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1.  Catheter-directed thrombolysis for acute limb ischaemia: An audit 
The Australasian Medical Journal  2014;7(12):471-475.
Background
Acute limb ischaemia (ALI) is commonly managed with surgical intervention but catheter-directed thrombolysis (CDT) is a proven treatment alternative. CDT as a treatment for ALI is not common and is dependent on local practice. All patients receiving urokinase infusions at our institution currently require a bed in the high-dependency unit (HDU). Administering the infusion requires significant nursing time and this can be accommodated in HDU where the nurse-to-patient ratio is higher than it is on general wards.
Aims
To report the outcomes of the initial admission of patients who received CDT to manage ALI, and to give a cost estimate of their care.
Method
A retrospective audit was undertaken of all patients who received CDT with urokinase for the management of ALI over a four-year period. Success of thrombolysis was defined as a patient’s survival with no need for any surgical intervention prior to discharge. Outcome measures included the requirement for further vascular procedures in the same admission, the complication rate, and the median urokinase dose and duration. Cost estimates were based on hospital pharmacy and administration data.
Results
Seventy-three patients (median age 66 years, range 27–93 years) were included in the audit. The median urokinase dose was 2.3 million units (range 0.9–5.0 million units) with a median duration of treatment of 26 hours (range 3–96 hours). Fifty-seven patients did not require any further intervention prior to discharge, 14 had further intervention, and two died (one from a brainstem haemorrhage and one who deteriorated despite thrombolysis).
The total cost per CDT case at our institution is currently approximately AUD $4,500 and AUD $6,700 for a patient being treated in HDU for one and two days, respectively. If patients were treated on a general ward, the cost would be approximately AUD $2,600 and AUD $3,000, respectively.
Conclusion
Rates of clinically acceptable clot lysis were high for patients treated with urokinase for ALI. Complication rates were comparable with published studies. Infusions can be required for prolonged periods of time and given the low complication rate, managing patients on a general ward rather than in the HDU is a feasible alternative and would reduce costs substantially.
doi:10.4066/AMJ.2014.2065
PMCID: PMC4286578  PMID: 25646123
Acute limb ischaemia; Catheter-directed thrombolysis; Urokinase
2.  An educational intervention’s effect on healthcare professionals’ attitudes towards pharmacovigilance 
The Australasian Medical Journal  2014;7(12):478-489.
Background
Pharmacovigilance concerns the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. Consumer pharmacovigilance is the involvement of consumers in adverse drug reaction (ADR) reporting. Assessing healthcare professionals’ (HCPs) knowledge of and attitude towards pharmacovigilance and consumer pharmacovigilance is integral to strengthening adverse drug reaction reporting systems.
Aims
To study knowledge of and attitude towards pharmacovigilance and consumer pharmacovigilance among HCPs from KIST Medical College, Lalitpur, Nepal, and to plan an appropriate educational intervention to address deficiencies noted.
Method
The study was conducted from February 2013 to December 2013 at KIST Medical College using a self-administered, pretested, structured questionnaire. The maximum possible scores for knowledge, attitude, and total were 100, 95, and 195, respectively. Baseline knowledge and attitude were studied. Two months after the questionnaire, an intervention that used a combination of methods about pharmacovigilance and consumer pharmacovigilance was undertaken. Knowledge and attitudes were studied immediately after the intervention. Scores before and after the intervention were compared using Wilcoxon signed-rank test.
Results
A total of 105 HCPs participated. The median (interquartile range) knowledge, attitude, and total scores before the intervention were 56 (7), 72 (9), and 127 (16), respectively. After the intervention the scores increased significantly to 72 (8), 75 (11.5), and 146 (16.5) (p<0.001), respectively.
Conclusion
The intervention was effective in improving HCPs’ knowledge of and attitude towards pharmacovigilance and consumer pharmacovigilance. More studies on this topic among HCPs at other institutions and in the community are required.
doi:10.4066/AMJ.2014.2235
PMCID: PMC4286579  PMID: 25646124
Attitude; pharmacovigilance; consumer pharmacovigilance; healthcare professionals; Nepal
3.  Team-based learning as a teaching strategy for first-year medical students 
The Australasian Medical Journal  2014;7(12):490-499.
