Mailed treatment to augment primary care for alcohol disorders : a randomised controlled trial

Introduction and Aims: Remote delivery of interventions is needed to address large numbers of people with alcohol use disorders who are spread over large areas. Previous correspondence trials typically examined its effects as stand-alone treatment. This study aimed to test whether adding postal treatment to general practitioner (GP) support would lower alcohol use more than GP intervention alone. Design and Methods: A single-blind, randomised controlled trial with a crossover design was conducted over 12 months on 204 people with alcohol use disorders. Participants in an immediate correspondence condition received treatment over the first 3 months; those receiving delayed treatment received it in months 3–6. Results: Few participants were referred from GPs, and little intervention was offered by them. At 3 months, 78% of participants remained in the study. Those in immediate treatment showed greater reductions in alcohol per week, drinking days, anxiety, depression and distress than those in the delayed condition. However, post-treatment and follow-up outcomes still showed elevated alcohol use, depression, anxiety and distress. Greater baseline anxiety predicted better alcohol outcomes, although more mental distress at baseline predicted dropout. Discussion and Conclusions: The study gave consistent results with those from previous research on correspondence treatments, and showed that high levels of participant engagement over 3 months can be obtained. Substantial reductions in alcohol use are seen, with indications that they are well maintained. However, many participants continue to show high-risk alcohol use and psychological distress.

Beneficial effects of exercise : shifting the focus from body weight to other markers of health

Background: Exercise is widely promoted as a method of weight management, while the other health benefits are often ignored. The purpose of this study was to examine whether exercise-induced improvements in health are influenced by changes in body weight. Methods: Fifty-eight sedentary overweight/obese men and women (BMI 31.8 (SD 4.5) kg/m2) participated in a 12-week supervised aerobic exercise intervention (70% heart rate max, five times a week, 500 kcal per session). Body composition, anthropometric parameters, aerobic capacity, blood pressure and acute psychological response to exercise were measured at weeks 0 and 12. Results: The mean reduction in body weight was −3.3 (3.63) kg (p<0.01). However, 26 of the 58 participants failed to attain the predicted weight loss estimated from individuals’ exercise-induced energy expenditure. Their mean weight loss was only −0.9 (1.8) kg (p<0.01). Despite attaining a lower-than-predicted weight reduction, these individuals experienced significant increases in aerobic capacity (6.3 (6.0) ml/kg/min; p<0.01), and a decreased systolic (−6.00 (11.5) mm Hg; p<0.05) and diastolic blood pressure (−3.9 (5.8) mm Hg; p<0.01), waist circumference (−3.7 (2.7) cm; p<0.01) and resting heart rate (−4.8 (8.9) bpm, p<0.001). In addition, these individuals experienced an acute exercise-induced increase in positive mood. Conclusions: These data demonstrate that significant and meaningful health benefits can be achieved even in the presence of lower-than-expected exercise-induced weight loss. A less successful reduction in body weight does not undermine the beneficial effects of aerobic exercise. From a public health perspective, exercise should be encouraged and the emphasis on weight loss reduced.

Working in groups

This chapter is a condensation of a guide written by the chapter authors for both university teachers and students (Fowler et al., 2006). All page references given in this chapter are to this guide, unless otherwise stated. University students often work in groups. It may be a formal group (i.e. one that has been formed for a group presentation, writing a report, or completing a project) or an informal group (i.e. some students have decided to form a study group or undertake research together). Whether formal or informal, this chapter aims to make working in groups easier for you. Health care professionals also often work in groups. Yes, working in groups will extend well beyond your time at university. In fact, the skills and abilities to work effectively in groups are some of the most sought-after attributes in health care professionals. It seems obvious, then, that taking the opportunity to develop and enhance your skills and abilities for working in groups is a wise choice.

