Prevalence of vitamin D deficiency prior to cardiothoracic surgery.

BACKGROUND: Vitamin D deficiency is one of the most common chronic medical conditions in the world and also prevalent in Australia. A growing body of evidence suggests that low vitamin D also has adverse effects on cardiovascular health, including coronary risk factors and adverse cardiovascular outcomes such as myocardial infarction, cardiac failure and stroke. There is some evidence suggesting that a greater proportion of people with cardiovascular disease have low vitamin D compared to the general population. We examined the prevalence of vitamin D deficiency and insufficiency in elective cardiothoracic surgical patients presenting to the Alfred Hospital in Melbourne, Australia and compared this to recent Victorian statistics for people of the same age group. METHODS: Consecutive adult elective cardiothoracic surgical patients listed for either coronary artery bypass graft surgery or heart valve repair or replacement surgery attending The Alfred Hospital, Melbourne between July 2011 and October 2012 were invited to participate. This ensured that patients were enrolled over all four seasons. Fasting serum samples were taken on the day of surgery, immediately after admission. Eighty volunteers participated in the study. Of the group, 40% were due to have coronary artery bypass graft surgery, 35% valve surgery and 25% a combination of the two; 74% reported having hypertension, 69% hyperlipidaemia, 26% diabetes and 39% had a BMI >30 kg/m(2). RESULTS: Test results revealed that 92.5% of patients had Vitamin D levels < 75 nmol/L, 67.5% had levels < 60 nmol/L, 52.5% had levels between 30-59 nmol/L and 15% had levels < 30 nmol/L. Inadequate vitamin D levels were found in 80% of obese patients (BMI > 30 kg/m(2)) compared to 59% of non-obese patients. CONCLUSIONS: Based on our small screening study, a substantial proportion of elective cardiothoracic surgical patients have less than optimal serum vitamin D3 levels prior to surgery. We found two-thirds of patients had serum vitamin D levels below 60 nmol/L, placing them at higher risk of falls. This finding is of concern as these patients would have received multiple consultations with various medical practitioners prior to hospital admission and yet their inadequate vitamin D status remained. Failing to identify patients with low vitamin D and correcting it with supplementation places older adults at unnecessary risk, especially of falls, which are associated with a high risk of mortality. In an ageing population with CVD, vitamin D status needs to be assessed and any inadequacy corrected. Whether low vitamin D status prior to cardiac surgery affects post-surgery outcomes, is another issue which deserves future investigation.

Physical conditioning and mental stress reduction--a randomised trial in patients undergoing cardiac surgery.

BACKGROUND: Preoperative anxiety and physical unfitness have been shown to have adverse effects on recovery from cardiac surgery. This study involving cardiac surgery patients was primarily aimed at assessing the feasibility of delivering physical conditioning and stress reduction programs within the public hospital setting. Secondary aims were to evaluate the effect of these programs on quality of life (QOL), rates of postoperative atrial fibrillation (AF) and length of stay (LOS) in hospital. METHODS: Elective patients scheduled for coronary artery bypass graft and/or valve surgery at a public hospital in Melbourne, Australia were enrolled. Patients were randomized to receive either holistic therapy (HT) or usual care (UC). HT consisted of a series of light physical exercise sessions together with a mental stress reduction program administered in an outpatient setting for the first two weeks after placement on the waiting list for surgery. A self-administered SF-36 questionnaire was used to measure QOL and hospital records to collect data on LOS and rate of postoperative AF. RESULTS: The study population comprised 117 patients of whom 60 received HT and 57 received UC. Both programs were able to be delivered within the hospital setting but ongoing therapy beyond the two week duration of the program was not carried out due to long waiting periods and insufficient resources. HT, as delivered in this study, compared to UC did not result in significant changes in QOL, LOS or AF incidence. CONCLUSIONS: Preoperative holistic therapy can be delivered in the hospital setting, although two weeks is insufficient to provide benefits beyond usual care on QOL, LOS or postoperative AF. Further research is now required to determine whether a similar program of longer duration, or targeted to high risk patients can provide measurable benefits. TRIAL REGISTRATION: This trial was conducted as part of a larger study and according to the principles contained in the CONSORT statement 2001.

The prevalence and experience of Australian naturopaths and Western herbalists working within community pharmacies.

BACKGROUND: Naturopaths and Western herbal medicine (WHM) practitioners were surveyed to identify their extent, experience and roles within the community pharmacy setting and to explore their attitudes to integration of complementary medicine (CM) practitioners within the pharmacy setting. METHOD: Practising naturopaths and WHM practitioners were invited to participate in an anonymous, self-administered, on-line survey. Participants were recruited using the mailing lists and websites of CM manufacturers and professional associations. RESULTS: 479 practitioners participated. 24% of respondents (n=111) reported they had worked in community pharmacy, three-quarters for less than 5 years. Whilst in this role 74% conducted specialist CMs sales, 62% short customer consultations, 52% long consultations in a private room and 51% staff education. This was generally described as a positive learning experience and many appreciated the opportunity to utilise their specialist knowledge in the service of both customers and pharmacy staff. 14% (n=15) did not enjoy the experience of working in pharmacy at all and suggested pharmacist attitude largely influenced whether the experience was positive or not. Few practitioners were satisfied with the remuneration received. 44% of the total sample provided comment on the issue of integration into pharmacy, with the main concern being the perceived incommensurate paradigms of practice between pharmacy and naturopathy. Of the total sample, 38% reported that they would consider working as a practitioner in retail pharmacy in future. CONCLUSIONS: The level of integration of CM into pharmacy is extending beyond the mere stocking of supplements. Naturopaths and Western Herbalists are becoming utilised in pharmacies.

