Enhancing clinician participation in quality improvement training: implementation and impact of an evidence-based initiative to maximise antenatal clinician participation in training regarding women's alcohol consumption during pregnancy.

BACKGROUND: There are significant challenges in ensuring sufficient clinician participation in quality improvement training. Clinician capability has been identified as a barrier to the delivery of evidence-based care. Clinician training is an effective strategy to address this barrier, however, there are significant challenges in ensuring adequate clinician participation in training. This study aimed to assess the extent of participation by antenatal clinicians in evidence-based training to address alcohol consumption during pregnancy, and to assess differences in participation by profession. METHODS: A 7-month training initiative based on six evidence-based principles was implemented in a maternity service in New South Wales, Australia. Descriptive statistics described participation in training (% attending: any training; six evidence-based principles of training; all principles). Regression analyses examined differences by profession. RESULTS: Almost all antenatal clinicians participated in some training (182/186; 98%); 69% participated in ≥1 h of training (µ = 88.2mins, SD:56.56). The proportion of clinicians participating in training that satisfied each of the six principles ranged from 35% (training from peers and experts) to 82% (training was educational and instructional). Only 7% participated in training that satisfied all principles. A significantly higher proportion of midwifery compared to medical clinicians participated in training satisfying five of the six training principles. CONCLUSIONS: A training initiative based on evidence-based principles resulted in almost all clinicians receiving some training and 69% participating in at least 1 h of training. Variability between professions suggests training needs to be tailored to such groups. Further research is required to determine possible associations with care delivery outcomes. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

The Picture Talk Project: Starting a Conversation with Community Leaders on Research with Remote Aboriginal Communities of Australia.

BACKGROUND: Researchers are required to seek consent from Indigenous communities prior to conducting research but there is inadequate information about how Indigenous people understand and become fully engaged with this consent process. Few studies evaluate the preference or understanding of the consent process for research with Indigenous populations. Lack of informed consent can impact on research findings. METHODS: The Picture Talk Project was initiated with senior Aboriginal leaders of the Fitzroy Valley community situated in the far north of Western Australia. Aboriginal people were interviewed about their understanding and experiences of research and consent processes. Transcripts were analysed using NVivo10 software with an integrated method of inductive and deductive coding and based in grounded theory. Local Aboriginal interpreters validated coding. Major themes were defined and supporting quotes sourced. RESULTS: Interviews with Aboriginal leaders (n = 20) were facilitated by a local Aboriginal Community Navigator who could interpret if necessary and provide cultural guidance. Participants were from all four major local language groups of the Fitzroy Valley; aged 31 years and above; and half were male. Themes emerging from these discussions included Research-finding knowledge; Being respectful of Aboriginal people, Working on country, and Being flexible with time; Working together with good communication; Reciprocity-two-way learning; and Reaching consent. CONCLUSION: The project revealed how much more there is to be learned about how research with remote Aboriginal communities should be conducted such that it is both culturally respectful and, importantly, meaningful for participants. We identify important elements in community consultation about research and seeking consent.

The national incidence and clinical picture of SLE in children in Australia - a report from the Australian Paediatric Surveillance Unit.

OBJECTIVES: The objectives of this paper are to prospectively determine the incidence of paediatric systemic lupus erythematosus (pSLE) in Australia as well as describe the demographics, clinical presentation and one-year outcome. STUDY DESIGN: Newly diagnosed cases of pSLE were ascertained prospectively from October 2009 to October 2011 through the Australian Paediatric Surveillance Unit (a national monthly surveillance scheme for notification of childhood rare diseases) as well as national subspecialty groups. Questionnaires were sent to notifying physicians at presentation and at one year. RESULTS: The annual incidence rate was 0.32 per 10(5) children aged less than 16 years. The incidence was significantly higher in children of Asian or Australian Aboriginal and Torres Strait Islander parents. Approximately one-third of children underwent a renal biopsy at presentation and 7% required dialysis initially although only one child had end-stage kidney disease (ESKD) at one-year follow-up. CONCLUSION: The incidence of pSLE in Australia is comparable to that worldwide with a significantly higher incidence seen in children of Asian and Australian Aboriginal and Torres Strait Islander backgrounds. Renal involvement is common but progression to ESKD, at least in the short term, is rare.

