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SDG 3

Medical Dominance in the Australian Health System: The Case of the Bionic Ear
06 June 2006
University of Sydney

Collyer, Fran

The material for this paper is based on approximately 60 face-to-face interviews with specialist doctors, consumers, administrators, policy makers, various officials, researchers and company representatives. It is a case study of the development of the Australian Bionic Ear (or cochlear implant prosthesis) providing an analysis of the key social relationships within medicine - between doctors, scientists, consumers, government officials, industry representatives and others - which shape the development and implementation of new medical technologies.
Understanding Ulcers: Medical Knowledge, Social Constructionism, and Helicobacter Pylori
13 September 2006
University of Sydney

Collyer, Fran

The study of historical change in the content of medical knowledge in regard to specific illnesses or diseases provides sociologists with the opportunity to investigate both social processes and social theory. In this study of medical knowledge, propositions from the social constructionist school of sociology are utilised to highlight the way new knowledge about ulcers is generated, and to identify the cultural and social factors which inhibit the dissemination of new knowledge. The paper then explores recent challenges to this school of thought, using the case study of ulcers to suggest that there are limits to social constructionism and its capacity to explain change in medical knowledge and practice.
Clonal diversity in carcinomas: its implications for tumour progression and the contribution made to it by epithelial-mesenchymal transitions.
21 August 2008
University of Sydney

Lyons, J. Guy;Lobo, Erwin;Martorana, Anna M;Myerscough, Mary R

The progression of tumours to malignancy is commonly considered to arise through lineal evolution, a process in which mutations conferring pro-oncogenic cellular phenotypes are acquired by a succession of ever-more dominant clones. However, this model is at odds with the persistent polyclonality observed in many cancers. We propose that an alternative mechanism for tumour progression, called interclonal cooperativity, is likely to play a role at stages of tumour progression when mutations cause microenvironmental changes, such as occur with epithelial-mesenchymal transitions (EMTs). Interclonal cooperativity occurs when cancer cell-cancer cell interactions produce an emergent malignant phenotype from individually non-malignant clones. In interclonal cooperativity, the oncogenic mutations occur in different clones within the tumour that complement each other and cooperate in order to drive progression. This reconciles the accepted genetic and evolutionary basis of cancers with the observed polyclonality in tumours. Here, we provide a conceptual basis for examining the importance of cancer cell-cancer cell interactions to the behaviour of tumours and propose specific mechanisms by which clonal diversity in tumours, including that provided by EMTs, can drive the progression of tumours to malignancy.
Associations between overweight and obesity and risk factors for cardiovascular disease and fatty liver in young offenders serving community orders
01 December 2008
University of Sydney

Denney-Wilson, Elizabeth;Kenny, Dianna T;Hardy, Louise;Nelson, Paul

Purpose: The health of young offenders supervised in the community has not been previously studied. This paper describes the prevalence of overweight, obesity and obesity associated cardiovascular and hepatic risk factors in a sample of young offenders supervised in the community in New South Wales, Australia. Methods: During 2003-2005, 802 (85% male) young offenders took part in a comprehensive health survey that included direct measurement of height and weight as well as blood sampling. Results: The prevalence of combined overweight and obesity was 33.7% in boys and 35.3% in girls; both rates were higher than those of a comparable community sample. Cardiovascular risk factor prevalence was extremely high compared with other published studies, with over 90% of boys and almost 80% of girls having low levels of HDL cholesterol, and over 40% of both boys and girls having elevated LDL cholesterol. Risk factors for fatty liver disease were also prevalent with almost 15% of boys, and 30% of girls having raised ALT suggesting hepatic cell injury. Cardiovascular and fatty liver disease risk factors were significantly associated with overweight and obesity among boys, but not girls in this sample. Young people of Aboriginal or Torres Strait Islander decent were at no greater risk than the rest of the population. Conclusions: Young offenders are among the most disadvantaged people in Australian society and are particularly vulnerable to a range of health problems. The high prevalence of risk factors represents a substantial health burden for these young people in early adulthood. Timely intervention is required to address the complex health needs of this under-served population.
Reliability of self-report of health in juvenile offenders
01 December 2008
University of Sydney

Kenny, Dianna T;Grant, Jennifer

The aim of the present study was to investigate the accuracy of self-reports of juvenile offenders on physical factors (e.g., sleep difficulties, weight related behaviors and weight perceptions), health risk behaviors (e.g., alcohol use), trauma history (e.g., physical and sexual abuse) and psychological factors (e.g., anxiety, suicidal and self-harm behaviors). Self-reports obtained via a Health Questionnaire from 242 incarcerated juvenile offenders were compared with standardized measures (Body Mass Index, Adolescent Psychopathology Scale and Child Trauma Questionnaire) to investigate the reliability (via construct validity) and veracity of their self-report. Using kappa estimates and receiver operating characteristic curves, results generally showed high agreement across measures, suggesting that self-report questions from the health survey could all be used reliably. The degree of accuracy indicated that young offenders are as reliable as clinical and community samples of adolescents in their self-report. These findings have implications for routine assessments and practice evaluations that rely on self-report as the method of data collection and as the basis for clinical formulation and treatment planning.
Oxaliplatin induces drug resistance more rapidly than cisplatin in H69 small cell lung cancer cells
24 February 2009
University of Sydney

Stordal, Britta K;Davey, Mary W;Davey, Ross

Cisplatin produces good responses in solid tumours including small cell lung cancer (SCLC) but this is limited by the development of resistance. Oxaliplatin is reported to show activity against some cisplatin-resistant cancers but there is little known about oxaliplatin in SCLC and there are no reports of oxaliplatin resistant SCLC cell lines. Studies of drug resistance mainly focus on the cellular resistance mechanisms rather than how the cells develop resistance. This study examines the development of cisplatin and oxaliplatin resistance in H69 human SCLC cells in response to repeated treatment with clinically relevant doses of cisplatin or oxaliplatin for either 4 days or 2h. Treatments with 200ng/ml cisplatin or 400ng/ml oxaliplatin for 4 days produced sublines (H69CIS200 and H69OX400 respectively) that showed low level (approximately 2-fold)resistance after 8 treatments. Treatments with 1000ng/ml cisplatin or 2000ng/ml oxaliplatin for 2h also produced sublines, however these were not stably resistant suggesting shorter treatment pulses of drug may be more effective. Cells survived the first five treatments without any increase in resistance, by arresting their growth for a period and then regrowing. The period of growth arrest was reduced after the sixth treatment and the H69CIS200 and H69OX400 sublines showed a reduced growth arrest in response to cisplatin and oxaliplatin treatment suggesting that "regrowth resistance" initially protected against drug treatment and this was further upregulated and became part of the resistance phenotype of these sublines. Oxaliplatin dose escalation produced more surviving sublines than cisplatin dose escalation but neither set of sublines were associated with increased resistance as determined by 5-day cytotoxicity assays, also suggesting the involvement of regrowth resistance. The resistant sublines showed no change in platinum accumulation or glutathione levels even though the H69OX400 subline was more sensitive to buthionine sulfoximine treatment. The H69CIS200 cells were cross-resistant to oxaliplatin demonstrating that oxaliplatin does not have activity against low level cisplatin resistance. Relative to the H69 cells, the H69CIS200 and H69OX400 sublines were more sensitive to paclitaxel and taxotere suggests the taxanes may be useful in the treatment of platinum resistant SCLC. These novel cellular models of cisplatin and oxaliplatin resistant SCLC will be useful in developing strategies to treat platinum-resistant SCLC.
Oxaliplatin for the treatment of cisplatin-resistant cancer: a systematic review
24 February 2009
University of Sydney

Stordal, Britta;Pavlakis, Nick;Davey, Ross

Oxaliplatin is widely regarded as being active in cisplatin-resistant cancer. We undertook a systematic review of the literature to identify, describe and critique the clinical and pre-clinical evidence for the use of oxaliplatin in patients with “cisplatin-resistant” cancer. We identified 25 pre-clinical cell models of platinum resistance and 24 clinical trials reporting oxaliplatin based salvage therapy for cisplatin-resistant cancer. The pre-clinical data suggests that there is cross-resistance between cisplatin and oxaliplatin in low-level resistance models. In models with high level resistance (>10 fold) there is less cross resistance between cisplatin and oxaliplatin, which may be a reason why oxaliplatin is thought to be active in cisplatin-resistant cancer. In clinical trials where oxaliplatin has been used as part of salvage therapy for patients who have failed cisplatin or carboplatin combination chemotherapy, there was a much lower response rate in patients with platinum-refractory or resistant cancers compared to platinum-sensitive cancers. This suggests that there may be cross-resistance between cisplatin and oxaliplatin in the clinic. Oxaliplatin as a single agent had a poor response rate in cisplatin refractory and resistant cancer. Oxaliplatin performed better in combination with other agents for the treatment of platinum resistant/refractory cancer suggesting that the benefit of oxaliplatin may lie in its more favourable toxicity and ability to be combined with other drugs rather than an underlying activity in cisplatin resistance. Oxaliplatin therefore should not be considered broadly active in cisplatin-resistant cancer.
A systematic review of platinum and taxane resistance from bench to clinic: an inverse relationship
24 February 2009
University of Sydney

Stordal, Britta;Pavlakis, Nick;Davey, Ross

We undertook a systematic review of the pre-clinical and clinical literature for studies investigating the relationship between platinum and taxane resistance. Medline was searched for 1) cell models of acquired drug resistance reporting platinum and taxane sensitivities and 2) clinical trials of platinum or taxane salvage therapy in ovarian cancer. 137 models of acquired drug resistance were identified. 68.1% of cisplatin-resistant cells were sensitive to paclitaxel and 66.7% of paclitaxel-resistant cells were sensitive to cisplatin. A similar inverse pattern was observed for cisplatin vs docetaxel, carboplatin vs paclitaxel and carboplatin vs docetaxel. These associations were independent of cancer type, agents used to develop resistance and reported mechanisms of resistance. 65 eligible clinical trials of paclitaxel-based salvage after platinum therapy were identified. Studies of single agent paclitaxel in platinum-resistant ovarian cancer where patients had previously recieved paclitaxel had a pooled response rate of 35.3% n=232, compared to 22% in paclitaxel naïve patients n=1918 (p<0.01 Chi-squared). Suggesting that pre-treatment with paclitaxel may improve the response of salvage paclitaxel therapy. The response rate to paclitaxel/platinum combination regimens in platinum-sensitive ovarian cancer was 79.5% n=88 compared to 49.4% n=85 for paclitaxel combined with other agents (p<0.001 Chi-squared), suggesting a positive interaction between taxanes and platinum. Therefore the inverse relationship between platinum and taxanes resistance seen in cell models is mirrored in the clinical response to these agents in ovarian cancer. An understanding of the cellular and molecular mechanisms responsible would be valuable in predicting response to salvage chemotherapy and may identify new therapeutic targets.
On-line sexuality education and health professional students’ comfort in dealing with sexual issues.
09 June 2009
University of Sydney

Weerakoon, Patricia

A study of comfort level for sexually related topics in a sample of allied health professional students shows an improvement in their comfort level after completing an online sexuality unit. This finding supports the argument that modern technology can offer an excellent opportunity and means to develop personal and professional skills in sexually related issues. Raising the comfort levels of health professional students will better prepare them for professional interaction on sexually related issues they could encounter with their clients. Future research examining different ways to build not only comfort levels but also professional communication skills is warranted. The current and future research would aid in development of new programs based on distant education platforms, which could provide effective ways of appropriate sexual interventions education for health professionals in clinical settings.
Doctors' perspectives on PSA testing illuminate established differences in prostate cancer screening rates between Australia and the UK: a qualitative study.
05 November 2009
University of Sydney

Pickles, K;Carter, SM;Rychetnik, L;Entwistle, V

Objectives To examine how general practitioners (GPs) in the UK and GPs in Australia explain their prostate-specific antigen (PSA) testing practices and to illuminate how these explanations are similar and how they are different. Design A grounded theory study. Setting Primary care practices in Australia and the UK. Participants 69 GPs in Australia (n=40) and the UK (n=29). We included GPs of varying ages, sex, clinical experience and patient populations. All GPs interested in participating in the study were included. Results GPs' accounts revealed fundamental differences in whether and how prostate cancer screening occurred in their practice and in the broader context within which they operate. The history of prostate screening policy, organisational structures and funding models appeared to drive more prostate screening in Australia and less in the UK. In Australia, screening processes and decisions were mostly at the discretion of individual clinicians, and varied considerably, whereas the accounts of UK GPs clearly reflected a consistent, organisationally embedded approach based on local evidence-based recommendations to discourage screening. Conclusions The GP accounts suggested that healthcare systems, including historical and current organisational and funding structures and rules, collectively contribute to how and why clinicians use the PSA test and play a significant role in creating the mindlines that GPs employ in their clinic. Australia's recently released consensus guidelines may support more streamlined and consistent care. However, if GP mindlines and thus routine practice in Australia are to shift, to ultimately reduce unnecessary or harmful prostate screening, it is likely that other important drivers at all levels of the screening process will need to be addressed.
Challenges in assessing the characteristics of influential public health research.
18 May 2010
University of Sydney

Derrick, Gemma E.;Hall, Wayne D;Haynes, Abby S;Chapman, Simon;Redman, Sally;Leeder, Stephen R;Sturk, Heidi

The development of frameworks to effectively measure both the scientific and social impact of research is a topic of international debate. This paper examines how Australian public health researchers in six fields (alcohol, drugs, injury, obesity, skin cancer and tobacco) classified the scientific and social impact of what they judged to be their five most influential papers. We compared classifications of researchers rated as most influential by their peers with those not as highly ranked. Highly ranked researchers more often indicated social impact characteristics (Χ2 = 8.13; P = 0.004) than their less influential colleagues. Traditional measures of scientific impact (publication in high impact journals and high citations) were nominated by all researchers regardless of peer-nominated research influence status. There was strong consensus on who were the most influential researchers in five of the six research fields examined. This would appear to provide a sound platform on which to base more qualitative, interview or portfolio-based investigations into the complexities of wider conceptions of research and researcher influence.
Medical interns' reflections on their training in use of personal protective equipment
08 November 2010
University of Sydney

Barratt, Ruth;Wyer, Mary;Hor, Su-yin;Gilbert, Gwendolyn L.

BACKGROUND: The current COVID-19 pandemic has demonstrated that personal protective equipment (PPE) is essential, to prevent the acquisition and transmission of infectious diseases, yet its use is often sub-optimal in the clinical setting. Training and education are important to ensure and sustain the safe and effective use of PPE by medical interns, but current methods are often inadequate in providing the relevant knowledge and skills. The purpose of this study was to explore medical graduates' experiences of the use of PPE and identify opportunities for improvement in education and training programmes, to improve occupational and patient safety. METHODS: This study was undertaken in 2018 in a large tertiary-care teaching hospital in Sydney, Australia, to explore medical interns' self-reported experiences of PPE use, at the beginning of their internship. Reflexive groups were conducted immediately after theoretical and practical PPE training, during hospital orientation. Transcripts of recorded discussions were analysed, using a thematic approach that drew on the COM-B (capability, opportunity, motivation - behaviour) framework for behaviour. RESULTS: 80% of 90 eligible graduates participated. Many interns had not previously received formal training in the specific skills required for optimal PPE use and had developed potentially unsafe habits. Their experiences as medical students in clinical areas contrasted sharply with recommended practice taught at hospital orientation and impacted on their ability to cultivate correct PPE use. CONCLUSIONS: Undergraduate teaching should be consistent with best practice PPE use, and include practical training that embeds correct and safe practices.
‘Disease, Disaster and Despair’? The Presentation of Health in Low- and Middle-Income Countries on Australian Television
28 June 2011
University of Sydney

Imison, Michelle;Chapman, Simon

In high-income nations mainstream television news remains an important source of information about both general health issues and low- and middle-income countries (LMICs). However, research on news coverage of health in LMICs is scarce. The present paper examines the general features of Australian television coverage of LMIC health issues, testing the hypotheses that this coverage conforms to the general patterns of foreign news reporting in high-income countries and, in particular, that LMIC health coverage will largely reflect Australian interests. We analysed relevant items from May 2005 – December 2009 from the largest health-related television dataset of its kind, classifying each story on the basis of the region(s) it covered, principal content relating to health in LMICs and the presence of an Australian reference point. LMICs that are culturally proximate and politically significant to Australia had higher levels of reportage than more distant and unengaged nations. Items concerning communicable diseases, injury and aspects of child health generally consonant with ‘disease, disaster and despair’ news frames predominated, with relatively little emphasis given to chronic diseases which are increasingly prevalent in many LMICs. Forty-two percent of LMIC stories had explicit Australian content, such as imported medical expertise or health risk to Australians in LMICs. Media consumers’ perceptions of disease burdens in LMICs and of these nations’ capacity to identify and manage their own health priorities may be distorted by the major news emphasis on exotic disease, disaster and despair stories. Such perceptions may inhibit the development of appropriate policy emphases in high-income countries. In this context, non-government organisations concerned with international development may find it more difficult to strike a balance between crises and enduring issues in their health programming and fundraising efforts.
Media Miracles: The Separation of Conjoined Twins, and Reflections on Minimal Television News Coverage of Health from Low- and Middle-Income Countries
28 June 2011
University of Sydney

