Social structures of science and approaches to outcomes-based medical research

Recently, two seemingly divergent approaches have emerged in outcomes-based medical research. Proponents of evidence-based medicine (EBM) argue that the most effective treatments will be found by adopting a hierarchical approach that gives pre-eminence to randomized controlled clinical trials, where these are available. Proponents of participatory medical research argue that research undertaken with consumers and other partners in the community will produce the best outcomes. While one approach marginalizes consumer experience the other approach draws consumers into it. EBM assumes a high level of consensus in a scientific community, while participatory medical research relies on co-opting consumer experience. This paper indicates that each approach involves a particular view of social structure in science. The paper uses theories of social relations among scientists for the purpose of critically assessing EBM and the participatory model.

A qualitative study exploring barriers to a model of shared care for pre-school children`s oral health

Objective To explore the oral health beliefs and practices of primary health care professionals which may act as barriers to the development of a model of shared care for the oral health of pre-school children.

Design Qualitative focus group discussions and semi-structured interviews.

Setting Four rural local government areas in Victoria, Australia, 2003.

Subjects and methods Subjects: maternal and child health nurses, general medical practitioners, dental professionals and paediatricians working in the four local government areas. Data collection: discipline specific focus groups and semi-structured interviews. Data analysis: transcription, coding, clustering and thematic analysis.

Results Several strong themes emerged from the data. All participants agreed that dental caries is a significant health issue for young children and their families. Beliefs about the aetiology of dental caries and its prevention were variable and often simplistic, focusing predominantly on diet. Dental professionals did not believe that they had a primary role in the oral health of pre-school aged children but that others particularly maternal and child health nurses did. However other health care professionals were not confident in assuming this role.

Conclusions This study has identified important barriers and possible strategies for the development of an integrated and shared approach to preventing dental caries in pre-school aged children. Clear and consistent oral health information and agreed roles and responsibilities need to be developed.

Internet-based psychological and oral medical treatment compared to psychological treatment alone for ED

Introduction. Sexual function through pregnancy and the postpartum period is an important aspect of quality of life.
Despite this, prospective studies are limited, and the impact of body image on sexual function has not been explored.
Aims. The current study reports on a pilot study that evaluated the effectiveness of a combined Internet-based
psychological treatment program and oral medication compared to an Internet-based psychological program.
Methods. Twelve men with ED participated in the study.
Main Outcome Measures. Assessments were made pre and postintervention on ED, relationship satisfaction, sexual
satisfaction, self-esteem, and quality of life.
Results. Multivariate analyses of variance demonstrated that both treatment conditions showed improvements from
pretest to posttest in sexual functioning, relationships, and personal well-being.
Conclusions. This study indicates the importance of targeting psychological and relationship variables in the
treatment of ED. Further research with larger numbers of participants is necessary for a more rigorous evaluation
of treatment programs that combine psychological and medication interventions for ED.

Enhancing the health of medical students : outcomes of an integrated mindfulness and lifestyle program

Medical students experience various stresses and many poor health behaviours. Previous studies consistently show that student wellbeing is at its lowest pre-exam. Little core-curriculum is traditionally dedicated to providing self-care skills for medical students. This paper describes the development, implementation and outcomes of the Health Enhancement Program (HEP) at Monash University. It comprises mindfulness and ESSENCE lifestyle programs, is experientially-based, and integrates with biomedical sciences, clinical skills and assessment. This study measured the program’s impact on medical student psychological distress and quality of life. A cohort study performed on the 2006 first-year intake measured effects of the HEP on various markers of wellbeing. Instruments used were the depression, anxiety and hostility subscales of the Symptom Checklist-90-R incorporating the Global Severity Index (GSI) and the WHO Quality of Life (WHOQOL) questionnaire. Pre-course data (T1) was gathered mid-semester and post-course data (T2) corresponded with pre-exam week. To examine differences between T1 and T2 repeated measures ANOVA was used for the GSI and two separate repeated measures MANOVAs were used to examine changes in the subscales of the SCL-90-R and the WHOQOL-BREF. Follow-up t-tests were conducted to examine differences between individual subscales. A total of 148 of an eligible 270 students returned data at T1 and T2 giving a response rate of 55%. 90.5% of students reported personally applying the mindfulness practices. Improved student wellbeing was noted on all measures and reached statistical significance for the depression (mean T1 = 0.91, T2 = 0.78; p = 0.01) and hostility (0.62, 0.49; 0.03) subscales and the GSI (0.73, 0.64; 0.02) of the SCL-90, but not the anxiety subscale (0.62, 0.54; 0.11). Statistically significant results were also found for the psychological domain (62.42, 65.62; p < 0.001) but not the physical domain (69.11, 70.90; p = 0.07) of the WHOQOL. This study is the first to demonstrate an overall improvement in medical student wellbeing during the pre-exam period suggesting that the common decline in wellbeing is avoidable. Although the findings of this study indicate the potential for improving student wellbeing at the same time as meeting important learning objectives, the limitations in study design due to the current duration of follow-up and lack of a control group means that the data should be interpreted with caution. Future research should be directed at determining the contribution of individual program components, long-term outcomes, and impacts on future attitudes and clinical practice.