Background
Teaching programmes in medical education are now routinely employing active learning strategies to enhance the learning process and engage students in higher levels of learning. Team-based learning (TBL) is one active learning strategy that builds on individuals’ strengths by allowing them to collaborate and work as a team to achieve a common learning objective.
Aims
The present study aims to evaluate the impact of TBL on student performance. It also aims to assess students' attitudes towards TBL and the feasibility of its incorporation into the course curriculum.
Methods
From a class of 241 students, 128 who agreed to participate in the study underwent two sessions of TBL each consisting of Individual and Group Readiness Assurance Tests (IRATs and GRATs). The readiness assurance tests each had 13 multiple choice questions (MCQ). To analyse the impact of TBL supplementation, the median sessional MCQ scores of students who underwent TBL supplementation (group 1) were compared with those who did not undergo the session (group 2). Students' experiences with TBL and their attitudes towards incorporation of TBL into the course curriculum were analysed using a feedback questionnaire that was given to students who underwent TBL.
Results
Students belonging to the TBL group performed significantly better than the students who did not undergo TBL (p<0.001). The median sessional MCQ score of the TBL group was seven and non-TBL group was six. The overall mean attitude score obtained from feedback questionnaires was 3.57, which indicates a positive attitude towards TBL.
Conclusion
The team-based learning session improved student engagement with course content. The majority of the students felt that TBL supplementation enhanced their understanding of course content and believe that it will help them perform better in their exams.
doi:10.4066/AMJ.2014.2244
PMCID: PMC4286580  PMID: 25646125
Team-based learning; medical students; individual readiness assurance test; group readiness assurance test; active learning
4.  Satisfaction amid professional challenges: International medical graduates in rural Tasmania 
The Australasian Medical Journal  2014;7(12):500-517.
Background
At the time of recruitment, migration, and placement, international medical graduates (IMGs) encounter professional challenges. These challenges may include a loss of status and professional identity, professional isolation in rural practice, restrictions on medical practice, and social isolation. Understanding the nature of these challenges may facilitate the recruitment, placement, and success of international medical graduates within rural Tasmania.
Aims
The aim of this study was to investigate the experiences, challenges, and barriers that IMGs encounter as they work and live in rural Tasmania.
Methods
The study used a mixed-methods design where data were collected using a questionnaire and semi-structured interviews across the south, north, and northwest of Tasmania. IMGs were recruited through purposive snowball and convenience sampling.
Results
A total of 105 questionnaires were returned (response rate 30.0 per cent) and 23 semi-structured interviews were conducted with IMGs across Tasmania. Questionnaire participants indicated that the majority of IMGs are satisfied in their current employment; however, interview participants indicated there were a number of barriers to practising medicine in Tasmania as well as factors that would influence ongoing employment in the state. Despite these challenges, professional support was recognised as a key contributor to professional satisfaction, particularly among IMGs who had just arrived.
Conclusion
The study contributes to the current knowledge and understanding of IMGs who live and work in rural areas. The study shows that there are high levels of satisfaction among IMGs with their current position; however, the research also provides insight into the complexities and factors that impact IMGs as they work and live within rural areas such as Tasmania. This study offers an understanding for policy to improve greater retention of IMGs across rural areas.
doi:10.4066/AMJ.2014.2267
PMCID: PMC4286581  PMID: 25646126
international medical graduates; professional challenges; employment; satisfaction; rural practice
5.  Student feedback on problem-based learning processes 
The Australasian Medical Journal  2014;7(12):522-529.
Background
Problem-based learning (PBL) sessions consist of a brainstorming phase, search phase, individual study, and reporting phase. At the Xavier University School of Medicine, Aruba, PBL is a new learning modality first introduced in May 2013.
Aims
PBL processes have not been studied previously at the Xavier University School of Medicine, hence the present study was carried out to obtain information about the PBL processes and note differences, if any, among different groups of students.
Method
The study was conducted among first- to fourth-semester undergraduate medical students during July 2014 using a previously validated PBL processes instrument developed by van den Hurk et al. Information about gender, semester, weekly hours of study, and learning resources used was obtained. Respondents’ agreement with a set of 23 statements was noted using a Likert-type scale, which was scored as 1=totally disagree with the statement, 2=disagree, 3=neutral, 4=agree, and 5=totally agree with the statement. Mean scores were compared among different groups of respondents.