The use of low-glycaemic index diets in diabetes control.

The aim of diabetes management is to normalise blood glucose levels since improved blood glucose control is associated with fewer complications. Food affects blood glucose levels; however, there is no universal approach to the optimal diabetic diet and there is controversy about the usefulness of the low-glycaemic index (GI) diet. To assess the effects of low-GI diets on glycaemic control in diabetes, we conducted electronic searches of the Cochrane Library, MEDLINE, EMBASE and CINAHL. We assessed randomised controlled trials (RCT) with interventions >4 weeks that compared a low-GI diet with a higher-GI diet for type 1 or type 2 diabetes. Twelve RCT (n 612) were identified. There was a significant decrease in glycated Hb (HbA1c) with low-GI diet than with the control diet, indicating improved glycaemic control (seven trials, n 457, weighted mean difference (WMD) - 0.4 % HbA1c, 95% CI - 0.7, - 0.20, P = 0.001). In four studies reporting the results for glycaemic control as fructosamine, three of which were 6 weeks or less in duration, pooled data showed a decrease in fructosamine (WMD - 0.23 mmol/l, 95% CI - 0.47, 0.00, P = 0.05), n 141, with low-GI diet than with high-GI diet. Glycosylated albumin levels decreased significantly with low-GI diet, but not with high-GI diet, in one study that reported this outcome. Lowering the GI of the diet may contribute to improved glycaemic control in diabetes.

Community Priority setting for Fetal Alcohol Spectrum Disorder Research in Australia.

INTRODUCTION: Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by prenatal alcohol exposure (PAE). FASD research is a rapidly growing field that crosses multiple disciplines. To ensure research is relevant and meaningful for people living with FASD, their families, and the broader public there is a need to engage community members in setting priorities for research. OBJECTIVES: Our primary objective was to formally identify the views of people living with FASD, their parents/caregivers, service providers, and the general community on the research priorities for FASD and alcohol use in pregnancy in Australia. Our secondary objective was to provide an overview of current research in the highest priority areas identified. METHODS: The approach for this study involved two community surveys and a consensus workshop, followed by a rapid literature review. Survey responses (n = 146) were collected and grouped using qualitative thematic analysis. The themes identified were then ranked in a second survey (n = 45). The 22 highest ranked themes were considered in a workshop with 21 community members, and consensus on the top ten priority areas was sought. The priority areas were grouped into conceptually similar topics and rapid literature reviews were undertaken on each. RESULTS: A diverse range of priorities was identified within key areas of prevention, diagnosis, and therapy. On request from participants, separate priority lists were developed by Aboriginal and non-Aboriginal participants. CONCLUSION: There is need for a national network of researchers to take forward the research commenced by the Centre of Research Excellence, FASD Research Australia, in addressing community priorities. KEY WORDS: Community, priorities, FASD, rapid review, Australia.

Low glycaemic index or low glycaemic load diets for overweight and obesity.

BACKGROUND: Obesity is increasingly prevalent, yet the nutritional management remains contentious. It has been suggested that low glycaemic index or load diets may stimulate greater weight loss than higher glycaemic index or load diets or other weight reduction diets. OBJECTIVES: To assess the effects of low glycaemic index or load diets for weight loss in overweight or obese people. SEARCH STRATEGY: Trials were identified through The Cochrane Library, MEDLINE, EMBASE, CINAHL and manual searches of bibliographies. SELECTION CRITERIA: Randomised controlled trials comparing a low glycaemic index or load diet (LGI) with a higher glycaemic index or load diet or other diet (Cdiet) in overweight or obese people. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed quality and extracted data, including any information provided on adverse effects. MAIN RESULTS: We identified six eligible randomised controlled trials (total of 202 participants). Interventions ranged from five weeks to six months duration with up to six months follow-up after the intervention ceased. The decrease in body mass (WMD -1.1 kg, 95% confidence interval (CI) -2.0 to -0.2, P < 0.05) (n = 163), total fat mass (WMD -1.1 kg, 95% CI -1.9 to -0.4, P < 0.05) (n =147) and body mass index (WMD -1.3, 95% CI -2.0 to -0.5, P < 0.05) (n = 48) was significantly greater in participants receiving LGI compared to Cdiets. The decrease in total cholesterol was significantly greater with LGI compared to Cdiets (WMD -0.22 mmol/L, 95% CI -0.43 to -0.02, P < 0.05), as was the change in LDL-cholesterol (WMD -0.24 mmol/L, 95% CI -0.44 to -0.05, P < 0.05). No study reported adverse effects, mortality or quality of life data. AUTHORS' CONCLUSIONS: Overweight or obese people on LGI lost more weight and had more improvement in lipid profiles than those receiving Cdiets. Body mass, total fat mass, body mass index, total cholesterol and LDL-cholesterol all decreased significantly more in the LGI group. In studies comparing ad libitum LGI diets to conventional restricted energy low-fat diets, participants fared as well or better on th LGI diet, even though they could eat as much as desired. Lowering the glycaemic load of the diet appears to be an effective method of promoting weight loss and improving lipid profiles and can be simply incorporated into a person's lifestyle. Further research with longer term follow-up will determine whether improvement continues long-term and improves quality of life.