Examination of the "all hazards" approach to disaster management as applied to field disaster management and pre-hospital care in Australia

Disasters, emergencies, incidents, and major incidents - they all come back to the same thing regardless of what they are called. The common denominator is that there is loss of life, injury to people and animals and damage and destruction of property. The management of such events relies on four phases: 1. Prevention 2. Preparation 3. Response 4. Recovery Each of these phases is managed in a different way and often by different teams. Here, concentration has been given to phases 2 and 3, with particular emphasis on phase 3, Response. The words used to describe such events are often related to legislation. The terminology is detailed later. However, whatever the description, whenever prevention is not possible, or fails, then the need is to respond. Response is always better when the responders are prepared. Training is a major part of response preparation and this book is designed to assist those in the health industry who need to be ready when something happens. One of the training packages for responders is the Major Incident Medical Management and Support (MIMMS) Course and this work was designed to supplement the manual prepared by Hodgetts and Macway-Jones(87) in the UK. Included is what the health services responder, who may be sent to an event in which the main concern is trauma, should know. Concentration is on the initial response and does not deal in any detail with hospital reaction, the public health aspects, or the mental health support that provides psychological help to victims and responders, and which are also essential parts of disaster management. People, in times of disaster, have always been quick to offer assistance. It is now well recognised however, that the 'enthusiastic amateur', whilst being a well meaning volunteer, isn't always what is needed. All too often such people have made things worse and have sometimes ended up as victims themselves. There is a place now for volunteers and there probably always will be. The big difference is that these people must be well informed, well trained and well practiced if they are to be effective. Fortunately such people and organisations do exist. Without the work of the St John Ambulance, the State Emergency Service, the Rural Fire Service the Red Cross and the Volunteer Rescue Association, to mention only a few, our response to disasters would be far less effective. There is a strong history of individuals being available to help the community in times of crisis. Mostly these people were volunteers but there has also always been the need for a core of professional support. In the recent past, professional support mechanisms have been developed from lessons learned, particularly to situations that need a rapid and well organised response. As lessons are learned from an analysis of events, philosophy and methods have changed. Our present system is not perfect and perhaps never will be. The need for an 'all-hazards approach' makes detailed planning very difficult and so there will probably always be criticisms about the way an event was handled. Hindsight is a wonderful thing, provided we learn from it. That means that this text is certainly not the 'last word' and revisions as we learn from experience will be inevitable. Because the author works primarily in New South Wales, many of the explanations and examples are specific to that state. In Australia disaster response is a State, rather than a Commonwealth, responsibility and consequently, and inevitably, there are differences in management between the states and territories within Australia. With the influence of Emergency Management Australia, these differences are being reduced. This means that across state and territory boundaries, assistance is common and interstate teams can be deployed and assimilated into the response rapidly, safely, effectively and with minimum explanation. This text sets out to increase the understanding of what is required, what is in place and how the processes of response are managed. By way of introduction and background, examples are given of those situations that have occurred, or could happen. Man Made Disasters has been divided into two distinct sections. Those which are related to structures or transport and those related directly to people. The first section, Chapter 3, includes: • Transport accidents involving land, rail, sea or air vehicles. • Collapse of buildings for reasons other than earthquakes or storms. • Industrial accidents, including the release of hazardous substances and nuclear events. A second section dealing with the consequences of the direct actions of people is separated as Chapter 4, entitled 'People Disasters'. Included are: • Crowd incidents involving sports and entertainment venues. • Terrorism From Chapter 4 on, the emphasis is on the Response phase and deals with organisation and response techniques in detail. Finally there is a section on terminology and abbreviations. An appendix details a typical disaster pack content. War, the greatest of all man made disasters is not considered in this text.