Results
Fifty-one of the 58 students (87.9 per cent) participated. The weekly average study time was 29.9 hours. Lecture handouts and textbooks were commonly used information sources. The mean scores (scale 1 to 5) for learning-issue-driven searching, and extensiveness of searching were 3.49 and 3.45, respectively. The score for explanation-oriented preparation was 3.94, while those for breadth and depth of discussion were 3.75 and 3.62, respectively. Most scores were higher among second-semester students, but the difference was not significant.
Conclusion
The self-reported scores were comparable to those reported in previous studies done using the same PBL processes instrument in other medical schools. At Xavier University School of Medicine interactive lectures are the major teaching method and topics covered during PBL are also likely to be covered during lectures, which could influence the scores. The findings of our study providing information about how students function during PBL brainstorming and presentation sessions and how they use different learning resources would be of interest to other medical schools worldwide following a hybrid curriculum. Further studies are required.
doi:10.4066/AMJ.2014.2208
PMCID: PMC4286583  PMID: 25646128
Medical school; presentation; problem-based learning; reporting; search; self-directed learning
6.  The effectiveness of self-directed learning (SDL) for teaching physiology to first-year medical students 
The Australasian Medical Journal  2014;7(11):448-453.
Background
Self-directed learning (SDL) has become popular in medical curricula and has been advocated as an effective learning strategy for medical students to develop competence in knowledge acquisition.
Aims
The primary aim was to find out if there was any benefit of supplementing self-directed learning activity with a traditional lecture on two different topics in physiology for first-year medical students.
Method
Two batches of first-year Bachelor of Medicine and Bachelor of Surgery (MBBS) (Batch A and Batch B) comprising 125 students each, received an SDL session on Morphological classification of anaemia. The students belonging to Batch A received a one-hour lecture on the same topic three days prior to the SDL session. The students were given a 10 multiple choice questions (MCQ) test for a maximum of 10 marks immediately following the SDL session. The next topic, Conducting system of the heart, disorders and conduction blocks was taught to both batches in traditional lecture format. This was followed by an SDL session on the same topic for Batch A only. The students were evaluated with a MCQ test for a maximum of 10 marks.
Results
The mean test scores on the first topic were 4.38±2.06 (n=119) and 4.17±1.71 (n=118) for Batch A and Batch B, respectively. The mean test scores on the second topic were 5.4± 1.54 (n=112) and 5.15±1.37 (n=107) for Batch A and Batch B, respectively. There was no significant difference between the groups.
Conclusion
For first-year medical students, SDL is an effective teaching strategy for learning physiology. However, no additional benefit is gained by supplementing SDL with a lecture to facilitate learning physiology.
doi:10.4066/AMJ.2014.2211
PMCID: PMC4259209  PMID: 25550716
lecture; self-directed learning; physiology; medical education
7.  Young Australian adults’ reactions to viewing personalised UV photoaged photographs 
The Australasian Medical Journal  2014;7(11):454-461.
Background
Despite two nationwide sun-protection awareness campaigns, young Australian adults continue to sunbathe. Since their primary motivation for tanning is appearance enhancement, it may well be that campaigns that highlight the negative effects of tanning on appearance are more effective than campaigns that emphasise the health risks associated with sun exposure.
Aims
This study aims to explore young adults’ reactions to viewing a photoaged photograph of the sun damage already visible in their facial image.
Method
Semi-structured interviews were conducted with seven females and three males aged 20–30 years. The interview transcripts were transcribed verbatim and were then subjected to Interpretive Phenomenological Analysis (IPA).
Results
Three themes and eight sub-themes emerged from the analysis. Collectively they revealed that participants’ fear-based reaction to their photoaged photographs triggered in them feelings of unattractiveness, which in turn motivated them to change to their existing sun-tanning behaviours.