Imison, Michelle;Chapman, Simon

Australian television news and current affairs remain an important source of information for domestic audiences about both health and low- and middle-income countries. In November 2009, the successful surgical separation in Australia of conjoined infant twins from Bangladesh generated large-scale domestic media interest. In the 66 months to October 2010, only 75 health-related stories about Bangladesh were broadcast on Sydney television, 70 of them (93%) about these twins. Drawing on the television database of the Australian Health News Research Collaboration, this paper presents a thematic analysis of the Australian television news and current affairs coverage of the twins and why their case attained such a profile relative to other coverage of health from this nation. In addition to the predictable newsworthiness of a rare and bizarre medical condition and the made-for-television tension inherent in the saga of their arrival, preparation and eventual lengthy operation, prominent themes centred around the story’s opportunities to praise Australian individuals, medical skill and national character. The focus in this story on identified individuals with an uncommon condition requiring tertiary medical intervention only available in a high-income nation contrasts with a lack of coverage of, or critical consideration for, the well-being of anonymous individuals or less culturally-favoured groups, more long-term and mundane health considerations or any broader social or financial context to health issues in low- and middle-income countries. Reportage of foreign health issues appears contingent on the availability of populist ‘rule of rescue’ news frames, arresting footage and dramatic narratives that resonate with audiences’ expectations of such nations. The analysis offered in this paper illuminates the potential implications of such reporting for the wider news space available to health stories from low- and middle-income countries.
M-health and health promotion: the digital cyborg and surveillance society
05 April 2012
University of Sydney

Lupton, Deborah

The new mobile wireless computer technologies and social media applications using Web 2.0 platforms have recently received attention from those working in health promotion as a promising new way of achieving their goals of preventing ill-health and promoting healthy behaviours at the population level. There is very little critical examination in this literature of how the use of these digital technologies may affect the targeted groups, in terms of the implications for how individuals experience embodiment, selfhood and social relationships. This article addresses these issues, employing a range of social and cultural theories to do so. It is argued that m-health technologies produce a digital cyborg body. They are able to act not only as prostheses but also as interpreters of the body. The subject produced through the use of m-health technologies is constructed as both an object of surveillance and persuasion and as a responsible citizen who is willing and able to act on the health imperatives issuing forth from the technologies and to present their body/self as open to continual measurement and assessment. The implications of this new way of surveilling the body’s health are discussed.
NON-ADHERENCE TO PATIENT SAFETY GUIDELINES: AN EVOLUTIONARY, ECOLOGICAL HYPOTHESIS
16 April 2012
University of Sydney

de Almeida Neto, Abílio César

Often well meaning health care workers do not adhere to patient safety guidelines or recommendations, with serious consequences; patient injuries and mortality. Non-adherence has been attributed to external limitations, such as heavy workload, the non-availability of resources or how health care workers perceive the expectation of their superiors towards their performance. This paper presents new thoughts and ideas on such non-adherence. It presents a theoretical argument for how current policies for promoting patient safety in health care delivery might be hindered by a particular evolved mechanism that has not been considered. Non-adherence is argued to be an adaptation, or, more specifically, it is argued to be structured in such a way to generate adaptive outcomes when elicited by those in positions of power in dominance hierarchies wherein it is an efficient strategy. The core explanatory dynamics of non-adherence to patient safety guidelines are presented in terms of the social dominance hierarchy within which physicians function and that accounts for these evolved adaptations that enable maintenance of dominant status and cohesive (cooperative) group living and social rank-related mate selection behavior. Applied approaches to minimizing non-adherence to patent safety guidelines among health care workers (primarily physicians) are also presented.
Lessons from an online debate about measles-mumps-rubella (MMR) immunization
17 May 2012
University of Sydney

Nicholson, Michelle S.;Leask, J

OBJECTIVE: To provide strategies for immunization advocates on how best to participate in online discussion forums about immunization. METHODS: Content and thematic analysis of an online discussion forum held following the national screening of a documentary about the measles-mumps-rubella (MMR) vaccine and autism scare. A subsample of branches containing more than 20 posts was analysed. Each distinct message (a "post") was coded for the author's manifest position on immunization, author type, topic, and evidence presented or sought. RESULTS: From 103 distinct branches there were 1193 posts sent over a 3½h period. We selected the 13 longest branches containing 466 posts from 166 individuals. One third of these individuals were explicitly critical of MMR immunization and one third sought information. The remainder were ambivalent but seeking no information (5%), supportive (14%), or unstated (15%). Among five author categories, only 4% identified themselves as health professionals. Topics included alleged adverse effects of immunization (35%); autism spectrum disorders treatment and causes (31%); vaccine ingredients (12%); a conspiracy (9%); immunization policies (8%); and measles, mumps or rubella (4%). Scientific concepts of evidence failed to compete with lay concepts and personal anecdotes prevailed. CONCLUSIONS: Health professionals and other advocates of immunization should engage in similar types of post-broadcast online discussion forums in a planned and strategic manner that accounts for the decision processes of lay people. This involves expanding and diversifying the support base of people contributing to the forum; setting the agenda; introducing messages known to influence behaviour; not overselling vaccination; and avoiding personal attacks.
A disease in search of a cause: a study of self-citation and press release pronouncement in the factoid of wind farms causing “vibroacoustic disease”.
18 May 2012
University of Sydney

Chapman, Simon;St.George, Alexis

Background In recent years, claims have proliferated that wind turbines cause a large variety of diseases. Two of these, “Wind Turbine Syndrome” (WTS) and “Vibroacoustic disease” (VAD) are frequently mentioned. Seventeen reviews of the evidence for wind turbines causing harm have concluded the evidence to be poor yet some regulatory authorities are now referencing health concerns as part of the rationale for set-back guidelines from residences, greatly reducing siting opportunities. Methods and Findings Google returns 158,000 hits for WTS and 298,000 for VAD. We conducted a search for all papers and citations on WTS or VAD, and searched for evidence for any association between wind turbine exposure and VAD. No papers on WTS were found in indexed journals. Thirty five papers on VAD were found, none reporting on an association between VAD and wind turbines. Of the 35 papers on VAD, 34 had a first author from a single Portuguese research group. Seventy four per cent of citations to these papers were self-citations by the group. Median self-citation rates in science are around 7%. Two unpublished case reports presented at conferences were found alleging that VAD was “irrefutably demonstrated” to be caused by wind turbines. Conclusions VAD has received virtually no scientific recognition beyond the group who invented the term. The claim that wind turbines cause VAD is a factoid that has gone “viral” in cyberspace and may be contributing to nocebo effects among those living near turbines.
The case for a smokers' licence.
21 May 2012
University of Sydney

Chapman, Simon

The history of tobacco control has seen the introduction of policies initially considered radical, but which rapidly came to be considered normal and essential to the goals of reducing use and the burden of disease that tobacco causes. No other consumer product is subject to total advertising bans. None are required to be sold in plain packaging, as will be the case in Australia from December 2012. Again uniquely, 47 nations now require large graphic warnings on tobacco packaging. Smokefree public transport, workplaces, restaurants, bars, and stadiums are now the rule rather than the exception in an increasingly large number of nations. The legally binding World Health Organisation’s Framework Convention on Tobacco Control which requires such measures has been ratified by 174 nations. Despite these developments, the sale of tobacco and cigarettes is subject to trivial controls compared with other dangerous products that threaten either public or personal health or safety. In this paper, I outline a proposal for a major new development with potential to reduce tobacco use: the smokers’ license, and consider its likely benefits and the main objections.
Predicting breakfast consumption: A comparison of the theory of planned behaviour and the health action process approach
28 May 2012
University of Sydney

Mullan, Barbara;Wong, Cara;Kothe, Emily Jane;MacCann, Carolyn

Purpose: Breakfast consumption is associated with a range of beneficial health outcomes including improved overall diet quality, lower BMI, decreased risk of chronic disease, and improved cognitive function. Although there are many models of health and social behaviour, there is a paucity of research utilising these in breakfast consumption and very few studies that directly compare these models. This study compares the Theory of Planned Behaviour (TPB) and the Health Action Process Approach (HAPA) in predicting breakfast consumption. Methodology: University students (N=102; M = 19.5 years) completed a questionnaire measuring demographics, TPB and HAPA motivational variables, and intentions. Behaviour and HAPA volitional variables were measured four weeks later. Findings: Using structural equation modelling, it was found that the TPB model was a superior fit to the data across a range of model indices compared to the HAPA. Both models significantly predicted both intentions and behaviour at follow up; however, the TPB predicted a higher proportion of the variance in breakfast consumption (47.6%) than the HAPA (44.8%). Further, the volitional variables did not mediate the intention-behaviour gap, and the data were not an adequate statistical fit to the model compared to the TPB. Research Implications: The results support the use of the TPB and shows that that some aspects of the HAPA are useful in predicting breakfast consumption, suggesting that risk perception and self-efficacy be targeted in interventions to increase behaviour. The volitional variables did not appear to mediate breakfast consumption indicating that intention is still the strongest predictor, at least in this behaviour Originality: The current study is the first to compare the TPB and HAPA in predicting breakfast consumption
An Extension of the Theory of Planned Behavior to Predict Immediate Hedonic Behaviors and Distal Benefit Behaviors
04 June 2012
University of Sydney

Collins, Anna;Mullan, Barbara

The importance of understanding different behaviortypes is fundamental to changing patterns of dietary consumption toward optimal health. This study investigates fruit and vegetable (F&V) consumption as a distalbenefitbehavior and snacking as an immediatehedonicbehavior, within the framework of the theory of plannedbehavior (TPB; Ajzen, 1991). The model was extended to examine the predictive value of past behavior and self-regulatory ability across these two dietary behaviors. A total of 190 undergraduate students from an Australian university were administered two online questionnaires over two measurement points with 1-week interval. At time one, participants completed TPB questionnaires and a behavioral measure of self-regulation. At time two, self-reported dietary behavior was measured. Multiple and hierarchical regression analyses showed that the TPB model significantly predicted intention to perform both dietary behaviors and intention significantly predicted both behaviors. However consistent with hypotheses, there was a large intention-behavior gap and the predictive value of the TPB differed depending on whether the behavior had immediate vs. distal rewards. When past behavior was added to the model, intention was a significant predictor for the hedonicbehavior, but not for the distalbehavior. Differences in the predictive variables for the two behavior types suggest that the distalbenefitbehavior vs. immediatehedonicbehavior distinction may be useful when designing interventions by considering the temporal element of health decision-making.
The Role of Executive Function in Bridging the Intention-Behaviour Gap for Binge-Drinking in University Students
04 June 2012
University of Sydney

Mullan, Barbara;Wong, Cara;Allom, Vanessa;Pack, Sophia

Background Alcohol consumption contributes to a significant proportion of disease and the high prevalence amongst young adults is a worldwide health concern. Purpose To determine which aspects of executive function (EF) distinguish binge-drinkers from non binge-drinkers and to establish the role of EF in predicting behaviour. Methods Self-report questionnaires, four tests of self-regulation and a behaviour measure were administered to 153 students. Results The Theory of Planned Behaviour model was significant in predicting both intentions and behaviour. Although binge-drinkers and non binge-drinkers were found to differ on three of the four measures of EF, none predicted additional variance in behaviour. Planning ability and inhibition control moderated the relationship between intention and behaviour such that for individuals who intended to binge-drink, those with high planning ability or high inhibitory control were more likely to avoid doing so. Conclusions Interventions targeting binge-drinking behaviour should aim to develop planning skills and inhibitory control.
Consumer food-safety education for the domestic environment: a systematic review
05 June 2012
University of Sydney

Milton, Alyssa;Mullan, Barbara

Purpose Despite the recognised importance of food-safety, a large number of consumers do not practice adequate food-safety in the home. Many studies have recommended that education is a key step in preventing food borne illness in the domestic environment. However, few educational or psychosocial interventions have been designed and implemented to improve food-safety knowledge, attitudes and behaviours. Even fewer of these studies have been subject to rigorous appraisal. A systematic review of studies that described and evaluated a food-safety intervention in a non-clinical adult sample was conducted. Design/methodology/approach A total of ten studies met the criteria for inclusion in the systematic review. Outcomes of interest included food-safety behaviour, behavioural intention, attitudes, knowledge, microbial transfer and the use of Social Cognition Models. Findings The evidence regarding the effectiveness of the reviewed interventions on these food-safety outcomes was somewhat positive, however, many gaps remained. For example, of the 5 self-report behaviour change studies all reported some significant improvement post intervention. However, the percentage of specific behaviours that significantly changed within each study varied between 0.04 to 100%. There were methodological flaws in many of the studies which complicated the interpretation of these results and indicate a need for more research. Research limitations/implications Future research should include better defined outcomes, longer follow-up, more rigorous reporting of results and intervention design, the use of randomised controlled trial protocols, and utilising health models to have a greater theoretical underpinning to the studies. Originality/value This is the first systematic review examining the effect of psychosocial food-safety interventions on behaviour, attitudes and knowledge.
Strategic approaches to enhanced health service delivery for Aboriginal and Torres Strait Islander people with chronic illness: a qualitative study
22 June 2012
University of Sydney

Aspin, Clive;Brown, Ngiare;Jowsey, Tanisha;Yen, Laurann;Leeder, Stephen

Background Aboriginal and Torres Strait Islander people with chronic illness confront multiple challenges that contribute to their poor health outcomes, and to the health disparities that exist in Australian society. This study aimed to identify barriers and facilitators to care and support for Aboriginal and Torres Strait Islander people with chronic illness.Methods Face-to-face in-depth interviews were conducted with Aboriginal and Torres Strait Islander people with diabetes, chronic heart failure or chronic obstructive pulmonary disease (n-16) and family carers (n = 3). Interviews were transcribed verbatim and the transcripts were analysed using content analysis. Recurrent themes were identified and these were used to inform the key findings of the study. Results Participants reported both negative and positive influences that affected their health and well- being. Among the negative influences, they identified poor access to culturally appropriate health services, dislocation from cultural support systems, exposure to racism, poor communication with health care professionals and economic hardship. As a counter to these, participants pointed to cultural and traditional knowledge as well as insights from their own experiences. Participants said that while they often felt overwhelmed and confused by the burden of chronic illness, they drew strength from being part of an Aboriginal community, having regular and ongoing access to primary health care, and being well-connected to a supportive family network. Within this context, elders played an important role in increasing people’s awareness of the impact of chronic illness on people and communities. Conclusions Our study indicated that non-Indigenous health services struggled to meet the needs of Aboriginal and Torres Strait Islander people with chronic illness. To address their complex needs, health services could gain considerably by recognising that Aboriginal and Torres Strait Islander patients have a wealth of cultural knowledge at their disposal. Strategies to ensure that this knowledge is integrated into care and support programs for Aboriginal and Torres Strait Islander people with chronic illness should achieve major improvements.
Children’s Understandings of Mediated Health Campaigns for Childhood Obesity
28 June 2012
University of Sydney

Babooram, Melanie;Mullan, Barbara;Sharpe, Louise

Purpose: The present study investigated children’s understandings of the intent and importance of current media initiatives designed to target childhood obesity. Semi structured interviews were analysed using qualitative content analysis, for the responses of overweight and normal weight children. Methodology: Thirty-three children were interviewed, 24 of normal weight and 9 overweight. They were shown 2 print and 4 television advertisements from the New South Wales Health Department website that were popularly broadcast between 2003-2007. Children were then asked if they had seen the advertisement prior to the interview, and their understanding of the intent and importance of the advertisements. Findings: Most children in both weight groups recalled seeing 5 out of the 6 presented advertisements prior to interview. The main themes identified were ‘Health Maintenance’ and ‘Illness Prevention’ for 5 of the 6 advertisements. Overweight children were more numerous in their detection of a health message as opposed to normal weight children who mostly commented on the safety aspect of advertisement 6. Practical implications: Future evaluations of mediated health campaigns should go beyond recording simple recall of campaign material and investigate instead the understandings of target groups. Mediated health campaigns should also specify messages to particular target groups, as they appear to be most likely to facilitate behaviour change. Originality/value: Mediated health campaigns are mostly evaluated quantitatively rather than by qualitative means. In addition, no study has evaluated the views of overweight and normal weight children with regards to these health campaigns.
Australian journalists’ reflections on local coverage of a health-related story from the developing world
19 July 2012
University of Sydney

Imison, Michelle;Chapman, Simon

Given the limited Australian media coverage of health news from low- and middle-income countries (LMICs), the 2009 story of conjoined Bangladeshi twins Trishna and Krishna was conspicuous for its scale. This paper draws on interviews with journalists who reported the story and considers what those seeking to increase the news exposure given to LMIC health issues might learn from this coverage. It considers, in particular, the extent to which the twins’ story fitted with prevailing journalistic norms and beliefs about both health and news, and suited professional expectations and routines, especially in relation to choice of sources and access to material. Finally, the paper surveys opportunities for broader and deeper coverage of such news in the future.
Reporting Obesity: A Resource For Journalists
12 November 2012
University of Sydney

Bonfiglioli, Catriona

The aim of this publication is to highlight current debates in relation to obesity as a health problem, point to evidencebased research, suggest alternative news angles and illuminate the choices journalists can make in how they cover this topic.
Evidence Update On Obesity Prevention Across The Life-course
12 November 2012
University of Sydney

Hector, Debra;King, Lesley;Hardy, Louise;Alexis, St.George;Hebden, Lana;Espinel, Paola;Rissel, Chris

This Evidence Update, prepared for NSW Ministry of Health, provides a summary of evidence on the prevention of overweight and obesity in order to guide the development of the NSW State Obesity Plan 2012–2015. A solutions-focused approach to identifying promising strategies across different stages of the life course has been applied.
Healthy Workplace Guide: Ten Steps to Implementing A Workplace Health Program
15 November 2012
University of Sydney

