Vitamin D levels in an Australian population

BACKGROUND

Levels of vitamin D in the population have come under increasing scrutiny, however there are only a few studies in Australia which measure levels in the general population. The aim of this study was to measure the levels of vitamin D within a large population cohort and examine the association with seasons and selected demographic and health risk factors.

METHODS

A longitudinal cohort study of 2413 participants in the northwest suburbs of Adelaide, South Australia conducted between 2008 and 2010 was used to examine serum levels of 25-hydroxy vitamin D (25(OH)D) in relation to demographic characteristics (age, sex, income, education and country of birth), seasons, the use of vitamin D supplements and selected health risk factors (physical activity, body mass index and smoking). Both unadjusted and adjusted mean levels of serum 25(OH)D were examined, as were the factors associated with the unadjusted and adjusted prevalence of serum 25(OH)D levels below 50 and 75 nmol/L.

RESULTS

Overall, the mean level of serum 25(OH)D was 69.2 nmol/L with 22.7% of the population having a serum 25(OH)D level below 50 nmol/L, the level which is generally recognised as vitamin D deficiency. There were significantly higher levels of 25(OH)D among males compared to females (t = 4.65, p < 0.001). Higher levels of 25(OH)D were also measured in summer and autumn compared with winter and spring. Generally, mean levels of 25(OH)D were lower in those classified as obese. Smokers and those undertaking no or less than 150 minutes/week of physical activity also had lower levels of serum vitamin D. Obesity (as classified by body mass index), season and undertaking an insufficient level of physical activity to obtain a health benefit were significantly associated with the prevalence of vitamin D deficiency.

CONCLUSIONS

Vitamin D deficiency is prevalent in South Australia, affecting almost one quarter of the population and levels are related to activity, obesity and season even when adjusted for confounding factors. Improved methods of addressing vitamin D levels in population are required.

TRialing individualized interventions to prevent functional decline in at-risk older adults (TRIIFL): study protocol for a randomized controlled trial nested in a longitudinal observational study

BACKGROUND

Functional decline (FD) is a largely preventable feature of aging, characterized as gradual erosion of functional autonomy. This reduces an older person's capacity for safe, independent community living. The healthcare needs of an unprecedented aging population places pressure on health systems to develop innovative approaches to ensuring older people live healthy and independent lives for as long as possible. TRIIFL aims to demonstrate that: 1. Incipient FD in older people can be identified using a simple telephone-screening process within four weeks of discharge from an emergency department presentation for a minor health event; and 2. Early engagement into a person-centered individualized intervention arrests or reduces the rate of FD over the next 12 months.

METHODS/DESIGN

A randomized controlled trial (RCT) nested within a 13-month longitudinal cohort study. The RCT (conducted over 12 months) tests the effectiveness of a novel, early, home-based, personalized program (compared with no intervention) in arresting or slowing FD. TRIIFL focuses on older adults living independently in the community, who have not yet had a serious health event, yet are potentially on the cusp of FD. Participants in the longitudinal cohort study will be recruited as they present to one large tertiary hospital Emergency Department, providing they are not subsequently admitted to a ward. Sample size calculations indicate that 570 participants need to be recruited into the longitudinal study, with 100 participants randomized into the trial arms. Measures from all subjects will be taken face-to-face at baseline (recruitment), then subsequently by telephone at one, four, seven and thirteen months later. Measures include functional abilities, quality of life, recent falls, mobility dependence, community supports and health service usage. Specific to the nested RCT, the quality of life tool (SF12) applied at one month, will identify individuals with low mental component quality of life scores, who will be invited to enter the RCT.Assessors will be blinded to RCT arm allocation, and subjects in the RCT will be blinded to the intervention being received by other subjects.

TRIALS REGISTRATION

Australian & New Zealand Clinical Trials Registry: ACTRN12613000234718.

Do trial-and-error practices and the use of the internet influence how medicines are used?

The aim of this research was to identify if people understood and used a practice termed 'trial and error' and the association of this practice to: (1) taking medicines as prescribed; and (2) use of the internet to assist their self-care decision-making. A national Computer Assisted Telephone Interview (CATI) was conducted in 2011 of a random sample of 3003 adults aged 18 years and over. Multivariable modelling, in stages, was undertaken adjusting for a range of demographics and associated health variables. There is a very strong relationship between the use of trial-and-error practices and not taking prescription medicines as prescribed. In addition, adults who state that they use trial-and-error practices to assist their health-related decision-making are more likely to have used the internet for information and then as a result, adjusted medicines or treatment. Any health care initiative directed at ensuring people take medicines as prescribed cannot dismiss the use of trial-and-error practices derived from information found on the internet.