Exercise for type 2 diabetes mellitus.

BACKGROUND: Exercise is generally recommended for people with type 2 diabetes mellitus. However, some studies evaluate an exercise intervention including diet or behaviour modification or both, and the effects of diet and exercise are not differentiated. Some exercise studies involve low participant numbers, lacking power to show significant differences which may appear in larger trials. OBJECTIVES: To assess the effects of exercise in type 2 diabetes mellitus. SEARCH STRATEGY: Trials were identified through the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and manual searches of bibliographies. Date of last search was March 3, 2005. SELECTION CRITERIA: All randomised controlled trials comparing any type of well-documented aerobic, fitness or progressive resistance training exercise with no exercise in people with type 2 diabetes mellitus. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed trial quality and extracted data. Study authors were contacted for additional information. Any information on adverse effects was collected from the trials. MAIN RESULTS: Fourteen randomised controlled trials comparing exercise against no exercise in type 2 diabetes were identified involving 377 participants. Trials ranged from eight weeks to twelve months duration. Compared with the control, the exercise intervention significantly improved glycaemic control as indicated by a decrease in glycated haemoglobin levels of 0.6% (-0.6 % HbA(1c), 95% confidence interval (CI) -0.9 to -0.3; P < 0.05). This result is both statistically and clinically significant. There was no significant difference between groups in whole body mass, probably due to an increase in fat free mass (muscle) with exercise, as reported in one trial (6.3 kg, 95% CI 0.0 to 12.6). There was a reduction in visceral adipose tissue with exercise (-45.5 cm(2), 95% CI -63.8 to -27.3), and subcutaneous adipose tissue also decreased. No study reported adverse effects in the exercise group or diabetic complications. The exercise intervention significantly increased insulin response (131 AUC, 95% CI 20 to 242) (one trial), and decreased plasma triglycerides (-0.25 mmol/L, 95% CI -0.48 to -0.02). No significant difference was found between groups in quality of life (one trial), plasma cholesterol or blood pressure. AUTHORS' CONCLUSIONS: The meta-analysis shows that exercise significantly improves glycaemic control and reduces visceral adipose tissue and plasma triglycerides, but not plasma cholesterol, in people with type 2 diabetes, even without weight loss.

Comparison of rat and human intestinal perfusion models for assessing efficacy of oral rehydration solutions.

The optimal composition for oral rehydration solutions remains controversial. Animal models have been used to assess the efficacy of new formulations but the relevance of these studies to the handling of oral rehydration solutions in human intestine during diarrhoeal disease states remains uncertain. Using steady state perfusion techniques we have compared water and solute transport from a variety of oral rehydration solutions in both the entire rat small intestine and in the human jejunum. Overall the pattern of water, sodium and glucose absorption was similar from the three oral rehydration solutions tested, indicating close parallelism between the two models despite the species and methodological differences. Although the relationship between the findings of these studies to the handling of oral rehydration solution in diarrhoeal disease states remains uncertain, we believe they do support the view that animal models may have a part to play in the preliminary screening of oral rehydration solutions before clinical trial.