Mitchell, Julie Ann;Eden, Barbara;Dunn, Scott;Cramp, Jo;Chapman, Kathy;Jayewardene, Vikki;King, Lesley;St.George, Alexis

To assist businesses to improve the health of their employees, the Heart Foundation, Cancer Council NSW and Physical Activity, Nutrition and Obesity Research Group (PANORG) from the School of Public Health at The University of Sydney, collaborated to develop this practical ten step guide. The guide provides easy to follow steps on creating a workplace that supports employees in leading healthy lifestyles, including how to get started, construct, implement and evaluate a workplace health program.
Target the fence-sitters
06 March 2013
University of Sydney

Leask, J

Past waves of vaccine rejection in industrialized nations have a lot to teach us about preventing future ones.
Spatio-temporal differences in the history of health and noise complaints about Australian wind farms: evidence for the psychogenic, “communicated disease” hypothesis.
14 March 2013
University of Sydney

Chapman, Simon;St.George, Alexis;Waller, Karen;Cakic, Vince

Background and objectives With often florid allegations about health problems arising from wind turbine exposure now widespread in parts of rural Australia and on the internet, nocebo effects potentially confound any future investigation of turbine health impact. Historical audits of health complaints across periods when such claims were rare are therefore important. We test 4 hypotheses relevant to psychogenic explanations of the variable timing and distribution of health and noise complaints about wind farms in Australia. Setting All (n=51) Australian wind farms (with 1634 turbines) operating from 1993–2012 . Methods Records of complaints about noise or health obtained from wind farm companies regarding residents living near 51 Australian wind farms, expressed as proportions of estimated populations residing within 5km of wind farms, and corroborated with complaints in submissions to 3 government public enquiries and news media records and court affidavits . Results There are large spatio-temporal variations in wind farm noise and health complaints.33/51(64.7%) of Australian wind farms including 17/34(50%) with turbine size >1MW have never been subject to noise or health complaints. These 33 farms have some 21,592 residents within 5km of their turbines and have operated complaint-free for a cumulative total of 267 years. Western Australia and Tasmania Have seen no complaints. Only 131 individuals across Australia representing approximately 1 in 250 residents living within 5km of wind farms appear to have ever complained, with 94(72%) of these being residents near 6 wind farms which have been targeted by anti wind farm groups . About 1 in 87 (126/10901) of those living near turbines >1MW have ever complained. The large majority 104/131(79%) of health and noise complaints commenced after 2009 when anti wind farm groups began to add health concerns to their wider opposition. In the preceding years, health or noise complaints were rare despite large and small turbined wind farms having operated for many years. Conclusions In view of scientific consensus that the evidence for wind turbine noise and infrasound causing health problems is poor, the reported spatio-temporal variations in complaints are consistent with psychogenic hypotheses that health problems arising are “communicated diseases” with nocebo effects likely to play an important role in the aetiology of complaints.
'The best thing for the baby': mothers' concepts and experiences related to promoting their infants' health and development
08 April 2013
University of Sydney

Lupton, Deborah

Mothers and pregnant women in contemporary western societies are at the centre of a web of expert and lay discourses concerning the ways they should promote and protect the health and development of their foetuses and infants. This article reports the findings from an Australian study involving interviews with 60 mothers. The findings explore in detail four topics discussed in the interviews related to pregnancy and caring for young infants: disciplining the pregnant body; promoting infants’ health; immunisation; and promoting infants’ development. It is concluded that the mothers were highly aware of their responsibilities in protecting their foetuses and infants from harm and promoting their health and development. They conceptualised the infant body as highly vulnerable and requiring protection from contamination. They therefore generally supported the idea of vaccination as a way of protecting their babies’ immature immune systems, but were also often ambivalent about it. The mothers were aware of the judgemental attitudes of others, including other mothers, towards their caring efforts and attempted to conform to the ideal of the ‘good mother’. The emotional dimensions of caring for infants and protecting their health are discussed in relation to the voluntary participation of mothers in conforming to societal expectations.
How the factoid of wind turbines causing “vibroacoustic disease” came to be “irrefutably demonstrated”.
23 May 2013
University of Sydney

Chapman, Simon;St.George, Alexis

Objective In recent years, claims have proliferated in cyberspace that wind turbines cause a large variety of symptoms and diseases. One of these, “vibroacoustic disease” (VAD) is frequently mentioned. Seventeen reviews of the evidence for wind turbines causing harm have concluded the evidence to be poor yet regulatory authorities are now referencing health concerns as part of the rationale for set-back guidelines from residences, greatly reducing siting opportunities. The aim of this study is to examine the quality of the evidence on how VAD came to be associated with wind turbine exposure by wind farm opponents. Methods Searches of the web (Google advanced) and major research databases for papers on VAD and wind turbines. Self-citation analysis of research papers on VAD. Results Google returned 24,700 hits for VAD and wind turbines. Thirty five research papers on VAD were found, none reporting any association between VAD and wind turbines. Of the 35 papers, 34 had a first author from a single Portuguese research group. Seventy four per cent of citations to these papers were self-citations by the group. Median self-citation rates in science are around 7%. Two unpublished case reports presented at conferences were found asserting that VAD was “irrefutably demonstrated” to be caused by wind turbines. The quality of these reports was abject. Conclusions VAD has received virtually no scientific recognition beyond the group who coined and promoted the concept. There is no evidence of even rudimentary quality that vibroacoustic disease is associated with or caused by wind turbines. Implications The claim that wind turbines cause VAD is a factoid that has gone “viral” in cyberspace and may be contributing to nocebo effects among those living near turbines.
'...a story that's got all the right elements': Australian media audiences talk about the coverage of a health-related story from the developing world
06 June 2013
University of Sydney

Imison, Michelle

Australian news coverage of low- and middle-income countries (LMICs) generally, and of their health contexts specifically, has long been criticised as problematic. This paper considers an exemplary LMIC health story and presents findings of an audience reception study that examined how different groups of Australian participants responded to it, the possible implications for future LMIC health coverage and for domestic perceptions of global public health. In particular, the paper examines how audiences talked about three of the story’s principal themes and suggests that greater audience engagement with LMIC health news may be possible as the mass-media landscape continues to evolve.
Issues affecting therapist workforce and service delivery in the disability sector in rural and remote New South Wales, Australia: perspectives of policymakers, managers and senior therapists
13 June 2013
University of Sydney

Veitch, Craig;Dew, Angela;Bulkeley, Kim;Lincoln, Michelle;Bundy, Anita;Gallego, Gisselle;Griffiths, Scott

Introduction: The disability sector encompasses a broad range of conditions and needs, including children and adults with intellectual and developmental disabilities, people with acquired disabilities, and irreversible physical injuries. Allied health professionals (therapists), in the disability sector, work within government and funded or charitable non-government agencies, schools, communities, and private practice. This article reports the findings of a qualitative study of therapist workforce and service delivery in the disability sector in rural and remote New South Wales (NSW), Australia. The aim was to investigate issues of importance to policy-makers, managers and therapists providing services to people with disabilities in rural and remote areas. Methods: The project gathered information via semi-structured interviews with individuals and small groups. Head office and regional office policy-makers, along with managers and senior therapists in western NSW were invited to participate. Participants included 12 policy-makers, 28 managers and 10 senior therapists from NSW government agencies and non-government organisations (NGOs) involved in providing services and support to people with disabilities in the region. Information was synthesised prior to using constant comparative analysis within and across data sets to identify issues.Results: Five broad themes resonated across participants’ roles, locations and service settings: (1) challenges to implementing policy in rural and remote NSW; (2) the impact of geographic distribution of workforce and clients; (3) workforce issues - recruitment, support, workloads, retention; (4) equity and access issues for rural clients; and (5) the important role of the NGO sector in rural service delivery and support. Conclusions: Although commitment to providing best practice services was universal, policy-related information transfer between organisations and employees was inconsistent. Participants raised some workforce and service delivery issues that are similar to those reported in the rural health literature but rarely in the context of allied health and disability services. Relatively recent innovations such as therapy assistants, information technology, and trans-disciplinary approaches, were raised as important service delivery considerations within the region. These and other innovations were expected to extend the coverage provided by therapists. Nongovernment organisations played a significant role in service delivery and support in the region. Participants recognised the need for therapists working for different organisations, in rural areas, to collaborate both in terms of peer support and service delivery to clients.
Folding of dinuclear platinum anticancer complexes within the cavity of para-sulphonatocalix[4]arene
25 July 2013
University of Sydney

Brown, Sarah D.;Plumb, Jane A.;Johnston, Blair F.;Wheate, Nial J.

The binding of three dinuclear platinum complexes, where the bridging ligand of the complexes is N,N0- (alkane-1,n-diyl)diisonicotinamide (n = 4, 6 or 8 for butane, hexane and octane, respectively) to the macrocycle para-sulphonatocalix[4]arene (sCX[4]) has been studied by 1H nuclear magnetic resonance (NMR) spectroscopy and molecular modelling. The NMR spectra show two important features, large upfield shifts of the methylene proton resonances of up to 1.8 ppm, which clearly places them within the shielding environment of the macrocycle’s cavity, and a loss of chemical symmetry of the metal complexes with extra resonances observed upon sCX[4] binding. Molecular models of the platinum–sCX[4] host–guest complexes show significant folding of the metal complexes’ aliphatic chain and a non-symmetrical interaction with the macrocycle. One side of the metal complexes forms three hydrogen bonds to sCX[4], whereas the opposite side of the metal complexes forms just one hydrogen bond, giving rise to the loss of chemical symmetry in the 1H NMR spectra. As the dinuclear platinum complexes are model anticancer drugs, the effect of sCX[4] binding was investigated in vitro in the human ovarian carcinoma cell line A2780 and its cisplatin-resistant sub-line A2780cp70. Whilst the free metal complexes are a magnitude of order more active than cisplatin in the A2780 cell line, they are all highly cross-resistant with cisplatin in the A2780cp70 line. Binding by sCX[4] has little affect on the metal complexes’ cytotoxicity in the sensitive cell line, but has a large effect in the resistant cell line. The two shortest metal complexes become less active when bound by sCX[4], whereas the longest metal complex becomes more cytotoxic.
Evaluation of anionic half generation 3.5–6.5 poly(amidoamine) dendrimers as delivery vehicles for the active component of the anticancer drug cisplatin
25 July 2013
University of Sydney

Kirkpatrick, Gordon J.;Plumb, Jane A.;Sutcliffe, Oliver B.;Flint, David J.;Wheate, Nial J.

Aquated cisplatin was added to half-generation PAMAM dendrimers and the resultant complexes were purified by centrifuge. The drug–dendrimer complexes were then characterised by 1-D and diffusion 1H NMR and ICP-AES. The amount of drug bound was found to increase in proportion with dendrimer size: G3.5, 22 cis- {Pt(NH3)2} molecules per dendrimer; G4.5, 37; G5.5, 54; and G6.5, 94, which represent only a fraction of the available binding sites on each dendrimer (68, 58, 42 and 37%, respectively). Drug release studies showed that some drug remains bound to the dendrimer even after prolonged incubation with 5′—GMP at temperatures of 60 °C for over a week (percentage of drug released 18, 30, 35 and 63%, respectively). Attachment of the drug was found to decrease the radius of the dendrimers. Finally, the effect of the dendrimer on drug cytotoxicity was determined using in vitro assays with the A2780, A2780cis and A2780cp ovarian cancer cell lines. The free dendrimers display no cytotoxicity whilst the drug–dendrimer complexes showed moderate activity. In vivo activity was examined using an A2780 tumour xenograft. Cisplatin, at its maximum tolerated dose of 6 mg/kg, reduced tumour size by 33% compared to an untreated control group. The G6.5 cisplatin–dendrimer complex was administered at two doses (6 and 8 mg/kg equivalent of cisplatin). Both were well tolerated by the mice. The lower dose displayed comparable activity to cisplatin with a tumour volume reduction of 32%, but the higher dose was significantly more active than free cisplatin with a tumour reduction of 45%.
Cisplatin drug delivery using gold-coated iron oxide nanoparticles for enhanced tumour targeting with external magnetic fields
31 July 2013
University of Sydney

Wagstaff, Amelia A.;Brown, Sarah D.;Holden, Megan R.;Craig, Gemma E.;Plumb, Jane A.;Brown, Roisin E.;Schreiter, Norbert;Chrzanowski, Wojciech;Wheate, Nial J.

The platinum-based chemotherapeutic drug cisplatin is highly effective in the treatment of solid tumours, but its use is restricted by poor bioavailability, severe dose-limiting side effects and rapid development of drug resistance. In light of this we have tethered the active component of cisplatin to goldcoated iron oxide nanoparticles to improve its delivery to tumours and increase its efficacy. Iron oxide nanoparticles (FeNPs) were synthesised via a co-precipitation method before gold was reduced onto the surface (Au@FeNPs). Aquated cisplatin was used to attach {Pt(NH3)2} to the nanoparticles by a thiolated polyethylene glycol linker forming the desired product (Pt@Au@FeNP). The nanoparticles were characterised by dynamic light scattering, scanning transmission electron microscopy, UV–Vis spectrophotometry, inductively coupled plasma mass spectrometry and electron probe microanalysis. The nanoparticles increase in size as they are constructed, with the synthesised FeNPs having a diameter of 5– 50 nm, which increases to 20–80 nm for the Au@FeNPs, and to 60–120 nm for the Pt@Au@FeNPs. Nanoparticle drug loading was found to be 7.9 10 4 moles of platinum per gram of gold. The FeNPs appear to have little inherent cytotoxicity, whereas the Au@FeNPs are as active as cisplatin in the A2780 and A2780/cp70 cancer cell lines. More importantly the Pt@Au@FeNPs are up to 110-fold more cytotoxic than cisplatin. Finally, external magnets were used to demonstrate that the nanoparticles could be accumulated in specific regions and that cell growth inhibition was localised to those areas.
What factors in rural and remote extended clinical placements may contribute to preparedness for practice, from the perspective of students and clinicians?
07 August 2013
University of Sydney

Daly, Michele;Perkins, David;Kumar, Koshila;Roberts, Chris;Moore, Malcolm

What factors in rural and remote extended clinical placements may contribute to preparedness for practice, from the perspective of students and clinicians? Michele Daly, David Perkins, Koshila Kumar, Chris Roberts and Malcolm Moore Background: Community based rural education opportunities have expanded in Australia, attracting more medical students to placements in rural and remote settings. Aim: To identify the factors in an integrated, community engaged rural placement that may contribute to preparedness for practice (P4P), from the perspective of students and clinicians Methods: Forty two semi-structured interviews with medical students, supervisors and clinicians analysed thematically. Results: Opportunities for clinical learning, personal and professional development and cultural awareness were reported by students and clinicians as key factors that contribute to preparedness for practice. Potential barriers in rural and remote settings included geographical and academic isolation, perceived educational risk and differing degrees of program engagement. Conclusions: A longitudinal clinical placement in a rural setting may enable development of enhanced competencies leading to P4P. A rural setting can help provide a unique experience through hands-on learning, enhanced personal and professional development opportunities and observation of the cultural and contextual impact on health.
The need for new models for delivery of therapy intervention to people with a disability in rural and remote areas of Australia
26 September 2013
University of Sydney

Dew, Angela;Veitch, Craig;Lincoln, Michelle;Brentnall, Jennie;Bulkeley, Kim;Gallego, Gisselle;Bundy, Anita;Griffiths, Scott

Early therapy intervention by occupational therapists, physiotherapists, and speech pathologists (therapists) is recognised to yield benefits across the lifecourse (Carpenter, 2007; Law, 2002; Thomaidis, Kaderoglou, Stefou, Damianou, & Bakoula, 2000; Ziviani, Feeney, Rodger, & Watter, 2010). As a result,there have recently been increases in funding for therapy positions in disability services in New South Wales(NSW), Australia (New South Wales Government, 2006). However, research by Keane, Smith, Lincoln,and Fisher (2011), Chisholm, Russell, and Humphreys (2011), and Denham and Shaddock (2004) indicated that there is a shortage of therapists living and working in rural and remote areas of Australia.
'It's a terrible thing when your children are sick': motherhood and home healthcare work
21 October 2013
University of Sydney

Lupton, Deborah

This article draws upon research involving indepth interviews with 60 mothers of young children about the home healthcare in which they engage when promoting their children’s health and dealing with their illnesses, allergies or developmental problems. The study found that a series of often interconnected discourses were evident in the women’s accounts. These included the discourses of health states as controllable, good health as an outcome of good management and the child’s body as vulnerable. Other discourses were related to the concept of the ‘good mother’. The interviewees also employed the discourses of home health care as emotionally distressing and as hard work and of children’s illness as a mother’s loss of control. As this suggests, such caring was often an intensely embodied and negative emotional experience for the mothers, particularly if they felt as if they had lost control over their children’s bodies.
Longitudinal integrated rural placements: a social learning systems perspective
24 October 2013
University of Sydney

