An Approach for Enhancing Adoption, Use and Utility of Shared Digital Health Records in Rural Australian Communities.

Internationally, shared digital health records are considered an important addition to improving modern health care provision. Australia launched its version, My Health Record (MyHR), in 2012 but has experienced low adoption and challenges in practical implementation and evaluation. Individuals living with complex and chronic conditions in rural and remote communities often experience challenges in obtaining equitable access to health care provision. They are also supposed to face additional barriers to adopting and using eHealth services. This paper reports on research investigating adoption, use and utility of MyHR, in rural remote Australian community settings. Based on this research an approach for improving national roll out of MyHR is presented. The approach highlights a means to understand and engage communities with complex care needs, to support their adoption and use of digital tools. It also draws attention to holistic methods for evaluating and assessing impact at individual, community and health care provision levels.

South Asia as a Reservoir for the Global Spread of Ciprofloxacin-Resistant Shigella sonnei: A Cross-Sectional Study.

BACKGROUND: Antimicrobial resistance is a major issue in the Shigellae, particularly as a specific multidrug-resistant (MDR) lineage of Shigella sonnei (lineage III) is becoming globally dominant. Ciprofloxacin is a recommended treatment for Shigella infections. However, ciprofloxacin-resistant S. sonnei are being increasingly isolated in Asia and sporadically reported on other continents. We hypothesized that Asia is a primary hub for the recent international spread of ciprofloxacin-resistant S. sonnei. METHODS AND FINDINGS: We performed whole-genome sequencing on a collection of 60 contemporaneous ciprofloxacin-resistant S. sonnei isolated in four countries within Asia (Vietnam, n = 11; Bhutan, n = 12; Thailand, n = 1; Cambodia, n = 1) and two outside of Asia (Australia, n = 19; Ireland, n = 16). We reconstructed the recent evolutionary history of these organisms and combined these data with their geographical location of isolation. Placing these sequences into a global phylogeny, we found that all ciprofloxacin-resistant S. sonnei formed a single clade within a Central Asian expansion of lineage III. Furthermore, our data show that resistance to ciprofloxacin within S. sonnei may be globally attributed to a single clonal emergence event, encompassing sequential gyrA-S83L, parC-S80I, and gyrA-D87G mutations. Geographical data predict that South Asia is the likely primary source of these organisms, which are being regularly exported across Asia and intercontinentally into Australia, the United States and Europe. Our analysis was limited by the number of S. sonnei sequences available from diverse geographical areas and time periods, and we cannot discount the potential existence of other unsampled reservoir populations of antimicrobial-resistant S. sonnei. CONCLUSIONS: This study suggests that a single clone, which is widespread in South Asia, is likely driving the current intercontinental surge of ciprofloxacin-resistant S. sonnei and is capable of establishing endemic transmission in new locations. Despite being limited in geographical scope, our work has major implications for understanding the international transfer of antimicrobial-resistant pathogens, with S. sonnei acting as a tractable model for studying how antimicrobial-resistant Gram-negative bacteria spread globally.

Three-dimensional spheroid cell model of in vitro adipocyte inflammation.

To improve treatment of obesity, a contributing factor to multiple systemic and metabolic diseases, a better understanding of metabolic state and environmental stress at the cellular level is essential. This work presents development of a three-dimensional (3D) in vitro model of adipose tissue displaying induced lipid accumulation as a function of fatty acid supplementation that, subsequently, investigates cellular responses to a pro-inflammatory stimulus, thereby recapitulating key stages of obesity progression. Three-dimensional spheroid organization of adipose cells was induced by culturing 3T3-L1 mouse preadipocytes on an elastin-like polypeptide-polyethyleneimine (ELP-PEI)-coated surface. Results indicate a more differentiated phenotype in 3D spheroid cultures relative to two-dimensional (2D) monolayer analogues based on triglyceride accumulation, CD36 and CD40 protein expression, and peroxisome proliferator-activated receptor-γ (PPAR-γ) and adiponectin mRNA expression. The 3T3-L1 adipocyte spheroid model was then used to test the effects of a pro-inflammatory microenvironment, namely maturation in the presence of elevated fatty acid levels followed by acute exposure to tumor necrosis factor alpha (TNF-α). Under these conditions, we demonstrate that metabolic function was reduced across all cultures exposed to TNF-α, especially so when pre-exposed to linoleic acid. Further, in response to TNF-α, enhanced lipolysis, monitored as increased extracellular glycerol and fatty acids levels, was observed in adipocytes cultured in the presence of exogenous fatty acids. Taken together, our 3D spheroid model showed enhanced adipogenic differentiation and presents a platform for elucidating the key phenotypic responses that occur in pro-inflammatory microenvironments that characterize obesogenic states.