Hip protectors: are they beneficial in protecting older people from fall-related injuries?

AIMS AND OBJECTIVES

To report findings of an investigation into the methodological quality of research informing the use of hip protectors for those clients in residential aged care considered to be at high risk of falls and to contribute to the translation of research evidence into practice by identifying issues surrounding the use of hip protectors in practice.

BACKGROUND

Falls risk is a predominant concern when nursing older people, especially those in residential aged care. Fall-related injuries, specifically pertaining to the hip, yield a high cost to the individual both physically and psychologically. Accordingly, hip protectors are argued in related literature as a form of protection against such injuries.

DESIGN

A database search as per a specified search strategy was conducted for quantitative research publications and randomised control trials.

METHODS

English language publications were sought from the year 2000-2011. Searches were made, using specific combinations of keywords, in the following databases: MEDLINE via OvidSP, CINAHL via EBSCOHost, Ageline via OvidSP, Cochrane Library, The Joanna Briggs Institute and Google Scholar.

RESULTS

Six articles were selected for review. Methodological quality of the research publications collated varied, and the use of hip protectors was deemed inconclusive. Compliance was raised as a prevailing issue.

CONCLUSION

The problem of fall-related injuries is significant. Whilst some evidence is inconclusive, the use of hip protectors is recommended as best practice.

RELEVANCE TO CLINICAL PRACTICE

The issue of compliance, however, was identified to affect the use of appliances in residential aged care. Addressing compliance issues must be tackled if hip protectors are to be part of a resident-centred approach.

A survey to assist in targeting the adults who undertake risky behaviours, know their health behaviours are not optimal and who acknowledge being worried about their health

BACKGROUND

Research indicates that those who are worried about their health are more likely to change their in-appropriate behavioural-related risk factors. A national survey was undertaken to determine adults who correctly perceive and actually undertake in-appropriate behavioural-related risk factors (smoking, physical activity, alcohol intake, fruit and vegetable consumption, weight and psychological distress) and are worried about their health.

METHODS

Australian 2010 CATI survey of 3003 randomly selected adults. Perception and self-reported levels of each risk factor, and whether they worried that the level was affecting their health were assessed using univariate and multivariate analyses.

RESULTS

The comparisons between perception of healthy behaviour and actual behaviour varied for each risk factor with 44.1% of people in the un-healthy weight range and 72.9% of those eating less than sufficient fruit and vegetables having the perception that their behaviour was healthy. The demographic and other related variables in the multivariate analyse for each risk factor varied considerably. For example the variables in the final multivariate model for smokers who were worried about their risk factor were markedly different to the other risk factor models and 45 to 54 year olds were more likely to be included in the final models for nearly all of the risk factor analyses.

CONCLUSION

By limiting this analyses to those who are acknowledging (correctly or otherwise) that their perception of behaviour is making their health worse, this study has shown that the profile for each risk factor varies considerably. As such, evidence suggests specific targeted programs are required rather than a broad brush approach.

Intergenerational learning about keeping health: a qualitative regional Australian study

Understanding the conditions under which families try to influence members' health-related practices can provide information to build concepts adding to models of health promotion. This paper reports on an exploratory qualitative study examining the influences of intergenerational relationships in shaping beliefs, knowledge and practices about health and illness in a regional Australian city. We conducted semi-structured interviews with 27 adults with family members of other generations living in the city, all of whom had experience of asthma. We found that overall people's experience of health and illness, particularly in childhood, was taken for granted and not reflected upon. It was in the face of serious illness or death of a family member that objective knowledge about health and illness was sought and integrated within the family leading, in most cases, to significant lifestyle changes or 'doing things differently'. We drew on Bourdieu's concept of the three forms of theoretical knowledge in analysing our findings. We found the concept of knowledge as 'primary taken-for-granted experience', and the concept of praxeological knowledge as the knowledge created by the dialectical relationships between an individual subject and objectives structures were helpful. To influence individual health practices, we need to acknowledge how the family context confirms the taken-for-granted health practices of an individual and the family circumstances that might lead families to seek objective knowledge and make lifestyle changes to promote health.

The doctor and the patient--how is a clinical encounter perceived?

OBJECTIVE

To examine the population distribution of different types of relationships between people with chronic conditions and their doctors that influence decisions being made from a shared-decision making perspective.

METHODS

A survey questionnaire based on recurring themes about the doctor/patient relationship identified from qualitative in-depth interviews with people with chronic conditions and doctors was administered to a national population sample (n=999) of people with chronic conditions.

