results (mean VAS 26.2). In the standard squat group the results were poor, with only one athlete returning to previous activity. Mean VAS scores in this group were 79.0 at baseline and 72.3 at 12 weeks (p = 0.144).

Conclusion: In a small group of patients with patellar tendinopathy, eccentric squats on a decline board produced encouraging results in terms of pain reduction and return to function in the short term. Eccentric exercise using standard single leg squats in a similar sized group appeared to be a less effective form of rehabilitation in reducing pain and returning subjects to previous levels of activity.

Prevalence of Myopia in adults: implications for refractive surgeons

BACKGROUND: We reviewed the research on the prevalence of myopia in the adult population to compare the refractive distribution of patients being treated with excimer laser photorefractive keratectomy to correct myopia, and assess the potential market for excimer laser surgery. METHODS: All published reports of myopia prevalence in adults were reviewed, as well as the prevalence in the Melbourne Visual Impairment Project and the distribution of refractive errors treated by the Melbourne Excimer Laser Group in 1994. RESULTS: A large population-based study of people aged 4 to 74 years in the U.S. showed that 43% had low myopia (less than -5.00 diopters (D)), 3.2% had high myopia (-5.01 to -10.00 D), and 0.2% had extreme myopia (more than -10.00 D). In Asian populations these proportions may be much higher and in African and Pacific island groups, much lower. In the Melbourne Visual Impairment Project, we found the prevalence of low myopia was 21%, high myopia 2%, and extreme myopia 0.3%. A single excimer laser has operated for 3 years in Melbourne. Of those treated, 45% had low myopia, 42% high myopia, and 13% extreme myopia. Compared to low myopes, high myopes were ten times (OR: 9.8; Confidence interval: 6.69 to 12.91) more likely to have excimer laser treatment and extreme myopes were 16 times (OR: 16.40; Confidence interval: 12.53 to 20.27) more likely. CONCLUSIONS: Although there are many more people with lower amounts of myopia in the population and the clinical results have been more predictable after one procedure in this group, the perceived benefits of excimer laser treatment may be greater for those with higher amounts of myopia, thus influencing their decision to undergo excimer laser surgery to correct their myopia. There is clearly a large market potential for excimer laser surgery in people with low myopia.

Nocebo effects in the treatment of major depression: results from an individual study participant-level meta-analysis of the placebo arm of duloxetine clinical trials

BACKGROUND: The nocebo effect, when a harmless substance creates harmful effects in a person who takes it, is a clinically salient yet seldom studied phenomenon that may be associated with poorer treatment outcomes, perceived adverse events, and treatment discontinuation. The covert presence of nocebo responders in clinical trials may contribute to outcome variance in both placebo and active treatment arms for important primary and secondary endpoints. Nocebo effects are thought to be driven by expectancy and conditioning. METHOD: This study analyzed pooled clinical trial data in the placebo arms of controlled trials of antidepressant medications to investigate variables associated with the emergence of adverse outcomes in placebo-treated participants (N = 2,457). Specifically, we examined treatment-emergent adverse events (TEAEs) and discontinuation in placebo-treated individuals. Trials were commenced between 1993 and 2010 as studies of duloxetine versus active comparator and/or placebo. RESULTS: TEAEs were reported by 1,569 placebo-treated participants (63.9%), with 115 (4.7%) discontinuing from the studies due to TEAEs and 274 (11.2%) showing worsening of Hamilton Depression Rating Scale total score during placebo treatment. There was specifically no evidence to support the expectancy hypothesis, that reported TEAEs were influenced by adverse effects described in the clinical trials participant information and consent forms, or the conditioning hypothesis, that reported TEAEs would be influenced by adverse effect profiles of previous antidepressant medications used by these study participants. There was some evidence to suggest that people who had previously used complementary medications were more likely to report TEAEs. Variables specific to individual studies were the strongest predictors of TEAEs. DISCUSSION: In this study, TEAEs were very common among placebo-treated clinical trial participants. Unexpectedly, there was no evidence to associate TEAEs with adverse clinical outcomes, nor were the conditioning or expectancy hypotheses supported by these data. CONCLUSIONS: The nocebo effect is a common, covert, and poorly understood driver of clinical outcomes that requires further investigation.

Australian doctors’ non-clinical activities: results from the MABEL survey of doctors

Objective. The aim of the present study was to investigate non-clinical work conducted by Australian doctors.
Methods. This study was an exploratory descriptive study using data from Wave 5 of the Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey, collected in 2012 from Australian medical practitioners (2200 general practitioners (GPs), 3455 specialists, 1270 specialists in training and 1656 hospital non-specialists). The main outcome measure was the number of hours worked per week in non-clinical work. Regression analysis was used to determine associations between non-clinical activities (i.e. education-related, management and administration and other) and personal and professional characteristics, including age, gender, job and life satisfaction, total clinical working hours, sector of practice
(public or private) and doctor type.
Results. Australian doctors spend an average of just under 7 h per week, or 16% of their working time, on non-clinical activities. Doctors who worked more hours on non-clinical activities overall, and in education-related and management and
administration specifically, were male, younger, had lower life satisfaction and generally spent fewer hours on clinical work. Lower job satisfaction was associated with longer management and administration hours, but not with time spent in
education-related activities. Specialists were more likely to work long non-clinical hours, whereas GPs were more likely to report none. Hospital non-specialists reported relatively high management and administration hours.
Conclusions. Further work is required to better understand the full range of non-clinical activities doctors are involved in and how this may impact future workforce projections.