Daly, Michele;Roberts, Chris;Kumar, Koshila;Perkins, David

OBJECTIVES There is currently little theoretically informed exploration of how non-traditional clinical placement programmes that are longitudinal, immersive, based on community-engaged education principles and located in rural and remote settings may contribute to medical student learning. This paper aims to theoretically illustrate the pedagogical and socio-cultural underpinnings of student learning within a longitudinal, integrated, community-engaged rural placement. METHODS Data collected using semi-structured interviews with medical students, their supervisors and other health clinicians participating in a longitudinal rural placement programme were analysed using framework analysis. Data interpretation was informed by the theory of social learning systems (SLSs). RESULTS In a longitudinal, rural clinical placement students participate in an SLS with distinct yet interrelated learning spaces that contain embedded communities of practice (CoPs). These spaces are characterised by varying degrees of formality, membership and interaction, and different learning opportunities and experiences. They are situated within and shaped by a unique geography of place comprising the physical and social features of the placement setting. Within these learning spaces, students acquire clinical knowledge, skills and competencies, professional attitudes, behaviours and professional values. The process of connectivity helps explain how students access and cross the boundaries between these learning spaces and develop a more complex sense of professional identity. CONCLUSIONS Longitudinal, integrated clinical placement models can be understood as SLSs comprising synergistic and complementary learning spaces, in which students engage and participate in multiple CoPs. This occurs in a context shaped by unique influences of the geography of place. This engagement provides for a range of student learning experiences, which contribute to clinical learning and the development of a more sophisticated professional identity. A range of pedagogical and practical strategies can be embedded within this SLS to enhance student learning.
Examining stress and response to stress in medical students and new medical graduates
06 November 2013
University of Sydney

Daly, Michele

MOST MEMBERS OF THE MEDICAL PROFESSION feel stressed at some time. If stress is ongoing, impairment may occur (defined as being unable to safely or reliably perform one’s role). A continuum appears to exist between functioning well, being distressed and becoming impaired, with external (environment-related) and internal (personalrelated) stressors determining where an individual will lie on the continuum. We are conducting a study which aims to determine whether distress in new medical graduates can be predicted before the graduates become impaired and unable to safely or reliably perform their role. Study commencement Our study, which commenced in 1997, initially looked at predictors for “troubled” and “troublesome” interns. Hospital- based focus groups comprising interns (postgraduate Year 1), resident medical officers (postgraduate Year 2 and above), ward-based nursing staff and medical administrators reported on internal and external stressors for junior medical staff. Residents and nurses reported similar external stressors, whereas the internal stressors reported by the two groups were quite different (Box 1). Residents tended to report issues relating to “troubled” interns (eg, poor support, few outside interests), whereas nurses identified factors relating more to “troublesome” interns (eg, poor attitude, unprofessionalism). In other words, resident staff seemed to be able to identify their stressed and at-risk peers before effects on performance were observed (Box 1).
Law and the Crime of Practicing Popular Medicine in Early Modern Society
06 January 2014
University of Sydney

O'Brien, Karen

Research into the ecclesiastical court records of Northwest England suggests that legal accusations initiated by the community were spontaneous demonstrations of fear that increased during periods of social dislocation, principally when large numbers of children died at any one time in a particular community. There is evidence to suggest that the cunning folk were caught up in these community outpourings of anguish and were often held responsible by members of the community for causing the misfortune. The primary documents consulted for this investigation provide an important historical source. They offer an insight into a little understood social account of the widespread affairs and popular form of treatment that contributes a unique perspective of popular medicine and the connection with the supernatural world, while offering an insight into the lives and mentalities of villagers and townspeople of early modern England.
Contribution of DEAF1 structural domains to the interaction with the breast cancer oncogene LMO4.
23 January 2014
University of Sydney

Cubeddu, Liza;Joseph, Soumya;Richard, D.J.;Matthews, Jacqueline

The proteins LMO4 and DEAF1 contribute to the proliferation of mammary epithelial cells. During breast cancer LMO4 is upregulated, affecting its interaction with other protein partners. This may set cells on a path to tumour formation. LMO4 and DEAF1 interact, but it is unknown how they cooperate to regulate cell proliferation. In this study, we identify a specific LMO4-binding domain in DEAF1. This domain contains an unstructured region that directly contacts LMO4, and a coiled coil that contains the DEAF1 nuclear export signal (NES). The coiled coil region can form tetramers and has the typical properties of a coiled coil domain. Using a simple cell-based assay, we show that LMO4 modulates the activity of the DEAF NES, causing nuclear accumulation of a construct containing the LMO4-interaction region of DEAF1
The reliability of a new scoring system for knee osteoarthritis MRI and the validity of bone marrow lesion assessment: BLOKS (Boston–Leeds Osteoarthritis Knee Score)
28 January 2014
University of Sydney

Hunter, David J.

Aim: MRI provides unparalleled visualisation of all the anatomical structures involved in the osteoarthritis (OA) process. There is a need for reliable methods of quantifying abnormalities of these structures. The aim of this work was to assess the reliability of a novel MRI scoring system for evaluating OA of the knee and explore the validity of the bone marrow lesion (BML) scoring component of this new tool. Methods: After review of the relevant literature, a collaborative group of rheumatologists and radiologists from centres in the UK and USA established preliminary anatomical divisions, items (necessarily broadly inclusive) and scaling for a novel semi-quantitative knee score. A series of iterative reliability exercises were performed to reduce the initial items, and the reliability of the resultant Boston–Leeds Osteoarthritis Knee Score (BLOKS) was examined. A further sample had both the BLOKS and WORMS (Whole Organ MRI Score) bone marrow lesion (BML) score performed to assess the construct validity (relation to knee pain) and longitudinal validity (prediction of cartilage loss) of each scoring method. Results: The BLOKS scoring method assesses nine intraarticular regions and contains eight items, including features of bone marrow lesions, cartilage, osteophytes, synovitis, effusions and ligaments. The scaling for each feature ranges from 0–3. The inter-reader reliability for the final BLOKS items ranged from 0.51 for meniscal extrusion up to 0.79 for meniscal tear. The reliability for other key features was 0.72 for BML grade, 0.72 for cartilage morphology, and 0.62 for synovitis. Maximal BML size on the BLOKS scale had a positive linear relation with visual analogue scale (VAS) pain, however the WORMS scale did not. Baseline BML was associated with cartilage loss on both BLOKS and WORMS scale. This association was stronger for BLOKS than WORMS. Conclusion: We have designed a novel scoring system for MRI OA knee, BLOKS, that demonstrates good reliability. Preliminary inspection of the validity of one of the components of this new tool supports the validity of the BLOKS BML scoring method over an existing instrument. Further iterative development will include validation for use in both clinical trials and epidemiological studies.
Management of osteoarthritis of the knee
28 January 2014
University of Sydney

Bennell, Kim L;Hunter, David J.;Hinman, Rana S

Osteoarthritis is a chronic disease; management should be patient centred and coordinated, with attention to modifiable risk factors and comorbidities Focus on conservative non-drug treatment, particularly exercise; for overweight or obese patients weight loss is recommended Management should be evidence based; do not use interventions with high cost and risk that outweigh their benefits Use paracetamol or non-steroidal anti-inflammatory drugs for pain relief, with due attention to precautions and contraindications Refer patients to a physiotherapist for exercise, manual therapy, and gait aids; orthotist for bracing; psychologist for cognitive behavioural therapy; and dietitian for nutritional advice Do not use arthroscopy for pain management; refer patients for joint replacement only when symptoms are severe and other treatments have failed
Strength Training for Arthritis Trial (START): design and rationale
28 January 2014
University of Sydney

Messier, Stephen P;Mihalko, Shannon L;Beavers, Daniel P;Nicklas, Barbara J.;DeVita, Paul;Carr, J. Jeffery;Hunter, David J.;Williamson, Jeff D;Bennell, Kim L;Guermazi, Ali;Lyles, Mary;Loeser, Richard F.

Background Muscle loss and fat gain contribute to the disability, pain, and morbidity associated with knee osteoarthritis (OA), and thigh muscle weakness is an independent and modifiable risk factor for it. However, while all published treatment guidelines recommend muscle strengthening exercise to combat loss of muscle mass and strength in knee OA patients, previous strength training studies either used intensities or loads below recommended levels for healthy adults or were generally short, lasting only 6 to 24 weeks. The efficacy of high-intensity strength training in improving OA symptoms, slowing progression, and affecting the underlying mechanisms has not been examined due to the unsubstantiated belief that it might exacerbate symptoms. We hypothesize that in addition to short-term clinical benefits, combining greater duration with high-intensity strength training will alter thigh composition sufficiently to attain long-term reductions in knee-joint forces, lower pain levels, decrease inflammatory cytokines, and slow OA progression. Methods/Design This is an assessor-blind, randomized controlled trial. The study population consists of 372 older (age ≥ 55 yrs) ambulatory, community-dwelling persons with: (1) mild-to-moderate medial tibiofemoral OA (Kellgren-Lawrence (KL) = 2 or 3); (2) knee neutral or varus aligned knee ( -2° valgus ≤ angle ≤ 10° varus); (3) 20 kg.m-2 ≥ BMI ≤ 45 kg.m-2; and (3) no participation in a formal strength-training program for more than 30 minutes per week within the past 6 months. Participants are randomized to one of 3 groups: high-intensity strength training (75-90% 1Repetition Maximum (1RM)); low-intensity strength training (30-40%1RM); or healthy living education. The primary clinical aim is to compare the interventions’ effects on knee pain, and the primary mechanistic aim is to compare their effects on knee-joint compressive forces during walking, a mechanism that affects the OA disease pathway. Secondary aims will compare the interventions’ effects on additional clinical measures of disease severity (e.g., function, mobility); disease progression measured by x-ray; thigh muscle and fat volume, measured by computed tomography (CT); components of thigh muscle function, including hip abductor strength and quadriceps strength, and power; additional measures of knee-joint loading; inflammatory and OA biomarkers; and health-related quality of life. Discussion Test-retest reliability for the thigh CT scan was: total thigh volume, intra-class correlation coefficients (ICC) = 0.99; total fat volume, ICC = 0.99, and total muscle volume, ICC = 0.99. ICC for both isokinetic concentric knee flexion and extension strength was 0.93, and for hip-abductor concentric strength was 0.99. The reliability of our 1RM testing was: leg press, ICC = 0.95; leg curl, ICC = 0.99; and leg extension, ICC = 0.98. Results of this trial will provide critically needed guidance for clinicians in a variety of health professions who prescribe and oversee treatment and prevention of OA-related complications. Given the prevalence and impact of OA and the widespread availability of this intervention, assessing the efficacy of optimal strength training has the potential for immediate and vital clinical impact.
Does lumbar spinal degeneration begin with the anterior structures? A study of the observed epidemiology in a community-based population
28 January 2014
University of Sydney

Suri, Pradeep;Miyakoshi, Asako;Hunter, David J.;Jarvik, Jeffrey G;Rainville, James;Guermazi, Ali;Li, Ling;Katz, Jeffrey N.

Background- Prior studies that have concluded that disk degeneration uniformly precedes facet degeneration have been based on convenience samples of individuals with low back pain. We conducted a study to examine whether the view that spinal degeneration begins with the anterior spinal structures is supported by epidemiologic observations of degeneration in a community-based population. Methods- 361 participants from the Framingham Heart Study were included in this study. The prevalences of anterior vertebral structure degeneration (disk height loss) and posterior vertebral structure degeneration (facet joint osteoarthritis) were characterized by CT imaging. The cohort was divided into the structural subgroups of participants with 1) no degeneration, 2) isolated anterior degeneration (without posterior degeneration), 3) combined anterior and posterior degeneration, and 4) isolated posterior degeneration (without anterior structure degeneration). We determined the prevalence of each degeneration pattern by age group < 45, 45-54, 55-64, ≥65. In multivariate analyses we examined the association between disk height loss and the response variable of facet joint osteoarthritis, while adjusting for age, sex, BMI, and smoking. Results- As the prevalence of the no degeneration and isolated anterior degeneration patterns decreased with increasing age group, the prevalence of the combined anterior/posterior degeneration pattern increased. 22% of individuals demonstrated isolated posterior degeneration, without an increase in prevalence by age group. Isolated posterior degeneration was most common at the L5-S1 and L4-L5 spinal levels. In multivariate analyses, disk height loss was independently associated with facet joint osteoarthritis, as were increased age (years), female sex, and increased BMI (kg/m2), but not smoking. Conclusions- The observed epidemiology of lumbar spinal degeneration in the community-based population is consistent with an ordered progression beginning in the anterior structures, for the majority of individuals. However, some individuals demonstrate atypical patterns of degeneration, beginning in the posterior joints. Increased age and BMI, and female sex may be related to the occurrence of isolated posterior degeneration in these individuals.
Association between bone marrow lesions detected by magnetic resonance imaging and knee pain in community residents in Korea
28 January 2014
University of Sydney

Kim, I. J.;Kim, D. H.;Jung, J. Y.;Song, Y. W.;Guermazi, Ali;Crema, M. D.;Hunter, David J.;Kim, H. A.

Objective: To describe the frequency of bonemarrowlesions (BMLs) detected bymagnetic resonance imaging (MRI), and to examine the association of BMLs with knee pain severity in community residents in Korea. Methods: Participants were randomly chosen from the population-based Hallym Aging Study, irrespective of whether they had knee osteoarthritis (OA) or pain. Demographic and knee pain data were obtained by questionnaire. Radiographic evaluations consisted of weight-bearing knee anteroposterior radiographs and 1.5-T MRI scans. MRI was performed in the dominant knees of subjects without knee pain and in the more symptomatic knees of subjects with knee pain. BMLs were graded according to the whole-organ MRI score. Results: The mean age of the 358 study subjects was 71.8 years, and 34.5% of subjects had radiographically detected knee OA. The prevalences of BMLs and large BMLs in the tibiofemoral compartments were 80.3% and 40.4%, respectively. After adjusting for age, sex, and body mass index, total and medial compartment BML scores were significantly associated with the presence of knee pain, and the association was stronger as the summary score for BML increased. In proportional regression analysis, knee pain severity increased with BML severity in any compartment and in the medial compartment. Conclusion: BMLs detected by MRI were highly prevalent in this elderly Asian population. BMLs were significantly linked to knee pain, and BML severity correlated with knee pain severity. BMLs may be important surrogate targets for monitoring pain and structure modification in OA therapeutics.
Structural correlates of pain in joints with osteoarthritis.
28 January 2014
University of Sydney

Hunter, David J.;Guermazi, Ali;Roemer, Frank;Zhang, Yuqing;Neogi, Tuhina

Objective: To describe the insights on the epidemiology of pain-structure association and the ramifications of these studies for clinical trials. Design: Narrative review summarizing the pertinent literature in this area, summarizing some of the methodologic challenges inherent and proposing some research initiatives to further understanding of this complex science. Results: The predominant symptom in most patients presenting with osteoarthritis (OA) is pain. Over recent years a number of imaging based studies have narrowed the discord between structural findings on imaging and symptoms. The interpretation of pain in OA is still enigmatic and difficult to deal with both for clinicians and scientists. Conclusions: We would envisage that over the next few years many of the pressing questions pertaining to research into the structure pain relationship will continue to be addressed. With this, we can expect clinically appropriate therapeutic advance
Disease-modifying drugs for knee osteoarthritis: can they be cost-effective?
28 January 2014
University of Sydney

Losina, Elena;Daigle, Meghan E.;Reichmann, William M.;Suter, Lisa G.;Hunter, David J.;Solomon, Daniel H.;Walensky, Rochelle P.;Jordan, Joanne M.;Burbine, Sara A.;Patiel, A. Daniel;Katz, Jeffrey N.

OBJECTIVE: Disease-modifying osteoarthritis drugs (DMOADs) are under development. Our goal was to determine efficacy, toxicity, and cost thresholds under which DMOADs would be a cost-effective knee OA treatment. DESIGN: We used the Osteoarthritis Policy Model, a validated computer simulation of knee OA, to compare guideline-concordant care to strategies that insert DMOADs into the care sequence. The guideline-concordant care sequence included conservative pain management, corticosteroid injections, total knee replacement (TKR), and revision TKR. Base case DMOAD characteristics included: 50% chance of suspending progression in the first year (resumption rate of 10% thereafter) and 30% pain relief among those with suspended progression; 0.5%/year risk of major toxicity; and costs of $1,000/year. In sensitivity analyses, we varied suspended progression (20-100%), pain relief (10-100%), major toxicity (0.1-2%), and cost ($1,000-$7,000). Outcomes included costs, quality-adjusted life expectancy, incremental cost-effectiveness ratios (ICERs), and TKR utilization. RESULTS: Base case DMOADs added 4.00 quality-adjusted life years (QALYs) and $230,000 per 100 persons, with an ICER of $57,500/QALY. DMOADs reduced need for TKR by 15%. Cost-effectiveness was most sensitive to likelihoods of suspended progression and pain relief. DMOADs costing $3,000/year achieved ICERs below $100,000/QALY if the likelihoods of suspended progression and pain relief were 20% and 70%. At a cost of $5,000, these ICERs were attained if the likelihoods of suspended progression and pain relief were both 60%. CONCLUSIONS: Cost, suspended progression, and pain relief are key drivers of value for DMOADs. Plausible combinations of these factors could reduce need for TKR and satisfy commonly cited cost-effectiveness criteria
Imaging Biomarker Validation and Qualification Report: 6th OARSI Workshop on Imaging in Osteoarthritis Combined with 3rd OA Biomarkers Workshop.
28 January 2014
University of Sydney

Hunter, David J.;Eckstein, Felix;Kraus, Virginia Byers;Lousina, Elena;Sandell, Linda;Guermazi, Ali

Summary The sixth Osteoarthritis Research Society International (OARSI) Workshop on Imaging in Osteoarthritis combined with the third osteoarthritis (OA) Biomarkers Workshop is the first to bring together the imaging and molecular biomarker communities to focus on clinical validation and qualification of OA biomarkers. The workshop was held in Hilton Head, SC, USA, from June 12–14, 2012; 138 attendees participated, including representatives from academia, pharmaceutical and magnetic resonance imaging (MRI) industries, Food and Drug Administration (FDA), and National Institutes of Health (NIH). Presentations and discussions raised awareness, consolidated knowledge, and identified strategies to overcome challenges for the development and application of imaging and biochemical biomarkers in OA research studies and clinical trials. Conclusion The OA research communities need to work alongside regulatory agencies across the world, to qualify and validate new chemical and imaging biomarkers for future research and clinical trials.
Imaging of Osteoarthritis
28 January 2014
University of Sydney

Guermazi, Ali;Hayashi, Daichi;Eckstein, Felix;Hunter, David J.;Duryea, Jeff;Roemer, Frank W.