Fracture toughness of titanium foams for medical applications

The fracture behavior of titanium open foam is characterized and the R-curves of crack propagation from pre-cracks are measured. The crack growth has been optically observed, the measured initiation toughness, J_IC, has been analyzed and the effect of material morphology on the J_IC is discussed. The fracture toughness was found to be dependent on the expanding crack bridging zone at the back of the crack tip. The compact tension specimens also have some plastic collapse along the ligaments and it has shown that the titanium foam with a higher relative density is tougher. The non-uniform stressing within the plastic zone at the crack tip and the plastic collapse of cell topology behind the tip was found to be the primary cause of the R-curve behavior in low relative density titanium foams.

Zebrafish as a genetic model in pre-clinical drug testing and screening

The traditional drug discovery pipeline for the identification and development of compounds that selectively target specific molecules to ameliorate disease remains a major focus for medical research. However, the zebrafish is increasingly providing alternative strategies for various components of this pipeline. Zebrafish and their embryos are small, easily accessible and relatively low cost, making them applicable to high-throughput, small molecule screening. Zebrafish can also be manipulated by a range of forward and reverse genetics techniques to facilitate gene discovery and functional studies. Moreover, their physiological and developmental complexity provides accurate models of human disease to underpin mechanism of action and in vivo validation studies. Finally, several of these biological characteristics make zebrafish eminently suitable for toxicity testing, including eco-toxicology. Here we review the application of zebrafish to preclinical drug development and toxicity testing, including recent advances in mutant generation, drug screening and toxicology that serve to further enhance the capabilities of this valuable model organism in drug discovery.

Australian Mothers' notions of risk and uncertainty in relation to their pre-teen children

In this article we examine the ways discourses of risk manifested and played out within and across two groups of Australian mothers living in two large urban centres in Australia: the first comprised of mothers who had a pre-teen child diagnosed with an eating disorder (n = 13); the second of mothers who had a pre-teen child without the symptoms or diagnosis of an eating disorder (n = 13). In 2011 and 2012, we conducted in-depth interviews with the mothers in their homes on their ideas about health and their relationships with their children. An analysis of the data collected from these interviews indicated that having a pre-teen child diagnosed with an eating disorder had a decisive impact on how the mothers constituted and responded to risk. For mothers, who had a pre-teen child with an eating disorder, risk was intensified by bio-medical discourses. The particular intensifications of risk limited the ways in which mothers could act and often threatened to undermine their abilities as competent carers. By contrast, the mothers who did not have a pre-teen child with an eating disorder spoke about risk less directly, and with less sense of immediacy. Where these mothers acknowledged risk discourses particularly in regard to health, they were in a stronger position to negotiate them. Our analysis indicates that the ways in which mothers responded to risk is contingent on circumstances and contexts. Mothers’ responses to risk were related to the calculability of the risk and their perceived capacity to manage it.

Increasing Iron and Zinc in Pre-Menopausal Women and Its Effects on Mood and Cognition: A Systematic Review.

Iron and zinc are essential minerals often present in similar food sources. In addition to the adverse effects of frank iron and zinc-deficient states, iron insufficiency has been associated with impairments in mood and cognition. This paper reviews current literature on iron or zinc supplementation and its impact on mood or cognition in pre-menopausal women. Searches included MEDLINE complete, Excerpta Medica Database (EMBASE), psychINFO, psychARTICLES, pubMED, ProQuest Health and Medical Complete Academic Search complete, Scopus and ScienceDirect. Ten randomized controlled trials and one non-randomized controlled trial were found to meet the inclusion criteria. Seven studies found improvements in aspects of mood and cognition after iron supplementation. Iron supplementation appeared to improve memory and intellectual ability in participants aged between 12 and 55 years in seven studies, regardless of whether the participant was initially iron insufficient or iron-deficient with anaemia. The review also found three controlled studies providing evidence to suggest a role for zinc supplementation as a treatment for depressive symptoms, as both an adjunct to traditional antidepressant therapy for individuals with a diagnosis of major depressive disorder and as a therapy in its own right in pre-menopausal women with zinc deficiency. Overall, the current literature indicates a positive effect of improving zinc status on enhanced cognitive and emotional functioning. However, further study involving well-designed randomized controlled trials is needed to identify the impact of improving iron and zinc status on mood and cognition.

