International collaboration to improve physiotherapists' training, Viet Nam.

Problem: Like most low- and middle-income countries, Viet Nam has a scarcity of rehabilitation professionals and lacks training programmes that meet international standards. Approach: In 2018, four Vietnamese medical universities, the Université Catholique de Louvain, the Université Libre de Bruxelles, the Humanity & Inclusion charity and World Physiotherapy agreed to collaborate on strengthening pre-service education for physiotherapists in the country. Local setting: Viet Nam has a favourable environment for nurturing rehabilitation services and education: development funds have been available; government investment is increasing; and rehabilitation education has existed for many decades. Relevant changes: The collaboration resulted in the establishment of: (i) a 4-year, competency-based, entry-level curriculum for physiotherapists (bachelor's degree); (ii) opportunities for continuing professional development; (iii) a 2-year master's programme for physiotherapy lecturers and clinical supervisors; and (iv) a national physiotherapy association. In addition, four students were supported in studying for PhD degrees. Strong collaboration and comprehensive and complementary interventions have laid the foundations for sustainable, high-quality, educational programmes for physiotherapists, which will improve access to, and the standard of, rehabilitation services in Viet Nam, thereby leading to better patient outcomes. Lessons learnt: Curricula for entry-level physiotherapy programmes should be competency-based, be actively managed by national educators and meet international standards while being responsive to local priorities. To strengthen the rehabilitation workforce, educators involved in teaching and supervising training programmes should have the skills and knowledge required. A national professional physiotherapy association should be established to provide continuing professional development for physiotherapists and to take part in international collaborations.

Acupuncture for chronic low back pain: a randomized controlled feasibility trial comparing treatment session numbers.

OBJECTIVE: To evaluate the feasibility of a randomized controlled trial investigating the optimal number of treatment sessions of acupuncture, used as an adjunct to usual care, for managing chronic low back pain. METHODS: In total, 45 participants with chronic low back pain were recruited and randomly allocated to receive usual care plus 4, 7, or 10 sessions of acupuncture (15/group). Primary outcomes were recruitment rate, randomization rate, treatment compliance, completion of the outcome measures, and retention rates. Secondary outcomes included back function, pain intensity and bothersomeness, generic health status, activity disability, and participant satisfaction. Data were collected at baseline and discharge, and at 6 and 12 weeks post randomization. RESULTS: The recruitment method was demonstrated to be successful: recruitment rate was 43.7%, and randomization rate was 100%. Compliance with treatment was high among participants (86.7%, 86.7%, and 100% for the 4-, 7-, and 10-session group, respectively). Outcome questionnaires used in this study were found to be appropriate for a future randomized controlled trial. Participant retention rates were 88.9% at discharge and at 6 weeks post randomization and 84.4% at 12 weeks post randomization. Secondary outcomes (except for pain intensity) favored the 10-session acupuncture group at 12 weeks post randomization. Over 90% of participants indicated that they were "very satisfied" and/or "extremely satisfied" with the acupuncture treatment. CONCLUSION: This study demonstrated that a full-scale randomized controlled trial using the methodology described above is feasible, and such a trial is essential to test the dose dependence of acupuncture.

Exploring clinical learning experiences of novice physiotherapy students in a hospital setting.

BACKGROUND: Exposure to clinical practice experiences ensures undergraduate physiotherapy students meet the clinical competencies required to graduate as autonomous practitioners. Much of the research literature has investigated the clinical experiences of medical students. While recent studies have explored physiotherapy students' experiences with simulation, few have explored their perspectives of a clinical placement in a hospital setting at the early learning stage of a four-year programme. OBJECTIVE: To explore the perspectives of novice undergraduate physiotherapy students on a clinical placement in a real hospital setting. METHODS: Fifteen Year 3 undergraduate physiotherapy students participated in semi-structured interviews midway through a three-week tertiary care clinical placement. Interviews were transcribed, coded and analyzed using thematic analysis. RESULTS: Three main themes emerged: 1) student attributes affecting placement experience; 2) impact of the educator on student experience; and 3) effects of the clinical environment on student experiences. CONCLUSION: The real clinical environment promotes a rich learning experience for students, while the clinical educator is pivotal to guiding student learning through provision of resources and feedback. Provision of early orientation and timely clarification of expectations is important to alleviate anxiety and allow students to prepare themselves.

Consumption of gold kiwifruit reduces severity and duration of selected upper respiratory tract infection symptoms and increases plasma vitamin C concentration in healthy older adults.

In the elderly, immunosenescence and malnourishment can contribute to increased risk and severity of upper respiratory tract infections (URTI). Gold kiwifruit (Actinidia chinensis 'Hort16A') contains nutrients important for immune function and mitigation of symptoms of infection, including vitamins C and E, folate, polyphenols and carotenoids. The objective of the present study was to evaluate whether regular consumption of gold kiwifruit reduces symptoms of URTI in older people, and determine the effect it has on plasma antioxidants, and markers of oxidative stress, inflammation and immune function. A total of thirty-two community-dwelling people (≥65 years) participated in a randomised crossover study, consuming the equivalent of four kiwifruit or two bananas daily for 4 weeks, with treatments separated by a 4-week washout period. Participants completed the Wisconsin Upper Respiratory Symptom Survey-21 daily, and blood samples were collected at baseline and at the end of each treatment and washout period. Gold kiwifruit did not significantly reduce the overall incidence of URTI compared with banana, but significantly reduced the severity and duration of head congestion, and the duration of sore throat. Gold kiwifruit significantly increased plasma vitamin C, α-tocopherol and lutein/zeaxanthin concentrations, and erythrocyte folate concentrations, and significantly reduced plasma lipid peroxidation. No changes to innate immune function (natural killer cell activity, phagocytosis) or inflammation markers (high-sensitivity C-reactive protein, homocysteine) were detected. Consumption of gold kiwifruit enhanced the concentrations of several dietary plasma analytes, which may contribute to reduced duration and severity of selected URTI symptoms, offering a novel tool for reducing the burden of URTI in older individuals.

Arabinogalactan proteins contribute to the immunostimulatory properties of New Zealand honeys.

CONTEXT: Factors in honey that improve wound healing are poorly understood, but are thought to include lipopolysaccharide (LPS), apalbumin-1 and -2, and a 5.8 kDa component that stimulate cytokine release from macrophages. OBJECTIVE: To characterize the ability of New Zealand honeys to elicit the release of tumor necrosis factor-α (TNF-α) from monocytic cell lines as a model for early events within a wound site. MATERIALS AND METHODS: The ability of kanuka (Kunzea ericoides), manuka (Leptospermum scoparium), and clover (Trifolium spp.) honeys to stimulate the release of TNF-α from monocytic cell lines THP-1 and U937 was assayed by ELISA. RESULTS: All three honeys stimulated TNF-α release from THP-1 cells, with kanuka honey being the most active. The activity of kanuka honey was associated with a high molecular weight (>30 kDa) component that was partially heat labile and inhibitable with polymyxin B. LPS concentrations in the honeys were too low to adequately explain the level of immunostimulation. The contribution of type II arabinogalactan proteins (AGPs) we recently identified in kanuka honey was tested, as AGPs are known immunostimulators. AGPs purified from kanuka honey stimulated the release of TNF-α from THP-1 and U937 cells. DISCUSSION: Here we demonstrated that AGPs we recently identified in kanuka honey have immunostimulatory activity. We propose that the immunostimulatory properties of individual honeys relate to their particular content of LPS, apalbumins, the 5.8 kDa component and AGPs. CONCLUSION: The immunostimulatory activity of kanuka honey may be particularly dependent on AGPs derived from the nectar of kanuka flowers.

Changes in markers of inflammation, antioxidant capacity and oxidative stress in smokers following consumption of milk, and milk supplemented with fruit and vegetable extracts and vitamin C.

Two milk-based beverages delivering twice the average daily antioxidant intake were formulated, based on synergistic combinations of fruit and vegetable extracts, and containing vitamin C (1.00 mg/ml) for shelf stability. Smokers (n = 42) consumed prototype milk A, B or non-supplemented milk (no extracts or vitamin C; 200 ml) twice daily for 6 weeks. Fasting and post-prandial (2 h after milk consumption) blood samples were collected at baseline and the end of each treatment. Non-supplemented milk significantly reduced fasting inflammatory cytokines (interleukin (IL) 6, IL-1ß, tumour necrosis factor-α) compared to baseline. Both supplemented milk-based beverages significantly increased fasting plasma vitamin C concentrations and antioxidant potential and decreased serum uric acid, compared to non-supplemented milk. The beverages did not induce post-prandial oxidative stress or inflammation. Therefore, regular consumption of the supplemented milks may confer health benefits because of increased antioxidant potential or through mechanisms resulting from increased vitamin C or decreased uric acid concentrations.

Kiwifruit-based polyphenols and related antioxidants for functional foods: kiwifruit extract-enhanced gluten-free bread.

The present study investigates the production of gluten-free bread enhanced with polyphenols and related antioxidants derived from a natural aqueous extract from green-fleshed kiwifruit (Actinidia deliciosa). Puree and four aqueous extracts, produced from ripe green kiwifruit in the absence of artificial preservatives, were subjected to storage stability trials at 4 degrees C, 20 degrees C and 38 degrees C, and were chemically characterized (phenolic, vitamin C and pectic polysaccharide contents). The aqueous extract with good stability and high phenolic and vitamin C contents was used for gluten-free bread-making. The resultant kiwifruit extract-enhanced bread was acceptable to a taste panel, possessing softer and smoother texture than plain gluten-free bread. Thus, the aqueous extract of kiwifruit puree containing health-beneficial constituents can be considered a functional ingredient for gluten-free bread formulation.

Chemical composition and in vitro anti-inflammatory activity of apple phenolic extracts and of their sub-fractions.

Apple extract powders from three different manufacturers were investigated for their anti-inflammatory activity, their total phenolic content, and their chemical composition. The samples represented two production batches for two products and a single batch of a third. The samples showed similar, but clearly different, anti-inflammatory activities, and had substantially different total phenolic contents, and different chemical compositions. Differences in chemical composition for batches of the same product were significant, although not as great as differences between products. The samples were fractionated into chemical classes. The most active fractions were those that contained epicatechin, catechin with phloridzin and quercetin glycosides, or those that contained procyanidin polymers. It was not possible to link activity to the presence of individual components or combinations of these. If fruit extracts are to be reliably linked to validated health benefits, then the source materials, the extraction processes, and the final composition of such products need to be more clearly defined than at present.

Phosphatidylinositol mannosides are efficient mucosal adjuvants.

The development of defined sub-unit vaccines requires the inclusion in the vaccine of an immunological adjuvant. The most important property of adjuvants for vaccines aimed at inducing optimal protection against intracellular bacteria such as Mycobacterium tuberculosis or M. bovis is the ability to enhance cell-mediated immunity, specifically Th1 responses. In this paper, we describe a system where transgenic mice expressing a high proportion of T cells specific for an ovalbumin (OVA) peptide are used to assess the ability of a novel class of adjuvants to positively modulate cell-mediated immune responses. Defined fractions containing purified native or synthetic phosphatidylinositol mannosides (PIMs) from mycobacteria were assessed for their adjuvant activities in response to the model antigen (OVA). Purified PIM preparations given to mice with OVA by the subcutaneous route were shown to elicit an enhanced release of interferon-gamma (IFN-gamma) in cellular responses to OVA peptide in vitro. Very little interleukin-4 (IL-4) was released by cells from mice immunized with PIMs and OVA, whereas cells from animals immunized with complete Freund's adjuvant (CFA) and OVA released IL-4 as well as IFN-gamma. Synthetic preparations of PIM2 and PIM4 also acted as adjuvants in the mouse model studied. In addition, PIM preparations were shown to generate an efficient cell-mediated immune response to OVA, when the antigen/adjuvant preparations were administered via the oral route or intranasal route. PIM preparations elicited substantial release of interleukin-12 (IL-12) from dendritic cells (DCs). These data suggest that purified or synthetic PIMs act as adjuvants when administered at mucosal surfaces and represent a new class of adjuvants for mucosal immunization against intracellular pathogens.

The potential influence of fruit polyphenols on colonic microflora and human gut health.

The effect of common dietary polyphenols on growth of human gut bacteria and their adhesion to enterocytes was investigated. The influence on the growth of a probiotic (Lactobacillus rhamnosus), a commensal (Escherichia coli) and two pathogenic bacteria (Staphylococcus aureus, Salmonella typhimurium) was determined, together with effects on adhesion of pathogenic and probiotic bacteria to cultured Caco-2 cells. All polyphenols, except rutin, were found to affect the viability of representative gut flora in vitro, at doses likely to be present in the gastrointestinal tract, but to differing degrees. Naringenin and quercetin were the most active with the lowest minimum inhibitory concentrations for all the four bacteria tested. The remaining polyphenols had the most marked effect on the Gram positive enteropathogen S. aureus. Naringenin and phloridzin were the most effective inhibitors of S. typhimurium adherence to Caco-2 enterocytes while phloridzin and rutin enhanced the adherence of the probiotic L. rhamnosus. Polyphenols appear to have potential to alter gut microecology and, by affecting the total number of beneficial microflora in the gut, may confer positive gut health benefits.

Efficacy of the 'tennis ball technique' versus nCPAP in the management of position-dependent obstructive sleep apnoea syndrome.

BACKGROUND AND OBJECTIVE: Avoidance of sleep in the supine position is recommended in the management of position-dependent OSA hypopnoea syndrome (OSAHS). Our aim was to evaluate the efficacy of a thoracic anti-supine band (TASB), designed to mimic the so-called 'tennis ball technique', compared with nasal CPAP (nCPAP). METHODS: Twenty adults with mild to moderately severe position-dependent OSAHS (mean AHI +/- SD) 22.7 +/- 12.0/H (range 6.0-51.2); AHI supine, 59.6 +/- 27.5/H, were included in a randomized cross-over trial. Portable sleep studies were undertaken at baseline and after 1 month on each treatment. A successful treatment outcome was defined as AHI

Comparison of enzymically glucuronidated flavonoids with flavonoid aglycones in an in vitro cellular model of oxidative stress protection.

This study modeled, in vitro, the potential effect of conjugative (phase II) metabolism on the cytoprotective capacity of fruit flavonoids against oxidative stress. Flavonoid aglycones were compared with their corresponding isomeric mixtures of glucuronides for their ability to enhance the survival of cultured human Jurkat T and neuroblastoma cells stressed with hydrogen peroxide. Various polyphenolic compounds were tested as substrates in vitro for an ovine liver glucuronyl transferase preparation. Flavonoids and their glycoside derivatives were found to be good substrates, whereas phenolic acids were either poor or nonsubstrates. Five common flavonoids were glucuronidated to prepare mixtures for bioassay testing. Glucuronidation generally weakened the cytoprotective capacities of flavonoids (in the presence of H(2)O(2)), but some compounds were weakened much more than others. The concentration that halved cell death was well below 0.5 microM for most flavonoids tested, but glucuronidation increased median effective concentration values to a range of 1-16 microM. This compares with the generally accepted physiological range (0.1-10 microM) for circulating dietary polyphenolics detected in the body. Therefore, some flavonoids may retain a reduced cytoprotective capacity in vitro, after glucuronidation, whereas others may be effectively inactivated.

Proposal for a National Interprofessional School of Rural Health.

Shortages of health professionals persist in much of rural New Zealand despite a range of targeted university and professional college initiatives. In response to this a collective of universities, professional colleges and sector groups have put a proposal to Government for a National Interprofessional School of Rural Health. If adopted, this proposal would embed rural health professional education and research in rural communities around New Zealand, empowering them to organise the education that occurs in their community, in a coherent and coordinated way. What is being proposed is not a new or separate education provider but rather an 'enabling body' that would lever off the expertise and resources of the existing tertiary institutions, colleges and rural communities. It calls for an 'all of systems' approach that encompasses all the health professions that practise in rural areas, undergraduate education and postgraduate training, and rural health research. Although modelled on successful Australian rural clinical schools, it is a uniquely New Zealand solution that is cognisant of the New Zealand context and resources.

Methylated polyphenols are poor "chemical" antioxidants but can still effectively protect cells from hydrogen peroxide-induced cytotoxicity.

Several polyphenolic compounds, including flavonoids and phenolic acids, were compared with their per-methylated forms in both chemical and cell-based assays for antioxidant capacity. Methylation largely eliminated "chemical" antioxidant capacity, according to ferric reducing antioxidant power and oxygen radical absorbance capacity assays. Methylation, however, only moderately reduced protection of human Jurkat cells in culture, from hydrogen peroxide-mediated cytotoxicity, at physiologically relevant concentrations. Neither methylated nor un-methylated compounds were detectably metabolized by the cells. It appears that the protective mechanism of polyphenolic antioxidants against high concentrations of hydrogen peroxide in human cells may be largely unrelated to chemical antioxidant capacity.

Free radical scavenging and cytoprotective activities of phenolic antioxidants.

The free radical scavenging activities of three flavonoids (quercetin, rutin and catechin) and four hydroxycinnamic acids (caffeic, ferulic, sinapic, and chlorogenic acids) were evaluated using both oxygen radical absorbance capacity (ORAC) and lipid peroxidation inhibition capacity (LPIC) assays. The cytoprotective effects of these compounds were also measured by the degree of protection against H(2)O(2)-induced damage of human Jurkat cells. All compounds exhibited protection against H(2)O(2)-mediated cytotoxicity in a dose-dependent manner. The concentrations required to result in a 50% reduction in cell death (EC(50) value) were calculated from their dose-response curves. These ranged from 0.15-2.65 microM. Overall, the four hydroxycinnamic acids tested were less effective than the three flavonoids, and of all compounds tested, quercetin offered the strongest protection against H(2)O(2)-induced cell death. A comparison of the results showed that the ability to inhibit peroxidation of lipids in a liposomal system (LPIC) correlated well with the cytoprotective activities (EC(50)), but not with the ability to protect an aqueous fluorescent substrate in the ORAC assays. The results suggest that the behavior of antioxidants in a liposomal membrane is to some extent similar to the mechanism involved in the protection of living cells from oxidative damage.

Interprofessional education in a rural community: the perspectives of the clinical workplace providers.

INTRODUCTION Interprofessional education is internationally recognised as a key element in preparing a collaborative practice-ready health workforce, for improving health care outcomes and patient-centred practice. The Tairawhiti interprofessional education (TIPE) programme was introduced in 2012 in a rural area with a high Maori population. Students from seven health professions: dentistry, dietetics, medicine, nursing, occupational therapy, pharmacy and physiotherapy participated in clinical rotations as well as working in Maori communities with Maori health providers. AIM The primary aim was to retrospectively investigate clinical workplace providers' perspectives on their participation in the TIPE project over its first 3 years. METHODS Face-to-face, semi-structured interviews were completed with 16 clinical workplace providers involved in TIPE. A qualitative approach using template analysis methodology and a priori themes was used to identify predominant themes from the providers' perspectives. RESULTS All 16 providers reported positive experiences during their involvement in TIPE and wished to continue with this educational model. Benefits described included greater interprofessional collaboration at the workplace; improved engagement between students and providers; enhanced patient-centred care, particularly with Maori and whanau; and positive outcomes from community projects undertaken by the students. Although providers acknowledged additional costs on time, pressure on staff and extra workloads, all confirmed that the benefits from the project far outweighed the costs. CONCLUSION From the providers' perspectives, the TIPE project met its objectives. Furthermore, providers noted several students had re-located back to Tairawhiti to work as health professionals, which suggests that investment in TIPE adds long-term value to the community.

Traditional Chinese Medicine acupuncture and myofascial trigger needling: The same stimulation points?

BACKGROUND: Acupuncture originates in China, and its effectiveness has been well documented in musculoskeletal pain disorders and other conditions. A widely accepted contemporary medical treatment option for myofascial pain is trigger point needling. Although there are many differences between Traditional Chinese Medicine acupuncture theory and the myofascial trigger point needling framework, it is argued that the stimulation sites for these two needling modalities are similar. DISCUSSION: In this paper we examined the correspondence between Traditional Chinese Medicine acupoints and myofascial trigger points. Based on this correspondence, we considered exploration of Ah-shi points from four aspects: pain recognition, distal Ah-shi points, Anti-Ah-shi points, and management approaches. SUMMARY: The extent of correspondence is influenced by definitions of acupoints. Myofascial trigger points are significantly correlated to Traditional Chinese Medicine acupoints, including primary channel acupoints, extra acupoints, and Ah-shi points. Considering the correlation between MTrPs and acupoints and the rarely-studied research area of Ah-shi points, it may be reasonable to incorporate research findings of myofascial trigger points into further investigations into Ah-shi points. Correspondence between myofascial trigger points and acupoints enhances contemporary understanding of the mechanism of action of acupuncture, and may serve to facilitate increased integration of acupuncture into clinical management.

Consumption of antimicrobial manuka honey does not significantly perturb the microbiota in the hind gut of mice.

The aim of this study was to test the hypothesis that consuming manuka honey, which contains antimicrobial methylglyoxal, may affect the gut microbiota. We undertook a mouse feeding study to investigate whether dietary manuka honey supplementation altered microbial numbers and their production of organic acid products from carbohydrate fermentation, which are markers of gut microbiota function. The caecum of C57BL/6 mice fed a diet supplemented with antimicrobial UMF® 20+ manuka honey at 2.2 g/kg animal did not show any significantly changed concentrations of microbial short chain fatty acids as measured by gas chromatography, except for increased formate and lowered succinate organic acid concentrations, compared to mice fed a control diet. There was no change in succinate-producing Bacteroidetes numbers, or honey-utilising Bifidobacteria, nor any other microbes measured by real time quantitative PCR. These results suggest that, despite the antimicrobial activity of the original honey, consumption of manuka honey only mildly affects substrate metabolism by the gut microbiota.

Cattle as a model for development of vaccines against human tuberculosis.

The identification of tuberculosis vaccines and vaccination strategies, which in small animal models appear to be more effective than BCG, offer some exciting possibilities for control of human tuberculosis in the future. However, some major problems remain including selecting which vaccines should go into human trials and the length of time it will take for testing these vaccines in humans. The cattle model is well suited for the secondary screening of tuberculosis vaccines as there is a strong similarity between the disease in cattle and humans and outbred animals are used. Moreover, there are many similarities in the results from field trials of BCG in both cattle and humans, with BCG often failing to protect when the trials are extended over a number of years. In addition, calves, like human infants, are immunocompetent at birth. Recent studies in calves have shown that BCG vaccination of calves within hours of birth is highly effective in protecting animals against bovine tuberculosis, but BCG revaccination at 6 weeks of age is contraindicated. Prime boost vaccination strategies using BCG and DNA vaccines have provided evidence that these combinations may give better protection in calves than either vaccine alone. Based on antigens whose genes are absent from the BCG genome, advances have also been made to develop diagnostic reagents distinguishing infected and vaccinated animals (differential diagnosis). The cattle model has been particularly useful in prioritizing such antigens for testing in humans. Finally, there is an urgent need to identify an immunological correlate of protection against tuberculosis. The cattle model can be particularly helpful in this area as it is relatively easy to collect large volumes of blood from calves at intervals following vaccination and challenge, and a large number of immunological reagents are now available for cattle.

Accuracy of monitoring for sleep-related breathing disorders in the coronary care unit.

STUDY OBJECTIVES: To evaluate the frequency of sleep-disordered breathing (SDB) in patients presenting with acute cardiovascular events. DESIGN: Repeat observational study. SETTING: Coronary care unit of a university hospital. PATIENTS: A total of 26 patients presenting with unstable angina, myocardial infarction, or left ventricular failure. MEASUREMENTS: Level 3 portable sleep study performed at the time of acute presentation (study 1; 26 patients) and again > or = 6 weeks later (study 2; 18 patients). RESULTS: SDB (apnea-hypopnea index > or = 15) was identified in 13 of 26 patients (50%) during study 1. One patient had central sleep apnea. Of the 18 who completed the two studies, SDB was confirmed in 10 of 18 patients (56%) during study 1 but in only 5 of 18 patients (28%) during study 2. All five of those patients had obstructive sleep apnea (OSA). Six patients were deemed to have false-positive results for SDB at follow-up, and one patient was deemed to have a false-negative result. Detailed analysis suggested that supine posture during study 1 may have contributed to the high false-positive rate, even though only three of six patients fulfilled the criteria for positional OSA. CONCLUSIONS: SDB occurs commonly in patients presenting with an acute cardiovascular event. Consideration of the diagnosis of SDB is an important strategy for secondary prevention. However, our findings indicate that SDB abnormalities may be transient. Sleep studies to investigate SDB as a potential risk factor for cardiovascular morbidity should be carried out when the patient is clinically stable.