Efficacy of a standard United Kingdom oral rehydration solution (ORS) and a hypotonic ORS assessed by human intestinal perfusion.

Human triple-lumen intestinal perfusion was used to compare water and solute absorption from the oral rehydration solution (ORS) most widely used in the United Kingdom and a new experimental hypotonic ORS (HYPO-ORS). HYPO-ORS (osmolality 210 mOsm/kg) promoted significantly greater water absorption than UK-ORS (7.03 +/- 1.1 vs 2.73 +/- 1.0 ml cm-1 h-1; P less than 0.01). HYPO-ORS produced net sodium and chloride absorption whereas the low sodium UK-ORS produced a net secretion of these ions. Bicarbonate absorption was also greater from HYPO-ORS although potassium and glucose absorption were similar from both solutions. This study suggests that UK-ORS may not promote optimal water and solute absorption and that clinical studies with HYPO-ORS are indicated.

Oral rehydration therapy without bicarbonate for prevention and treatment of dehydration: a double-blind controlled trial.

Forty children (less than or equal to 2 years of age) were admitted to hospital with acute gastroenteritis and were randomly assigned to receive either an oral rehydration solution (ORS) containing bicarbonate (Na 35, K 20, Cl 37, HCO3 18, glucose 202 mmol litre-1) or an identical solution in which bicarbonate was replaced by chloride ions. Groups were matched for age, sex, ethnic origin, duration of diarrhoea and nutritional status. On admission, degree of dehydration, biochemical and haematological parameters were similar. The majority had minimal or no dehydration and only 30% had moderate to severe dehydration. All children were treated successfully with no complications. Oral rehydration solution intake by each group was similar. Clinical outcome, as judged by speed of rehydration or maintenance of hydration, duration of diarrhoea, stool frequency and length of hospital stay, was the same in both groups. After 24 h of ORS there was no difference between groups in venous pH, serum bicarbonate, urea and electrolytes. In hospitalized children with acute gastroenteritis in the United Kingdom an ORS without bicarbonate is a safe, effective means to prevent dehydration and maintain hydration and acid-base status where dehydration is not severe. Exclusion of bicarbonate would simplify production, increase stability and reduce the cost of ORS without apparent impairment of efficacy.

Evaluation of three oral rehydration solutions designed for use in developed communities.

One hundred and sixteen children (less than 2 years old) admitted to a London hospital with acute gastroenteritis were randomized to receive either an oral rehydration solution (ORS) with low sodium and high glucose concentration (Na+ 35, glucose 200 mmol/L), an ORS with a high sodium but low glucose concentration (Na+ 60, glucose 111 mmol/L), or an ORS containing glycine and a glucose polymer (Na+ 50, glucose 50, glycine 50 mmol/L). Clinical, biochemical and haematological features of the three groups were similar on admission. Rotavirus was common (31%); the majority of children had minimal dehydration or acid-base disturbance. The clinical outcome, including ORS intake, prevention of dehydration, rehydration, and duration of hospital stay was similar in the three treatment groups. All initial electrolyte abnormalities were corrected; no child developed hypernatraemia or hyponatraemia. At 24 h, the mean serum urea was higher in those who received the ORS containing glycine than in other groups, and it had not fallen significantly since admission. Eighteen per cent of children had carbohydrate intolerance: four children with greater than or equal to 2% reducing substances in their stool had all received ORS with a high glucose content and had numerous watery green stools containing rotavirus. All ORS solutions were safe and effective for rehydration and correction of biochemical abnormalities, however carbohydrate intolerance was more prevalent in children who received the ORS with a high glucose content.

alpha 1-tubulin expression in proximally axotomized mouse cortical neurons.

This paper further characterizes the response to axotomy of mouse transcallosal cortical neurons, a population of neurons that seems to be particularly refractory to regeneration. Mouse transcallosal cortical neurons did not upregulate mRNA for the growth-associated protein alpha 1-tubulin following axotomy, even when the axonal distance from injury to cell body was only 100-300 microns. Previous experiments had found no upregulation of another growth-associated protein, GAP-43, by transcallosal neurons following axotomy 1-2 mm from the cell body. These latest results establish that this population of neurons fails to respond to axotomy even when it is extremely proximal and that this failure is not a peculiarity specific to one growth-associated protein but is indicative of a generally poor regenerative response.