Clinically and microbiologically derived azithromycin susceptibility breakpoints for Salmonella enterica serovars Typhi and Paratyphi A.

Azithromycin is an effective treatment for uncomplicated infections with Salmonella enterica serovar Typhi and serovar Paratyphi A (enteric fever), but there are no clinically validated MIC and disk zone size interpretative guidelines. We studied individual patient data from three randomized controlled trials (RCTs) of antimicrobial treatment in enteric fever in Vietnam, with azithromycin used in one treatment arm, to determine the relationship between azithromycin treatment response and the azithromycin MIC of the infecting isolate. We additionally compared the azithromycin MIC and the disk susceptibility zone sizes of 1,640 S. Typhi and S. Paratyphi A clinical isolates collected from seven Asian countries. In the RCTs, 214 patients who were treated with azithromycin at a dose of 10 to 20 mg/ml for 5 to 7 days were analyzed. Treatment was successful in 195 of 214 (91%) patients, with no significant difference in response (cure rate, fever clearance time) with MICs ranging from 4 to 16 µg/ml. The proportion of Asian enteric fever isolates with an MIC of ≤ 16 µg/ml was 1,452/1,460 (99.5%; 95% confidence interval [CI], 98.9 to 99.7) for S. Typhi and 207/240 (86.3%; 95% CI, 81.2 to 90.3) (P < 0.001) for S. Paratyphi A. A zone size of ≥ 13 mm to a 5-µg azithromycin disk identified S. Typhi isolates with an MIC of ≤ 16 µg/ml with a sensitivity of 99.7%. An azithromycin MIC of ≤ 16 µg/ml or disk inhibition zone size of ≥ 13 mm enabled the detection of susceptible S. Typhi isolates that respond to azithromycin treatment. Further work is needed to define the response to treatment in S. Typhi isolates with an azithromycin MIC of >16 µg/ml and to determine MIC and disk breakpoints for S. Paratyphi A.

Components of a hyperthermia clinic: recommendations for staffing, equipment, and treatment monitoring.

Like other technically sophisticated medical endeavours, a hyperthermia clinic relies on skilled staffing. Physicians, physicists and technologists perform multiple tasks to ensure properly functioning equipment, appropriate patient selection, and to plan and administer this treatment. This paper reviews the competencies and tasks that are used in a hyperthermia clinic.

Susceptibility of community-acquired pathogens to antibiotics in Africa and Asia in neonates--an alarmingly short review.

OBJECTIVE: To assess the susceptibility of community-acquired pathogens in neonatal sepsis to commonly prescribed antibiotics in sub-Saharan Africa and Asia since 2002. METHODS: Literature review in PubMed and Embase. Susceptibility was estimated for pathogens individually and stratified by region. Isolates were also classified into Gram positive and Gram negative pathogens to estimate their pooled susceptibility. RESULTS AND CONCLUSIONS: Only nine studies met the inclusion criteria. The available data indicated poor susceptibility to almost all commonly used antibiotics in pathogens such as Staphylococcus aureus and Klebsiella spp. Only Streptococcus pneumoniae exhibited good susceptibility to all drugs other than cotrimoxazole. The extreme scarcity of data prevents drawing any firm conclusions beyond the urgent need for more studies to identify the best treatments for neonatal sepsis in the developing world.