Insulin in general practice - barriers and enablers for timely initiation.

BACKGROUND: Insulin is effective at lowering blood glucose, and most people with type 2 diabetes need insulin within 10 years of diagnosis. However, initiating insulin is often delayed in general practice. This study explores barriers and enablers to insulin initiation in general practice. METHOD: A qualitative study using semistructured, in-depth interviews. Ten general practitioners, four diabetes nurse educators and 12 patients were interviewed. Participants were purposively selected and recruited through snowballing. Data analysis drew on the Normalisation Process Model framework. RESULTS: The understanding of the primary aim of diabetes care and its context (improving pathophysiology, complex multimorbidity, the patient-doctor relationship, impact of living with the condition) was important. There was disagreement and uncertainty about whose role it is to initiate insulin. It was also important whether insulin initiation was conceptualised as a simple, protocol driven intervention, or as a complex and demanding addition to an overwhelming clinical picture. DISCUSSION: Insulin initiation seems more likely if the multiple perspectives on the primary aim of clinical care are acknowledged, and if roles are explicitly discussed and clarified.

Perceptions, use and attitudes of pharmacy customers on complementary medicines and pharmacy practice.

BACKGROUND: Complementary medicines (CMs) are popular amongst Australians and community pharmacy is a major supplier of these products. This study explores pharmacy customer use, attitudes and perceptions of complementary medicines, and their expectations of pharmacists as they relate to these products. METHODS: Pharmacy customers randomly selected from sixty large and small, metropolitan and rural pharmacies in three Australian states completed an anonymous, self administered questionnaire that had been pre-tested and validated. RESULTS: 1,121 customers participated (response rate 62%). 72% had used CMs within the previous 12 months, 61% used prescription medicines daily and 43% had used both concomitantly. Multivitamins, fish oils, vitamin C, glucosamine and probiotics were the five most popular CMs. 72% of people using CMs rated their products as 'very effective' or 'effective enough'. CMs were as frequently used by customers aged 60 years or older as younger customers (69% vs. 72%) although the pattern of use shifted with older age. Most customers (92%) thought pharmacists should provide safety information about CMs, 90% thought they should routinely check for interactions, 87% thought they should recommend effective CMs, 78% thought CMs should be recorded in customer's medication profile and 58% thought pharmacies stocking CMs should also employ a complementary medicine practitioner. Of those using CMs, 93% thought it important for pharmacists to be knowledgeable about CMs and 48% felt their pharmacist provides useful information about CMs. CONCLUSIONS: CMs are widely used by pharmacy customers of all ages who want pharmacists to be more involved in providing advice about these products.

Adverse reactions to complementary medicines: the Australian pharmacy experience.

OBJECTIVES: The primary aim was to determine the prevalence of adverse reactions to over-the-counter complementary medicines and their severity, as described by consumers. Secondary aims were to identify consumers' reporting behaviours and understanding of the AUST L designation on product labels. METHODS: An anonymous, self-administered survey was completed by randomly selected pharmacy customers at 60 community pharmacy locations between August 2008 and February 2009. KEY FINDINGS: Of the 1121 survey participants (response rate 62%), 72% had used a complementary medicine product in the previous 12 months, and 7% of this group (n = 55) reported having experienced an adverse reaction at some time. Of these, 71% described the reaction as mild and not requiring treatment, 22% as moderate and/or requiring advice from a healthcare professional and 7% (n = 4) described it as severe and requiring hospitalisation. If they were to report the reaction, it was most commonly to a medical practitioner. Most (88%) of complementary medicine consumers had never noticed the term 'AUST L'. CONCLUSIONS: Complementary medicines are widely used by pharmacy customers. Adverse reactions to these products are under-reported to healthcare authorities. Most adverse reactions are mild and serious reactions are rare. Customers have little awareness of the designation AUST L.

Massage therapy for cardiac surgery patients--a randomized trial.

OBJECTIVES: To determine whether massage significantly reduces anxiety, pain, and muscular tension and enhances relaxation compared with an equivalent period of rest time after cardiac surgery. The feasibility of delivering the treatment, effects on heart rate, blood pressure, and respiratory rate, and patient satisfaction were also assessed. METHODS: Elective cardiac surgery patients were randomized to receive massage or rest time at 2 points after surgery. Visual analog scales were used to measure pain, anxiety, relaxation, muscular tension, and satisfaction. Heart rate, respiratory rate, and blood pressure were measured before and after treatment. Focus groups and feedback were used to collect qualitative data about clinical significance and feasibility. RESULTS: A total of 152 patients (99% response rate) participated. Massage therapy produced a significantly greater reduction in pain (P = .001), anxiety (P < .0001), and muscular tension (P = .002) and increases in relaxation (P < .0001) and satisfaction (P = .016) compared to the rest time. No significant differences were seen for heart rate, respiratory rate, and blood pressure. Pain was significantly reduced after massage on day 3 or 4 (P < .0001) and day 5 or 6 (P = .003). The control group experienced no significant change at either time. Anxiety (P < .0001) and muscular tension (P < .0001) were also significantly reduced in the massage group at both points. Relaxation was significantly improved on day 3 or 4 for both groups (massage, P < .0001; rest time, P = .006), but only massage was effective on day 5 or 6 (P < .0001). Nurses and physiotherapists observed patient improvements and helped facilitate delivery of the treatment by the massage therapists on the ward. CONCLUSIONS: Massage therapy significantly reduced the pain, anxiety, and muscular tension and improves relaxation and satisfaction after cardiac surgery.