Clinical experience with a hypotonic oral rehydration solution for treatment of pediatric gastroenteritis in the United Kingdom.

Animal and human perfusion studies suggest that water absorption can be optimized by glucose-electrolyte solutions with low total osmolality. A new oral rehydration solution (ORS), reformulated Dioralyte (RD), containing 60 mmol/L of sodium and 90 mmol/L of glucose with an osmolality of 240 mosm/kg, was tested for safety and efficacy in children in the United Kingdom with acute gastroenteritis. In a double-blind, controlled trial, RD was compared with standard Dioralyte (SD), a widely used low-sodium, high-glucose solution containing 35 mmol/L of sodium and 200 mmol/L of glucose, with an osmolality of 310 mosm/kg. Infants and children aged 2 weeks to 3 years admitted with acute gastroenteritis of less than five days' duration and mild to moderate dehydration were randomized to receive either RD or SD. Clinical and laboratory assessments were made on admission and 12, 24, and 48 hours after treatment. Thirty-two children were enrolled in the study; 14 received RD and 18 SD. No adverse effects from either ORS were reported. Efficacy was evaluated in 24 patients, of whom eight received RD and 16 SD. Total ORS intake and intake in milliliters per kilogram were similar in both treatment groups. Mean fluid balance, mean percentage weight change, and median stool frequency did not differ between the groups at 12, 24, and 48 hours after onset of treatment. Three (12.5%) patients had greater than or equal to 0.05% reducing substances in the stool during treatment, and the incidence was similar in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The anion in salt taste: a possible role for paracellular pathways.

It is well established from psychophysical and electrophysiological measurements that both Na and Cl contribute to the taste response to NaCl. The contribution of Na to the NaCl response can be studied using amiloride, a drug that inhibits Na transport in taste and other epithelial cells. The pathways involved in response to Cl are less well understood. We undertook a series of experiments in the rat to determine whether tonic chorda tympani responses to NaCl are inhibited by specific inhibitors of anion transport. Whole nerve responses to NaCl were unchanged by bathing the tongue in SITS, DIDS, bumetanide, furosemide, 9-anthracene carboxylic acid, or an antibody that blocks Cl conductance pathways in many epithelia. Thus, Cl co-transporters, exchangers, and channels (at least in the apical membrane of taste cells) are probably not involved in NaCl taste responses. When other anions (acetate, isethionate, methane sulfonate, gluconate, tartrate), which are generally impermeant in other Cl-selective pathways, were substituted for Cl, the dose-response curves for the chorda tympani response were shifted toward higher concentrations than the response to NaCl, but achieved the same maximum value at sufficiently high concentrations (1.0 M Na). For all the organic Na salts, the amiloride-insensitive portion of the response was substantially less than for NaCl. Experiments with Na acetate at different pHs showed that intracellular acidification is not responsible for the differences between NaCl and organic salts of Na. One possibility which remains is that apical stimulation with these other Na salts results in a taste cell membrane potential that is hyperpolarized with respect to the membrane potential in NaCl.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of proximal axotomy on GAP-43 expression in cortical neurons in the mouse.

As an approach to understanding why central neurons fail to regenerate, we have studied the response to proximal axotomy of transcallosal neurons of the cerebral cortex of the mouse. Anatomical studies have indicated only very slight regenerative responses by this population of cortical neurons. To further examine the regenerative response of these cells, we have looked by in situ hybridization at the expression of GAP-43 mRNA following axotomy caused by a stab wound delivered within about 200 microm to 1.25 mm of the cell body. Axotomized transcallosal neurons were compared with near-by unaxotomized transcallosal neurons, as well as with distant unaxotomized cortical neurons in the contralateral hemisphere. All three populations of neurons had been pre-labeled with Fluoro-Gold to allow identification. No up-regulation of GAP-43 mRNA above background levels was detected for axotomized cortical neurons at 1, 3 or 7 days after injury. In contrast, increases in mean silver grain density of up to 8-fold were measured in axotomized spinal cord motor neurons used as positive controls. Thus, as a population, the transcallosal cortical pyramidal neurons did not show a significant regenerative response, as monitored by GAP-43 upregulation, even with very close axotomy. These results identify this population of neurons as among the least regenerative studied, and suggest that, on a molecular level, inherent neuronal properties play a role in the limited regenerative response to brain injury.