New insights into appetite, inflammation and the use of fish oil in hemodialysis patients

Protein-energy wasting (PEW) is commonly seen in patients with chronic kidney disease (CKD). The condition is characterised by chronic, systemic low-grade inflammation which affects nutritional status by a variety of mechanisms including reducing appetite and food intake and increasing muscle catabolism. PEW is linked with co-morbidities such as cardiovascular disease, and is associated with lower quality of life, increased hospitalisations and a 6-fold increase in risk of death1. Significant gender differences have been found in the severity and effects of several markers of PEW. There have been limited studies testing the ability of anti-inflammatory agents or nutritional interventions to reduce the effects of PEW in dialysis patients. This thesis makes a significant contribution to the understanding of PEW in dialysis patients. It advances understanding of measurement techniques for two of the key components, appetite and inflammation, and explores the effect of fish oil, an anti-inflammatory agent, on markers of PEW in dialysis patients. The first part of the thesis consists of two methodological studies conducted using baseline data. The first study aims to validate retrospective ratings of hunger, desire to eat and fullness on visual analog scales (VAS) (paper and pen and electronic) as a new method of measuring appetite in dialysis patients. The second methodological study aims to assess the ability of a variety of methods available in routine practice to detect the presence of inflammation. The second part of the thesis aims to explore the effect of 12 weeks supplementation with 2g per day of Eicosapentaenoic Acid (EPA), a longchain fatty acid found in fish oil, on markers of PEW. A combination of biomarkers and psychomarkers of appetite and inflammation are the main outcomes being explored, with nutritional status, dietary intake and quality of life included as secondary outcomes. A lead in phase of 3 months prior to baseline was used so that each person acts as their own historical control. The study also examines whether there are gender differences in response to the treatment. Being an exploratory study, an important part of the work is to test the feasibility of the intervention, thus the level of adherence and factors associated with adherence are also presented. The studies were conducted at the hemodialysis unit of the Wesley Hospital. Participants met the following criteria: adult, stage 5 CKD on hemodialysis for at least 3 months, not expected to receive a transplant or switch to another dialysis modality during the study, absence of intellectual impairment or mental illness impairing ability to follow instructions or complete the intervention. A range of intermediate, clinical and patient-centred outcome measures were collected at baseline and 12 weeks. Inflammation was measured using five biomarkers: c-reactive protein (CRP), interleukin-6 (IL6), intercellular adhesion molecule (sICAM-1), vascular cell adhesion molecule (sVCAM-1) and white cell count (WCC). Subjective appetite was measured using the first question from the Appetite and Dietary Assessment (ADAT) tool and VAS for measurements of hunger, desire to eat and fullness. A novel feature of the study was the assessment of the appetite peptides leptin, ghrelin and peptide YY as biomarkers of appetite. Nutritional status/inflammation was assessed using the Malnutrition-Inflammation Score (MIS) and the Patient-Generated Subjective Global Assessment (PG-SGA). Dietary intake was measured using 3-day records. Quality of life was measured using the Kidney Disease Quality of Life Short Form version 1.3 (KDQOL-SF™ v1.3 © RAND University), which combines the Short-Form 36 (SF36) with a kidney-disease specific module2. A smaller range of these variables was available for analysis during the control phase (CRP, ADAT, dietary intake and nutritional status). Statistical analysis was carried out using SPSS version 14 (SPSS Inc, Chicago IL, USA). Analysis of the first part of the thesis involved descriptive and bivariate statistics, as well as Bland-Altman plots to assess agreement between methods, and sensitivity analysis/ROC curves to test the ability of methods to predict the presence of inflammation. The unadjusted (paired ttests) and adjusted (linear mixed model) change over time is presented for the main outcome variables of inflammation and appetite. Results are shown for the whole group followed by analyses according to gender and adherence to treatment. Due to the exploratory nature of the study, trends and clinical significance were considered as important as statistical significance. Twenty-eight patients (mean age 61±17y, 50% male, dialysis vintage 19.5 (4- 101) months) underwent baseline assessment. Seven out of 28 patients (25%) reported sub-optimal appetite (self-reported as fair, poor or very poor) despite all being well nourished (100% SGA A). Using the VAS, ratings of hunger, but not desire to eat or fullness, were significantly (p<0.05) associated with a range of relevant clinical variables including age (r=-0.376), comorbidities (r=-0.380) nutritional status (PG-SGA score, r=-0.451), inflammatory markers (CRP r=-0.383; sICAM-1 r=-0.387) and seven domains of quality of life. Patients expressed a preference for the paper and pen method of administering VAS. None of the tools (appetite, MIS, PG-SGA, albumin or iron) showed an acceptable ability to detect patients who are inflamed. It is recommended that CRP should be tested more frequently as a matter of course rather than seeking alternative methods of measuring inflammation. 27 patients completed the 12 week intervention. 20 patients were considered adherent based on changes in % plasma EPA, which rose from 1.3 (0.94)% to 5.2 (1.1)%, p<0.001, in this group. The major barriers to adherence were forgetting to take the tablets as well as their size. At 12 weeks, inflammatory markers remained steady apart from the white cell count which decreased (7.6(2.5) vs 7.0(2.2) x109/L, p=0.058) and sVCAM-1 which increased (1685(654) vs 2249(925) ng/mL, p=0.001). Subjective appetite using VAS increased (51mm to 57mm, +12%) and there was a trend towards reduction in peptide YY (660(31) vs 600(30) pg/mL, p=0.078). There were some gender differences apparent, with the following adjusted change between baseline and week 12: CRP (males -3% vs females +17%, p=0.19), IL6 (males +17% vs females +48%, p=0.77), sICAM-1 (males -5% vs females +11%, p=0.07), sVCAM-1 (males +54% vs females +19%, p=0.08) and hunger ratings (males 20% vs females -5%, p=0.18). On balance, males experienced a maintainence or reduction in three inflammatory markers and an improvement in hunger ratings, and therefore appeared to have responded better to the intervention. Compared to those who didn’t adhere, adherent patients maintained weight (mean(SE) change: +0.5(1.6) vs - 0.8(1.2) kg, p=0.052) and fat-free mass (-0.1 (1.6) vs -1.8 (1.8) kg, p=0.045). There was no difference in change between the intervention and control phase for CRP, appetite, nutritional status or dietary intake. The thesis makes a significant contribution to the evidence base for understanding of PEW in dialysis patients. It has advanced knowledge of methods of assessing inflammation and appetite. Retrospective ratings of hunger on a VAS appear to be a valid method of assessing appetite although samples which include patients with very poor appetite are required to confirm this. Supplementation with fish oil appeared to improve subjective appetite and dampen the inflammatory response. The effectiveness of the intervention is influenced by gender and adherence. Males appear to be more responsive to the primary outcome variables than females, and the quality of response is improved with better adherence. These results provide evidence to support future interventions aimed at reducing the effects of PEW in dialysis patients.