Interstitial microwave transition from hyperthermia to ablation: historical perspectives and current trends in thermal therapy.

This work reviews the transition from hyperthermia to ablation for cancer treatment with interstitial microwave (MW) antennas. Early work utilising MW energy for thermal treatment of cancer tissue began in the late 1970s using single antennas applied interstitially or the use of multiple interstitial antennas driven with the same phase and equal power at 915 or 2450 MHz. The original antenna designs utilised monopole or dipole configurations. Early work in thermal therapy in the hyperthermia field eventually led to utilisation of these antennas and methods for MW ablation of tumours. Efforts to boost the radiated MW power levels while decreasing antenna shaft temperatures led to incorporation of internally cooled antennas for ablation. To address larger tumours, MW treatment utilised arrays that were simultaneously activated by either non-synchronous or synchronous phase operation, benefiting both hyperthermia and ablation strategies. Numerical modelling was used to provide treatment planning guidance for hyperthermia treatments and is expected to provide a similar benefit for ablation therapy. Although this is primarily a review paper, some new data are included. These new data show that three antennas with 2.5 cm spacing at 45 W/channel and 10 min resulted in a volume of 89.8 cm(3) when operated synchronously, but only 53.4 cm(3) non-synchronously. Efficiency was 1.1 (synchronous) versus 0.7 (non-synchronous). MW systems, treatment planning, and image guidance continue to evolve to provide better tools and options for clinicians and patients in order to provide better approach and targeting optimisation with the goal of improved treatment for the patient.

Patient self-management and chronic illness: evaluating outcomes and impacts of information technology.

Chronic illness is increasing in Australia and throughout the world. It is proving to be a large burden upon health systems. In response, a number of approaches are being tried including the introduction of self-management programmes to assist people in improving their health outcomes. There are also claims that the introduction of information and communications technology (ICT) tools can improve the management of these chronic conditions.This paper investigates the influence of ICT on the health outcomes and experiences of patients with chronic obstructive pulmonary disease (COPD) participating in a mentored self-management programme. It utilises a combined quantitative and qualitative methodology and introduces the use of triad interviews to provide a broader evaluation of the experiences of individuals within a controlled trial. Two sub-groups of participants within the controlled trial were examined, both received mentoring but one sub-group was also supported with access to an ICT symptom monitoring tool. This research highlights the need for more holistic perspectives on patients and towards the use of a variety of methodological approaches in designing and evaluating e-health projects. Critically, this research highlights the need to expand our understanding of participant's outcomes beyond conventional clinical or cohort based measures.

Transforming clinical practice amongst community nurses: mentoring for COPD patient self-management.

AIMS AND OBJECTIVES: To report on the process of transforming clinical practice amongst community nurses through a mentoring programme implemented to support self-management amongst community-based sufferers of chronic obstructive pulmonary disease. BACKGROUND: The increasing incidence of and health burden from, chronic diseases has led to the emergence of more proactive, integrated chronic disease management approaches across the acute and primary care sectors. An important part of these approaches is the direct involvement of patients in their own care. Despite some difficulties with comparing the benefits of chronic disease self-management programmes, many evaluations report some benefit and all highlight the importance of health professionals in supporting self-management behaviours. In the primary care sector, community nurses are ideally situated to support these behaviours, but to do this effectively transformation of nursing practice must occur. DESIGN: Qualitative, longitudinal study informed by action research methods and involving monthly group discussions with community nurse mentors. METHODS: Community nurses from four community health centres in Tasmania were trained in motivational interviewing techniques to promote self-management amongst chronic obstructive pulmonary disease patients. Nurses' mentoring experiences were monitored during group discussions and subjected to thematic analysis. RESULTS: The paper reports the findings of the first 12 months of the project. In this phase, nurses experienced a transformation in their constructions of chronic obstructive pulmonary disease and their clinical practice. This involved a shift from a fatalistic, prescriptive, biomedical approach to a primary healthcare approach characterised by empathy, consultation, facilitation and a holistic focus. CONCLUSIONS: Community nurses face challenges in supporting chronic disease self-management. These challenges can be overcome and a transformation in clinical practice instilled. RELEVANCE TO CLINICAL PRACTICE: This study highlights that it is possible to support community nurses to take a lead role in the ongoing management of chronic disease in the community.