RESULTS

Three factors explained the doctor/patient relationship. Factor 1 identified a positive partnership characteristic of involvement and shared decision-making; Factor 2 doctor-controlled relationship; Factor 3 relationship with negative dimensions. Cluster analysis identified four population groups. Cluster 1 doctor is in control (9.7% of the population); Cluster 2 ambivalent (27.6%); Cluster 3 positive long-term relationship (58.6%); Cluster 4 unhappy relationship (4.4%). The proportion of 18-34 year olds is significantly higher than expected in Cluster 4. The proportion of 65+ year olds is significantly higher than expected in Cluster 1, and significantly lower than expected in Cluster 4.

CONCLUSION

This study adds to shared decision-making literature in that it shows in a representative sample of people with chronic illnesses how their perceptions of their experiences of the doctor-patient relationship are distributed across the population.

PRACTICE IMPLICATIONS

Consideration needs to be given as to whether it is better to help doctors to alter their styles of interactions to suit the preferences of different patients or if it is feasible to match patients with doctors by style of decision-making and patient preference.

Clostridium difficile prevalence rates in a large healthcare system stratified according to patient population, age, gender, and specimen consistency

We evaluated Clostridium difficile prevalence rates in 2,807 clinically indicated stool specimens stratified by inpatient (IP), nursing home patient (NH), outpatient (OP), age, gender, and specimen consistency using bacterial culture, toxin detection, and polymerase chain reaction (PCR) ribotyping. Rates were determined based on the detection of toxigenic C. difficile isolates. We identified significant differences in the rates between patient populations and with age. Specimens from NH had a higher rate (46%) for toxigenic C. difficile than specimens from IP (18%) and OP (17%). There were no gender-related differences in the rates. Liquid specimens had a lower rate (15%) than partially formed and soft specimens (25%) and formed specimens (18%) for the isolation of toxigenic C. difficile. The nontoxigenic rate was lowest for NH (4%) and highest for patients<20 years of age (23%). We identified 31 different toxigenic ribotypes from a sampling of 190 isolates that showed the lowest diversity in NH. Fluoroquinolone resistance was observed in 93% of the 027 isolates, all of the 053 isolates, and in four other ribotypes. We observed different rates for toxigenic C. difficile in stratified patient populations, with the highest rate for NH, a low overall nontoxigenic rate, and fluoroquinolone resistance.

An integrated QSAR-PBPK modelling approach for predicting the inhalation toxicokinetics of mixtures of volatile organic chemicals in the rat

The objective of this study was to predict the inhalation toxicokinetics of chemicals in mixtures using an integrated QSAR-PBPK modelling approach. The approach involved: (1) the determination of partition coefficients as well as V(max) and K(m) based solely on chemical structure for 53 volatile organic compounds, according to the group contribution approach; and (2) using the QSAR-driven coefficients as input in interaction-based PBPK models in the rat to predict the pharmacokinetics of chemicals in mixtures of up to 10 components (benzene, toluene, m-xylene, o-xylene, p-xylene, ethylbenzene, dichloromethane, trichloroethylene, tetrachloroethylene, and styrene). QSAR-estimated values of V(max) varied compared with experimental results by a factor of three for 43 out of 53 studied volatile organic compounds (VOCs). K(m) values were within a factor of three compared with experimental values for 43 out of 53 VOCs. Cross-validation performed as a ratio of predicted residual sum of squares and sum of squares of the response value indicates a value of 0.108 for V(max) and 0.208 for K(m). The integration of QSARs for partition coefficients, V(max) and K(m), as well as setting the K(m) equal to K(i) (metabolic inhibition constant) within the mixture PBPK model allowed to generate simulations of the inhalation pharmacokinetics of benzene, toluene, m-xylene, o-xylene, p-xylene, ethylbenzene, dichloromethane, trichloroethylene, tetrachloroethylene and styrene in various mixtures. Overall, the present study indicates the potential usefulness of the QSAR-PBPK modelling approach to provide first-cut evaluations of the kinetics of chemicals in mixtures of increasing complexity, on the basis of chemical structure.

Factors associated with the participation of children with complex communication needs

The aim of this study was to conduct a preliminary analysis of relations between child and environmental variables, including factors related to communication aid provision, and participation in informal everyday activities in a sample of children with complex communication needs. Ninety-seven caregivers of children provided with communication aids responded to a questionnaire survey. Child variables assessed were level of ability, trait emotional self-efficacy, and competence in communication aid use. Environmental variables assessed were the impact of childhood disability on the family, family socio-economic category, perceived reliability of electronic communication aids provided to children, and ease of use of the aid. The outcome measure was the intensity of child participation in informal activities. Significant correlations were observed between participation scores and the following variables: child age, level of ability, trait emotional self-efficacy, and family impact of childhood disability. Regression analyses highlighted trait emotional self-efficacy and, to a lesser degree, family impact of childhood disability as the strongest potential predictors of participation. While aspects of child personality may be difficult to disentangle from behaviours related to disability type or developmental age, this research highlights a clinical requirement to assess systematically child behaviours relating to their general emotional functioning.

