Self-management programs in stage 1-4 chronic kidney disease : a literature review.

Background Chronic kidney disease (CKD) is a complex health problem, which requires individuals to invest considerable time and energy in managing their health and adhering to multifaceted treatment regimens. Objectives To review studies delivering self-management interventions to people with CKD (Stages 1–4) and assess whether these interventions improve patient outcomes. Design: Systematic review. Methods Nine electronic databases (MedLine, CINAHL, EMBASE, ProQuest Health & Medical Complete, ProQuest Nursing & Allied Health, The Cochrane Library, The Joanna Briggs Institute EBP Database, Web of Science and PsycINFO) were searched using relevant terms for papers published between January 2003 and February 2013. Results The search strategy identified 2,051 papers, of which 34 were retrieved in full with only 5 studies involving 274 patients meeting the inclusion criteria. Three studies were randomised controlled trials, a variety of methods were used to measure outcomes, and four studies included a nurse on the self-management intervention team. There was little consistency in the delivery, intensity, duration and format of the self-management programmes. There is some evidence that knowledge- and health-related quality of life improved. Generally, small effects were observed for levels of adherence and progression of CKD according to physiologic measures. Conclusion The effectiveness of self-management programmes in CKD (Stages 1–4) cannot be conclusively ascertained, and further research is required. It is desirable that individuals with CKD are supported to effectively self-manage day-to-day aspects of their health.

An examination of Saudi high school teachers' ICT knowledge and implementation

This study investigated Saudi high school teachers' implementation of ICT in schools. The study also explored the relationship between the teachers' level of TPACK and their implementation of ICT. In the first phase of the study, more than 250 Saudi teachers from Al-Madinah administrative area filled in a four-part self reported questionnaire while in the second, 12 teachers completed semi-structured interviews. Findings from both phases of the study revealed that Saudi high school teachers demonstrated low level of effectiveness of ICT implementation. Among a number of barriers, Teachers' TPACK knowledge was found as the best predictor of the effectiveness of ICT implementation.

The OnTrack Diabetes web-based program for type 2 diabetes and dysphoria self-management: A randomized controlled trial protocol

Background: The prevalence of type 2 diabetes is rising with the majority of patients practicing inadequate disease self-management. Depression, anxiety, and diabetes-specific distress present motivational challenges to adequate self-care. Health systems globally struggle to deliver routine services that are accessible to the entire population, in particular in rural areas. Web-based diabetes self-management interventions can provide frequent, accessible support regardless of time and location Objective: This paper describes the protocol of an Australian national randomized controlled trial (RCT) of the OnTrack Diabetes program, an automated, interactive, self-guided Web program aimed to improve glycemic control, diabetes self-care, and dysphoria symptoms in type 2 diabetes patients. Methods: A small pilot trial is conducted that primarily tests program functionality, efficacy, and user acceptability and satisfaction. This is followed by the main RCT, which compares 3 treatments: (1) delayed program access: usual diabetes care for 3 months postbaseline followed by access to the full OnTrack Diabetes program; (2) immediate program: full access to the self-guided program from baseline onward; and (3) immediate program plus therapist support via Functional Imagery Training (FIT). Measures are administered at baseline and at 3, 6, and 12 months postbaseline. Primary outcomes are diabetes self-care behaviors (physical activity participation, diet, medication adherence, and blood glucose monitoring), glycated hemoglobin A1c (HbA1c) level, and diabetes-specific distress. Secondary outcomes are depression, anxiety, self-efficacy and adherence, and quality of life. Exposure data in terms of program uptake, use, time on each page, and program completion, as well as implementation feasibility will be conducted. Results: This trial is currently underway with funding support from the Wesley Research Institute in Brisbane, Australia. Conclusions: This is the first known trial of an automated, self-guided, Web-based support program that uses a holistic approach in targeting both type 2 diabetes self-management and dysphoria. Findings will inform the feasibility of implementing such a program on an ongoing basis, including in rural and regional locations.

Prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility: a cross-sectional prevalence study

Background Australian subacute inpatient rehabilitation facilities face significant challenges from the ageing population and the increasing burden of chronic disease. Foot disease complications are a negative consequence of many chronic diseases. With the rapid expansion of subacute rehabilitation inpatient services, it seems imperative to investigate the prevalence of foot disease and foot disease risk factors in this population. The primary aim of this cross-sectional study was to determine the prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility. Methods Eligible participants were all adults admitted at least overnight into a large Australian subacute inpatient rehabilitation facility over two different four week periods. Consenting participants underwent a short non-invasive foot examination by a podiatrist utilising the validated Queensland Health High Risk Foot Form to collect data on age, sex, medical co-morbidity history, foot disease risk factor history and clinically diagnosed foot disease complications and foot disease risk factors. Descriptive statistics were used to determine the prevalence of clinically diagnosed foot disease complications, foot disease risk factors and groups of foot disease risk factors. Logistic regression analyses were used to investigate any associations between defined explanatory variables and appropriate foot disease outcome variables. Results Overall, 85 (88%) of 97 people admitted to the facility during the study periods consented; mean age 80 (±9) years and 71% were female. The prevalence (95% confidence interval) of participants with active foot disease was 11.8% (6.3 – 20.5), 32.9% (23.9 – 43.5) had multiple foot disease risk factors, and overall, 56.5% (45.9 – 66.5) had at least one foot disease risk factor. A self-reported history of peripheral neuropathy diagnosis was independently associated with having multiple foot disease risk factors (OR 13.504, p = 0.001). Conclusion This study highlights the potential significance of the burden of foot disease in subacute inpatient rehabilitation facilities. One in eight subacute inpatients were admitted with active foot disease and one in two with at least one foot disease risk factor in this study. It is recommended that further multi-site studies and management guidelines are required to address the foot disease burden in subacute inpatient rehabilitation facilities. Keywords: Subacute; Inpatient; Foot; Complication; Prevalence

Women with self-reported lower-limb lymphedema after treatment for gynecological cancers: Are they more likely to self-report psychosocial symptoms and less likely to use services?

Background: Due to improved screening and treatment for gynaecological cancers survivorship has increased. Use of supportive care services after treatment is important to improve quality of life. Objective: To assess self-reported lower-limb lymphoedema (LLL), depression, anxiety, quality of life, unmet supportive care needs, and service use among gynaecological cancer survivors. Methods: In 2010 a population-based cross-sectional mail survey was conducted (n=160 gynaecological cancer survivors 5 to 30 month post-diagnosis (53% response rate)). Results: Overall, 30% of women self-reported LLL, 21% and 24% depression or anxiety, respectively. Women with LLL were more likely to also report symptoms of depression or anxiety, and with these symptoms had higher unmet supportive care needs. Services needed but not used by 10-15% of women with LLL, anxiety or depression respectively were lymphoedema specialist, pain specialist and physiotherapist, or psychiatrists, psychologists and pain specialists. Limitations: Small sample size, self-report data, limited generalisation to other countries, underrepresentation of older women (age >70) and women from non-Caucasian backgrounds. Conclusions: Women with LLL or high distress were less likely to use services they needed. Funding: This study was funded by Cancer Australia.

A survey of radiographers' confidence and self-perceived accuracy in frontline image interpretation and their continuing educational preferences

Introduction The provision of a written comment on traumatic abnormalities of the musculoskeletal system detected by radiographers can assist referrers and may improve patient management, but the practice has not been widely adopted outside the United Kingdom. The purpose of this study was to investigate Australian radiographers’ perceptions of their readiness for practice in a radiographer commenting system and their educational preferences in relation to two different delivery formats of image interpretation education, intensive and non-intensive. Methods A cross-sectional web-based questionnaire was implemented between August and September 2012. Participants included radiographers with experience working in emergency settings at four Australian metropolitan hospitals. Conventional descriptive statistics, frequency histograms, and thematic analysis were undertaken. A Wilcoxon signed-rank test examined whether a difference in preference ratings between intensive and non-intensive education delivery was evident. Results The questionnaire was completed by 73 radiographers (68% response rate). Radiographers reported higher confidence and self-perceived accuracy to detect traumatic abnormalities than to describe traumatic abnormalities of the musculoskeletal system. Radiographers frequently reported high desirability ratings for both the intensive and the non-intensive education delivery, no difference in desirability ratings for these two formats was evident (z = 1.66,P = 0.11). Conclusions Some Australian radiographers perceive they are not ready to practise in a frontline radiographer commenting system. Overall, radiographers indicated mixed preferences for image interpretation education delivered via intensive and non-intensive formats. Further research, preferably randomised trials, investigating the effectiveness of intensive and non-intensive education formats of image interpretation education for radiographers is warranted.