Optimal bacteriophage mutation rates for phage therapy.

The mutability of bacteriophages offers a particular advantage in the treatment of bacterial infections not afforded by other antimicrobial therapies. When phage-resistant bacteria emerge, mutation may generate phage capable of exploiting and thus limiting population expansion among these emergent types. However, while mutation potentially generates beneficial variants, it also contributes to a genetic load of deleterious mutations. Here, we model the influence of varying phage mutation rate on the efficacy of phage therapy. All else being equal, phage types with historical mutation rates of approximately 0.1 deleterious mutations per genome per generation offer a reasonable balance between beneficial mutational diversity and deleterious mutational load. We determine that increasing phage inoculum density can undesirably increase the peak density of a mutant bacterial class by limiting the in situ production of mutant phage variants. For phage populations with minimal genetic load, engineering mutation rate increases beyond the mutation-selection balance optimum may provide even greater protection against emergent bacterial types, but only with very weak selective coefficients for de novo deleterious mutations (below approximately 0.01). Increases to the mutation rate beyond the optimal value at mutation-selection balance may therefore prove generally undesirable.

Medical error management and the role of information technology--a new approach to investigating medical handover in acute care settings.

While identifying reasons why medical errors occur and constructing models of how to manage them has proved relatively straightforward, implementing and meaningfully evaluating solutions in 'real-world' settings has proven considerably more difficult. From an information systems (IS) perspective, although the promise of technology remains powerful, the continuing high incidence of medical errors suggest that eHealth approaches are struggling to acquire a clear understanding of the complex, dynamic and multi-layered nature of acute care settings and clinical practices, and to respond effectively to address the range of errors that actually occur. Using medical handover as a field-site, this research-in-progress paper presents an adaptation of James Reason's 'Swiss Cheese Model' to conceptualize the complex factors at play in medical errors in terms of human, system and informational elements. This research paper then examines how drawing on this model it is possible to generate and implement a methodological approach that both enhances a holistic understanding of medical error management and illuminates criteria that can be used to meaningfully identify an appropriate role for information technology in medical error mitigation. This research-in-progress paper aims to make a significant contribution to research into medical error management in 'real-world' acute care settings. This research is part of a bigger project that aims to develop, implement and evaluate an information technology artefact as part of an holistic information systems approach to improving medical error management at medical handover.

Determinants of aflatoxin M1 in breast milk in a selected group of Egyptian mothers.

In Egypt, there is a paucity of biomarker data on aflatoxin (AF) exposure. The study assessed the level and frequency of breast milk AFM1 as a biomarker of maternal exposure. Breast milk samples were collected from a selected group of 388 Egyptian lactating mothers of children attending the New El-Qalyub Hospital, Qalyubiyah governorate, Egypt, during May-September 2003. Following aflatoxin extraction, AFM1 levels were assessed by high-performance liquid chromatography (HPLC) with fluorescence detection. Approximately 36% of mothers tested positive for AFM1 (median 13.5 pg ml-1, interquartile range (IQR) 10.27-21.43). Non-working status (p = 0.018, odds ratio (OR) = 2.87), obesity (p = 0.004, OR = 3.01), high corn oil consumption (p = 0.002, OR = 2.21), number of children (>1) (p = 0.025, OR = 1.99), and early lactation stage (<1 month) (p = 0.028 OR = 3.57), contributed to the occurrence of AF in breast milk. AFM1 contamination of breast milk was frequent, albeit at moderate levels. Growth and development of the infant is rapid and thus it is possible that AF exposure through breast milk has a significant health effect.

Ferrite-enhanced MRI monitoring in hyperthermia.