Conclusion
Although media-popularised representations of suntanned skin being the desired norm were identified as a barrier to skin-protective behavioural change, personalised ultraviolet (UV) photoaged photographs, when accompanied by an explanation of the skin damage that unprotected ultraviolet radiation (UVR) exposure causes, were effective in changing young adults’ sun-tanning intentions. Hence, a need exists for positive non-tanning appearance-related messages to be incorporated into sun exposure education campaigns.
doi:10.4066/AMJ.2014.2253
PMCID: PMC4259210  PMID: 25550717
photoaged photography; young adults sun-tanning intentions; unprotected UVR sun exposure; skin-protective measures
8.  Proton pump inhibitors: Are we still prescribing them without valid indications? 
The Australasian Medical Journal  2014;7(11):465-470.
Background
Evidence from several Western studies has shown an alarmingly high and inappropriate rate of prescription of proton pump inhibitors (PPIs), which may be associated with increased healthcare costs and adverse outcomes. PPI prescribing patterns remain largely unknown in well-developed healthcare systems in Southeast Asia.
Aims
We aimed to determine the prevalence of inappropriate prescription of PPI among elderly patients without documentation of valid indications, in a tertiary teaching hospital in Singapore.
Method
We carried out a retrospective clinical records review of 150 elderly patients aged ≥65 years that had been admitted to two internal medicine wards between 25 May 2011 and 28 June 2011 to determine the appropriateness of indications for PPIs prescribed at hospital discharge. PPI indications were categorised as “valid”, “likely invalid”, and “probable” based on current clinical literature. Pre-admission and discharge prescriptions were reviewed to determine continuation of pre-admission and new PPI prescriptions at discharge. Data on clinical characteristics and concurrent use of ulcerogenic medications were collected.
Results
From a total of 150 patients, 80 (53 per cent) received prescriptions for PPIs. Of these, 65 (81.2 per cent) had no valid documented indications (i.e., the indication was classed as “likely invalid”); 10 (12.5 per cent) had valid indications; and in five cases (6.2 per cent) the indication was “probable”. The most common “likely invalid” indication was primary gastrointestinal bleeding prophylaxis (GIP) among low-dose aspirin users in 28 patients (43 per cent) of invalid PPI prescriptions.
Conclusion
Inappropriate prescribing of PPIs without documented valid indications was prevalent among elderly patients at our tertiary teaching hospital in Singapore, providing evidence that shows a similar trend to PPI prescribing to data from Western countries.
doi:10.4066/AMJ.2014.2093
PMCID: PMC4259212  PMID: 25550719
Proton pump inhibitors; prescribing; elderly; valid indications
9.  A study of acute otitis externa at Wellington Hospital, 2007–2011 
The Australasian Medical Journal  2014;7(10):392-399.
Background
Acute otitis externa (AOE) is a common inflammatory condition affecting the external ear that occasionally presents with persistent, severe pain, which may be unresponsive to first-line therapy and require assessment and treatment in the hospital setting.
Aims
To identify the microorganisms responsible for cases of otitis externa presenting to Wellington Hospital, New Zealand, over a five-year period between 2007 and 2011. We also aim to evaluate current management of this condition and to recommend future treatment options.
Method
A five-year retrospective study, with data obtained from case notes and electronic records for all patients presenting with otitis externa to Wellington Hospital between 2007 and 2011.
Results
Of 347 cases identified, 144 were included in the study. Pseudomonas aeruginosa (P. aeruginosa) was the most common organism (46.5 per cent), while Staphylococcus aureus (S. aureus) was the second most common (31.9 per cent). Most patients received appropriate topical treatment. However, a significant number were treated with systemic antibiotics alone without adverse outcomes.
Conclusion
Pseudomonas aeruginosa is the most common microbe causing acute otitis externa in patients that require hospital level management in Wellington, New Zealand. In most cases, patients received appropriate topical therapy; however, it appears a large number received systemic antibiotic therapy without topical treatment. We recommend broad-spectrum topical antimicrobial therapy in all patients with uncomplicated AOE and culture-sensitive topical treatment with consideration of systemic antimicrobials for severe AOE requiring hospital admission.
doi:10.4066/AMJ.2014.2094
PMCID: PMC4221774  PMID: 25379060
Acute otitis externa; microbiology; epidemiology
10.  Clinical handover: An audit from Australia 
The Australasian Medical Journal  2014;7(9):363-371.
Background
The Australian National Safety and Quality Health Service (NHQHS) Standards (the “Standards”) provide external criteria for hospitals to assess their practices. Since the introduction of the Standards, no Australian hospital has published a report on how its handover practices compare to these Standards.