The Australian prehospital pandemic risk perception study and an examination of new public health roles in pandemic response for ambulance services

This report is one of a series of products resulting from a National Health and Medical Research Council (NHMRC) Urgent Research Grant – Pandemic Influenza [No 409973]. The research targeted two key aspects of planning and preparedness for a human influenza pandemic, namely:

Psychological well-being status among medical and dental students in Makkah, Saudi Arabia: A cross-sectional study

Objectives Medical and dental students experience poor psychological well-being relative to their peers. This study aimed to assess the psychological well-being among medical and dental students in Saudi Arabia, identify the high-risk groups and assess the association between the psychological well-being and the academic performance. Methods In this cross-sectional study, 422 preclinical medical and dental students at Umm Al-Qura University, Saudi Arabia, were recruited to assess their depression, anxiety, stress, self-efficacy and satisfaction with life levels using 21-items Depression Anxiety Stress Scale (DASS-21), General Self-Efficacy (GSE) scale and Satisfaction With Life Scale (SWLS). Students’ academic weighted grades were obtained later. Descriptive statistics and univariate general linear model were used to analyse data. Results High levels of depression (69.9%), anxiety (66.4%) and stress (70.9%) were indicated, whereas self-efficacy (mean = 27.22, sd = 4.85) and life satisfaction (mean = 23.60, sd = 6.37) were within the normal range. Female medical students had higher psychological distress in contrast to dental students. In general, third-year students were more depressed and stressed in comparison with second-year students, except for stress among dental students. Moreover, all females had higher self-efficacy than males. Life satisfaction was higher within the second-year and high family income students. Depression was the only psychological variable correlated with the academic performance. Conclusion High levels of psychological distress were found. Female medical students had higher psychological distress than males, whereas male dental students had higher distress than female. Medical students at third year were more depressed and stressed. Dental students were more depressed in the third year, but more stressed in the second year. Attention should be directed towards reducing the alarming levels of depression, anxiety and stress among medical and dental students.

Examination of the properties of IMRT and VMAT beams and evaluation against pre-treatment quality assurance results

This study aimed to provide a detailed evaluation and comparison of a range of modulated beam evaluation metrics, in terms of their correlation with QA testing results and their variation between treatment sites, for a large number of treatments. Ten metrics including the modulation index (MI), fluence map complexity (FMC), modulation complexity score (MCS), mean aperture displacement (MAD) and small aperture score (SAS) were evaluated for 546 beams from 122 IMRT and VMAT treatment plans targeting the anus, rectum, endometrium, brain, head and neck and prostate. The calculated sets of metrics were evaluated in terms of their relationships to each other and their correlation with the results of electronic portal imaging based quality assurance (QA) evaluations of the treatment beams. Evaluation of the MI, MAD and SAS suggested that beams used in treatments of the anus, rectum, head and neck were more complex than the prostate and brain treatment beams. Seven of the ten beam complexity metrics were found to be strongly correlated with the results from QA testing of the IMRT beams (p < 0.00008). For example, Values of SAS (with MLC apertures narrower than 10 mm defined as “small”) less than 0.2 also identified QA passing IMRT beams with 100% specificity. However, few of the metrics are correlated with the results from QA testing of the VMAT beams, whether they were evaluated as whole 360◦ arcs or as 60◦ sub-arcs. Select evaluation of beam complexity metrics (at least MI, MCS and SAS) is therefore recommended, as an intermediate step in the IMRT QA chain. Such evaluation may also be useful as a means of periodically reviewing VMAT planning or optimiser performance.

Exercise barriers self-efficacy : development and validation of a subcale for individuals with cancer-related lymphedema

Background No tool exists to measure self-efficacy for overcoming lymphedema-related exercise barriers in individuals with cancer-related lymphedema. However, an existing scale measures confidence to overcome general exercise barriers in cancer survivors. Therefore, the purpose of this study was to develop, validate and assess the reliability of a subscale, to be used in conjunction with the general barriers scale, for determining exercise barriers self-efficacy in individuals facing lymphedema-related exercise barriers. Methods A lymphedema-specific exercise barriers self-efficacy subscale was developed and validated using a cohort of 106 cancer survivors with cancer-related lymphedema, from Brisbane, Australia. An initial ten-item lymphedema-specific barrier subscale was developed and tested, with participant feedback and principal components analysis results used to guide development of the final version. Validity and test-retest reliability analyses were conducted on the final subscale. Results The final lymphedema-specific subscale contained five items. Principal components analysis revealed these items loaded highly (> 0.75) on a separate factor when tested with a well-established nine-item general barriers scale. The final five-item subscale demonstrated good construct and criterion validity, high internal consistency (Cronbach’s alpha=0.93) and test-retest reliability (ICC=0.67, p< 0.01). Conclusions A valid and reliable lymphedema-specific subscale has been developed to assess exercise barriers self-efficacy in individuals with cancer-related lymphedema. This scale can be used in conjunction with an existing general exercise barriers scale to enhance exercise adherence in this understudied patient group.