In an MRI hyperthermia hybrid system, T1 changes are investigated for monitoring thermal therapy at 0.2 T. The water bolus, which is needed for power transmission and cooling of the skin, limits MR image quality by signal compression and artifacts. Superparamagnetic ferrofluid in different concentration was investigated with MR relaxometry and MRI methods. We found that using ferrofluid in a low concentration of 70-90 ppm magnetite the water signal can be suppressed without susceptibility artifacts. With our method of signal suppression, a significant improvement of spatial and temporal resolution is possible. The ferrofluid is stable and allows RF heating at 100 MHz. This method of signal extinction may also be useful for other experimental setups where suppression of water is necessary.

Experimental and numerical investigation of feed-point parameters in a 3-D hyperthermia applicator using different FDTD models of feed networks.

Experimental and numerical methods were used to determine the coupling of energy in a multichannel three-dimensional hyperthermia applicator (SIGMA-Eye), consisting of 12 short dipole antenna pairs with stubs for impedance matching. The relationship between the amplitudes and phases of the forward waves from the amplifiers, to the resulting amplitudes and phases at the antenna feed-points was determined in terms of interaction matrices. Three measuring methods were used: 1) a differential probe soldered directly at the antenna feed-points; 2) an E-field sensor placed near the feed-points; and 3) measurements were made at the outputs of the amplifier. The measured data were compared with finite-difference time-domain (FDTD) calculations made with three different models. The first model assumes that single antennas are fed independently. The second model simulates antenna pairs connected to the transmission lines. The measured data correlate best with the latter FDTD model, resulting in an improvement of more than 20% and 20 degrees (average difference in amplitudes and phases) when compared with the two simpler FDTD models.

Traitement homeopathique de la fibromyalgie primaire: a propos de deux essais cliniques en double insu / Homeopathic treatment of primary fibromyalgy: as regards of two clinic essays in double blind

Peu d'essais cliniques en double-insu avec controle par placebo ont ete effectues dans le domaine de la therapeutique homeopathique en rhumatologie. Les differentes methodes employees ont conduit a des resultats varies. Deux approches nouvelles sont decrites ici dans le cadre du traitement de la fibromyalgie primaire. Lors d'un premier essai 24 malades recurent pendant trois mois, selon l'indication, un remede homeopathique choisi parmi trois medicaments: Arnica, Bryonia, Rhus tox. La surveillance mensuelle portait sur les parametres suivants douleur, nombre de points douloureux et sommeil. Un "score d'indication homeopathique" a ete attribue a chaque prescription. Les resultats, analyses par le test "Wilcoxon Rank Sum", ont montre que le traitement actif produisait une amelioration statistiquement significative, mais seulement lorsque son indication etait bien posee. Le deuxieme essai consista en la comparaison de l'effect de Rhus tox. 6 CH a celui d'un placebo sur un groupe de trente patients souffrant de fibromyalgie primaire et choisis sur des criteres symptomatologiques correspondant a l'indication de Rhus tox. L'etude fut conduite selon la methode du double-insu croise contre placebo. L'amelioration par Rhus tox. 6 CH fut significativement plus importante que celle induite par le placebo: ceci, sur les parametres objectifs aussi bien que subjectifs

Efeito de tratamento homeopatico na fibrosite (fibromialgia primaria) / Effect of homeopathic treatment on fibrositis (primary fibromyalgia)

A fibrosite (fibromialgia primaria) e uma condicao controvertida, mas que vem se tornando cada vez mais aceita. E de dificil tratamento. Demonstramos que o remedio homeopatico Rhus toxicodendron C6 foi eficaz para um sub-grupo selecionado de pacientes com fibrosite. A melhora em relacao a sensibilidade, que e o melhor discriminador da fibrosite, foi particularmente perceptivel. A melhora experimentada pelos nossos pacientes enquanto recebiam tratamento ativo foi, no minimo, tao grande quanto o relatado para muitos outros tratamentos que tem sido testados em ensaios de tipo duplo-cego. Somos gratos a Jean Boiron por suas opinioes e encorajamento