Aims
To evaluate house medical officer (HMO) shift-to-shift handover practices against the Standards at a large regional hospital.
Method
All HMOs employed by Barwon Health were invited to participate in our qualitative and quantitative study by completing an online questionnaire and taking part in a focus group.
Results
Of the 100 HMOs, 61 completed the questionnaire and 11 HMOs participated in focus groups. Questionnaire results revealed that HMOs were concerned about the quality of shift-to-shift handovers. Fifty-three per cent reported that current shift-to-shift handover practices could be putting patients at risk of adverse events. Ninety-eight per cent indicated that the handover processes could be improved. One hundred per cent of the HMOs stated that the quality of handover varies according to the doctors involved. In the focus groups, issues were raised about current handover structure, documentation, attendance, content, and training.
Conclusion
HMOs in the current study identified multiple deficiencies in handover practice with regard to structure, documentation, attendance, content, and training. The primary methods to improve handover include making it more structured and standardised, and to provide HMOs with handover training.
doi:10.4066/AMJ.2014.2060
PMCID: PMC4185328  PMID: 25324901
Handover; House Medical Officer; Shift-to-shift; Communication; Accreditation
11.  A win for the patient: Direct patient notification improves treatment rates of active Helicobacter pylori infection 
The Australasian Medical Journal  2014;7(8):350-354.
Background
Current international guidelines recommend the commencement of effective eradication therapy as soon as active Helicobacter pylori (H. pylori) infection is confirmed. At our institution, all positive Campylobacter-like Organism (CLO) test results were automatically communicated to general practitioners (GPs) via a standardised letter, which also advised the commencement of eradication therapy. Despite this endeavour, a clinical audit conducted in 2011 demonstrated that only 66 per cent of confirmed H. pylori-positive South Auckland patients received eradication treatment and only 83 per cent of these patients received treatment within one month.
Aims
Improve the timely initiation of H. pylori eradication therapy through direct patient notification.
Method
A prospective clinical audit of 109 consecutive outpatients with a positive CLO test identified at gastroscopy. In addition to standard general practitioner notification, patients were also directly notified of their positive CLO test result via a standardised letter, which provided information about H. pylori and its disease associations as well as advising patients to seek consultation with their GP to commence eradication therapy. Dispensing data was examined using Test Safe electronic records to determine the total uptake and timing of treatment compared to data from a preliminary 2011 audit.
Results
Ninety-five per cent of H. pylori-positive patients received standard triple therapy; therefore, treatment of active H. pylori infection was significantly higher when patients were directly notified in addition to standard GP notification, when compared to GP notification alone (95 per cent vs 66 per cent, p<0.001). All patients who received eradication therapy did so within one month of notification, a significant improvement compared to data from the previous audit in 2011 (100 per cent vs. 83 per cent, p<0.001).
Conclusion
Direct patient notification using a standardised letter is a simple and economical strategy that significantly improves the timely initiation of eradication therapy for active H. pylori infection. This has since been integrated into standard practice at our District Health Board (DHB).
doi:10.4066/AMJ.2014.2132
PMCID: PMC4157155  PMID: 25279011
Helicobacter pylori; H. pylori; patient education; triple therapy
12.  Potential cost to Western Australia of proposed patient co-payments according to healthcare organisational structure: A preliminary analysis 
The Australasian Medical Journal  2014;7(8):357-360.
Background
The Australian federal government has proposed an AUD $7 patient co-payment for a general practitioner (GP) consultation. One effect of the co-payment may be that patients will seek assistance at public hospital emergency departments (EDs), where currently there is no user charge.
Aims
We studied the possible financial impact of patient diversion on the Western Australia (WA) health budget.
Method
We constructed a spreadsheet model of changes in annual cash flows including the co-payment, GP fees for service, and rates of diversion to emergency departments with additional marginal costs for ED attendance.
Results
Changes in WA cash flows are the aggregate of marginal ED costs of treating diverted patients and added expenditure in fees paid to rural doctors who also man local emergency centres. The estimated costs to WA are AUD $6.3 million, $35.9 million and $87.4 million at 1, 5, and 10 per cent diversion, respectively. Commonwealth receipts increase and expenditure on Medicare benefits declines.