A problem-based approach to clinical education in dietetics

Developing the clinical skills and knowledge of dietetic students provides a challenge for both universities and health care agencies. Deakin University has recently adopted a group learning model using problem-based learning to deliver the clinical component of the Master of Nutrition and Dietetics course. This approach was designed to enhance integration of clinical theory and practice, develop closer links between on-campus and off-campus learning environments and provide students with more active learning experiences. The impact of the new approach was evaluated using student questionnaires, academic and competency outcomes, and a focus group convened with hospital supervisors. The evaluation indicated that students generally thought that this method of learning had helped to integrate their basic knowledge with dietetic case management. There was no difference in academic scores from the previous year and an apparent reduction in the number of students requiring additional placement time to mee t competency standards. Hospital supervisors were supportive of the changes, although they had some reservations regarding the time and structure of clinical placements. As a result of this evaluation, recommendations for future development of the program include introducing problem-based learning to students earlier in their course, providing additional placement days during the block and increasing the amount of time dedicated to more complex topics. Based on the evaluation results obtained, this collaborative learning using a problem-based approach will continue to be used in the clinical education program at Deakin University.

Role of knowledge and ability in student nurses` clinical decision-making

Little is known about the acquisition of decision-making skills in nursing students as a function of experience and academic ability. Knowing how experience and academic skills interact may help inform clinical education programs and formulate ways of assessing students' progress. The aims of the present study were to develop a problem-solving task capable of measuring clinical decision-making skills in novice nurses at different levels of domain-specific knowledge; and to establish the relative impact on decision-making of domain-specific knowledge and general ability as determinants of the acquisition of decision-making skills. Three types of clinical problems of increasing complexity were developed. Sixty second-year and third-year student nurses with high and low academic scores were studied in terms of their ability to generate hypotheses for a hypothetical case, recognize disconfirming information and the need to access additional information, and diagnostic accuracy. The results showed that general academic ability and knowledge function partly independently in the acquisition of expertise in nursing. Academic ability affects decision-making in low complexity tasks, but as case complexity increases, domain-specific knowledge and experience determines decision-making skills. There are important differences in the way novices with different levels of knowledge and ability make clinical decisions and these can be studied by systematically increasing the complexity of the decision task. These results have implications for the way in which clinical education is structured and evaluated.

Australian women`s experiences of living with hepatitis C virus: results from a cross-sectional survey

Background: Of the estimated 160 000 Australians currently infected with the hepatitis C virus (HCV), over one-third are women and very few have received clinical treatment, with most managing their illness in non-specialist settings. Little is known about the experiences of women living with HCV in the general community. The present study provides the results from the first comprehensive social survey of Australian women's experiences of living with HCV.

Methods: In 2000, a questionnaire was administered to a largely non-clinical sample of women with HCV (n = 462) living in the state of Victoria and the Australian Capital Territory, Australia. The questionnaire was self-administered with a return rate of 75%. The mean age was 35 years and 83% were 'current' or 'past' injecting drug users. The mean time since diagnosis was 4.6 years (SD = 4.0) and the mean time since infection was 10.5 years (SD = 8.2).

Results: Fifty-eight percent of women reported experiencing symptoms related to their HCV, the most common being tiredness (78%) and nausea (44%). Of the sample, 56% currently saw a doctor for their HCV, and while 52% had ever been referred to a specialist, only 17% of the total sample had ever begun interferon-based combination or monotherapy. Forty-eight percent of women reported experiencing less favorable treatment by a health professional because of their HCV. Age-related self-assessed health status was significantly lower than Australian norms, as were SF-12 physical and mental health scores. The SF-12 physical and mental health scores were highly correlated, indicating a significant physical and mental health burden associated with HCV.

Conclusion: The social, physical and mental health needs of women living with HCV are considerable. Most women had not accessed specialist treatment and the response of the primary health care system to HCV-related women's health issues requires improvement.

The clinical application of three screening tools for recognizing post-partum depression

Postnatal depression is a major health issue for childbearing women world-wide, as it is not always identified early. This study aimed to evaluate the clinical application of three screening instruments for the early recognition of post-partum depression, the Postpartum Depression Prediction Inventory, the Postpartum Depression Screening Scale and the Edinburgh Postnatal Depression Scale, and to examine nurse interventions following use of the instruments. Data were collected at two points, at 28 weeks prenatal (107 women) and eight weeks postnatal (84 women). Results showed that 17% of the women scored significant symptoms of post-partum depression and 10–15% had a positive screen for major postnatal depression. There was a statistically significant correlation between the total score on the Postpartum Depression Screening Scale and the Edinburgh Postnatal Depression Scale. Of those eight women identified as being at risk, seven had received anticipatory guidance and five had received counselling by the nurses. The Postpartum Depression Prediction Inventory enabled nurses to identify women at risk of post-partum depression and offer interventions.