Doping of GaN by Ion Implantation: Does it Work?

Epitaxially grown GaN by metal organic chemical vapor deposition (MOCVD) on SiC were implanted with 100 keV Si+ (for n-type) and 80 keV Mg+ (for p-type) with various fluences from 1×1012 to 7×1015 ions/cm2 at liquid nitrogen temperature (LT), room temperature (RT), and 700 °C (HT). High temperature (1200 °C and 1500 °C) annealing was carried out after capping the GaN with epitaxial AIN by MOCVD to study damage recovery. Samples were capped by a layer of AIN in order to protect the GaN surface during annealing. Effects of implant temperature, damage and dopant activation are critically studied to evaluate a role of ion implantation in doping of GaN. The damage was studied by Rutherford Backscattering/Channeling, spectroscopic ellipsometry and photoluminescence. Results show dependence of radiation damage level on temperature of the substrate during implantation: implantations at elevated temperatures up to 550 °C decrease the lattice disorder; “hot implants” above 550 °C can not be useful in doping of GaN due to nitrogen loss from the surface. SE measurements have indicated very high sensitivity to the implantation damage. PL measurements at LT of 80 keV Mg+ (5×1014 cm-2) implanted and annealed GaN showed two peaks : one ∼100 meV and another ∼140 meV away from the band edge.

Multimorbidity - not just an older person's issue. Results from an Australian biomedical study

BACKGROUND

Multimorbidity, the simultaneous occurrence of two or more chronic conditions, is usually associated with older persons. This research assessed multimorbidity across a range of ages so that planners are informed and appropriate prevention programs, management strategies and health service/health care planning can be implemented.

METHODS

Multimorbidity was assessed across three age groups from data collected in a major biomedical cohort study (North West Adelaide Health Study). Using randomly selected adults, diabetes, asthma, and chronic obstructive pulmonary disease were determined clinically and cardio-vascular disease, osteoporosis, arthritis and mental health by self-report (ever been told by a doctor). A range of demographic, social, risk and protective factors including high blood pressure and high cholesterol (assessed bio-medically), health service use, quality of life and medication use (linked to government records) were included in the multivariate modelling.

RESULTS

Overall 4.4% of the 20-39 year age group, 15.0% of the 40-59 age group and 39.2% of those aged 60 years of age or older had multimorbidity (17.1% of the total). Of those with multimorbidity, 42.1% were aged less than 60 years of age. A variety of variables were included in the final logistic regression models for the three age groups including family structure, marital status, education attainment, country of birth, smoking status, obesity measurements, medication use, health service utilisation and overall health status.

CONCLUSIONS

Multimorbidity is not just associated with older persons and flexible care management support systems, appropriate guidelines and care-coordination programs are required across a broader age range. Issues such as health literacy and polypharamacy are also important considerations. Future research is required into assessing multimorbidity across the life course, prevention of complications and assessment of appropriate self-care strategies.

Making breathing your business: enterprising practices at the margins of orthodoxy

Over the last 30 years there has been a gradual but nonetheless significant shift in the political economy of healthcare in developed countries. The health reforms that have accompanied this shift have had a significant impact upon medicine, nursing and a number of other orthodox health professions, but to date, little work has been done to explore the changing nature of physiotherapy practice. This study draws on Foucault's notion of governmentality to explore the enterprising practices of a new physiotherapy clinic established in Auckland, New Zealand. Drawing on a critical history of respiratory physiotherapy, which had previously been firmly anchored within the public health sector, we show that the actions and practices of the clinic's staff are testing the margins of orthodox physiotherapy practice and exploring the new market possibilities offered by consumer demand for optimal health. The study explores how the physiotherapists at the clinic are problematizing the practices, clinical spaces and clientele associated with orthodox practice, and, most notably, commodifying breathing, to create a space within which it is possible to think about physiotherapy otherwise. This study builds on the instability now surrounding the orthodox health professions and asks if exemplars like that offered in this article provide some meaningful insights into the future for healthcare practice.