Osteoarthritis (OA) is the most prevalent joint disorder in the elderly, and there is no effective treatment. Imaging is essential for evaluating the synovial joint structures (including cartilage, meniscus, subchondral bone marrow and synovium) for diagnosis, prognosis, and follow-up. This article describes the roles and limitations of both conventional radiography and magnetic resonance (MR) imaging, and considers the use of other modalities (eg, ultrasonography, nuclear medicine, computed tomography [CT], and CT/MR arthrography) in clinical practice and OA research. The emphasis throughout is on OA of the knee. This article emphasizes research developments and literature evidence published since 2008.
Osteoarthritis Preface
28 January 2014
University of Sydney

Hunter, David J.

Osteoarthritis (OA) is the leading cause of disability among older adults. It is an incredibly prevalent condition affecting upward of 1 in 8 adults. Societal trends in aging, obesity, and increasing joint injury will lead to a doubling of the number of persons with OA in the next decade. In this context, this issue of Rheumatic Disease Clinics of North America is timely, as we envision this increasingly prevalent disabling condition in an era where health care expenditure is increasingly scrutinized.
Presence and Extent of Severe Facet Joint Osteoarthritis Are Associated with Back Pain in Older Adults
28 January 2014
University of Sydney

Suri, Pradeep;Hunter, David J.;Rainville, James;Guermazi, Ali;Katz, Jeffrey N.

Objective To determine whether the presence and extent of severe lumbar facet joint osteoarthritis (OA) are associated with back pain in older adults, accounting for disc height narrowing and other covariates. Design Two hundred and fifty-two older adults from the Framingham Offspring Cohort (mean age 67 years) were studied. Participants received standardized computed tomography (CT) assessments of lumbar facet joint OA and disc height narrowing at the L2–S1 interspaces using four-grade semi-quantitative scales. Severe facet joint OA was defined according to the presence and/or degree of joint space narrowing, osteophytosis, articular process hypertrophy, articular erosions, subchondral cysts, and intraarticular vacuum phenomenon. Severe disc height narrowing was defined as marked narrowing with endplates almost in contact. Back pain was defined as participant report of pain on most days or all days in the past 12 months. We used multivariable logistic regression to examine associations between severe facet joint OA and back pain, adjusting for key covariates including disc height narrowing, sociodemographics, anthropometrics, and health factors. Results Severe facet joint OA was more common in participants with back pain than those without (63.2% vs 46.7%; P = 0.03). In multivariable analyses, presence of any severe facet joint OA remained significantly associated with back pain (odds ratio (OR) 2.15 [95% confidence interval (CI) 1.13–4.08]). Each additional joint with severe OA conferred greater odds of back pain [OR per joint 1.20 (95% CI 1.02–1.41)]. Conclusions The presence and extent of severe facet joint OA on CT imaging are associated with back pain in community-based older adults, independent of sociodemographics, health factors, and disc height narrowing.
'Targeting care: tailoring non-surgical management according to clinical presentation'
29 January 2014
University of Sydney

Eyles, Jillian;Lucas, Barbara R;Hunter, David J.

International evidence-based guidelines recommend a multitude of nonsurgical treatment options for the management of osteoarthritis. This article summarizes the evidence available for patient characteristics that have been analyzed as potential predictors of response to nonsurgical interventions for patients with hip and knee osteoarthritis. The specific variables targeted for this review include body mass index, psychological factors, muscle strength, tibiofemoral alignment, radiographic changes, and signs of inflammation. Several studies provide moderate to good evidence of potential predictors of response to nonsurgical treatments, and areas for future research are illuminated. Copyright 2013 Elsevier Inc. All rights reserved.
The Health and Structural Consequences of Acute Knee Injuries Involving Rupture of the Anterior Cruciate Ligament
29 January 2014
University of Sydney

Riordan, Edward A;Frobell, Richard B;Roemer, Frank W.;Hunter, David J.

Although there is an abundance of literature regarding the development of knee osteoarthritis after rupture of the anterior cruciate ligament (ACL), the mechanism underlying this link is not clear. Recent studies have reported that several factors may be predictive of the development of osteoarthritis, including damage to the menisci and articular cartilage during the initial trauma, altered knee biomechanics after injury, and episodic instability. This article summarizes recent developments in the understanding of the joint damage resulting from an ACL tear, and the influence that current and future treatment methods may have on the long-term progression to osteoarthritis.
Long term joint consequences of sporting activity: preventing and managing osteoarthritis in the athlete
30 January 2014
University of Sydney

Bennell, Kim L;Hunter, David J.;Vicenzino, Bill

Sports participation is associated with an increased risk of future osteoarthritis (OA), much of which results from joint injury. No strong evidence exists that moderate sporting activity in the presence of normal joints predisposes to OA. Whether high-level participation in sport, particularly impact-type sports, is truly associated with OA is unclear owing to difficulties in differentiating the confounding effect of joint injury. Attention to strategies that prevent joint injury in athletes is paramount. Evidence does support the use of targeted neuromuscular exercise programmes, ankle taping and/or bracing and equipment or rule changes to prevent joint injuries in athletes. Optimal injury management, including rehabilitation and surgery if appropriate, is needed to facilitate healing and address biomechanical and neuromuscular impairments to reduce the risk of re-injury and minimize the onset and extent of joint symptoms. Management of OA in athletes requires attention to load-reducing strategies, activity modification, muscle strengthening and weight control.
Lifetime risk and age of diagnosis of symptomatic knee osteoarthritis in the US
30 January 2014
University of Sydney

Losina, Elena;Weinstein, Alexander M.;Reichmann, William M.;Burbine, Sara A.;Solomon, Daniel H.;Daigle, Meghan E.;Rome, Benjamin N.;Chen, Stephanie P.;Hunter, David J.;Suter, Lisa G.;Jordan, Joanne M.;Katz, Jeffrey N.

OBJECTIVE: To estimate the incidence and lifetime risk of diagnosed symptomatic knee osteoarthritis (OA) and the age at diagnosis of knee OA based on self-reports in the US population. METHODS: We estimated the incidence of diagnosed symptomatic knee OA in the US by combining data on age-, sex-, and obesity-specific prevalence from the 2007-2008 National Health Interview Survey, with disease duration estimates derived from the Osteoarthritis Policy (OAPol) Model, a validated computer simulation model of knee OA. We used the OAPol Model to estimate the mean and median ages at diagnosis and lifetime risk. RESULTS: The estimated incidence of diagnosed symptomatic knee OA was highest among adults ages 55-64 years, ranging from 0.37% per year for nonobese men to 1.02% per year for obese women. The estimated median age at knee OA diagnosis was 55 years. The estimated lifetime risk was 13.83%, ranging from 9.60% for nonobese men to 23.87% in obese women. Approximately 9.29% of the US population is diagnosed with symptomatic knee OA by age 60 years. CONCLUSION: The diagnosis of symptomatic knee OA occurs relatively early in life, suggesting that prevention programs should be offered relatively early in the life course. Further research is needed to understand the future burden of health care utilization resulting from earlier diagnosis of knee OA. Copyright 2013 by the American College of Rheumatology.
Osteoarthritis: What does imaging tell us about its etiology.
30 January 2014
University of Sydney

Johnson, Victoria L;Giuffre, Bruno M;Hunter, David J.

Osteoarthritis (OA) is the most common joint disorder and a leading cause of disability. Due to an aging population and increasing obesity, the incidence of OA is rising. The etiology of OA is multifactorial and complex; thus prevention of OA remains challenging. Risk factors can be divided into person-level factors such as age, sex, obesity, genetics, race/ethnicity, and diet, and joint-level factors including injury, malalignment, and abnormal loading of the joints. This review provides a brief overview of the person-level risk factors and a more in-depth analysis of those at the joint level. It is only through an improved understanding of risk factors for the disease that we may be able to intervene meaningfully and prevent its occurrence.
Tibial coverage, meniscus position, size and damage in knees discordant for joint space narrowing - data from the Osteoarthritis Initiative.
30 January 2014
University of Sydney

Bloecker, K;Guermazi, Ali;Wirth, W;Benichou, O;Kwoh, C. Kent;Englund, M;Hunter, David J.;Resch, H;Eckstein, Felix

INTRODUCTION: Meniscal extrusion is thought to be associated with less meniscus coverage of the tibial surface, but the association of radiographic disease stage with quantitative measures of tibial plateau coverage is unknown. We therefore compared quantitative and semi-quantitative measures of meniscus position and morphology in individuals with bilateral painful knees discordant on medial joint space narrowing (mJSN). METHODS: A sample of 60 participants from the first half (2,678 cases) of the Osteoarthritis Initiative cohort fulfilled the inclusion criteria: bilateral frequent pain, Osteoarthritis Research Society International (OARSI) mJSN grades 1-3 in one, no-JSN in the contra-lateral (CL), and no lateral JSN in either knee (43 unilateral mJSN1; 17 mJSN2/3; 22 men, 38 women, body mass index (BMI) 31.3 + 3.9 kg/m(2)). Segmentation and three-dimensional quantitative analysis of the tibial plateau and meniscus, and semi-quantitative evaluation of meniscus damage (magnetic resonance imaging (MRI) osteoarthritis knee score = MOAKS) was performed using coronal 3T MR images (MPR DESSwe and intermediate-weighted turbo spin echo (IW-TSE) images). CL knees were compared using paired t-tests (between-knee, within-person design). RESULTS: Medial tibial plateau coverage was 36 + 9% in mJSN1 vs 45 + 8% in CL no-JSN knees, and was 31 + 9% in mJSN2/3 vs 46 + 6% in no-JSN knees (both P < 0.001). mJSN knees showed greater meniscus extrusion and damage (MOAKS), but no significant difference in meniscus volume. No significant differences in lateral tibial coverage, lateral meniscus morphology or position were observed. CONCLUSIONS: Knees with medial JSN showed substantially less medial tibial plateau coverage by the meniscus. We suggest that the less meniscal coverage, i.e., less mechanical protection may be a reason for greater rates of cartilage loss observed in JSN knees. Copyright 2012 Osteoarthritis Research Society International. All rights reserved.
Quantitative Assessment of Abdominal Aortic Calcification and Disk Height Loss: The Framingham Study
30 January 2014
University of Sydney

Suri, Pradeep;Hunter, David J.;Rainville, James;Guermazi, Ali;Katz, Jeffrey N.

Abstract Background context Vascular disease has been proposed as a risk factor for disc height loss (DHL). Purpose To examine the relationship between quantitative measures of abdominal aortic calcifications (AACs) as a marker of vascular disease, and DHL, on computed tomography (CT). Study design Cross-sectional study in a community-based population. Patient sample Four hundred thirty-five participants from the Framingham Heart Study. Outcome measures Quantitative AAC scores assessed by CT were grouped as tertiles of “no” (reference), “low,” and “high” calcification. Disc height loss was evaluated on CT reformations using a four-grade scale. For analytic purposes, DHL was dichotomized as moderate DHL of at least one level at L2–S1 versus less than moderate or no DHL. Methods We examined the association of AAC and DHL using logistic regression before and after adjusting for cardiovascular risk factors and before and after adjusting for age, sex, and body mass index (BMI). Results In crude analyses, low AAC (odds ratio [OR], 2.05 [1.27–3.30]; p=.003) and high AAC (OR, 2.24 [1.38–3.62]; p=.001) were strongly associated with DHL, when compared with the reference group of no AAC. Diabetes, hypercholesterolemia, hypertension, and smoking were not associated with DHL and did not attenuate the observed relationship between AAC and DHL. Adjustment for age, sex, and BMI markedly attenuated the associations between DHL and low AAC (OR, 1.20 [0.69–2.09]; p=.51) and high AAC (OR, 0.74 [0.36–1.53]; p=.42). Conclusions Abdominal aortic calcification was associated with DHL in this community-based population. This relationship was independent of cardiovascular risk factors. However, the association of AAC with DHL was explained by the effects of age, sex, and BMI.
The association between reduced knee joint proprioception and medial meniscal abnormalities using MRI in knee osteoarthritis: results from the Amsterdam osteoarthritis cohort.
31 January 2014
University of Sydney

van der Esch, Martin;Knoop, Jesper;Hunter, David J.;Klein, Jan-Paul;van der Leeden, Marike;Knol, Dirk L;Reiding, Dick;Vooreman, Ramon E;Gerritsen, Martijn;Roorda, Leo D;Lems, Willem F;Dekker, Joost

BACKGROUND: Osteoarthritis (OA) of the knee is characterized by pain and activity limitations. In knee OA, proprioceptive accuracy is reduced and might be associated with pain and activity limitations. Although causes of reduced proprioceptive accuracy are divergent, medial meniscal abnormalities, which are highly prevalent in knee OA, have been suggested to play an important role. No study has focussed on the association between proprioceptive accuracy and meniscal abnormalities in knee OA. OBJECTIVE: To explore the association between reduced proprioceptive accuracy and medial meniscal abnormalities in a clinical sample of knee OA subjects. METHODS: Cross-sectional study in 105 subjects with knee OA. Knee proprioceptive accuracy was assessed by determining the joint motion detection threshold in the knee extension direction. The knee was imaged with a 3.0 T magnetic resonance (MR) scanner. Number of regions with medial meniscal abnormalities and the extent of abnormality in the anterior and posterior horn and body were scored according to the Boston-Leeds Osteoarthritis Knee Score (BLOKS) method. Multiple regression analyzes were used to examine whether reduced proprioceptive accuracy was associated with medial meniscal abnormalities in knee OA subjects. RESULTS: Mean proprioceptive accuracy was 2.9degree + 1.9degree. Magnetic resonance imaging (MRI)-detected medial meniscal abnormalities were found in the anterior horn (78%), body (80%) and posterior horn (90%). Reduced proprioceptive accuracy was associated with both the number of regions with meniscal abnormalities (P < 0.01) and the extent of abnormality (P = 0.02). These associations were not confounded by muscle strength, joint laxity, pain, age, gender, body mass index (BMI) and duration of knee complaints. CONCLUSION: This is the first study showing that reduced proprioceptive accuracy is associated with medial meniscal abnormalities in knee OA. The study highlights the importance of meniscal abnormalities in understanding reduced proprioceptive accuracy in persons with knee OA. Copyright 2013 Osteoarthritis Research Society International. All rights reserved
Subchondral Bone Trabecular Integrity Predicts and Changes Concurrently with Radiographic and MRI Determined Knee Osteoarthritis Progression
31 January 2014
University of Sydney

Kraus, Virginia Byers;Feng, Sheng;Wang, Sheng Chu;White, Scott;Ainslie, Maureen;Le Graverand, Marie-Pierre Hellio;Brett, Alan;Eckstein, Felix;Hunter, David J.;Lane, Nancy E;Taljanovic, Mihra S.;Schnitzer, Thomas;Charles, H Cecil

OBJECTIVE: To evaluate subchondral bone trabecular integrity (BTI) on radiographs as a predictor of knee osteoarthritis (OA) progression. METHODS: Longitudinal (baseline, 12-month, and 24-month) knee radiographs were available for 60 female subjects with knee OA. OA progression was defined by 12- and 24-month changes in radiographic medial compartment minimal joint space width (JSW) and medial joint space area (JSA), and by medial tibial and femoral cartilage volume on magnetic resonance imaging. BTI of the medial tibial plateau was analyzed by fractal signature analysis using commercially available software. Receiver operating characteristic (ROC) curves for BTI were used to predict a 5% change in OA progression parameters. RESULTS: Individual terms (linear and quadratic) of baseline BTI of vertical trabeculae predicted knee OA progression based on 12- and 24-month changes in JSA (P < 0.01 for 24 months), 24-month change in tibial (P < 0.05), but not femoral, cartilage volume, and 24-month change in JSW (P = 0.05). ROC curves using both terms of baseline BTI predicted a 5% change in the following OA progression parameters over 24 months with high accuracy, as reflected by the area under the curve measures: JSW 81%, JSA 85%, tibial cartilage volume 75%, and femoral cartilage volume 85%. Change in BTI was also significantly associated (P < 0.05) with concurrent change in JSA over 12 and 24 months and with change in tibial cartilage volume over 24 months. CONCLUSION: BTI predicts structural OA progression as determined by radiographic and MRI outcomes. BTI may therefore be worthy of study as an outcome measure for OA studies and clinical trials. Copyright 2013 by the American College of Rheumatology.
Novel genetic variants associated with lumbar disc degeneration in northern Europeans: a meta-analysis of 4600 subjects.
31 January 2014
University of Sydney

Williams, Frances M K;Bansal, Aruna T;van Meurs, Joyce B;Bell, Jordana T;Meulenbelt, Ingrid;Suri, Pradeep;Rivadeneira, Fernando;Sambrook, Philip N;Hofman, Albert;Bierm-Zeinstra, Sita;Menni, Cristina;Kloppenburg, Megreet;Slagboom, P Eline;Hunter, David J.;MacGregor, Alex J;Uitterlinden, Andre G.;Spector, Tim D

OBJECTIVE: Lumbar disc degeneration (LDD) is an important cause of low back pain, which is a common and costly problem. LDD is characterised by disc space narrowing and osteophyte growth at the circumference of the disc. To date, the agnostic search of the genome by genome-wide association (GWA) to identify common variants associated with LDD has not been fruitful. This study is the first GWA meta-analysis of LDD. METHODS: We have developed a continuous trait based on disc space narrowing and osteophytes growth which is measurable on all forms of imaging (plain radiograph, CT scan and MRI) and performed a meta-analysis of five cohorts of Northern European extraction each having GWA data imputed to HapMap V.2. RESULTS: This study of 4600 individuals identified four single nucleotide polymorphisms with p<5x10(-8), the threshold set for genome-wide significance. We identified a variant in the PARK2 gene (p=2.8x10(-8)) associated with LDD. Differential methylation at one CpG island of the PARK2 promoter was observed in a small subset of subjects (beta=8.74x10(-4), p=0.006). CONCLUSIONS: LDD accounts for a considerable proportion of low back pain and the pathogenesis of LDD is poorly understood. This work provides evidence of association of the PARK2 gene and suggests that methylation of the PARK2 promoter may influence degeneration of the intervertebral disc. This gene has not previously been considered a candidate in LDD and further functional work is needed on this hitherto unsuspected pathway.
Quantitative MRI measures of cartilage predict knee replacement: a case-control study from the Osteoarthritis Initiative.
31 January 2014
University of Sydney

Eckstein, Felix;Kwoh, C. Kent;Boudreau, Robert M;Wang, Zhiiie;Hannon, Michael J;Cotofana, Sebastian;Hudelmaier, Martin I;Wirth, Wolfgang;Guermazi, Ali;Nevitt, Michael;John, Markus R.;Hunter, David J.