Microglial movement to sites of nerve lesion in the leech CNS.

The small glial cells in the central nervous system of the leech, Hirudo medicinalis, have been studied using two histological stains. Weak silver carbonate, a classic stain for vertebrate microglia, can selectively stain these small glial cells and shows that they are morphologically similar to vertebrate microglia. Feulgen's DNA-specific stain is useful for counting the compact and distinctive microglial nuclei. In uninjured connectives, which link segmental ganglia, there are 134 +/- 28 microglia per 210 micron of connective length. Within 24 h after the nerve cord is crushed leech microglia aggregate at the site of injury. This increase in cells, seen both in vivo and in culture, is approximately 5-fold. Although cells do not continue to accumulate at the injury site after the first day, their numbers continue to vary with time in the regions immediately adjacent to the crush for at least one week. A second crush made 24 h after the first shows that leech microglia are capable of responding to repeated injury.

Ion transport across lingual epithelium is modulated by chorda tympani nerve fibers.

Each chorda tympani (CT) nerve innervates taste cells in fungiform papillae on one side of the anterior two-thirds of mammalian tongues. In this study, three effects of unilateral CT transection were investigated: (1) the persistence of taste cells on the ipsilateral and contralateral sides; (2) the ability of the CT to modulate ion transport across the ipsilateral and contralateral sides of canine lingual lingual epithelia; and (3) the effect on contralateral CT responses. Unilateral transection of dog CT caused the mean number of taste buds/fungiform papilla on the ipsilateral side to decrease from five to zero by 29-30 days after surgery. Taste buds reappeared after 44 days but in reduced numbers (two taste buds/papilla). This reappearance of taste buds after 44 days is consistent with the time predicted for the CT to regenerate and reach the anterior portion of the tongue. The number of taste buds/papilla remained unchanged on the contralateral side. Measurements of the short-circuit current (Isc) across both ipsilateral and contralateral sections of isolated canine lingual epithelia were performed at various times after unilateral CT transection. Both sides responded similarly. The Isc began to decline after 3 days, reached a minimum after approximately 18 days (approximately 40% of control Isc) and increased to control values after approximately 40 days. This includes experiments performed 30 days after surgery, when no taste buds were present on the ipsilateral side and the Isc was 80% of control values. For all times after CT transection, amiloride, an epithelial Na+ channel blocker, inhibited Isc. Thus, epithelial cells in dog tongue have amiloride-inhibitable pathways. These results show that proteins involved in active Na+ transport across lingual epithelial can be modulated by CT nerve fibers.

Morphological evidence that regenerating axons can fuse with severed axon segments.

Regenerating axons of sensory neurons in the leech nerve cord usually reconnect with their normal targets by growing the entire distance from the site of lesion to the target. However, in less than 1% to nearly 10% of cases a rapid restoration of the normal arborization occurs when the regenerating axon connects with the severed distal segment of the same cell or another cell of the same modality. The passage of horseradish peroxidase (mol. wt approximately 40,000 daltons) from the regenerating axon selectively into the axon or cell with which it has connected indicates that the two have joined or fused, rather than become linked by an electrical synapse, as sometimes occurs for other neurons in the leech. These results support the conclusions, based largely on physiological data from regenerating motor axons in crayfish, that unusually rapid and complete regeneration can occur when a growing axon fuses with its severed distal segment.

Prognostic factors determining response to antidepressant drugs in psychiatric out-patients and general practice.

The outcome of antidepressant drug treatment was measured in 200 patients, 145 seen in psychiatric out-patient clinics and 55 in general practice, after 4 weeks of therapy. The results of the 200 patients taken together suggested that prognosis was largely determined by factors dependent on the natural history of the disorder and that clinical symptoms were unimportant, but when the results for patients in each drug group were analysed separately symptoms were more important than natural history factors. We conclude that clinical symptoms are only important predictors of response to antidepressant drugs when the patients studied are homogeneous with regard to natural history factors, particularly duration of illness.