Knowledge is not power, but it’s a start : young people and employment entitlements

This paper employs empirical evidence from a survey of Queensland secondary school students to examine their knowledge about their wages and working conditions. It does so within the theoretical lens of the Gagne (or Gagne-Briggs) theory of instruction, which centres on the content of learning and how learning is acquired (Gagne, Briggs & Wager, 1988). While Gagne articulates five categories of learning, our focus here is on two; verbal information or declarative knowledge (facts that people can declare), and procedural knowledge (the rules and procedures for achieving outcomes). We show that student workers know little about the instruments governing their employment, or their workplace entitlements. Of the total sample of year 9 and year 11 students surveyed (n=892), those students who worked, or who had worked in the past year (n=438), were asked to identify whether they were employed under an award, collective agreement or AWA. Eighty three per cent of students did not know which industrial instrument set their wages. We argue that if young workers do not have declarative knowledge of their entitlements, nor basic procedural knowledge about redress, then they are not in a position to deploy Gagne’s ‘cognitive strategies’ that would enable them to take action to ensure their working conditions meet legal minima. We advocate that young workers should be given summary information on their wages and other entitlements on appointment and that such summary information should be readily available on employers’ noticeboards and electronically on company websites, and that the information should include a brief summary of avenues for redressing issues of underpayment or sub-standard conditions.

A ‘cost-per-wear’ model based on contact lens replacement frequency

Purpose: The aim was to construct and advise on the use of a cost-per-wear model based on contact lens replacement frequency, to form an equitable basis for cost comparison. ---------- Methods: The annual cost of professional fees, contact lenses and solutions when wearing daily, two-weekly and monthly replacement contact lenses is determined in the context of the Australian market for spherical, toric and multifocal prescription types. This annual cost is divided by the number of times lenses are worn per year, resulting in a ‘cost-per-wear’. The model is presented graphically as the cost-per-wear versus the number of times lenses are worn each week for daily replacement and reusable (two-weekly and monthly replacement) lenses.---------- Results: The cost-per-wear for two-weekly and monthly replacement spherical lenses is almost identical but decreases with increasing frequency of wear. The cost-per-wear of daily replacement spherical lenses is lower than for reusable spherical lenses, when worn from one to four days per week but higher when worn six or seven days per week. The point at which the cost-per-wear is virtually the same for all three spherical lens replacement frequencies (approximately AUD$3.00) is five days of lens wear per week. A similar but upwardly displaced (higher cost) pattern is observed for toric lenses, with the cross-over point occurring between three and four days of wear per week (AUD$4.80). Multifocal lenses have the highest price, with cross-over points for daily versus two-weekly replacement lenses at between four and five days of wear per week (AUD$5.00) and for daily versus monthly replacement lenses at three days per week (AUD$5.50).---------- Conclusions: This cost-per-wear model can be used to assist practitioners and patients in making an informed decision in relation to the cost of contact lens wear as one of many considerations that must be taken into account when deciding on the most suitable lens replacement modality.

