The effectiveness of scoliosis screening programs: methods for systematic review and expert panel recommendations formulation

Background: Literature on scoliosis screening is vast, however because of the observational nature of available data and methodological flaws, data interpretation is often complex, leading to incomplete and sometimes, somewhat misleading conclusions. The need to propose a set of methods for critical appraisal of the literature about scoliosis screening, a comprehensive summary and rating of the available evidence appeared essential. METHODS: To address these gaps, the study aims were: i) To propose a framework for the assessment of published studies on scoliosis screening effectiveness; ii) To suggest specific questions to be answered on screening effectiveness instead of trying to reach a global position for or against the programs; iii) To contextualize the knowledge through expert panel consultation and meaningful recommendations. The general methodological approach proceeds through the following steps: Elaboration of the conceptual framework; Formulation of the review questions; Identification of the criteria for the review; Selection of the studies; Critical assessment of the studies; Results synthesis; Formulation and grading of recommendations in response to the questions. This plan follows at best GRADE Group (Grades of Recommendation, Assessment, Development and Evaluation) requirements for systematic reviews, assessing quality of evidence and grading the strength of recommendations. CONCLUSIONS: In this article, the methods developed in support of this work are presented since they may be of some interest for similar reviews in scoliosis and orthopaedic fields.

Assessing the accuracy of a computerized decision support system for digoxin dosing in primary care: an observational study

Background: This study was carried out as part of a European Union funded project (PharmDIS-e+), to develop and evaluate software aimed at assisting physicians with drug dosing. A drug that causes particular problems with drug dosing in primary care is digoxin because of its narrow therapeutic range and low therapeutic index. Objectives: To determine (i) accuracy of the PharmDIS-e+ software for predicting serum digoxin levels in patients who are taking this drug regularly; (ii) whether there are statistically significant differences between predicted digoxin levels and those measured by a laboratory and (iii) whether there are differences between doses prescribed by general practitioners and those suggested by the program. Methods: We needed 45 patients to have 95% Power to reject the null hypothesis that the mean serum digoxin concentration was within 10% of the mean predicted digoxin concentration. Patients were recruited from two general practices and had been taking digoxin for at least 4 months. Exclusion criteria were dementia, low adherence to digoxin and use of other medications known to interact to a clinically important extent with digoxin. Results: Forty-five patients were recruited. There was a correlation of 0·65 between measured and predicted digoxin concentrations (P < 0·001). The mean difference was 0·12 μg/L (SD 0·26; 95% CI 0·04, 0·19, P = 0·005). Forty-seven per cent of the patients were prescribed the same dose as recommended by the software, 44% were prescribed a higher dose and 9% a lower dose than recommended. Conclusion: PharmDIS-e+ software was able to predict serum digoxin levels with acceptable accuracy in most patients.

Detecting an impact of predation on bird populations depends on the methods used to assess the predators

Summary 1. In recent decades there have been population declines of many UK bird species, which have become the focus of intense research and debate. Recently, as the populations of potential predators have increased there is concern that increased rates of predation may be contributing to the declines. In this review, we assess the methodologies behind the current published science on the impacts of predators on avian prey in the UK. 2. We identified suitable studies, classified these according to study design (experimental ⁄observational) and assessed the quantity and quality of the data upon which any variation in predation rates was inferred. We then explored whether the underlying study methodology had implications for study outcome. 3. We reviewed 32 published studies and found that typically observational studies comprehensively monitored significantly fewer predator species than experimental studies. Data for a difference in predator abundance from targeted (i.e. bespoke) census techniques were available for less than half of the 32 predator species studied. 4. The probability of a study detecting an impact on prey abundance was strongly, positively related to the quality and quantity of data upon which the gradient in predation rates was inferred. 5. The findings suggest that if a study is based on good quality abundance data for a range of predator species then it is more likely to detect an effect than if it relies on opportunistic data for a smaller number of predators. 6. We recommend that the findings from studies which use opportunistic data, for a limited number of predator species, should be treated with caution and that future studies employ bespoke census techniques to monitor predator abundance for an appropriate suite of predators.