OBJECTIVE: Knee osteoarthritis commonly requires joint replacement, substantially reduces quality of life and increases healthcare utilisation and costs. This study aimed to identify whether quantitative measures of articular cartilage structure predict knee replacement, and to establish their utility as outcomes in clinical trials of disease-modifying therapy. METHODS: A nested case-control study was performed in Osteoarthritis Initiative participants, a multicentre observational cohort of 4796 participants with or at risk of knee osteoarthritis. 127 knees were replaced between baseline and 4 years follow-up, and one control knee per case matched for baseline radiographic disease stage (Kellgren-Lawrence grade; KLG), gender and age. Quantitative cartilage measures were obtained from 3 T magnetic resonance images at the exam before knee replacement, and longitudinal change during the previous 12 months when available (n=110). RESULTS: Cartilage thickness loss in the central and total medial femorotibial compartment (primary and secondary predictor variables) was significantly greater in case than control knees (AUC=0.59/0.58). Differences in cartilage loss were greater at earlier than later radiographic disease stages (p<0.01 for interaction with KLG). Cartilage thickness loss in the central tibia was the most predictive longitudinal measure (AUC=0.64). Denuded bone areas in the medial femur were the most predictive and discriminatory cross-sectional measure between case and control knees (AUC=0.66). CONCLUSIONS: This study demonstrates the predictive value of quantitative, MRI-based measures of cartilage for the clinically relevant endpoint of knee replacement, providing support for their utility in clinical trials to evaluate the effectiveness of structure-modifying intervention.
Prevalence of Anatomic Impediments to Interlaminar Lumbar Epidural Steroid Injection
31 January 2014
University of Sydney

Hameed, Farah;Hunter, David J.;Rainville, James;Li, Ling;Suri, Pradeep

OBJECTIVE: To determine the prevalence of anatomic impediments to interlaminar lumbar epidural steroid injection (LESI) in a community-based population. DESIGN: Cross-sectional observational study. SETTING: Community-based. PARTICIPANTS: Older adults (N=333) sampled irrespective of back pain status. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Computed tomography evaluation of 5 potential anatomic impediments to interlaminar LESI at the L2-S1 spinal levels, including (1) ligamentum flavum (LF) calcification, (2) interspinous ligament (ISL) calcification, (3) spinous process (SP) contact, (4) the absence of epidural fat in the posterior epidural space, and (5) the presence of fat density superficial to the LF in the midsagittal plane. Independent variables included age, sex, body mass index (BMI), and current smoking. RESULTS: LF and ISL calcifications were prevalent in 3% to 7% and 2% to 3% of spinal levels, respectively, without significant differences by spinal level. SP contact was most common at the L4-5 level (22%). Absence of posterior epidural fat was very common at L5-S1 (65%), but infrequent at other levels. The presence of midline fat density superficial to LF was most common at L5-S1 (55%). The prevalence of LF calcification, ISL calcification, and SP contact increased with age, but the prevalence of absence of posterior epidural fat and the presence of a midline fat density superficial to LF did not. Sex and smoking status were not associated with the prevalence of anatomic impediments, but higher BMI was associated with a lower prevalence of absence of posterior epidural fat. CONCLUSIONS: Anatomic impediments to interlaminar LESI were common in this community-based population, particularly at the L5-S1 spinal level. Because of the high overall prevalence of anatomic impediments, and differences in prevalence by spinal level, knowledge of the distribution and frequency of these impediments may aid in aspects of decision-making for the interventional spine physician. Copyright 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
A Randomized Trial of Patellofemoral Bracing for Treatment of Patellofemoral Osteoarthritis
31 January 2014
University of Sydney

Hunter, David J.;Harvey, William F;Gross, K. Douglas;Felson, D;McCree, P;Li, Ling;Hirko, Kelly;Zhang, B;Bennell, Kim L

Purpose The number of effective knee osteoarthritis (OA) interventions, especially those tailored to specific compartmental involvement, are small. The objective of this study was to determine the efficacy of a realigning patellofemoral (PF) brace in improving pain and function among persons with symptomatic lateral PF OA. Method We conducted a double blind, randomized crossover trial of a realigning PF brace for persons with lateral PF OA. Participants had lateral PF OA with anterior knee symptoms on most days of the month, lateral PF joint space narrowing, and radiographic evidence of a definite osteophyte in the PF joint. We compared two treatments: (1) Control treatment consisting of a BioSkin Q Brace with patellar realigning strap removed; and (2) Active treatment consisting of a realigning BioSkin Q Brace with the strap applied. For each participant, the trial lasted 18 weeks, including 6 weeks each of active and control treatment period separated by a 6-week washout period. The order of treatments was randomized. The primary outcome was change in knee pain on the visual analog scale (VAS). Secondary outcomes included WOMAC pain, function, and stiffness. An unstructured correlation matrix for observations within participants was used in generalized estimating equation fitting to derive a linear regression model that expressed the relation between the intervention and change in VAS pain. Results 80 participants (63 F) with a mean age and body mass index of 61 years and 28 kg/m2, respectively, were randomized by order of treatment. A model examining the main effects for change in VAS knee pain (0–100) demonstrated no significant treatment effect (−0.68 VAS units, 95% CI: −6.2, 4.8 units, P = 0.81) and no differential carryover effect. There was also no significant difference between active and control treatments for WOMAC pain, function, or stiffness outcomes. Conclusion The effects of a specific realigning PF brace are not of clinical or statistical significance.
Purine-Rich Foods Intake and Recurrent Gout Attacks
31 January 2014
University of Sydney

Zhang, Yuqing;Chen, Clara;Choi, Hyon;Chaisson, Christine E;Hunter, David J.;Niu, Jingbo;Neogi, Tuhina

OBJECTIVE: To examine and quantify the relation between purine intake and the risk of recurrent gout attacks among gout patients. METHODS: The authors conducted a case-crossover study to examine associations of a set of putative risk factors with recurrent gout attacks. Individuals with gout were prospectively recruited and followed online for 1 year. Participants were asked about the following information when experiencing a gout attack: the onset date of the gout attack, clinical symptoms and signs, medications (including antigout medications), and presence of potential risk factors (including daily intake of various purine-containing food items) during the 2-day period prior to the gout attack. The same exposure information was also assessed over 2-day control periods. RESULTS: This study included 633 participants with gout. Compared with the lowest quintile of total purine intake over a 2-day period, OR of recurrent gout attacks were 1.17, 1.38, 2.21 and 4.76, respectively, with each increasing quintile (p for trend <0.001). The corresponding OR were 1.42, 1.34, 1.77 and 2.41 for increasing quintiles of purine intake from animal sources (p for trend <0.001), and 1.12, 0.99, 1.32 and 1.39 from plant sources (p=0.04), respectively. The effect of purine intake persisted across subgroups by sex, use of alcohol, diuretics, allopurinol, NSAIDs and colchicine. CONCLUSIONS: The study findings suggest that acute purine intake increases the risk of recurrent gout attacks by almost fivefold among gout patients. Avoiding or reducing amount of purine-rich foods intake, especially of animal origin, may help reduce the risk of gout attacks.
Quantification of Walking Ability in Participants with Neurogenic Claudication from Lumbar Spinal Stenosis – A Comparative Study
31 January 2014
University of Sydney

Rainville, James;Childs, Lisa;Pena, Enrique;Suri, Pradeep;Limke, Janet;Jouve, Cristin;Hunter, David J.

Background context Walking limitations caused by neurogenic claudication (NC) are typically assessed with self-reported measures, although objective evaluation of walking using motorized treadmill test (MTT) or self-paced walking test (SPWT) has periodically appeared in the lumbar spinal stenosis (LSS) literature. Purpose This study compared the validity and responsiveness of MTT and SPWT for assessing walking ability before and after common treatments for NC. Study design Prospective observational cohort study. Patient sample Fifty adults were recruited from an urban spine center if they had LSS and substantial walking limitations from NC and were scheduled to undergo surgery (20%) or conservative treatment (80%). Outcome measures Walking times, distances, and speeds along with the characteristics of NC symptoms were recorded for MTT and SPWT. Self-reported measures included back and leg pain intensity assessed with 0 to 10 numeric pain scales, disability assessed with Oswestry Disability Index, walking ability assessed with estimated walking times and distances, and NC symptoms assessed with the subscales from the Spinal Stenosis Questionnaires. Methods Motorized treadmill test used a level track, and SPWT was conducted in a rectangular hallway. Walking speeds were self-selected, and test end points were NC, fatigue, or completion of the 30-minute test protocol. Results from MTT and SPWT were compared with each other and self-reported measures. Internal responsiveness was assessed by comparing changes in the initial results with the posttreatment results and external responsiveness by comparing walking test results that improved with those that did not improve by self-reported criteria. Results Mean age of the participants was 68 years, and 58% were male. Neurogenic claudication included leg pain (88%) and buttock(s) pain (12%). Five participants could not safely perform MTT. Walking speeds were faster and distances were greater with SPWT, although the results from both tests correlated with each other and self-reported measures. Of the participants, 72% reported improvement after treatment, which was confirmed by significant mean differences in self-reported measures. Motorized treadmill test results did not demonstrate internal responsiveness to change in clinical status after treatment but SPWT results did, with increased mean walking times (6 minutes) and distances (387 m). When responsiveness was assessed against external criterion, both SPWT and MTT demonstrated substantial divergence with self-reported changes in clinical status and alternative outcome measures. Conclusions Both MTT and SPWT can quantify walking abilities in NC. As outcome tools, SPWT demonstrated better internal responsiveness than MTT, but neither test demonstrated adequate external responsiveness. Neither test should be considered as a meaningful substitution for disease-specific measures of function
Risk Factors for Medial Meniscus Posterior Root Tear
02 February 2014
University of Sydney

Hwang, Byoung-Yoon;Kim, Sung Jae;Lee, Sang-Won;Lee, Ha-Eun;Lee, Choon-Key;Hunter, David J.;Jung, Kwang-Am

Background: Medial meniscus posterior root tears (MMPRT) have a different clinical effect from other types of meniscal tears. These tears are very common among Asian people and may be related to the frequent use of postures such as the lotus position or squatting. Purpose: The present study was designed to identify the risk factors for MMPRT among an Asian sample. Study Design: Cohort study; Level of evidence, 3. Methods: An observational study was performed of 476 consecutive patients undergoing an arthroscopic procedure on their medial meniscus from January 2010 to December 2010. One hundred four patients had MMPRT (group 1), and the other patients had other types of medial meniscal tears (group 2). Demographic characteristics (age, sex, body mass index [BMI]), radiographic features (mechanical axis angle, tibia vara angle, tibial slope angle, Kellgren-Lawrence grade [KLG]), and environmental factors (occupation, trauma history, sports activity level, table use or not, bed use or not—variables that are representative of the oriental lifestyle of lotus position and squatting) were surveyed. We assessed the relation of these risk factors to the type of meniscal tear (group 1 or 2). Results: In group 1, there were 7 male and 97 female patients, with an average age of 58.2 years (range, 39-78 years) and BMI of 26.7 ± 3.4 kg/m2. In group 2, there were 136 male and 236 female patients (P < .01 compared with group 1), with an average age of 54.3 years (range, 17-77 years; P < .01) and a BMI of 24.9 ± 3.1 kg/m2 (P < .01). With regard to radiographic features, the mechanical axis angle demonstrated a significantly increased varus alignment in group 1 (4.5° ± 3.4°) compared with group 2 (2.4° ± 2.7°; P < .01), and the KLG was 1.4 ± 0.8 in group 1 and 0.9 ± 0.6 in group 2 (P < .01). Environmental factors showed no differences in occupation, table use or not, and bed use or not, except sports activity level. There were 41 patients (42.7%) in group 1 and 77 patients (20.6%) in group 2 who did not participate in any recreational activity (P < .01). Multiple logistic regression analysis showed that female sex was associated with a 5.9-fold increase in risk (95% confidence interval [CI], 2.138-16.575), a varus mechanical axis angle with a 3.3-fold increase (95% CI, 1.492-7.153), a BMI more than 30 kg/m2 with a 4.9-fold increase (95% CI, 1.160-20.955), and lower sports activity level with a 2.7-fold increase (95% CI, 1.011-7.163) for MMPRT. Conclusion: Persons with MMPRT had significantly increased age, female sex predominance, higher BMI, increased KLG, greater varus mechanical axis angle, and lower sports activity level compared with persons with other types of meniscal tear. After adjusting for other factors, sex, BMI, mechanical axis angle, and lower sports activity level remained strong determinants of MMPRT. Interestingly, oriental postural positions including the lotus position and squatting showed no contribution to increased risk of MMPRT. This suggests that intrinsic risk factors (similar to those that predispose to osteoarthritis) predispose to MMPRT.
THE RELATIONSHIP OF TIBIAL BONE PERFUSION TO PAIN IN KNEE OSTEOARTHRITIS.
02 February 2014
University of Sydney

Seah, S;Wheaton, D;Li, Ling;Dyke, J P;Talmo, C;Harvey, William F;Hunter, David J.