Conclusion
A diversion of patients from GP surgeries to ED in WA caused by the co-payment will result in increased costs to the state, which may be substantial, and will reduce net costs to the Commonwealth.
doi:10.4066/AMJ.2014.2214
PMCID: PMC4157156  PMID: 25279012
Healthcare costs; Patient Medicare co-payment; general practice; public hospitals
13.  Factors associated with non-attendance in a general practice super clinic population in regional Australia: A retrospective cohort study 
The Australasian Medical Journal  2014;7(8):323-333.
Background
Non-attendance at medical appointments is associated with increased patient morbidity and is a significant drain on health service resources. Australian studies have focused on secondary healthcare settings, screening, and interventions to reduce non-attendance.
Aims
To explore factors associated with non-attendance in a regional primary care setting.
Method
A retrospective cohort of all patients with a scheduled appointment between October 2011 and October 2013 at a regional, primary care clinic providing medical and allied health services in a region of New South Wales (NSW) serving a large Aboriginal population (10.7 per cent). Using multivariate logistic regression, non-attendance was regressed on a range of covariates, including number of appointments per person, gender and ethnicity, and day of the week.
Results
The overall proportion of missed appointments was 7.6 per cent. Risk factors for non-attendance were day of the week [Mondays (8.1 per cent), Fridays (8.0 per cent), and Thursdays (7.9 per cent), (χ2(4)= 20.208, p<0.0005], having fewer scheduled appointments [≤5 appointments resulted in 19.1 per cent greater risk of failure to attend (FTA) (95% CI: 11–28%)]; Aboriginality (OR=4.022, 95% CI: 3.263, 4.956), and female gender (OR=1.077; 95% CI 1.024, 1.132). There was a trend toward an interaction between gender and Aboriginality, with Aboriginal females being the group most likely to miss appointments (OR=1.272, 95% CI: 0.949, 1.705).
Conclusion
This is the largest study of non-attendance in an Australian primary healthcare setting. While not a typical setting, the study had the advantage of a large, mixed population. The suggested high rates of non-attendance by Aboriginal females have potentially important policy implications.
doi:10.4066/AMJ.2014.2098
PMCID: PMC4157152  PMID: 25279008
Non-attendance; super clinic; Aboriginal
14.  Melanoma: A new strategy to reduce morbidity and mortality 
The Australasian Medical Journal  2014;7(7):266-271.
Background
Public awareness campaigns could address risk factors for melanoma to reinforce their sun protection message. The objective of this study is to prioritise risk factors associated with malignant melanoma (MM) to improve public awareness.
Method
Design: A cross-sectional study with retrospective data analysis from 2004 to 2010.
Setting: Western Australian Melanoma Advisory Service (WAMAS), a tertiary referral multidisciplinary organisation providing MM management advice. WAMAS data files were analysed with histologically confirmed cutaneous MM. Forty- seven patients had two or more melanomas, but the patient file was counted only once. Six MM data files with missing or incomplete information were excluded.
Main outcome measures: The number of naevi, blood relatives with MM, and previous sunburns were the primary variables collected.
Results
The results showed that 70.9 per cent (268/378) had previous sunburn; 40.2 per cent (152/378) had multiple naevi; and 22.5 per cent (85/378) had a positive family history. In the 110 MM data files not associated with sunburn, multiple naevi and a positive family history represented 34.5 per cent (38/110) and 20.0 per cent (22/110), respectively.
Conclusion
The results confirm the findings of previous studies that multiple naevi and a positive family history are important risk factors associated with MM. We suggest that MM can be detected earlier and its mortality decreased by focusing on these high-risk groups who are not targeted by current public awareness campaigns.
doi:10.4066/AMJ.2014.1949
PMCID: PMC4127957  PMID: 25157266
Risk factors; melanoma; prevention
15.  Impact of community pharmacy-based educational intervention on patients with hypertension in Western Nepal 
The Australasian Medical Journal  2014;7(7):304-313.
Background
There is a paucity of data regarding the feasibility and impact of community pharmacy-based educational interventions on the management of chronic diseases in developing countries.
Aims
The aim of this study was to establish the feasibility, and to investigate the impact, of community pharmacy-based educational intervention on knowledge, practice, and disease management of patients with hypertension in Western Nepal.