Peak expiratory flow values are higher in older and taller healthy male children: An observational study

Purpose: Peak expiratory flow (PEF) was measured in healthy children aged five to ten years in order to provide baseline values and to determine correlations between PEF and factors such as gender, age and type of school. Methods: After the Ethical Committee of Research in Human of the School of Medicine of ABC - FMABC approval, PEF and height were measured in 1942 children between five and ten years old from nine public schools and nine private schools throughout Sao Bernardo do Campo City. PEF was measured using the Mini-Wright Peak Flow Meter (Clement Clarke International Ltd.) and. height was measured using a Sanny professional stadiometer. Results: Significant differences were found in values for PEF: higher values were seen in older students in comparison with younger students, in males in comparison with females and in students from private schools in comparison with public schools, with average values ranging from 206 L/min to 248 L/min,. Linear correlations were seen for PEF values with both height and age (Spearman Coefficient). Conclusions: Differences were seen for PEF between genders and between types of school, and a linear correlation was seen for PEF with both age and height in healthy children from five to ten years old.

Unfulfilled rehabilitation needs and dissatisfaction with care 12 months after a stroke : an explorative observational study

BACKGROUND: People who have suffered a stroke commonly report unfulfilled need for rehabilitation. Using a model of patient satisfaction, we examined characteristics in individuals that at 3 months after stroke predicted, or at 12 months were associated with unmet need for rehabilitation or dissatisfaction with health care services at 12 months after stroke. METHODS: The participants (n = 175) received care at the stroke units at the Karolinska University Hospital, Sweden. The dependent variables "unfulfilled needs for rehabilitation" and "dissatisfaction with care" were collected using a questionnaire. Stroke severity, domains of the Stroke Impact Scale (SIS), the Sense of Coherence scale (SOC) and socio demographic factors were used as independent variables in four logistic regression analyses. RESULTS: Unfulfilled needs for rehabilitation at 12 months were predicted by strength (SIS) (odds ratio (OR) 7.05) at three months, and associated with hand function (SIS) (OR 4.38) and poor self-rated recovery (SIS) (OR 2.46) at 12 months. Dissatisfaction with care was predicted by SOC (OR 4.18) and participation (SIS) (OR 3.78), and associated with SOC (OR 3.63) and strength (SIS) (OR 3.08). CONCLUSIONS: Thirty-three percent of the participants reported unmet needs for rehabilitation and fourteen percent were dissatisfied with the care received. In order to attend to rehabilitation needs when they arise, rehabilitation services may need to be more flexible in terms of when rehabilitation is provided. Long term services with scheduled re-assessments and with more emphasis on understanding the experiences of both the patients and their social networks might better be able to provide services that attend to patients' needs and aid peoples' reorientation; this would apply particularly to those with poor coping capacity.

Usual clinical practice for early supported discharge after stroke with continued rehabilitation at home : an observational comparative study

Introduction: Based on randomised controlled trials, evidence exists that early supported discharge (ESD) from the hospital with continued rehabilitation at home has beneficial effects after stroke; however, the effects of ESD service in regular clinical practice have not been investigated. The purpose of the current study was to compare ESD service with conventional rehabilitation in terms of patient outcomes, caregiver burden at 3 and 12 months and the use and costs of healthcare during the first year after stroke. Material and methods: This study was a subgroup analysis of a longitudinal observational study of patients who received care in the stroke unit at Karolinska University Hospital in Sweden. Patients who met the inclusion criteria for ESD in previous experimental studies were included. The patients were referred to available rehabilitation services at discharge, and comparisons between those who received ESD service (the ESD group, n = 40) and those who received conventional rehabilitation (the NoESD group, n = 110) were performed with regard to independence in activities of daily living (ADL), the frequency of social activities, life satisfaction, and caregiver burden and the use and costs of healthcare during the first year after stroke. Results: At 3 and 12 months, no differences were observed with regard to patient outcomes; however, ESD was associated with a lower caregiver burden (p = 0.01) at 12 months. The initial length of stay (LOS) at the hospital was 8 days for the ESD group and 15 days for the NoESD group (p = 0.02). The median number of outpatient rehabilitation contacts was 20.5 for the ESD group (81% constituting ESD service) and 3 for the NoESD group (p<0.001). There was no difference between the groups with regard to overall healthcare costs. Conclusions: ESD service in usual clinical practice renders similar health benefits as conventional rehabilitation but a different pattern of resource use and with released capacity in acute stroke care.

Triage nurses' clinical decision making : an observational study of urgency assessment

Background. Researchers have described both the various decision tasks performed by triage nurses using self-report methods and identified time as a factor influencing the quality of triage decisions. However, little is known about the decision tasks performed by triage nurses when making acuity assessments, or the factors influencing triage duration in the real world.

Aims. The aims of this study were to: describe the data triage nurses collect from patients in order to allocate a triage priority using the Australasian Triage Scale (ATS); describe the duration of nurses' decision making for ATS categories 2–5; and to explore the impact of patient and nurse variables on the duration of the triage nurses' decision making in the clinical setting.

Design. A structured observational study was employed to address the research aims. Observational data was collected in one adult emergency department located in metropolitan Melbourne, Australia. A total of 26 triage nurses consented and were observed performing 404 occasions of triage. Data was collected by a single observer using a 20-item instrument that recorded the performance frequencies of a range of decision tasks and a number of observable patient, nurse and environmental variables. Additionally, the nurse–patient interaction was recorded as time in minutes.

Results. It was found that there was limited use of objective physiological data collected by the nurses' in order to decide patient acuity, and large variability in the duration of triage decisions observed. In addition, analysis of variance indicated strong evidence of a true difference between triage duration and a range of nurse, patient and environmental variables.

Conclusion. These findings have implications for the development of practice standards and triage education. In particular, it is argued that practice standards should include routine measurement of physiological parameters in all but the collapsed or obviously unwell patient, where further delay may impede the delivery oftime-critical intervention. Furthermore, the inclusion of arbitrary time frames for triage assessment in practice standards are not an appropriate method of evaluating triage decision making in the real world.

An observational study of health professionals’ use of evidence to inform the development of clinical management tools

Aim. This observational study sought to investigate the process of evidence use by health professionals during development of evidence-based clinical management tools.

Background. Studies conducted to explore the process of research use are scarce and knowledge of this process is essential for our understanding of the influences on research use in practice.

Design. A qualitative, non-participant, observational design.

Methods. Behaviour and actions of two separate multidisciplinary teams were observed and audio-recorded during a combined total of seven meetings for the development of clinical management tools. Semi-structured, one-to-one interviews were conducted approximately half-way through the development process and following completion of the clinical management tools.

Results. Three major themes emerged from this research. First, the process of clinical management tool development and evidence use. Nurses assumed responsibility for coordination of development which focused on describing current practice. Second, the forms of evidence employed during the development process included the use of experiential knowledge, opinions and knowledge of the context, in addition to research evidence. However, reference to research evidence was limited and its incorporation into the instrument was infrequently observed. Third, the use of research evidence emerged with respect to how such evidence was employed.

Conclusion. This study focused on real-life discussion and decision-making that occurred between health professionals when developing evidence-based clinical management tools. Health professionals may have a tendency to rely on their professional experience and current practice in preference to seeking and applying relevant research evidence.

Relevance to clinical practice. Nurses have an important role to play in the development of multidisciplinary evidence-based clinical management tools, but to actively participate in this process they need to be familiar with the relevant research evidence and have the skills and confidence to integrate the evidence into practice.

Use of an arginine-enriched oral nutrition supplement in the healing of pressure ulcers in patients with spinal cord injuries : an observational study

Aim: Pressure ulcers are a serious secondary consequence of spinal cord injuries. The objective of the present study was to determine whether an arginine-containing nutritional supplement can reduce the healing time of pressure ulcers in people with spinal cord injuries compared with those not consuming the supplement until full wound healing.

Methods: Thirty-four spinal cord injured patients with a grade 2, 3 or 4 pressure ulcer were prescribed two 237 mL tetrapaks/day of a supplement containing additional protein, arginine, zinc and vitamin C. Pressure ulcer healing was assessed with the Pressure Ulcer Scale for Healing tool.

Results: Twenty patients consumed the nutritional supplement until full pressure ulcer healing had occurred, while 14 patients ceased consuming the supplement before full healing occurred because of intolerance, compliance or taste issues. A 2.5-fold greater rate of healing was observed in patients consuming the supplement until full healing compared with those who ceased taking the supplement (8.5 ± 1.1 weeks vs 20.9 ± 7.0 weeks respectively; P = 0.04). There were no significant differences in age, nutritional status, gender or reason for admission between groups. Comparison of healing rates in the group consuming the supplement to full wound healing against expected rates derived from the medical literature showed a significantly shorter time-to-healing (grade 3 pressure ulcer: 6.5 ± 0.8 weeks vs 18.2 weeks; grade 4: 11.4 ± 2.0 weeks vs 22.1 weeks; P < 0.001).

Conclusion: The present small-scale study demonstrated the potential for specialised wound healing nutritional supplements to shorten the time to pressure ulcer healing in spinal cord injured patients.

Early diagnosis and treatment of necrotizing fasciitis can improve survival : an observational intensive care unit cohort study

Background
The aim of this study was to describe the clinical characteristics, causative pathogens, clinical management and outcomes of patients presenting to a tertiary adult Australian intensive care unit (ICU) with a diagnosis of necrotizing fasciitis (NF).
Methods
This retrospective observational study was conducted in a 19-bed, level III, adult ICU in a 450-bed tertiary, regional hospital. Clinical databases were accessed for patients diagnosed with NF and admitted to The Geelong Hospital ICU between 1 February 2000 and 1 June 2011. Information on severity of sepsis, surgical procedures and microbiological results were collected.
Results
Twenty patients with NF were identified. The median age was 52.5 years and 38% were female. The overall mortality rate was 8.3%. Common co-morbidities were diabetes (21%) and heart failure (17%), although 50% of patients had no co-morbidities. Group A Streptococcus was the identified pathogen in 11 (46%) patients, and Streptococcus milleri group in 5 (21%) patients. Hyperbaric oxygen therapy was not used in the majority of patients. The initial antibiotics administered were active against subsequently cultured bacteria in 83% of patients. Median time to surgical debridement was 20 h. Diagnosis and management was delayed in the nosocomial group.
Conclusions
This study reports physiological data, aetiology and therapeutic interventions in NF for an adult tertiary hospital. We demonstrate one of the lowest reported mortality rates, with early surgical debridement being achieved in the majority of patients. The main delay was found to be in the diagnosis of NF.

Morbid obesity in women on the rise : an observational, population-based study

Background The obesity epidemic is generally monitored by the proportion of the population whose body mass index (BMI) exceeds 30 kg/m2 but this masks the growing proportion of those who are morbidly obese. This issue is important as the adverse health risks amplify as the level of obesity increases. The aim of this study was to determine how the prevalence of morbid obesity (BMI >= 40.0 kg/m2) has changed over a decade among women living in south-eastern Australia.

Methods BMI was determined for women in the Geelong Osteoporosis study (GOS) during two time periods, a decade apart. Height and weight were measured for 1,494 women (aged 20--94 years) during 1993--7 and for 1,076 women (aged 20--93 years), 2004--8, and the BMI calculated as weight in kilograms divided by the square of the height in metres (kg/m2). Prevalence estimates were age-standardised to enable direct comparisons.

Results Mean BMI increased from 26.0 kg/m2 (95%CI 25.7-26.3) in 1993--7, to 27.1 kg/m2 (95%CI 26.8-27.4) in 2004--8. During this period, the prevalence of morbid obesity increased from 2.5% to 4.2% and the standardised morbidity ratio for morbid obesity was 1.69 (95%CI 1.26-2.27). Increases in mean BMI and prevalence of morbid obesity were observed for all ages and across the socioeconomic spectrum.

Conclusions These findings reveal that over a decade, there has been an increase in mean BMI among women residing in south-eastern Australia, resulting in a measurable increase in the prevalence of morbid obesity.

Is a perceived supportive physical environment important for self-reported leisure time physical activity among socioeconomically disadvantaged women with poor psychosocial characteristics? An observational study

Background Over the past decade, studies and public health interventions that target the physical environment as an avenue for promoting physical activity have increased in number. While it appears that a supportive physical environment has a role to play in promoting physical activity, social-ecological models emphasise the importance of considering other multiple levels of influence on behaviour, including individual (e.g. self-efficacy, intentions, enjoyment) and social (e.g. social support, access to childcare) factors (psychosocial factors). However, not everyone has these physical activity-promoting psychosocial characteristics; it remains unclear what contribution the environment makes to physical activity among these groups. This study aimed to examine the association between the perceived physical environment and self-reported leisure-time physical activity (LTPA) among women living in socioeconomically disadvantaged areas demonstrating different psychosocial characteristics.

Methods In 2007–8, 3765 women (18–45 years) randomly selected from low socioeconomic areas in Victoria, Australia, self-reported LTPA, and individual, social and physical environmental factors hypothesised within a social-ecological framework to influence LTPA. Psychosocial and environment scores were created. Associations between environment scores and categories of LTPA (overall and stratified by thirds of perceived environment scores) were examined using generalised ordered logistic regression.

Results Women with medium and high perceived environment scores had 20-38% and 44-70% greater odds respectively of achieving higher levels of LTPA than women with low environment scores. When stratified by thirds of psychosocial factor scores, these associations were largely attenuated and mostly became non-significant. However, women with the lowest psychosocial scores but medium or high environment scores had 76% and 58% higher odds respectively of achieving ≥120 minutes/week (vs. <120 minutes/week) LTPA.

Conclusions Acknowledging the cross-sectional study design, the findings suggest that a physical environment perceived to be supportive of physical activity might help women with less favourable psychosocial characteristics achieve moderate amounts of LTPA (i.e. ≥120 minutes/week). This study provides further support for research and public health interventions to target perceptions of the physical environment as a key component of strategies to promote physical activity.

Health-related quality of life and strain in caregivers of Australians with Parkinson’s disease : An observational study

Background: The relationship between health-related quality of life (HRQoL) in people with Parkinson’s disease and their caregivers is little understood and any effects on caregiver strain remain unclear. This paper examines these relationships in an Australian sample.
Methods: Using the generic EuroQol (EQ-5D) and disease-specific Parkinson’s Disease Questionnaire-39 Item (PDQ- 39), HRQoL was evaluated in a sample of 97 people with PD and their caregivers. Caregiver strain was assessed using the Modified Caregiver Strain Index. Associations were evaluated between: (i) caregiver and care-recipient HRQoL; (ii) caregiver HRQoL and caregiver strain, and; (iii) between caregiver strain and care-recipient HRQoL.
Results: No statistically significant relationships were found between caregiver and care-recipient HRQoL, or between caregiver HRQoL and caregiver strain. Although this Australian sample of caregivers experienced relatively good HRQoL and moderately low strain, a significant correlation was found between HRQoL of people with PD and caregiver strain (rho 0.43, p<.001).
Conclusion: Poor HRQoL in people with PD is associated with higher strain in caregivers. Therapy interventions may target problems reported as most troublesome by people with PD, with potential to reduce strain on the caregiver

Prospective observational study of emergent endotracheal intubation practice in the intensive care unit and emergency department of an Australian regional tertiary hospital

Objective: The present study aimed to describe the characteristics and outcomes of intubation occurring in the ICU and ED of an Australian tertiary teaching hospital. Methods: This was a prospective observational study of intubation practice across the Geelong Hospital over a 6 month period from 1 August 2012 to 31 January 2013. Data were entered by the intubating team through an online data collection form. Results: There were 119 patients intubated and 134 attempts at intubation in the ED and ICU over a 6 month period. The first-pass success rate was 104/119 (87.4%), and all but a single patient was intubated by the second attempt. Propofol, fentanyl, midazolam and suxamethonium were the most common drugs used in rapid sequence induction. AEs were reported in 44/134 (32.8%) of intubation attempts, with transient hypoxia and hypotension being the most common. A significant adverse outcome, namely aspiration pneumonitis, occurred in one patient. There were no peri-intubation deaths. Conclusion: The majority of airways are managed by ICU and ED consultants and trainees, with success rates and AE rates comparable with other published studies. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Psychiatric disorders, psychotropic medication use and falls among women: an observational study

BACKGROUND: Psychotropic agents known to cause sedation are associated with an increased risk of falls, but the role of psychiatric illness as an independent risk factor for falls is not clear. Thus, this study aimed to investigate the association between psychiatric disorders, psychotropic medication use and falls risk. METHODS: This study examined data collected from 1062 women aged 20-93 yr (median 50 yr) participating in the Geelong Osteoporosis Study, a large, ongoing, population-based study. Depressive and anxiety disorders for the preceding 12-month period were ascertained by clinical interview. Current medication use and falls history were self-reported. Participants were classified as fallers if they had fallen to the ground at least twice during the same 12-month period. Anthropometry, demographic, medical and lifestyle factors were determined. Logistic regression was used to test the associations, after adjusting for potential confounders. RESULTS: Fifty-six women (5.3%) were classified as fallers. Those meeting criteria for depression within the past 12 months had a 2.4-fold increased odds of falling (unadjusted OR = 2.4, 95% CI 1.2-4.5). Adjustment for age and mobility strengthened the relationship (adjusted OR = 2.7, 95% CI 1.4-5.2) between depression and falling, with results remaining unchanged following further adjustment for psychotropic medication use (adjusted OR = 2.7, 95% CI 1.3-5.6). In contrast, past (prior to 12-month) depression were not associated with falls. No association was observed between anxiety and falls risk. Falling was associated with psychotropic medication use (unadjusted OR = 2.8, 95% CI 1.5-5.2), as well as antidepressant (unadjusted OR = 2.4, 95% CI 1.2-4.8) and benzodiazepine use (unadjusted OR = 3.4, 95% CI 1.6-7.3); associations remained unchanged following adjustment for potential confounders. CONCLUSION: The likelihood of falls was increased among those with depression within the past 12 months, independent of psychotropic medication use and other recognised confounders, suggesting an independent effect of depression on falls risk. Psychotropic drug use was also confirmed as an independent risk factor for falls, but anxiety disorders were not. Further research into the underlying mechanisms is warranted.