Corticosteroid induced osteoporosis : guidelines for treatment

BACKGROUND: Last year, Australian Family Physician published Guidelines for Management of Postmenopausal Osteoporosis'. which were developed by Osteoporosis Australia. Recently, significant advances in our understanding of the treatment of corticosteroid osteoporosis have occurred.

OBJECTIVE: The following guidelines also developed by Osteoporosis Australia, and supported by the National Asthma Campaign, are to help general practitioners identify those patients at risk of this problem and to provide information about current treatment strategies.

DISCUSSION: Corticosteroids are widely used and effective agents for the control of many inflammatory diseases. Corticosteroid osteoporosis is a common problem associated with the long term high dose use of these medications.

Men and osteoporosis

BACKGROUND: While strict criteria have been developed for defining osteoporosis in women (bone mineral density measurements more than 2.5 standard deviations below the mean for young adult normal women, i.e. t-score value < -2.5), there still remains a controversy regarding the definition in men. Spinal fractures occur in 5% and hip fractures in 6% of men older than 50 years. There are significant differences between men and women with respect to the pathogenesis of osteoporosis, underlying medical conditions and postfracture sequelae.

OBJECTIVE: To provide an overview of the pathogenesis, diagnosis and prevention of osteoporosis in men.

DISCUSSION: Osteoporosis is increasingly recognised. Data from the Dubbo Osteoporosis Epidemiology Study suggests that 30% of men in Australia aged over 60 years will suffer from an osteoporotic fracture. It is estimated that 30-60% of men presenting with spinal fractures will have another illness contributing to their bone loss. Osteoporotic fractures in men are associated with higher morbidity and mortality than in women. Lifestyle changes together with daily calcium supplementation should be implemented and vitamin D3 should be considered in men with osteopenia.

ACCCN national nursing workforce survey of intensive care units

A descriptive study was designed and implemented by the Australian College of Critical Care Nurses (ACCCN) Workforce Planning Advisory Committee to capture data pertaining to workforce issues of intensive care nurses. All intensive care units (ICUs) within Australia were mailed a self reporting survey. Despite a low response rate (52 per cent) and difficulty reported by respondents in gaining the appropriate data requested, the results revealed an interesting snapshot of the intensive care nursing workforce.
Types of services offered by units varied considerably; paid overtime hours were low (<2 per cent of total hours worked) and use of both part-time and agency staff was also low (10 per cent of total hours worked). Private hospitals utilised a greater proportion of part-time and agency nursing staff than public hospitals (20:10 per cent). The turnover rate for registered nursing staff was estimated at 18 per cent, with education, skill acquisition and improved communication reported as the major incentives used by managers to attract and retain staff. This study demonstrated that valuable data are currently uncaptured and recommends a more refined process of a national database to record and manage this important information for future workforce planning.

Painful nipples in nursing mothers: fungal or staphylococcal?

Painful nipples, or ‘breast thrush’, in nursing mothers is a well recognised condition. It is a clinical diagnosis characterised by intense nipple pain often radiating into the breast, especially during breastfeeding. Between feeds it may cause a burning sensation and tenderness; breastfeeding may be abandoned because of it.

Cognitive behavioural strategies for general practice

Cognitive behavioural strategies (CBS) are circumscribed psychologial skills that can be incorporated into general practice, and need to be distinguished from cognitive behavioural therapy (CBT), a comprehensive therapeutic approach which require more intensive training.  The CBS outlined in this article can be integrated with other behavioural and structured problem solving approaches.

Guidelines for the management of postmenopausal osteoporosis for GPs

BACKGROUND : Since the last series of guidelines on the management of osteoporosis from Osteoporosis Australia was published in Australian Family Physician (October 2002), there have been further advances in our understanding of the treatment involved in both the prevention of bone loss and the management of established osteoporosis.

OBJECTIVE : This article provides updated guidelines for the management of postmenopausal osteoporosis to assist general practitioners identify those women at risk, and reviews current treatment strategies.

DISCUSSION : Osteoporosis and its associated problems are major health concerns in Australia, especially with an aging population. While important principles of management are still considered to be maximising peak bone mass and preventing postmenopausal bone loss, new clinical trial data about drugs such as the bisphosphonatesr raloxifene and oestrogen have recently become available and the relative role of various agents is gradually becoming clearer. The use of long term hormone therapy has mixed risks and benefits that requires individual patient counselling.