Objective To confirm altered perfusion within tibial bone marrow lesions (BMLs) and improve our understanding on the relationship between BMLs and pain in knee osteoarthritis (OA). Methods Participants with moderate to severe knee OA were recruited and pain was assessed using the pain subscale of the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Subchondral tibial BMLs were identified and graded on magnetic resonance imaging (MRI) proton density-weighted (PDW) fat suppressed images. A pharmacokinetic model was used to analyze perfusion parameters on dynamic contrast enhanced (DCE) MRI which represent transfer rates in and out of the BMLs. The relation between perfusion and pain was evaluated using multivariable linear regression after adjustment for BML grade, age, gender and body mass index (BMI). Results There were 37 participants (mean age 64.9 years, range 46–86) with radiographic Kellgren and Lawrence grades of 3 and 4 in the study knee; 75.6% had BMLs that were classified grades 1 and 2. The mean WOMAC pain score was 10.3 (0–20 scale). There was a significant correlation between BML Kel (rate of contrast elimination) and BML grade (P = 0.001 univariate, P = 0.002 multivariate analyses), although we did not demonstrate any significant multivariate association between BML perfusion and pain. We also found an inverse relationship between pain at sleep and BML grade (P < 0.05). Conclusions The absence of any significant association between bone perfusion and pain implies that the relationship of tibial BMLs to pain in OA is still incompletely understood. BMLs are just one component of the whole knee joint and are formed from various causes, all of which interact and collectively contribute to the genesis of pain in OA.
The MeTeOR Trial (Meniscal Tear in Osteoarthritis Research): Rationale and design features
02 February 2014
University of Sydney

Katz, Jeffrey N.;Chaisson, Christine E;Cole, Brian;Guermazi, Ali;Hunter, David J.;Jones, Morgan;Levy, Bruce A;Mandi, Lisa A;Martin, Scott;Marx, Robert G;Safran-Norton, Clare;Roemer, Frank W.;Skoniecki, Debra;Solomon, Daniel H.;Spindler, Kurt P.;Wright, John;Wright, Rick W;Losina, Elena

This paper presents the rationale and design features of the MeTeOR Trial (Meniscal Tear in Osteoarthritis Research; Clinical Trials.gov NCT00597012). MeTeOR is an NIH-funded seven-center prospective randomized controlled trial (RCT) designed to establish the efficacy of arthroscopic partial meniscectomy combined with a standardized physical therapy program as compared with a standardized physical therapy program alone in patients with a symptomatic meniscal tear in the setting of mild to moderate knee osteoarthritic change (OA). The design and execution of a trial that compares surgery with a nonoperative treatment strategy presents distinctive challenges. The goal of this paper is to provide the clinical rationale for MeTeOR and to highlight salient design features, with particular attention to those that present clinical and methodologic challenges.
Side Differences of Thigh Muscle Cross-Sectional Areas and Maximal Isometric Muscle Force in Bilateral Knees with the Same Radiographic Disease Stage, but Unilateral Frequent Pain – Data from the Osteoarthritis Initiative
02 February 2014
University of Sydney

Sattler, Martina;Dannhauer, Torben;Hudelmaier, Martin I;Wirth, Wolfgang;Sanger, Alexandra;Kwoh, C. Kent;Eckstein, Felix

Objective To determine whether anatomical thigh muscle cross-sectional areas (MCSAs) and strength differ between osteoarthritis (OA) knees with frequent pain compared with contra-lateral knees without pain, and to examine the correlation between MCSAs and strength in painful vs painless knees. Methods Forty-eight subjects (31 women; 17 men; age 45–78 years) were drawn from 4,796 Osteoarthritis Initiative (OAI) participants, in whom both knees displayed the same radiographic stage (KLG2 or 3), one with frequent pain (most days of the month within the past 12 months) and the contra-lateral one without pain. Axial MR images were used to determine MCSAs of extensors, flexors and adductors at 35% femoral length (distal to proximal) and in two adjacent 5 mm images. Maximal isometric extensor and flexor forces were used as provided from the OAI database. Results Painful knees showed 5.2% lower extensor MCSAs (P = 0.00003; paired t-test), and 7.8% lower maximal extensor muscle forces (P = 0.003) than contra-lateral painless knees. There were no significant differences in flexor forces, or flexor and adductor MCSAs (P > 0.39). Correlations between force and MCSAs were similar in painful and painless OA knees (0.44 < r < 0.66). Conclusions Knees with frequent pain demonstrate lower MCSAs and force of the quadriceps (but not of other thigh muscles) compared with contra-lateral knees without knee pain with the same radiographic stage. Frequent pain does not appear to affect the correlations between MCSAs and strength in OA knees. The findings suggest that quadriceps strengthening exercise may be useful in treating symptomatic knee OA.
Dengue Virus in Sub-tropical Northern and Central Viet Nam: Population Immunity and Climate Shape Patterns of Viral Invasion and Maintenance
12 February 2014
University of Sydney

Rabaa, Maia A.;Simmons, Cameron P.;Fox, Annette;Le, Mai Quynh;Nguyen, Thuy Thi Thu;Le, Hai Yen;Gibbons, Robert V.;Holmes, Edward C.;Aaskov, John G.

Dengue virus transmission occurs in both epidemic and endemic cycles across tropical and sub-tropical regions of the world. Incidence is particularly high in much of Southeast Asia, where hyperendemic transmission plagues both urban and rural populations. However, endemicity has not been established in some areas with climates that may not support yearround viral transmission. An understanding of how dengue viruses (DENV) enter these environments and whether the viruses persist in inapparent local transmission cycles is central to understanding how dengue emerges in areas at the margins of endemic transmission. Dengue is highly endemic in tropical southern Vietnam, while increasingly large seasonal epidemics have occurred in northern Viet Nam over the last decade. We have investigated the spread of DENV-1 throughout Vietnam to determine the routes by which the virus enters northern and central regions of the country. Phylogeographic analysis of 1,765 envelope (E) gene sequences from Southeast Asia revealed frequent movement of DENV between neighboring human populations and strong local clustering of viral lineages. Long-distance migration of DENV between human population centers also occurred regularly and on short time-scales, indicating human-mediated viral invasion into northern Vietnam. Human populations in southern Vietnam were found to be the primary source of DENV circulating throughout the country, while central and northern Vietnam acted as sink populations, likely due to reduced connectedness to other populations in the case of the central regions and to the influence of temperature variability on DENV replication and vector survival and competence in the north. Finally, phylogeographic analyses suggested that viral movement follows a gravity model and indicates that population immunity and physical and economic connections between populations may play important roles in shaping patterns of DENV transmission.
Time-Course Proteome Analysis Reveals the Dynamic Response of Cryptococcus gattii Cells to Fluconazole
28 February 2014
University of Sydney

Chong, Hin Siong;Campbell, Leona;Padula, Matthew;Hill, Cameron;Harry, Elizabeth;Li, Simone;Wilkins, Marc;Herbert, Ben;Carter, Dee

Cryptococcus gattii is an encapsulated fungus capable of causing fatal disease in immunocompetent humans and animals. As current antifungal therapies are few and limited in efficacy, and resistance is an emerging issue, the development of new treatment strategies is urgently required. The current study undertook a time-course analysis of the proteome of C. gattii during treatment with fluconazole (FLC), which is used widely in prophylactic and maintenance therapies. The aims were to analyze the overall cellular response to FLC, and to find fungal proteins involved in this response that might be useful targets in therapies that augment the antifungal activity of FLC. During FLC treatment, an increase in stress response, ATP synthesis and mitochondrial respiratory chain proteins, and a decrease in most ribosomal proteins was observed, suggesting that ATP-dependent efflux pumps had been initiated for survival and that the maintenance of ribosome synthesis was differentially expressed. Two proteins involved in fungal specific pathways were responsive to FLC. An integrative network analysis revealed co-ordinated processes involved in drug response, and highlighted hubs in the network representing essential proteins that are required for cell viability. This work demonstrates the dynamic cellular response of a typical susceptible isolate of C. gattii to FLC, and identified a number of proteins and pathways that could be targeted to augment the activity of FLC.
High osteoporotic fracture risk and CVD risk co-exist in postmenopausal women
18 March 2014
University of Sydney

Makovey, Joanna;Macara, Monique;Chen, Jian Sheng;Hayward, Christopher;March, Lyn;Sambrook, Philip

Introduction: Osteoporosis related risk factors such as BMD have been associated with cardiovascular endpoints in previous studies but there have been no studies of integrated risk using risk factor algorithms. Methods: A sample of 358 peri- and postmenopausal women, mean age 59.3 (range 45-74) years were studied. Each individual had bone mineral density (BMD) measurements by dual energy X-ray absorptiometiy. Fracture risk was assessed using the WHO FRAX algorithm and cardiovascular disease (CVD) risk using the Framingham Risk Tool. Results: Women with higher 10 year risk of major osteoporotic had significantly higher cardiovascular risk (4.634% vs 8.36%, p=0.001). In multiple regression analysis, 5-year CVD risk was significantly associated with the 10-year risk of having major osteoporotic (beta=0.095, p=0.001) and hip (beta=0.055, p=0.001) fracture. Women with the highest CVD risk were 5.4 times more likely to have higher risk of major osteoporotic fracture. Conclusions: Fracture risk, determined by using a multiple risk factor algorithm such as FRAX, was positively associated with higher cardiovascular risk determined by using the Framingham Risk Tool. Awareness regarding these concurrent risk factors needs to be raised so that appropriate risk reduction can be implemented. (C) 2012 Elsevier Inc. All rights reserved.
Serum uric acid plays a protective role for bone loss in peri- and postmenopausal women: A longitudinal study
18 March 2014
University of Sydney

Makovey, Joanna;Macara, Monique;Chen, Jian Sheng;Hayward, Christopher;March, Lyn;Seibel, Markus J.;Sambrook, Philip

Objective: Oxidative stress has been linked to osteoporosis. Serum uric acid (UA), a strong endogenous antioxidant, has been associated with higher bone mineral density (BMD), lower bone turnover and lower prevalence of fractures in a large cross-sectional study of men. Whether this relationship is present in women and how UA relates to changes in BMD longitudinally has not been examined. Methods: A sample of 356 peri- and postmenopausal women, mean age 60.5 years was studied. Each individual had baseline BMD and body composition measurements by dual energy x-ray absorptiometry (DXA) and at least one repeat measure, on average 9.7 years later. Annual rate of change in BMD (A%Delta BMD) was calculated. UA was measured at each DXA visit. Calciotropic hormones and bone turnover markers were measured at the final visit only. Results: Cross-sectional data analyses revealed that women with higher UA levels had significantly higher absolute BMD measures at all skeletal sites. These women also had higher measures of body weight and its components such as lean mass (LM) and fat mass (FM). Results of multiple regression analyses showed a positive association between UA and BMD that remained significant even after accounting for possible confounders including LM and FM. Regression analyses of the longitudinal BMD data demonstrated significant associations between serum UA levels and annual rates of change in BMD at all skeletal sites. After adjustment associations remained significant for lumbar spine, forearm and whole body BMD but not for hip BMD. Conclusion: Higher serum UA levels appear to be protective for bone loss in peri- and postmenopausal women and this relationship is not affected by changes in body composition measures.
Association between serum cholesterol and bone mineral density
18 March 2014
University of Sydney

Makovey, Joanna;Chen, Jian Sheng;Hayward, Christopher;Williams, Frances;Sambrook, Philip

Background: Hypercholesterolaemia has been associated with low bone mineral density (BMD) in some but not all studies. Objectives: To examine the influence of age, menopausal status and hormone replacement therapy (HRT) on the relationship between serum cholesterol and BMD in women. Patients and measurements: 497 female participants (age range 20-81) comprising 224 premenopausal and 273 postmenopausal women (156 on HRT and 117 no HRT) underwent measurements of bone mineral density (BMD) and serum lipid profile. Results: Total serum cholesterol (TC) and low density lipoprotein (LDL) levels were higher and lumbar spine BMD was lower in postmenopausal women not taking HRT compared to those taking HRT. TC and LDL were negatively associated with BMD at all measured sites among postmenopausal women not taking HRT in univariate regression analysis (all p<0.05). High density lipoprotein (HDL) had inverse relationships with BMD at all sites in pre-menopausal women and those who were exposed to HRT (p<0.05). In fully adjusted regression models the relationships between TC and BMD remained significant at the lumbar spine and whole body (p<0.05) and between LDL and lumbar spine BMD only (p<0.05). For subjects in the other groups, no significant associations between TC or LDL and BMD were found. Significant interactions between total cholesterol and LDL levels with HRT were detected among post-menopausal women in the regression analyses (all p<0.05). No such interactions were found between HDL levels and HRT. Conclusion: There is a modest inverse relationship between lumbar spine and whole body BMD and serum TC and LDL levels and in post-menopausal women and HDL in pre-menopausal women. HRT use appears to modify these relationships. The mechanisms of this relationship require further study. (C) 2008 Elsevier Inc. All rights reserved.
Recruitment and retention of allied health professionals in the disability sector in rural and remote New South Wales, Australia
03 April 2014
University of Sydney

Lincoln, Michelle;Gallego, Gisselle;Dew, Angela;Bulkeley, Kim;Veitch, Craig;Bundy, Anita;Brentnall, Jennie;Chedid, Rebecca;Griffiths, Scott

Background: People with disability living in rural areas are vulnerable to the loss of access to allied health services due to a critical shortage of allied health professionals (AHPs). This study aimed to investigate recruitment and retention issues of importance to AHPs providing services to people with disability in rural New South Wales, Australia. Method: Focus groups and semi-structured interviews were conducted with 97 purposively sampled service providers in the disability sector. Interviews and focus groups were digitally recorded and transcribed. A modified grounded theory approach using thematic analysis and constant comparison was used to analyse the data. Results: Three major themes relating to recruitment and retention were identified: (a) flexible recruitment, (b) retention strategies that work, and (c) challenges to retention. Conclusions: AHPs in the disability sector identified some of the same issues influencing recruitment and retention as AHPs in the health, education, and private sectors. Several unique issues were also identified that will assist policymakers to improve recruitment and retention of AHPs employed in the disability sector in rural areas.
Carer and service providers’ experiences of individual funding models for children with a disability in rural and remote areas
03 April 2014
University of Sydney

Dew, Angela;Bulkeley, Kim;Veitch, Craig;Bundy, Anita;Lincoln, Michelle;Brentnall, Jennie;Gallego, Gisselle;Griffiths, Scott

There is a global movement for people with a disability towards personcentred practices with opportunities for self-determination and choice. Person-centred approaches may involve individual funding (IF) for the purchase of required support. A shift to a person-centred model and IF should allow people with a disability and their carers greater choice in therapy access. However, individuals who live in rural and remote areas have less choice and access to therapy services than their metropolitan counterparts. Drawing on data from a larger study into therapy service delivery in a rural and remote area of New South Wales, Australia, this study describes some benefits and barriers to using IF to access therapy services in rural areas. Ten carers and 60 service providers participated in audio-recorded focus groups and individual interviews during which IF was discussed. Transcribed data were analysed using thematic analysis and constant comparison. Greater access to and choice of therapy providers were identified as benefits of IF. Four barriers were identified: (i) lack of information and advice; (ii) limited local service options and capacity; (iii) higher costs and fewer services and (iv) complexity of self-managing packages. A range of strategies is required to address the barriers to using IF in rural and remote areas. Carers indicated a need for: accessible information; a local contact person for support and guidance; adequate financial compensation to offset additional travel expenses and coordinated eligibility and accountability systems. Service providers required: coordinated cross-sector approaches; local workforce planning to address therapist shortages; certainty around service viability and growth; clear policies and procedures around implementation of IF. This study highlights the need for further discussion and research about how to overcome the barriers to the optimal use of an IF model for those living in rural and remote areas.
Integrating evidence into policy and sustainable disability services delivery in western New South Wales, Australia: the ‘wobbly hub and double spokes’ project
03 April 2014
University of Sydney

Veitch, Craig;Lincoln, Michelle;Bundy, Anita;Gallego, Gisselle;Dew, Angela;Bulkeley, Kim;Jennie, Brentnall;Griffiths, Scott

Background: Policy that supports rural allied health service delivery is important given the shortage of services outside of Australian metropolitan centres. The shortage of allied health professionals means that rural clinicians work long hours and have little peer or service support. Service delivery to rural and remote communities is further complicated because relatively small numbers of clients are dispersed over large geographic areas. The aim of this five-year multi-stage project is to generate evidence to confirm and develop evidence-based policies and to evaluate their implementation in procedures that allow a regional allied health workforce to more expeditiously respond to disability service need in regional New South Wales, Australia. Methods/Design: The project consists of four inter-related stages that together constitute a full policy cycle. It uses mixed quantitative and qualitative methods, guided by key policy concerns such as: access, complexity, cost, distribution of benefits, timeliness, effectiveness, equity, policy consistency, and community and political acceptability. Stage 1 adopts a policy analysis approach in which existing relevant policies and related documentation will be collected and reviewed. Policy-makers and senior managers within the region and in central offices will be interviewed about issues that influence policy development and implementation. Stage 2 uses a mixed methods approach to collecting information from allied health professionals, clients, and carers. Focus groups and interviews will explore issues related to providing and receiving allied health services. Discrete Choice Experiments will elicit staff and client/carer preferences. Stage 3 synthesises Stage 1 and 2 findings with reference to the key policy issues to develop and implement policies and procedures to establish several innovative regional workforce and service provision projects. Stage 4 uses mixed methods to monitor and evaluate the implementation and impact of new or adapted policies that arise from the preceding stages. Discussion: The project will provide policy makers with research evidence to support consideration of the complex balance between: (i) the equitable allocation of scarce resources; (ii) the intent of current eligibility and prioritisation policies; (iii) workforce constraints (and strengths); and (iv) the most effective, evidence-based clinical practice.
Improving quality of life by increasing outings after stroke: Study protocol for the Out-and-About trial
08 April 2014
University of Sydney

McCluskey, Annie;Ada, Louise;Middleton, Sandy;Kelly, PJ;Goodall, Stephen;Grimshaw, Jeremy M;Logan, Pip;Longworth, Mark;Karageorge, Aspasia

Almost one third of Australians need help to travel outdoors after a stroke. Ambulation training and escorted outings are recommended as best practice in Australian clinical guidelines for stroke. Yet fewer than 20% of people with stroke receive enough of these sessions in their local community to change outcomes. The Out-And-About trial aims to determine the efficacy and cost-effectiveness of an implementation program to change team behaviour and increase outings by people with stroke. A two-group cluster-randomised trial will be conducted using concealed allocation, blinded assessors and intention-to-treat analysis. Twenty community teams and their stroke clients (n=300) will be recruited. Teams will be randomized to receive either the Out-And-About program or written guidelines only. The primary outcome is the proportion of people with stroke receiving multiple escorted outings during therapy sessions, measured at baseline and 13 months post-intervention. Secondary outcomes include number of outings and distance travelled, measured using a self report diary at baseline and six months post-baseline, and a global positioning system (GPS) after six months. Cost-effectiveness will measure quality-adjusted life years and health service use, measured at baseline and six months post-baseline. A potential outcome of this study will be evidence for a costed, transferable implementation program. If successful, the program will have international relevance and transferability. Another potential outcome will be validation of a novel and objective method of measuring outdoor travel (GPS) to supplement self-report methods. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000554965)
EFFECTS OF INTENSIVE DIET AND EXERCISE ON KNEE JOINT LOADS, INFLAMMATION, AND CLINICAL OUTCOMES AMONG OVERWEIGHT AND OBESE ADULTS WITH KNEE OSTEOARTHRITIS
09 April 2014
University of Sydney

Messier, Stephen P;Mihalko, Shannon L;Legault, Claudine;Miller, Gary D.;Nicklas, Barbara J.;DeVita, Paul;Beavers, Daniel P;Hunter, David J.;Lyles, Mary F.;Eckstein, Felix;Williamson, Jeff D;Carr, J. Jeffery;Guermazi, Ali;Loeser, Richard F.