Do walking and leisure-time physical activity protect against arthritis in older women?

Objective: To examine the prospective dose–response relationships between both leisure-time physical activity (LTPA) and walking with self-reported arthritis in older women. Design, setting and participants: Data came from women aged 73–78 years who completed mailed surveys in 1999, 2002 and 2005 for the Australian Longitudinal Study on Women’s Health. Women reported their weekly minutes of walking and moderate to vigorous physical activities. They also reported on whether they had been diagnosed with, or treated for, arthritis since the previous survey. General estimating equation analyses were performed to examine the longitudinal relationship between LTPA and arthritis and, for women who reported walking as their only physical activity, the longitudinal relationship between walking and arthritis. Women who reported arthritis or a limited ability to walk in 1999 were excluded, resulting in data from 3613 women eligible for inclusion in these analyses. Main results: ORs for self-reported arthritis were lowest for women who reported “moderate” levels of LTPA (OR 0.78; 95% CI 0.67 to 0.92), equivalent to 75 to <150 minutes of moderate-intensity LTPA per week. Slightly higher odds ratios were found for women who reported “high” (OR 0.81; 95% CI 0.69 to 0.95) or “very high” (OR 0.84; 95% CI 0.72 to 0.98) LTPA levels, indicating no further benefit from increased activity. For women whose only activity was walking, an inverse dose–response relationship between walking and arthritis was seen. Conclusions: The results support an inverse association between both LTPA and walking with self-reported arthritis over 6 years in older women who are able to walk.

Fair flow control of ABR service by per-VC virtual queuing

In this paper, a rate-based flow control scheme based upon per-VC virtual queuing is proposed for the Available Bit Rate (ABR) service in ATM. In this scheme, each VC in a shared buffer is assigned a virtual queue, which is a counter. To achieve a specific kind of fairness, an appropriate scheduler is applied to the virtual queues. Each VC's bottleneck rate (fair share) is derived from its virtual cell departure rate. This approach of deriving a VC's fair share is simple and accurate. By controlling each VC with respect to its virtual queue and queue build-up in the shared buffer, network congestion is avoided. The principle of the control scheme is first illustrated by max–min flow control, which is realised by scheduling the virtual queues in round-robin. Further application of the control scheme is demonstrated with the achievement of weighted fairness through weighted round robin scheduling. Simulation results show that with a simple computation, the proposed scheme achieves the desired fairness exactly and controls network congestion effectively.

Panel studies of new venture creation : a review and suggestions for future research

We review all journal articles based on “PSED-type” research, i.e., longitudinal, empirical studies of large probability samples of on-going, business start-up efforts. We conclude that the research stream has yielded interesting findings; sometimes by confirming prior research with a less bias-prone methodology and at other times by challenging whether prior conclusions are valid for the early stages of venture development. Most importantly, the research has addressed new, process-related research questions that prior research has shunned or been unable to study in a rigorous manner. The research has revealed an enormous and fascinating variability in new venture creation that also makes it challenging to arrive at broadly valid generalizations. An analysis of the findings across studies as well as an examination of those studies that have been relatively more successful at explaining outcomes give good guidance regarding what is required in order to achieve strong and credible results. We compile and present such advice to users of existing data sets and designers of new projects in the following areas: Statistically representative and/or theoretically relevant sampling; Level of analysis issues; Dealing with process heterogeneity; Dealing with other heterogeneity issues, and Choice and interpretation of dependent variables.