Complexities of medicines safety: communicating about managing medicines at transition points of care across emergency departments and medical wards

To explore how health professionals, patients and family members communicate about managing medicines across transition points of care in two Australian public hospitals.

Mental health first aid training for Australian medical and nursing students: an evaluation study

BACKGROUND: The role and demands of studying nursing and medicine involve specific stressors that may contribute to an increased risk for mental health problems. Stigma is a barrier to help-seeking for mental health problems in nursing and medical students, making these students vulnerable to negative outcomes including higher failure rates and discontinuation of study. Mental Health First Aid (MHFA) is a potential intervention to increase the likelihood that medical and nursing students will support their peers to seek help for mental health problems. This study aimed to evaluate the effectiveness of a tailored MHFA course for nursing and medical students.

METHODS: Nursing and medical students self-selected into either a face-to-face or online tailored MHFA course. Four hundred and thirty-four nursing and medical students completed pre- and post-course surveys measuring mental health first aid intentions, mental health literacy, confidence in providing help, stigmatising attitudes and satisfaction with the course.

RESULTS: The results of the study showed that both the online and face-to-face courses improved the quality of first aid intentions towards a person experiencing depression, and increased mental health literacy and confidence in providing help. The training also decreased stigmatizing attitudes and desire for social distance from a person with depression.

CONCLUSION: Both online and face-to-face tailored MHFA courses have the potential to improve outcomes for students with mental health problems, and may benefit the students in their future professional careers.

Intradialytic Laughter Yoga therapy for haemodialysis patients: a pre-post intervention feasibility study.

BACKGROUND: Laughter Yoga consists of physical exercise, relaxation techniques and simulated vigorous laughter. It has been associated with physical and psychological benefits for people in diverse clinical and non-clinical settings, but has not yet been tested in a haemodialysis setting. The study had three aims: 1) to examine the feasibility of conducting Laughter Yoga for patients with end stage kidney disease in a dialysis setting; 2) to explore the psychological and physiological impact of Laughter Yoga for these patients; and 3) to estimate the sample size required for future research. METHODS: Pre/post intervention feasibility study. Eighteen participants were recruited into the study and Laughter Yoga therapists provided a four week intradialytic program (30-min intervention three times per week). Primary outcomes were psychological items measured at the first and last Laughter Yoga session, including: quality of life; subjective wellbeing; mood; optimism; control; self-esteem; depression, anxiety and stress. Secondary outcomes were: blood pressure, intradialytic hypotensive episodes and lung function (forced expiratory volume). Dialysis nurses exposed to the intervention completed a Laughter Yoga attitudes and perceptions survey (n = 11). Data were analysed using IBM SPSS Statistics v22, including descriptive and inferential statistics, and sample size estimates were calculated using G*Power. RESULTS: One participant withdrew from the study for medical reasons that were unrelated to the study during the first week (94 % retention rate). There were non-significant increases in happiness, mood, and optimism and a decrease in stress. Episodes of intradialytic hypotension decreased from 19 pre and 19 during Laughter Yoga to 4 post Laughter Yoga. There was no change in lung function or blood pressure. All nurses agreed or strongly agreed that Laughter Yoga had a positive impact on patients' mood, it was a feasible intervention and they would recommend Laughter Yoga to their patients. Sample size calculations for future research indicated that a minimum of 207 participants would be required to provide sufficient power to detect change in key psychological variables. CONCLUSIONS: This study provides evidence that Laughter Yoga is a safe, low-intensity form of intradialytic physical activity that can be successfully implemented for patients in dialysis settings. Larger studies are required, however, to determine the effect of Laughter Yoga on key psychological variables. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry - ACTRN12614001130651 . Registered 23 October 2014.