Importance Knee osteoarthritis (OA), a common cause of chronic pain and disability, has biomechanical and inflammatory origins and is exacerbated by obesity. Objective To determine whether a ≥10% reduction in body weight induced by diet, with or without exercise, would improve mechanistic and clinical outcomes more than exercise alone. Design, Setting, and Participants Single-blind, 18-month, randomized clinical trial at Wake Forest University between July 2006 and April 2011. The diet and exercise interventions were center-based with options for the exercise groups to transition to a home-based program. Participants were 454 overweight and obese older community-dwelling adults (age ≥55 years with body mass index of 27-41) with pain and radiographic knee OA. Interventions Intensive diet-induced weight loss plus exercise, intensive diet-induced weight loss, or exercise. Main Outcomes and Measures Mechanistic primary outcomes: knee joint compressive force and plasma IL-6 levels; secondary clinical outcomes: self-reported pain (range, 0-20), function (range, 0-68), mobility, and health-related quality of life (range, 0-100). Results Three hundred ninety-nine participants (88%) completed the study. Mean weight loss for diet + exercise participants was 10.6 kg (11.4%); for the diet group, 8.9 kg (9.5%); and for the exercise group, 1.8 kg (2.0%). After 18 months, knee compressive forces were lower in diet participants (mean, 2487 N; 95% CI, 2393 to 2581) compared with exercise participants (2687 N; 95% CI, 2590 to 2784, pairwise difference [Δ]exercise vs diet = 200 N; 95% CI, 55 to 345; P = .007). Concentrations of IL-6 were lower in diet + exercise (2.7 pg/mL; 95% CI, 2.5 to 3.0) and diet participants (2.7 pg/mL; 95% CI, 2.4 to 3.0) compared with exercise participants (3.1 pg/mL; 95% CI, 2.9 to 3.4; Δexercise vs diet + exercise = 0.39 pg/mL; 95% CI, −0.03 to 0.81; P = .007; Δexercise vs diet = 0.43 pg/mL; 95% CI, 0.01 to 0.85, P = .006). The diet + exercise group had less pain (3.6; 95% CI, 3.2 to 4.1) and better function (14.1; 95% CI, 12.6 to 15.6) than both the diet group (4.8; 95% CI, 4.3 to 5.2) and exercise group (4.7; 95% CI, 4.2 to 5.1, Δexercise vs diet + exercise = 1.02; 95% CI, 0.33 to 1.71; Ppain = .004; 18.4; 95% CI, 16.9 to 19.9; Δexercise vs diet + exercise, 4.29; 95% CI, 2.07 to 6.50; Pfunction < .001). The diet + exercise group (44.7; 95% CI, 43.4 to 46.0) also had better physical health-related quality of life scores than the exercise group (41.9; 95% CI, 40.5 to 43.2; Δexercise vs diet + exercise = −2.81; 95% CI, −4.76 to −0.86; P = .005). Conclusions and Relevance Among overweight and obese adults with knee OA, after 18 months, participants in the diet + exercise and diet groups had more weight loss and greater reductions in IL-6 levels than those in the exercise group; those in the diet group had greater reductions in knee compressive force than those in the exercise group.
Invisible Carers
09 May 2014
University of Sydney

Hutchinson, Karen;Roberts, Chris;Kurrle, Sue

This article highlights some of the lived experiences of this group of young carers often hidden from health and service care providers.
The emotional well-being of young people having a parent with younger onset dementia
09 May 2014
University of Sydney

Hutchinson, Karen;Roberts, Chris;Kurrle, Sue;Daly, Michele

Younger onset dementia (YOD) not only affects the person with the diagnosis but the whole family, which often includes young people. A limited body of research on this group of young people indicates that they experience varying degrees of emotional trauma. We explored the lived experiences of young people having a parent with YOD from the perspective of the social model of disability. Data were available from semi-structured interviews with 12 young people who had a parent with YOD looking at their lived experiences between 8 and 24 years. Thematic analysis identified four main themes: the emotional toll of caring, keeping the family together, grief and loss and psychological distress. The social model of disability theory provides a helpful framework for these families who experience significant emotional distress, demonstrating that the disability is often socially constructed by a society, which marginalizes and excludes them. A ‘whole family’ approach is proposed, where the needs of young people and their parents are respected and responded to age appropriately.
Service Quality in Community Pharmacy: an Exploration of Determinants
26 May 2014
University of Sydney

White, Lesley;Klinner, Christiane

BACKGROUND: Although various instruments have been developed to measure customer satisfaction with community pharmacy services, there is limited research regarding pharmacy staffs’ understanding of service quality and its determinants. OBJECTIVES: This study aimed to explore the perceptions of pharmacy staff regarding the factors which constitute a high level of service quality using the service quality determinants proposed by the Conceptual Model of Service Quality. METHODS: Structured interviews were conducted with 27 pharmacy assistants and 6 pharmacists in three community pharmacies in Sydney. The interview questions focused on the participants’ perceptions of consumer expectations, the translation of these perceptions into service quality specifications, the actual service delivery and the communication to customers. RESULTS: From the pharmacy staff perspective, service quality is significantly limited by insufficient organisation-internal communication and control processes which impede role clarity and the resolution of conflicting role expectations among customer service staff. Participants indicated that these problems could be alleviated through the implementation of more transparent, realistic, measurable and accepted quality specifications by pharmacy management. CONCLUSIONS: The study indicates that the extent and quality to which pharmacy management sets, maintains and communicates service quality specifications to staff directly affects role clarity, role conflict and organisational commitment among customer service staff, which in turn directly influence the level of service quality provided to customers.
Consumer Perspectives of the Australian Home Medicines Review Program: Benefits and Barriers
26 May 2014
University of Sydney

White, Lesley;Klinner, Christiane;Carter, Stephen R

BACKGROUND: The Australian Home Medicines Review (HMR) is a free consumer service to assist individuals living at home to maximize the benefits of their medicine regimen and prevent medication related problems. It consists of a pharmacist reviewing a person’s medicines and collaborating with the general practitioner to optimize the individual’s medicine management. The uptake of this service has remained below the projected use although the program has been shown to successfully identify medication related problems and improve patient drug knowledge and adherence. OBJECTIVES: This study investigates patients’ perceived benefits and barriers regarding the Home Medicines Review service who have used the service and those who are eligible for it but have never used it. METHODS: The consumer perceptions were drawn from 14 semi-structured focus groups with patients and carers belonging to the general HMR target population and to consumer segments that have been postulated to be underrepresented with regard to this service. RESULTS: The major benefits reported were acquisition of medicine information, reassurance, feeling valued and cared for, and willingness to advocate medication changes to the general practitioner. Perceived barriers were concerns regarding upsetting the general practitioner, pride and independence, confidence issues with an unknown pharmacist, privacy and safety concerns regarding the home visit, and lack of information about the program. Participants agreed that the potential benefits of the service outweighed its potential barriers. CONCLUSIONS: It is expected that direct-to-consumer promotion of HMRs would increase the uptake of this valuable service. It would be necessary to ensure that the process and benefits of the service are communicated clearly and sensitively to eligible patients and their carers to obviate common consumer misconceptions and/or barriers regarding the HMR service. Further, any direct-to-consumer promotion of the service must enable patient/carer self-identification of eligibility.
Elderly Chinese and Vietnamese Immigrants’ Medicine Use and Attitudes to a Home Medicines Review
26 May 2014
University of Sydney

White, Lesley;Klinner, Christiane

There is a paucity of research into the perceptions of elderly Australian ethnic minorities towards public health services related to quality use of medicines. Among the six fastest growing ethnic groups in Australia, the Mandarin-speaking Chinese and Vietnamese constitute the largest elderly populations with poor English skills. This paper investigates the relationships of elderly Chinese and Vietnamese migrants with medicines, general practitioners and pharmacists, and how these relationships influence their awareness and attitudes of the Home Medicines Review (HMR) program. Two semi-structured focus groups were held with a total of 17 HMR-eligible patients who have never received an HMR, one with Chinese and one with Vietnamese respondents, each in the respective community language. Confusion about medications and an intention to have an HMR were pronounced among all participants although none of them had heard of the program before participating in the focus groups. Respondents reported difficulties locating a pharmacist who spoke their native language, which contributed to an increased unmet need for medicine information. The Chinese group additionally complained about a lack of support from their general practitioners in relation to their medicine concerns and was adamant that they would prefer to have an HMR without the involvement of their general practitioner. Our results indicate a distinct HMR need but not use among elderly Chinese and Vietnamese eligible patients with poor English skills. HMR service use and perceived medication problems are likely to improve with an increasing availability of bi-lingual and culturally sensitive health care providers.
Improving the Uptake of the Australian Home Medicines Review through Patient Segmentation
26 May 2014
University of Sydney

White, Lesley;Klinner, Christiane;Cobelli, Nicola

The Australian Home Medicines Review (HMR) Program, aimed at reducing the number of medication-related problems and hospital admissions, has not been used to the extent projected and is little known among eligible consumers. PURPOSE: This paper investigates the problems patients and caregivers have with using medicines appropriately, their desire for assistance with managing medications and their self-perceived need for a Home Medicines Review. DESIGN: A qualitative research study was conducted with 8 semi-structured focus groups including a total of 50 HMR-eligible patients and caregivers. Participants who were purposively sampled represented older males, older females, younger chronically ill patients, patients from Chinese and Arabic backgrounds and the general HMR target group. FINDINGS: According to the types of medicine problems encountered by participants, their level of medicine understanding and their desire for assistance with using medicines, four distinct patient types are identified and explicated: the heedless patient, the aware patient, the scrupulous patient and the self-sufficient patient. PRACTICAL IMPLICATIONS: The uptake of the HMR service can be effectively increased by direct-to-consumer HMR promotion that is tailored to the behaviors, needs and desires of eligible patients and caregivers. The proposed segmentation model of HMR-eligible consumers addresses these differences and can be used to inform health policy makers regarding a more effective promotion of the HMR service. ORIGINALITY: This is the first study to investigate how the HMR-uptake could be increased from the perspective of eligible patients and their caregivers.
Addressing the barriers to accessing therapy services in rural and remote areas
23 June 2014
University of Sydney

Dew, Angela;Bulkeley, Kim;Veitch, Craig;Bundy, Anita;Gallego, Gisselle;Lincoln, Michelle;Brentnall, Jennie;Griffiths, Scott

Purpose: Throughout the world, people with a disability who live in rural and remote areas experience difficulty accessing a range of community-based services including speech-, physioand occupational therapy. This paper draws on information gathered from carers and adults with a disability living in a rural area in New South Wales (NSW), Australia to determine the extent to which people living in rural areas may receive a person-centred therapy service. Methods: As part of a larger study in rural NSW into the delivery of therapy services, focus groups and individual interviews were conducted with 78 carers and 10 adults with a disability. Data were analysed using constant comparison and thematic analysis. Results: Three related themes emerged: (i) travelling to access therapy; (ii) waiting a long time to get therapy; and (iii) limited access to therapy past early childhood. The themes overlaid the problems of recruiting and retaining sufficient therapists to work in rural areas. Conclusions: Community-based rehabilitation principles offer possibilities for increasing person-centred therapy services. We propose a person-centred and place-based approach that builds on existing service delivery models in the region and involves four inter-related strategies aimed at reducing travel and waiting times and with applicability across the life course.
Evidence and desperation in off-label prescribing: recombinant factor VIIa
23 June 2014
University of Sydney

Lipworth, W;Kerridge, I;Little, M;Day, R

Wendy Lipworth and colleagues explore why clinicians prescribe recombinant f actor VIIa off-label for major haemorrhage, despite a lack of supporting evidence—and why this matters
The law of gifts, conditional donation and biobanking
23 June 2014
University of Sydney

Steward, C;Fleming, J;Kerridge, I

Tissue banks are critical to research efforts into the causes and treatment of many diseases. Biobanks are created from donated tissue but property concepts have not played a major role in understanding methods of the collection and use of tissue. Little work has been done to study the proprietary dimensions of these gifts primarily because of the influence of the res nullius rule. Instead, the primary focus of studies has been the concept of informed consent, but this has proven to be problematic. This article examines how the law of gifts can help to resolve these difficulties. It argues that the concept of conditional donation is a more useful way to understand and explain how tissue can be donated to biobanks. The article also suggests ways that conditional donation could be regulated so as to balance the needs of researchers and the concerns of donors.
Umbilical cord blood banking: Beyond the public-private divide
23 June 2014
University of Sydney

O'Connor, MA;Samuel, G;Jordens, C;Kerridge, I

Umbilical cord blood is a source of haematopoietic progenitor cells, which are used to treat a range of malignant, genetic, metabolic and immune disorders. Until recently, cord blood was either collected through donations to publicly funded cord blood banks for use in allogeneic transplantation, or stored in commercial cord blood banks for use in autologous transplantation. The line between public and private cord blood banking is being blurred by the emergence of "hybrid" models that combine aspects of both the public and private systems. The authors describe these hybrid models and argue that their emergence is explained by both market forces and public sector policy They propose that the future of the sector will depend heavily on several key developments that will differentially affect public, private and hybrid banking models.
How clinical and research failures lead to suboptimal prescribing: the example of chronic gout
23 June 2014
University of Sydney

Lipworth, W;Kerridge, I;Brett, J;Day, R

Despite the existence of several effective drugs for chronic tophaceous gout, management is often neither rational nor effective. Wendy Lipworth and colleagues examine the possible reasons An evidence based or “rational” approach to prescribing is thought to maximise the benefit and minimise the harm from prescription drugs. Unfortunately, prescribing often does not meet this ideal despite clinicians’ best intentions. We use treatment of chronic tophaceous gout to show how apparently irrational prescribing arises from several interacting “failures” in both clinical practice and drug development.
Where to now for health-related journal peer review?
23 June 2014
University of Sydney

Lipworth, W;Kerridge, I

Peer review of health-related manuscripts has enormous power in determining what is published in health-related journals, and what makes its way into health policy and clinical practice. However, peer review is at times ethically problematic and not always effective in achieving its goals. Over the past 25 years, a large number of debates about, and studies of, the peer review process has been published. Despite this, there is limited agreement about the strengths and weaknesses of peer review, and limited evidence about whether peer review achieves its goals and whether interventions to improve it have been successful. The authors argue that this state of affairs is not acceptable and that there is a need to systematise efforts to understand and improve the review process.
An International Comparison of the Effect of Policy Shifts to Organ Donation Following Cardiocirculatory Death (DCD) on Donation Rates After Brain Death (DBD) and Transplantation Rates
23 June 2014
University of Sydney

Bendorf, A;Kelly, PJ;Kerridge, I;McCaughan, GW;Myerson, B;Steward, C;Pussell, BA

During the past decade an increasing number of countries have adopted policies that emphasize donation after cardiocirculatory death (DCD) in an attempt to address the widening gap between the demand for transplantable organs and the availability of organs from donation after brain death (DBD) donors. In order to examine how these policy shifts have affected overall deceased organ donor (DD) and DBD rates, we analyzed deceased donation rates from 82 countries from 2000–2010. On average, overall DD, DBD and DCD rates have increased over time, with the proportion of DCD increasing 0.3% per year (p = 0.01). Countries with higher DCD rates have, on average, lower DBD rates. For every one-per million population (pmp) increase in the DCD rate, the average DBD rate decreased by 1.02 pmp (95% CI: 0.73, 1.32; p<0.0001). We also found that the number of organs transplanted per donor was significantly lower in DCD when compared to DBD donors with 1.51 less transplants per DCD compared to DBD (95% CI: 1.23, 1.79; p<0.001). Whilst the results do not infer a causal relationship between increased DCD and decreased DBD rates, the significant correlation between higher DCD and lower DBD rates coupled with the reduced number of organs transplanted per DCD donor suggests that a national policy focus on DCD may lead to an overall reduction in the number of transplants performed.
Decoration or communication? A qualitative study of images displayed around the bedsides of hospitalised children
23 June 2014
University of Sydney

Jordens, C;Lewis, P;Kerridge, I

It is common to find images displayed around the bedsides of sick children who are hospitalized for extended periods. We report a qualitative study of bedside displays that is based on photographs taken at the bedside, and interviews with eight female patients and seven mothers of young children in an Australian paediatric hospital. We found that a va- riety of people contributed to the displays in different ways, and that the displays served a wide variety of purposes. We offer a general explanation of hospital bedside displays based on our analysis of the data collected for this study, and we differentiate three related domains for further research into hospital bedside displays. We conclude that bedside displays accomplish much more than decoration alone, and should be understood as aesthetic interventions that serve a wide range of communicative purposes.
The Strengths and Limitations of Empirical Bioethics
23 June 2014
University of Sydney

Strong, K;Lipworth, W;Kerridge, I

The past two decades have been witness to an "empirical turn" in bioethics. Whereas once this field of study concerned itself purely with theoretical analysis of ethical issues emerging in the design and delivery of health care, increasingly bioethics has embraced a range of empirical research methods from the social sciences and humanities. The emergence of "empirical bioethics" has, however, been the subject of enormous debate, both in regard to its methods and its purpose. For the most part these criticisms fail to appreciate the assumptions that underpin empirical bioethics or misrepresent the claims that are made about its moral utility. This article provides a brief account of the assumptions, strengths and limitations of empirical bioethics.

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