Civic engagement and associationalism : the impact of group membership scope versus intensity of participation

The relationship between participation in civic and political activities and membership of voluntary associations is now well established. What is less clear is the relative impacts of how much time people spend on group activities (associational intensity), and the number and type of groups that individuals are involved with (associational scope). Does it matter in terms of civic engagement, for example, whether one is a member of a quilting-circle or trade union? Does it matter whether association ‘membership’ is simply an annual payment or a major commitment of time and energy? In this article, we use a large survey to explore these questions empirically by focusing on the membership patterns and civic engagement practices of 4,001 citizens drawn from eight suburbs across Greater Melbourne, Australia. Our findings indicate that, while associational intensity is positively related to civic engagement, associational scope (the number of group memberships per person), is a more influential determinant of the level of civic and political participation. The results also suggest that while all forms of associationalism are important in terms of fostering greater levels of civic activity, not all forms have the same impact.

The short-term effect of air pollution on cardiovascular mortality in Tianjin, China : comparison of time series and case–crossover analyses

Background: Many studies have illustrated that ambient air pollution negatively impacts on health. However, little evidence is available for the effects of air pollution on cardiovascular mortality (CVM) in Tianjin, China. Also, no study has examined which strata length for the time-stratified case–crossover analysis gives estimates that most closely match the estimates from time series analysis. Objectives: The purpose of this study was to estimate the effects of air pollutants on CVM in Tianjin, China, and compare time-stratified case–crossover and time series analyses. Method: A time-stratified case–crossover and generalized additive model (time series) were applied to examine the impact of air pollution on CVM from 2005 to 2007. Four time-stratified case–crossover analyses were used by varying the stratum length (Calendar month, 28, 21 or 14 days). Jackknifing was used to compare the methods. Residual analysis was used to check whether the models fitted well. Results: Both case–crossover and time series analyses show that air pollutants (PM10, SO2 and NO2) were positively associated with CVM. The estimates from the time-stratified case–crossover varied greatly with changing strata length. The estimates from the time series analyses varied slightly with changing degrees of freedom per year for time. The residuals from the time series analyses had less autocorrelation than those from the case–crossover analyses indicating a better fit. Conclusion: Air pollution was associated with an increased risk of CVM in Tianjin, China. Time series analyses performed better than the time-stratified case–crossover analyses in terms of residual checking.

Household food expenditure and its contribution to socioeconomic inequalities in purchasing foods consistent with Australian dietary guideline recommendations

Aim: To examine the amount of money spent on food by household income, and to ascertain whether food expenditure mediates the relationship between household income and the purchase of staple foods consistent with Australian dietary guideline recommendations. ----- ----- Methods: In face-to-face interviews (n = 1003, 66.4% response rate), households in Brisbane, Australia were asked about their purchasing choices for a range of staple foods, including grocery items, fruits and vegetables. For each participant, information was obtained about their total weekly household food expenditure, along with their sociodemographic and household characteristics. ----- ----- Results: Household income was significantly associated with food expenditure; participants residing in higher-income households spent more money on food per household member than those from lower-income households. Lower income households were less likely to make food purchasing choices of dietary staples that were consistent with recommendations. However, food expenditure did not attenuate the relationship between household income and the purchase of staple foods consistent with dietary guideline recommendations. ----- ----- Conclusions: The findings suggest that food expenditure may not contribute to income inequalities in purchasing staple foods consistent with dietary guideline recommendations: instead, other material or psychosocial factors not considered in the current study may be more important determinants of these inequalities. Further research should examine whether expenditure on non-staple items and takeaway foods is a larger contributor to socioeconomic inequalities in dietary behavior.

Comparison of below-knee amputee gait performed overground and on a motorized treadmill

There has been no direct attempt to evaluate whether gait performed overground and on a treadmill is the same for lower limb amputees. A multiple case study approach was adopted to explore the degenerate movement behavior displayed by three male amputees. Participants walked overground at a self-selected preferred pace and when this speed was enforced on a treadmill (50 stride cycles per condition). The extremities of motion (i.e., maximum flexion) for the hip and knee joints differed between conditions (0.2–3.8°). For two participants, the temporal asymmetry of gait was reduced on the treadmill. Initial data suggest that research on amputees simulating overground walking on a treadmill might need to be interpreted with some caution.

Nascent venture performance : linking novelty of venture ideas and commitment of firm founders as predictors

The individual-opportunity nexus emphasizes that both the characteristics of individuals and venture ideas have roles in the entrepreneurial process (Shane & Venkataraman, 2000). Following upon this assertion the present study examined whether the venture idea novelty and investment of resources can make an important part in the venture creation process. Data analysed for a sample of nascent entrepreneurs in Australia suggests that the novelty of venture ideas restricts the performance of nascent ventures. However, the more investment of time and money do not show a significant impact to the venture performance.