The introduction of an undergraduate interventional radiology (IR) curriculum: impact on medical student knowledge and interest in IR

INTRODUCTION: Interventional radiology (IR) plays a vital role in modern medicine, with increasing demand for services, but with a shortage of experienced interventionalists. The aim of this study was to determine the impact of a recently introduced IR curriculum on perception, knowledge, and interest of medical students regarding various aspects of IR. METHODS: In 2014, an anonymous web-based questionnaire was sent to 309 4th year medical students in a single institution within an EU country, both before and after delivery of a 10-h IR teaching curriculum. RESULTS: Seventy-six percent (236/309) of the respondents participated in the pre-IR module survey, while 50 % (157/309) responded to the post-IR module survey. While 62 % (147/236) of the respondents reported poor or no knowledge of IR compared to other medical disciplines in the pre-IR module survey, this decreased to 17 % (27/157) in the post-IR module survey. The correct responses regarding knowledge of selected IR procedures improved from 70 to 94 % for venous access, 78 to 99 % for uterine fibroid embolization, 75 to 97 % for GI bleeding embolization, 60 to 92 % for trauma embolization, 71 to 92 % for tumor ablation, and 81 to 94 % for angioplasty and stenting in peripheral arterial disease. With regard to knowledge of IR clinical roles, responses improved from 42 to 59 % for outpatient clinic review of patients and having inpatient beds, 63-76 % for direct patient consultation, and 43-60 % for having regular ward rounds. The number of students who would consider a career in IR increased from 60 to 73 %. CONCLUSION: Delivering an undergraduate IR curriculum increased the knowledge and understanding of various aspects of IR and also the general enthusiasm for pursuing this specialty as a future career choice.

Student empathy levels across 12 medical and health professions: an interventional study

Background
Empathy is a difficult characteristic to define, teach and assess; the ‘nebulous’ properties of empathic behaviour often means that educators fail to incorporate the explicit teaching and assessment of empathy within the curriculum. One solution suggested is that teaching empathy in an interprofessional education setting is an effective educational approach in developing empathic behaviours.

Method
Student participants from Monash University, Deakin University, University of South Australia, and Edith Cowan University completed a self-reporting survey package pre and post two-hour empathy workshop consisting of the Jefferson Scale of Empathy – Health Profession – Student version (JSE-HP-S).

Results
A total of 293 students from 12 different medical and health care professions participated in the empathy workshops. The majority of participants were from Monash University n = 230 (78 %), the nursing profession n = 59 (20 %), < 26 years of age n = 215 (73 %) and enrolled in first year studies n = 123 (42 %). Using a paired t-test repeated measure self-reported empathy levels improved at p < 0.0001, mean 114.34 vs. 120.32 (d = 0.22).

Conclusion
This project has shown that self-reported empathy levels have been shown to statistically improve following DVD simulation-based workshops.

A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre-post study using full immersion simulation

AIMS AND OBJECTIVES: The aim of this study was to evaluate the effect of the new evidence-informed nursing assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) on the quality of patient assessment and fundamental nontechnical skills including communication, decision making, task management and situational awareness. BACKGROUND: Assessment is a core component of nursing practice and underpins clinical decisions and the safe delivery of patient care. Yet there is no universal or validated system used to teach emergency nurses how to comprehensively assess and care for patients. DESIGN: A pre-post design was used. METHODS: The performance of thirty eight emergency nurses from five Australian hospitals was evaluated before and after undertaking education in the application of the HIRAID assessment framework. Video recordings of participant performance in immersive simulations of common presentations to the emergency department were evaluated, as well as participant documentation during the simulations. Paired parametric and nonparametric tests were used to compare changes from pre to postintervention. RESULTS: From pre to postintervention, participant performance increases were observed in the percentage of patient history elements collected, critical indicators of urgency collected and reported to medical officers, and patient reassessments performed. Participants also demonstrated improvement in each of the four nontechnical skills categories: communication, decision making, task management and situational awareness. CONCLUSION: The HIRAID assessment framework improves clinical patient assessments performed by emergency nurses and has the potential to enhance patient care. RELEVANCE TO CLINICAL PRACTICE: HIRAID should be considered for integration into clinical practice to provide nurses with a systematic approach to patient assessment and potentially improve the delivery of safe patient care.