Evaluation of Adjuvant! Online to predict the effect of optimal endocrine therapy (ovarian function suppression plus tamoxifen) for premenopausal breast cancer patients with estrogen-receptor-positive breast cancer

585

Background: Adjuvant! Online (AOL) is a user-friendly, web-based tool that provides estimates of adjuvant therapy outcomes for individual patients. While reliable evidence underpins estimates for most patient cohorts, there is a paucity of data on the effect of adding chemotherapy to complete estrogen blockade for premenopausal women with estrogen-receptor positive breast cancer. Methods: International Breast Cancer Study Group (IBCSG) Trial 11–93 enrolled 174 premenopausal women with estrogen-receptor positive, node-positive breast cancer from 1993 to 1998. Fifty percent of patients had 1 positive axillary lymph node and 97% had between 1 and 3 positive nodes. Patients were randomized to receive ovarian function suppression plus five years of tamoxifen with or without chemotherapy. The estimated hazard rates and corresponding 10-year relapse-free survival percents obtained from Trial 11–93 data (Breast Cancer Res Treat. 2009;113:137–144) were compared with those predicted using AOL. Results: The 10-year relapse-free survival percents predicted from AOL were 64.4% (95% CI, 61.9% to 67.2%) for endocrine therapy alone and 74.9% (95% CI, 73.1% to 76.8%) for chemoendocrine therapy. By contrast, these estimates in Trial 11–93 were 76.4% (95% CI, 65.8% to 84.0%) for endocrine therapy alone and 74.9% (95% CI, 64.5% to 82.7%) for chemoendocrine therapy. The AOL estimate for the endocrine alone control group is lower than that observed in Trial 11–93 (p = 0.03), while the estimates for the two chemoendocrine therapy groups are similar. Conclusions: AOL appears to underestimate the effectiveness of adjuvant endocrine therapy alone for premenopausal women with endocrine responsive breast cancer, thus overestimating the added benefit - if any - from chemotherapy for this patient population. Prospective clinical trials addressing the question are warranted.

No significant financial relationships to disclose.

Phase II study of induction and adjuvant bevacizumab in patients with stage IB-IIIA non-small cell lung cancer (NSCLC) receiving induction docetaxel and cisplatin

7531

Background: VEGF supports growth of NSCLC and is blocked by bevacizumab. Bevacizumab with chemotherapy is an established treatment for advanced NSCLC. We conducted this study to assess the efficacy and toxicity of induction bevacizumab (Bev) with cisplatin (C) and docetaxel (D) in patients with resectable NSCLC. Methods: All patients (pts) had resectable Stage IB-IIIA NSCLC and received up to 4 cycles of D 75 mg/m2 and C 75 mg/m2 followed by surgery. Pts with non-squamous NSCLC also received 3 cycles of Bev 15 mg/kg along with induction DC (Bev-DC). Bev was not given in pre-operative cycle 4. Pts with squamous or central tumors or hemoptysis received 4 cycles of DC only (DC). All resected pts were eligible for adjuvant Bev 15 mg/kg q3 weeks for 1 year. The primary endpoint was rate of downstaging from pre-operative clinical stage to pathologic stage. Results: From Aug 2005 - Nov 2008, 47 pts were enrolled: 27 women; median age 62; Stage 1B -15%, Stage II-17%, Stage IIIA-68%. Of 36 pts given Bev-DC, 15/30 (50%) who have completed surgery were downstaged. Of 11 pts given DC, 3/11 (27%) were downstaged. In Bev-DC group, 22/33 (67%) completed all 4 cycles of DC without a dose reduction and 28/33 pts (85%) completed all 3 planned cycles of Bev. Pts received <3 cycles due to: hemoptysis (n=3), consent withdrawal (n=1), hypertension (n=1), and sepsis (n=1). For DC, 6/11 pts (55%) completed all 4 cycles of DC without a dose reduction. 42/43 patients were resected. R0 resection rate: 29/31 for Bev-DC and 9/11 for DC. Grade 3/4 surgical complications were seen in 5/31 pts (16%) in Bev-DC and 1/11 (9%) in DC. Only 17/41 (41%) who completed surgery received adjuvant bev (median 6 cycles), and 7/41 (17%) completed all adjuvant Bev. Pts did not receive adjuvant Bev due to: POD prior to adjuvant Bev (n=9), POD during adjuvant Bev (n=6), toxicity (n=4), consent withdrawal (n=1), RT for unresectable disease (n=1), surgical complications (n=4), chemotherapy complications (n=4). No treatment related deaths. Conclusions: Induction chemotherapy with Bev-DC in NSCLC is feasible and is associated with an improved rate of downstaging compared with historical controls (33%). In patients treated with DC-Bev, grade 3/4 surgical complications were increased by 7%.

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