Emotional growth: helping children and families 'bounce back'

Background: Depression is becoming increasingly prevalent in young people and is occurring earlier. General practitioners are prescribing antidepressants more frequently for this group, yet they are usually not the answer to the problem. Objective: This article examines the increase in prevalence rates of childhood and adolescent depression. We draw on recent research into resilience and positive psychology to suggest guidelines for the GP in helping young people and their parents develop better coping skills in the short term, and greater resilience in the long term. Discussion: Resilience is the ability to bounce back after encountering difficulties, negative events, hard times or adversity and to be able to return to the original level of emotional wellbeing. It is the capacity to maintain a healthy and fulfilling life despite adversity. Young people who have the skills to be resilient have a lower likelihood of becoming depressed or suicidal and a higher likelihood of maintaining emotional wellbeing. Self efficacy, optimistic and helpful thinking, and maintaining a success orientation are all important skills in being resilient.

Psychosocial issues facilitating recovery post-CABG surgery

Background
The acute illness phase following coronary artery bypass graft (CABG) surgery is a difficult time for patients as they try to adjust to the physical and emotional changes brought about by surgery.
Aims
To conduct an indepth examination of psychosocial issues experienced by patients post-CABG surgery and how patients manage these psychosocial issues during their recovery.
Methods
A qualitative research approach, naturalistic inquiry, guided the study. Thirty patients were interviewed 4–5 weeks following discharge from hospital after CABG surgery and at 12 months after the initial interview.
Results
esults found that adjusting to life after surgery was difficult, and patients experienced some form of physical pain or change. An unexpected finding was the extent to which many of the patients were attuned to their post-operative physical adjustments. Patients spoke of mental and emotional changes, and coming to terms with lifestyle adjustments.
Conclusion
Study findings suggest the need for a re-examination of hospital discharge preparation and further provision and monitoring of home support services.

Climate change and human health: what can GPs do?

In recent months articles in the most respected peer reviewed medical journals in Australia, the USA and Britain have called for urgent action to reduce climate change.1–4 The chief scientist of the United Kingdom has described climate change as ‘the most severe problem that we are facing today – more serious even than the threat of terrorism’.5 Yet, many of you will wonder if this is really such an urgent issue, and – even if it is – what on earth has it got to do with general practice?

Sedation and analgesia management for mechanically ventilated adults: literature review, case study and recommentations for practice.

The quality of sedation management in mechanically ventilated patients has been a source of concern in recent years. This paper summarises the literature on the principles of optimal sedation, discusses the consequences of over and undersedation, highlighting the importance of appropriate pain management, and presents a case study using the results of an audit of 48 mechanically ventilated adults. As a result of the review and audit, we are implementing changes to practice.

The most important recommendations from the literature are the use of a sedation scale, setting of a goal sedation score, appropriate pain management and implementation of a nurse initiated sedation algorithm. Other recommendations include use of bolus rather than continuous sedative infusions and recommencing regular medications for anxiety, depression and other phychiatric disorders as soon as possible. A recommendation arising from our audit was the need to identify patients at high risk of oversedation and undersedation and adopt a proactive rather than reactive approach to management. The practice goal is to provide adequate and appropriate analgesia and anxiolysis for patients. This will improve patient comfort while reducing length of mechanical ventilation and minimising risk of complications.

Changing places : testing the relevance of educational research and teacher education

Frequent reviews of teacher education in recent times seem to indicate that those charged with the responsibility for teacher education have little understanding of the contemporary needs of teachers. Just how does educational research inform teachers in their day-to-day practice and how is its relevance tested? As an educational researcher Professor Shirley Grundy challenges her own notions of 'relevance' by returning from academia to the school system in Western Australia. This experience expanded her understanding of how conceptual frameworks and the realities of schools complemented each other. She reflects on the agenda for change faced by education systems and the ensuing transformation of curriculum planning, pedagogy, assessment and reporting procedures in some schools while not in others.

Her reference to Habermas' work relating to 'system' and 'lifeworld' provided her with an explanation for the social conditions of schooling, while her exploration of discourse theory provides some understanding of the practices related to the exercise of power in school settings. Interchanges such as that experienced by Grundy are to the mutual benefit of both parties.

QTP in Victoria: listening to teachers leads to quality professional development

How do you get information and communication technology working for authentic learning across the curriculum? It depends on quality professional development. The author draws on her research and evaluation work on a Quality Teacher Program pilot project by the Victorian Department of Education and Training to explain why listening to teachers is leading to just that.

Guidelines for treatment of osteoporosis in men

BACKGROUND: Osteoporosis is associated with significant morbidity and mortality in men. Published randomised controlled trials assessing the benefits of therapy in men with osteoporosis are limited, but those available need to be used to develop management guidelines.

OBJECTIVE: To present evidence based guidelines for the treatment of osteoporosis in men.

DISCUSSION: It is estimated that 30-60% of men presenting with spinal fractures have another illness contributing to their bone disease. Therefore assessment and treatment of coexisting medical conditions is a vital part of management of osteoporosis. While primary prevention of fractures remains crucial, treatment to ensure further fractures do not occur is equally important. Alendronate is the treatment of choice for men with osteoporosis and fractures, with cyclical etidronate an appropriate alternative and testosterone replacement therapy is indicated in hypogonadal men presenting with osteoporosis.

Futures in education

Futures education (FE) in a rapidly changing world is critical if young people are to be empowered to be proactive rather than reactive about the future. Research into young people's images and ideas of the future lead to the disturbing conclusion that, for many, the future is a depressing and fearful place where they feel hopeless and disempowered. On the other hand, as Richard Slaughter writes, 'young people are passionately interested in their own futures, and that of the society in which they live. They universally 'jump at the chance to study something with such intrinsic interest that also intersects with their own life interests in so many ways'. FE explicitly attempts to build on this interest and counter these fears by offering a profound and empowering set of learning strategies and ideas that can help people think and act critically and creatively about the future, without necessarily trying to predict it. Futures educators have, over the past decades, developed useful tools, ideas and a language for use with students of all ages to enable them to develop foresight literacy. Most of us tend to view the future as somehow beyond the present and rarely consider how decisions and choices made today profoundly affect not just one fixed future but any number of futures. The underlying goal of FE is to move from the idea of a single, pre-determined future to that of many possible futures, so that students begin to see that they can determine the future, that they need not be reactive and that they are not powerless. How does one do that? Ideas include, but are not limited to: timelines and Y-diagrams, futures wheels and mind maps, and 'Preferable, possible and probable' futures - a.k.a. the 3Ps. Current Australian curricula present education about the future in various implicit or explicit guises. A plethora of statements and curriculum outcomes mention the future, but essentially take 'it' for granted, and are uninformed by FE literature, language, ideas or tools. Science, the humanities and technology tend to be the main areas where such an implicit futures focus can be found. It also appears in documents about vocational education, civics and lifelong learning. Explicit FE is, as Beare and Slaughter put it, still the missing dimension in education. Explicit FE attempts to develop futures literacy, and draws widely upon futures studies literature for processes and content. FE provides such a wide range of ideas and tools that it can be incorporated into education in any number of ways. Programs in two very different schools, one primary and one secondary, are described in this article to provide examples of some of these ways. The first school, Kimberley Park State Primary School in Brisbane, operates with multi-age classrooms based on a 'thinking curriculum' developed around four organisers: change, perspectives, interconnectedness and sustainability. The second school, St John's Grammar School in Adelaide, is an independent school where FE operates as an integrated approach in Year Seven, as a separate one-semester subject in Year Nine and in separate subjects at other levels. Teachers both at Kimberley Park and St John's are very positive about FE. They say it promotes valuable and authentic learning, assists students to realise they have choices that matter and helps them see that the future need not be all doom and gloom. Because students are interested in the Big Questions, as one teacher put it, FE provides a perfect opportunity to address them, and to consider values that are fundamental for them and the future of the planet. Like any innovation, the long-term success of FE in schools depends on an embedding process so that the innovation does not depend on the enthusiasm and energy of a few individuals, only to disappear when they move on. It requires strong leadership, teacher knowledge, support and enthusiasm, and the support and understanding of the wider school community.