Staged homicides: An examination of common features of faked burglaries, suicides, accidents and car accidents

A staged crime scene involves deliberate alteration of evidence by the offender to simulate events that did not occur for the purpose of misleading authorities (Geberth, 2006; Turvey, 2000). This study examined 115 staged homicides from the USA to determine common elements; victim and perpetrator characteristics; and specific features of different types of staged scenes. General characteristics include: multiple victims and offenders; a previous relationship be- tween parties involved; and victims discovered in their own home, often by the offender. Staged scenes were separated by type with staged burglaries, suicides, accidents, and car accidents examined in more detail. Each type of scene displays differently with separate indicators and common features. Features of staged burglaries were: no points of entry/exit staged; non-valuables taken; scene ransacking; offender self- injury; and offenders bringing weapons to the scene. Features of staged suicides included: weapon arrangement and simulating self-injury to the victim; rearranging the body; and removing valuables. Examples of elements of staged accidents were arranging the implement/weapon and re- positioning the deceased; while staged car accidents involved: transporting the body to the vehicle and arranging both; mutilation after death; attempts to secure an alibi; and clean up at the primary crime scene. The results suggest few staging behaviors are used, despite the credibility they may have offered the façade. This is the first peer-reviewed, published study to examine the specific features of these scenes, and is the largest sample studied to date.

Identifying risk factors and protective factors for venous leg ulcer recurrence using a theoretical approach : a longitudinal study

Background The high recurrence rate of chronic venous leg ulcers has a significant impact on an individual’s quality of life and healthcare costs. Objectives This study aimed to identify risk and protective factors for recurrence of venous leg ulcers using a theoretical approach by applying a framework of self and family management of chronic conditions to underpin the study. Design Secondary analysis of combined data collected from three previous prospective longitudinal studies. Setting The contributing studies’ participants were recruited from two metropolitan hospital outpatient wound clinics and three community-based wound clinics. Participants Data were available on a sample of 250 adults, with a leg ulcer of primarily venous aetiology, who were followed after ulcer healing for a median follow-up time of 17 months after healing (range: 3 to 36 months). Methods Data from the three studies were combined. The original participant data were collected through medical records and self-reported questionnaires upon healing and every 3 months thereafter. A Cox proportion-hazards regression analysis was undertaken to determine the influential factors on leg ulcer recurrence based on the proposed conceptual framework. Results The median time to recurrence was 42 weeks (95% CI 31.9–52.0), with an incidence of 22% (54 of 250 participants) recurrence within three months of healing, 39% (91 of 235 participants) for those who were followed for six months, 57% (111 of 193) by 12 months, 73% (53 of 72) by two years and 78% (41 of 52) of those who were followed up for three years. A Cox proportional-hazards regression model revealed that the risk factors for recurrence included a history of deep vein thrombosis (HR 1.7, 95% CI 1.07–2.67, p=0.024), history of multiple previous leg ulcers (HR 4.4, 95% CI 1.84–10.5, p=0.001), and longer duration (in weeks) of previous ulcer (HR 1.01, 95% CI 1.003–1.01, p<0.001); while the protective factors were elevating legs for at least 30 minutes per day (HR 0.33, 95% CI 0.19–0.56, p<0.001), higher levels of self-efficacy (HR 0.95, 95% CI 0.92–0.99, p=0.016), and walking around for at least three hours/day (HR 0.66, 95% CI 0.44–0.98, p=0.040). Conclusions Results from this study provide a comprehensive examination of risk and protective factors associated with leg ulcer recurrence based on the chronic disease self and family management framework. These results in turn provide essential steps towards developing and testing interventions to promote optimal prevention strategies for venous leg ulcer recurrence.