Haemodynamic instability after cardiac surgery: nurses` perceptions of clinical decision-making

Background. Cardiac surgical patients are distinguished by their potential for instability in the early postoperative period, highly invasive haemodynamic monitoring technologies and unique clinical presentations as a result of undergoing cardiopulmonary bypass. Little is known about nurses’ perceptions of assuming responsibility for such patients. An nderstanding of nurses’ perceptions may identify areas of practice that can be improved and assist in determining the adequacy of current decision supports.

Aim. The aim of this study was to describe critical care nurses’ perceptions of assuming responsibility for the nursing management of cardiac patients in the initial two-hour postoperative period. Design. An exploratory descriptive study based on naturalistic decision-making.

Methods. Thirty-eight nurses were interviewed immediately following a two-hour observation of their clinical practice. Content analysis and a systematic thematic analysis process called ‘Framework’ were used to analyse the interview transcripts.

Results. Nurses described their perceptions of managing patients in terms of how they felt about making decisions for complex cardiac surgical patients and in terms of how clinical processes unique to the admission phase impacted their decision-making. Nurses felt either daunted or stimulated and challenged when making decisions. Nurses identified handover from anaesthetists, settling in procedures and forms of
collegial assistance as important processes that impacted their decision-making.

Conclusion. Nurses’ previous experiences with similar patients influenced how they felt about making decisions during the initial two-hour postoperative period, but did not alter their views about processes important for patient safety during this time. Relevance to clinical practice. Feelings expressed by nurses in this study highlight the need for clinical supervision and appropriate allocation of resources during the immediate recovery period after cardiac surgery. Nurses identified ways to improve clinical processes that impacted their decision-making during the immediate recovery of cardiac surgical patients.

Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players

Background—Palpation is an important clinical test for jumper's knee.

Objectives—To (a) test the reproducibility of palpation tenderness, (b) evaluate the sensitivity and specificity of palpation in subjects with clinical symptoms of jumper's knee, and (c) determine whether tenderness to palpation may serve as a useful screening test for patellar tendinopathy. The yardstick for diagnosis of patellar tendinopathy was ultrasonographic abnormality.

Methods—In 326 junior symptomatic and asymptomatic athletes' tendons, palpation was performed by a single examiner before ultrasonographic examination by a certified ultrasound radiologist. In 58 tendons, palpation was performed twice to test reliability. Tenderness to palpation was scored on a scale from 0 to 3 where 0 represented no pain, and 1, 2, and 3 represented mild, moderate, and severe tenderness respectively.

Results—Patellar tendon palpation was a reliable examination for a single examiner (Pearson r = 0.82). In symptomatic tendons, the positive predictive value of palpation was 68%. As a screening examination in asymptomatic subjects, the positive predictive value of tendon palpation was 36–38%. Moderate and severe palpation tenderness were better predictors of ultrasonographic tendon pathology than absent or mild tenderness (p<0.001). Tender and symptomatic tendons were more likely to have ultrasound abnormality than tenderness alone (p<0.01).

Conclusions—In this age group, palpation is a reliable test but it is not cost effective in detecting patellar tendinopathy in a preparticipation examination. In symptomatic tendons, palpation is a moderately sensitive but not specific test. Mild tenderness in the patellar tendons in asymptomatic jumping athletes should be considered normal.

The clinical landscape of critical care: nurses' decision-making

Background. Many studies have tended to explore individual characteristics that impact on nurses' decision-making, despite significant acknowledgement that context is a major determinant in decision-making. The few studies that have examined environmental influences have tended not to study real decisions in the dynamic and complex clinical environment.

Aims. To investigate environmental influences on nurses' real decisions in the critical care setting.

Method. Naturalistic observations and semi-structured interviews were conducted with 18 critical care nurses in private, public and rural hospitals. Observations and interviews were recorded, transcribed verbatim and coded for themes using content analysis.

Results. All clinical decisions were strongly influenced by the context in which the decision was made. Three main environmental influences were identified: the patient situation, resource availability and interpersonal relationships. Time and risk guided all clinical decisions. Nurses established the state of the situation, the time constraints on decisions and the level of risk involved for both patient and nurse.

Conclusions. Decision-making is a manifestation of the landscape and although an increased understanding of the landscape is required, more important is the need to measure the impact of contextual variables on nurses' decision-making in order to improve health care outcomes.

The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinoplasty

Background: There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. Objective: To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. Methods: Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight  questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). Results: The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59–69), in presurgical patients 44 (28–60), and in control subjects it exceeded 96 (94–99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). Conclusions: The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis.