Effective clinical decision-making from practice-based evidence

This is an ongoing research investigating the use of health information technologies (HIT) to improve clinical decision-making processes. Effective and timely clinical decision-making can lead to positive improvements in patient’s health outcome...

The optimal frequency of aquatic physiotherapy for individuals with chronic musculoskeletal pain: a randomised controlled trial

Purpose: To establish whether there was a difference in health-related quality of life (HRQoL) in people with chronic musculoskeletal disorders (PwCMSKD) after participating in a multimodal physiotherapy program (MPP) either two or three sessions a week. Methods: Total of 114 PwCMSKD participated in this prospective randomised controlled trial. An individualised MPP, consisting of exercises for mobility, motor-control, muscle strengthening, cardiovascular training, and health education, was implemented either twice a week (G2: n = 58) or three times a week) (G3: n = 56) for 1 year. Outcomes: HRQoL physical and mental health state (PHS/MHS), Roland Morris disability Questionnaire (RMQ), Neck-Disability-Index (NDI) and Western Ontario and McMaster Universities’ Arthritis Index (WOMAC) were used to measure outcomes of MPP for people with chronic low back pain, chronic neck pain and osteoarthritis, respectively. Measures were taken at baseline, 8 weeks (8 w), 6 months (6 m), and 1 year (1 y) after starting the programme. Results: No statistically significant differences were found between the two groups (G2 and G3), except in NDI at 8 w (−3.34, (CI 95%: −6.94/0.84, p = 0.025 (scale 0–50)). All variables showed improvement reaching the following values (from baseline to 1 y) G2: PHS: 57.72 (baseline: 41.17; (improvement: 16.55%), MHS: 74.51 (baseline: 47.46, 27.05%), HRQoL 0.90 (baseline: 0.72, 18%)), HRQoL-VAS 84.29 (baseline: 58.04, 26.25%), RMQ 4.15 (baseline: 7.85, 15.42%), NDI 3.96 (baseline: 21.87, 35.82%), WOMAC 7.17 (baseline: 25.51, 19.10%). G3: PHS: 58.64 (baseline: 39.75, 18.89%), MHS: 75.50 (baseline: 45.45, (30.05%), HRQoL 0.67 (baseline: 0.88, 21%), HRQoL-VAS 86.91 (baseline: 52.64, 34.27%), RMQ 4.83 (baseline: 8.93, 17.08%), NDI 4.91 (baseline: 23.82, 37.82%), WOMAC 6.35 (baseline: 15.30, 9.32%). Conclusions: No significant differences between the two groups were found in the outcomes of a MPP except in the NDI at 8 weeks, but both groups improved in all variables during the course of 1 year under study.

External knowledge and query strategies in active learning: A study in clinical information extraction

This paper presents a new active learning query strategy for information extraction, called Domain Knowledge Informativeness (DKI). Active learning is often used to reduce the amount of annotation effort required to obtain training data for machine learning algorithms. A key component of an active learning approach is the query strategy, which is used to iteratively select samples for annotation. Knowledge resources have been used in information extraction as a means to derive additional features for sample representation. DKI is, however, the first query strategy that exploits such resources to inform sample selection. To evaluate the merits of DKI, in particular with respect to the reduction in annotation effort that the new query strategy allows to achieve, we conduct a comprehensive empirical comparison of active learning query strategies for information extraction within the clinical domain. The clinical domain was chosen for this work because of the availability of extensive structured knowledge resources which have often been exploited for feature generation. In addition, the clinical domain offers a compelling use case for active learning because of the necessary high costs and hurdles associated with obtaining annotations in this domain. Our experimental findings demonstrated that 1) amongst existing query strategies, the ones based on the classification model’s confidence are a better choice for clinical data as they perform equally well with a much lighter computational load, and 2) significant reductions in annotation effort are achievable by exploiting knowledge resources within active learning query strategies, with up to 14% less tokens and concepts to manually annotate than with state-of-the-art query strategies.

Trainee-therapists are not all equal: Examination of therapeutic efficiency, effectiveness and early client dropout after 12 months of clinical training

Objective Contemporary research demonstrates the feasibility of assessing therapeutic performance of trainee-therapists through the use of objective measures of client treatment outcome. Further, significant variation between individual therapists based on their client treatment outcomes has been demonstrated. This study sets out to determine whether a reliable composite measure of therapeutic efficiency, effectiveness and early dropout can be developed and used to objectively compare trainee-therapists against each other. Design and methods Treatment outcomes of 611 clients receiving treatment from 58 trainee-therapists enrolled in a professional training programme were tracked with the OQ-45.2 over a 6-year period to assess therapeutic efficiency, therapeutic effectiveness and early client dropout. Results Significant variation between trainee-therapists was observed for each index. Findings of a moderately strong correlation between therapeutic efficiency and effectiveness enabled the ranking of trainee-therapists based upon a composite measure of these indexes. A non-significant correlation was found between early client dropout and measures of therapeutic effectiveness and efficiency. Conclusions The findings stress the importance of utilizing objective measures to track the treatment outcomes. Despite all trainee-therapists being enrolled in the same training programme, significant variation between trainee-therapists' therapeutic efficiency and effectiveness was found to exist. Practitioner points Developing of potential benchmarking tools that enable trainee-therapists, supervisors and educational institutions to quickly assess therapeutic performance can become part of a holistic assessment of a trainee-therapist's clinical development. Despite an inherent optimistic belief that therapists do not cause harm, there appears to be a small and significant proportion of trainee-therapists who consistently evidence little therapeutic change. Considerable variability in trainee-therapists' therapeutic efficiency and effectiveness can exist in the one training programme. Early client dropout may not be associated with therapists' therapeutic effectiveness and efficiency.

Service-learning through multiple client-sponsored projects in an MBA marketing course

This paper outlines an approach for teaching Marketing Principles in an MBA course through service-learning to enable adult learners to connect the lectures’ marketing content to a real-world marketing project. During the course, 40 students in groups of four to five individuals were involved in eight different client-sponsored marketing projects executed simultaneously. The rationale, planning and management of this approach utilised current research on service-learning, living cases and client-sponsored projects in marketing education. The experimental curriculum design is presented in a timeline that mirrors the preparation and management of the group projects and the considerations to be taken into account when initiating and facilitating the projects. Reflections from this iteration of the service-learning design suggest the importance of: detailed project planning, the involvement of students in choosing the projects, the introduction of forms and feedback loops, the role of the instructor in facilitating the students and managing expectations, and the role of the company representative in supporting the groups.

Exploring an innovative educational approach to facilitating student nurses' clinical-reasoning skills in North Sulawesi Province, Indonesia

This study examined the effect of an educational intervention utilizing principles of cognitive apprenticeship on students’ ability to apply clinical reasoning skills within the context of a purpose-built clinical vignette. A quasi-experimental, non-equivalent control-group design was used to evaluate the effect of the educational intervention on students’ accuracy, inaccuracy and self-confidence in clinical reasoning. This study makes an important contribution to nursing education by providing evidence to understand how best to facilitate nursing students’ development of clinical reasoning.

Managing mental health co-morbidities in hepatitis C: A systematic review of clinical guidelines

BACKGROUND Mental health co-morbidities are prevalent in hepatitis C (HCV), and in practice often considered a contraindication for initiation of treatment. A systematic review was conducted to explore whether and how current HCV clinical practice guidelines address pre-existing mental health co-morbidities. METHODS A review of the literature was undertaken to identify guidelines for the management of HCV, published in English, between 2002 and January 2015. Characteristics of the guidelines were recorded and key themes on mental health were summarized across predefined stages in the patient journey (diagnosis, pre-HCV drug therapy, on HCV drug therapy, post-HCV drug therapy, advanced disease or palliative care). RESULTS Twenty-five HCV clinical guidelines were included. Referral to psychiatrist is generally recommended as pre- and in-treatment assessment of mental health co-morbidities but HCV guidelines do not offer explicit instructions on how to manage mental health co-morbidities. Post-treatment assessment of mental health co-morbidities were lacking. Conclusions Current chronic HCV clinical guidelines are limited in their advice to clinicians regarding the management of mental health co-morbidities.

A systematic review of hepatitis C clinical practice guidelines: Benefits, limitations and harms

Background Hepatitis C (HCV) was described as a “viral time bomb” due to its prevalence and potential for causing serious, life-threatening complications. The Australian’s National Hepatitis C Strategy calls for a coordinated, evidence-based approach to testing, management, care and support of HCV. This review aimed to systematically and comparatively appraise existing international HCV clinical guidelines. Methods A systematic search of bibliographic databases and reference lists from selected papers were the source of data. Inclusion criteria were latest clinical guidelines as defined by Institute of Medicine, published in English, between January 2002 and November 2014. Quality of the guidelines was independently assessed using the iCAHE instrument. Results Twenty-eight international clinical practice guidelines were included. The majority of the international guidelines were based on the same primary studies however clinical recommendations on pre- and in-treatment assessments, choice of pharmaceuticals, and dosages and duration of the same pharmaceutical agents varied considerably. This diversity was beyond what would be considered reasonable practice context variations. Furthermore, there is limited guidance on post-treatment surveillance and care. Conclusions/implications There is a need for a harmonised international consensus on the clinical management of HCV. Key message A lack of consistency among international HCV clinical guidelines may impede effective and efficient patient care.

Factors influencing radiation therapy student clinical placement satisfaction

Introduction Radiation therapy students at Queensland University of Technology (QUT) attend clinical placements at five different clinical departments with varying resources and support strategies. This study aimed to determine the relative availability and perceived importance of different factors affecting student support while on clinical placement. The purpose of the research was to inform development of future support mechanisms to enhance radiation therapy students’ experience on clinical placement. Methods This study used anonymous Likert-style surveys to gather data from years 1 and 2 radiation therapy students from QUT and clinical educators from Queensland relating to availability and importance of support mechanisms during clinical placements in a semester. Results The study findings demonstrated student satisfaction with clinical support and suggested that level of support on placement influenced student employment choices. Staff support was perceived as more important than physical resources; particularly access to a named mentor, a clinical educator and weekly formative feedback. Both students and educators highlighted the impact of time pressures. Conclusions The support offered to radiation therapy students by clinical staff is more highly valued than physical resources or models of placement support. Protected time and acknowledgement of the importance of clinical education roles are both invaluable. Joint investment in mentor support by both universities and clinical departments is crucial for facilitation of effective clinical learning.

Identification of major loci controlling clinical manifestations of ankylosing spondylitis

Objective. To identify genomic regions linked with determinants of age at symptom onset, disease activity, and functional impairment in ankylosing spondylitis (AS). Methods. A whole genome linkage scan was performed in 188 affected sibling pair families with 454 affected individuals. Traits assessed were age at symptom onset, disease activity assessed by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), and functional impairment assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI). Parametric and nonparametric quantitative linkage analysis was performed using parameters defined in a previous segregation study. Results. Heritabilities of the traits studied in this data set were as follows: BASDAI 0.49 (P = 0.0001, 95% confidence interval [95% CI] 0.23-0.75), BASFI 0.76 (P = 10-7, 95% CI 0.49-1.0), and age at symptom onset 0.33 (P = 0.005, 95% CI 0.04-0.62). No linkage was observed between the major histocompatibility complex (MHC) and any of the traits studied (logarithm of odds [LOD] score <1.0). "Significant" linkage (LOD score 4.0) was observed between a region on chromosome 18p and the BASDAI. Age at symptom onset showed "suggestive" linkage to chromosome 11p (LOD score 3.3). Maximum linkage with the BASFI was seen at chromosome 2q (LOD score 2.9). Conclusion. In contrast to the genetic determinants of susceptibility to AS, clinical manifestations of the disease measured by the BASDAI, BASFI, and age at symptom onset are largely determined by a small number of genes not encoded within the MHC.

Ectopic calcification among families in the Azores: Clinical and radiologic manifestations in families with diffuse idiopathic skeletal hyperostosis and chondrocalcinosis

Objective. Twelve families that were multiply affected with diffuse idiopathic skeletal hyperostosis (DISH) and/or chondrocalcinosis, were identified on the island of Terceira, The Azores, potentially supporting the hypothesis that the 2 disorders share common etiopathogenic factors. The present study was undertaken to investigate this hypothesis. Methods. One hundred three individuals from 12 unrelated families were assessed. Probands were identified from patients attending the Rheumatic Diseases Clinic, Hospital de Santo Espirito, in The Azores. Family members were assessed by rheumatologists and radiologists. Radiographs of all family members were obtained, including radiographs of the dorsolumbar spine, pelvis, knees, elbows, and wrists, and all cases were screened for known features of chondrocalcinosis. Results. Ectopic calcifications were identified in 70 patients. The most frequent symptoms or findings were as follows: axial pain, elbow, knee and metacarpophalangeal (MCP) joint pain, swelling, and/or deformity, and radiographic enthesopathic changes. Elbow and MCP joint periarticular calcifications were observed in 35 and 5 patients, respectively, and chondrocalcinosis was identified in 12 patients. Fifteen patients had sacroiliac disease (ankylosis or sclerosis) on computed tomography scans. Fifty-two patients could be classified as having definite (17%), probable (26%), or possible (31%) DISH. Concomitant DISH and chondrocalcinosis was diagnosed in 12 patients. Pyrophosphate crystals were identified from knee effusions in 13 patients. The pattern of disease transmission was compatible with an autosomal-dominant monogenic disease. The mean age at which symptoms developed was 38 years. Conclusion. These families may represent a familial type of pyrophosphate arthropathy with a phenotype that includes peripheral and axial enthesopathic calcifications. The concurrence of DISH and chondrocalcinosis suggests a shared pathogenic mechanism in the 2 conditions.

Pioneering use of narrative method in a first-year law course to provide an authentic, inquiry-based entry into the discipline of law

Law is saturated with stories. People tell their stories to lawyers; lawyers tell their client's stories to courts; and legislators develop regulation to respond to their constituent's stories of injustice or inequality. My approach to first-year legal education respects this narrative tradition. Both my curriculum design and assessment scheme in the compulsory first-year subject Australian Legal System deploy narrative methodology as the central teaching and learning device. Throughout the course, students work on resolving the problems of four hypothetical clients. Like a murder mystery, pieces of the puzzle come together as students learn more about legal institutions and the texts they produce, the process of legal research, the analysis and interpretation of primary legal sources, the steps in legal problem-solving, the genre conventions of legal writing style, the practical skills and ethical dimensions of professional practice, and critical inquiry into the normative underpinnings and impacts of the law. The assessment scheme mirrors this design. In their portfolio-based assignment, for example, students devise their own client profile, research the client's legal position and prepare a memorandum of advice.

Australian patients using a cardiac-diabetes web-based intervention program: Contributions to person-centered clinical practice

Rationale, aims and objectives: Patients with both cardiac disease and diabetes have poorer health outcomes than patients with only one chronic condition. While evidence indicates that internet based interventions may improve health outcomes for patients with a chronic disease, there is no literature on internet programs specific to cardiac patients with comorbid diabetes. Therefore this study aimed to develop a specific web-based program, then to explore patients’ perspectives on the usefulness of a new program. Methods: The interpretive approach using semi-structured interviews on a purposive sample of eligible patients with type 2 diabetes and a cardiac condition in a metropolitan hospital in Brisbane, Australia. Thematic analysis was undertaken to describe the perceived usefulness of a newly developed Heart2heart webpage. Results: Themes identified included confidence in hospital health professionals and reliance on doctors to manage conditions. Patients found the webpage useful for managing their conditions at home. Conclusions: The new Heart2heart webpage provided a positive and useful resource. Further research on to determine the potential influence of this resource on patients’ self-management behaviours is paramount. Implications for practice include using multimedia strategies for providing information to patients’ comorbidities of cardiac disease and type 2 diabetes, and further development on enhancement of such strategies

Whole blood transcriptional profiling in ankylosing spondylitis identifies novel candidate genes that might contribute to the inflammatory and tissue-destructive disease aspects

Introduction: A number of genetic-association studies have identified genes contributing to ankylosing spondylitis (AS) susceptibility but such approaches provide little information as to the gene activity changes occurring during the disease process. Transcriptional profiling generates a 'snapshot' of the sampled cells' activity and thus can provide insights into the molecular processes driving the disease process. We undertook a whole-genome microarray approach to identify candidate genes associated with AS and validated these gene-expression changes in a larger sample cohort. Methods: A total of 18 active AS patients, classified according to the New York criteria, and 18 gender- and age-matched controls were profiled using Illumina HT-12 whole-genome expression BeadChips which carry cDNAs for 48,000 genes and transcripts. Class comparison analysis identified a number of differentially expressed candidate genes. These candidate genes were then validated in a larger cohort using qPCR-based TaqMan low density arrays (TLDAs). Results: A total of 239 probes corresponding to 221 genes were identified as being significantly different between patients and controls with a P-value <0.0005 (80% confidence level of false discovery rate). Forty-seven genes were then selected for validation studies, using the TLDAs. Thirteen of these genes were validated in the second patient cohort with 12 downregulated 1.3- to 2-fold and only 1 upregulated (1.6-fold). Among a number of identified genes with well-documented inflammatory roles we also validated genes that might be of great interest to the understanding of AS progression such as SPOCK2 (osteonectin) and EP300, which modulate cartilage and bone metabolism. Conclusions: We have validated a gene expression signature for AS from whole blood and identified strong candidate genes that may play roles in both the inflammatory and joint destruction aspects of the disease.

Clinical factors associated with the humoral immune response to influenza vaccination in chronic obstructive pulmonary disease

Background and objective Individuals with chronic obstructive pulmonary disease (COPD) are at a high risk of developing significant complications from infection with the influenza virus. It is therefore vital to ensure that prophylaxis with the influenza vaccine is effective in COPD. The aim of this study was to assess the immunogenicity of the 2010 trivalent influenza vaccine in persons with COPD compared to healthy subjects without lung disease, and to examine clinical factors associated with the serological response to the vaccine. Methods In this observational study, 34 subjects (20 COPD, 14 healthy) received the 2010 influenza vaccine. Antibody titers at baseline and 28 days post-vaccination were measured using the hemagglutination inhibition assay (HAI) assay. Primary endpoints included seroconversion (≥4-fold increase in antibody titers from baseline) and the fold increase in antibody titer after vaccination. Results Persons with COPD mounted a significantly lower humoral immune response to the influenza vaccine compared to healthy participants. Seroconversion occurred in 90% of healthy participants, but only in 43% of COPD patients (P=0.036). Increasing age and previous influenza vaccination were associated with lower antibody responses. Antibody titers did not vary significantly with cigarette smoking, presence of other comorbid diseases, or COPD severity. Conclusion The humoral immune response to the 2010 influenza vaccine was lower in persons with COPD compared to non-COPD controls. The antibody response also declined with increasing age and in those with a history of prior vaccination.