Medical education and law: Withholding/withdrawing treatment from adults without capacity

BACKGROUND Law is increasingly involved in clinical practice, particularly at the end of life, but undergraduate and postgraduate education in this area remains unsystematic. We hypothesised that attitudes to and knowledge of the law governing withholding/withdrawing treatment from adults without capacity (the WWLST law) would vary and demonstrate deficiencies among medical specialists. AIMS We investigated perspectives, knowledge and training of medical specialists in the three largest (populations and medical workforces) Australian states, concerning the WWLST law. METHODS Following expert legal review, specialist focus groups, pre-testing and piloting in each state, seven specialties involved with end-of-life care were surveyed, with a variety of statistical analyses applied to the responses. RESULTS Respondents supported the need to know and follow the law. There were mixed views about its helpfulness in medical decision-making. Over half the respondents conceded poor knowledge of the law; this was mirrored by critical gaps in knowledge that varied by specialty. There were relatively low but increasing rates of education from the undergraduate to continuing professional development (CPD) stages. Mean knowledge score did not vary significantly according to undergraduate or immediate postgraduate training, but CPD training, particularly if recent, resulted in greater knowledge. Case-based workshops were the preferred CPD instruction method. CONCLUSIONS Teaching of current and evolving law should be strengthened across all stages of medical education. This should improve understanding of the role of law, ameliorate ambivalence towards the law, and contribute to more informed deliberation about end-of-life issues with patients and families.

Adolescent self-reported physical activity and autonomy: A case for constrained and structured environments?

The provision of autonomy supportive environments that promote physical activity engagement have become popular in contemporary youth settings. However, questions remain about whether adolescent perceptions of their autonomy have implications for physical activity. The purpose of this investigation was to examine the association between adolescents’ self-reported physical activity and their perceived autonomy. Participants (n = 384 adolescents) aged between 12 and 15 years were recruited from six secondary schools in metropolitan Brisbane, Australia. Self-reported measures of physical activity and autonomy were obtained. Logistic regression with inverse probability weights were used to examine the association between autonomy and the odds of meeting youth physical activity guidelines. Autonomy (OR 0.61, 95% CI 0.49-0.76) and gender (OR 0.62, 95% CI 0.46-0.83) were negatively associated with meeting physical activity guidelines. However, the model explained only a small amount of the variation in whether youth in this sample met physical activity guidelines (R2 = 0.023). For every 1 unit decrease in autonomy (on an index from 1 to 5), participants were 1.64 times more likely to meet physical activity guidelines. The findings, which are at odds with several previous studies, suggest that interventions designed to facilitate youth physical activity should limit opportunities for youth to make independent decisions about their engagement. However, the small amount of variation explained by the predictors in the model is a caveat, and should be considered prior to applying such suggestions in practical settings. Future research should continue to examine a larger age range, longitudinal observational or intervention studies to examine assertions of causality, as well as objective measurement of physical activity.

Prevalence of retinopathy among adults with self-reported diabetes mellitus: the Sri Lanka diabetes and Cardiovascular Study

Background: At present there are no large scale nationally-representative studies from Sri Lanka on the prevalence and associations of Diabetic Retinopathy (DR). The present study aims to evaluate the prevalence and risk factors for DR in a community-based nationally-representative sample of adults with self-reported diabetes mellitus from Sri Lanka. Methods: A cross-sectional community-based national study among 5,000 adults (≥18 years) was conducted in Sri Lanka, using a multi-stage stratified cluster sampling technique. An interviewer-administered questionnaire was used to collect data. Ophthalmological evaluation of patients with ‘known’ diabetes (previously diagnosed at a government hospital or by a registered medical practitioner) was done using indirect ophthalmoscopy. A binary-logistic regression analysis was performed with ‘presence of DR’ as the dichotomous dependent variable and other independent covariates. Results: Crude prevalence of diabetes was 12.0%(n=536),of which 344 were patients with ‘known’ diabetes.Mean age was 56.4 ± 10.9 years and 37.3% were males. Prevalence of any degree of DR was 27.4% (Males-30.5%, Females-25.6%; p = 0.41). In patients with DR, majority had NPDR (93.4%), while 5.3% had maculopathy. Patients with DR had a significantly longer duration of diabetes than those without. In the binary-logistic regression analysis in all adults duration of diabetes (OR:1.07), current smoking (OR:1.67) and peripheral neuropathy (OR:1.72)all were significantly associated with DR. Conclusions: Nearly 1/3rd of Sri Lankan adults with self-reported diabetes are having retinopathy. DR was associated with diabetes duration, cigarette smoking and peripheral neuropathy. However, further prospective follow up studies are required to establish causality for identified risk factors