Method
A single-cohort pre-/post-intervention study was conducted from August 2012 to April 2013. The participants included in the study were patients diagnosed with hypertension attending a pharmacist-led hypertension clinic. The educational intervention was conducted by pharmacists, was individualised, and consisted of three counselling sessions over a period of six months. The patients’ knowledge of hypertension, their practice of lifestyle modification and non-pharmacological approaches concerning hypertension management, and blood pressure were assessed at baseline and again after nine months by using a pre-validated questionnaire.
Results
Fifty patients met the inclusion criteria and were enrolled in the study. The median (IQR) knowledge score changed from 6 (4) to 13 (0) after the intervention (p<0.01) with the median (IQR) practice score changing from 7 (4) to 16 (2) (p<0.01). The mean (SD) systolic BP changed from 150.1 (7.8) to 137.7 (9.9) (p<0.01) and the mean (SD) diastolic BP from 104 (9.5) to 94.5 (7.8) after the intervention (p< 0.01).
Conclusion
A simple, educational intervention by community pharmacists had improved patients’ disease knowledge, practice, and management of their hypertension. Evidence suggests Nepalese community pharmacists need could play an important role in the management of chronic diseases like hypertension through simple interventions such as providing educational support for patients.
doi:10.4066/AMJ.2014.2133
PMCID: PMC4127961  PMID: 25157270
Community pharmacy; educational intervention; hypertension; Nepal
16.  The effect of an electronic health record system on nursing staff time in a nursing home: a longitudinal cohort study 
The Australasian Medical Journal  2014;7(7):285-293.
Background
Nursing homes are increasingly introducing electronic health record (EHR) systems into nursing practice; however, there is limited evidence about the effect of these systems on nursing staff time.
Aims
To investigate the effect of introducing an EHR system on time spent on activities by nursing staff in a nursing home.
Method
An observational work sampling study was undertaken with nursing staff between 2009 and 2011 at two months before, and at 3, 6, 12, and 23 months after implementation of an EHR system at an Australian nursing home. An observer used pre-determined tasks to record activities of the nursing staff at nine-minute intervals.
Results
There was no significant change in registered nurses and endorsed enrolled nurses’ time on most activities after implementation. Personal carers’ time on oral-communication reduced, and time on documentation increased at most measurement periods in the first 12 months after implementation. At 23 months, time on these activities had returned to pre-implementation levels. Nursing staff time on direct care remained stable after implementation. No considerable change was observed in time spent on other activities after implementation.
Conclusion
Findings suggest that successful introduction of an EHR system in a nursing home may not interfere with nursing staff time on direct care duties. However, there is scope for improving the support provided by EHR systems through incorporation of functions to support collaborative nursing care.
doi:10.4066/AMJ.2014.2072
PMCID: PMC4127959  PMID: 25157268
Activity; electronic health record; HER; impact; nurse; nursing home
17.  Validation of the Thai QOL-AD version in Alzheimer’s patients and caregivers 
The Australasian Medical Journal  2014;7(6):251-259.
Background
Quality of life (QOL) plays an important role in determining the improvement of patient care in Alzheimer’s disease (AD). The simple and easily used Thai instrument for measuring QOL is still limited.
Aims
This study aimed to translate the Quality of Life–Alzheimer’s Disease (QOL-AD) scale original version into a Thai version and test its psychometric properties.
Method
A Thai version of QOL-AD was translated following the sequential method. The validation was tested in 136 pairs of patients and their caregivers. Mild to moderate Alzheimer’s patients were recruited from outpatient clinics at Chiang Mai Neurological Hospital and Chiang Mai Psychiatry Hospital from April to September 2012. Internal consistency, factor analysis, and construct validity were evaluated.
Results
Internal consistency of Thai QOL-AD version was good for both patients (0.82) and caregivers (0.82). The results of factor analysis indicated three factors (physical and psychological well-being, social well-being, and close interpersonal relationships) in the patient group, while four factors were found (social well-being, functional ability, psychological well-being, and physical well-being) in the caregiver group. The scaling success in the patient group was around 80–83 per cent for convergent validity, and 70–83 per cent for discriminant validity. The caregiver group showed higher scaling success in convergent validity except for the psychological well-being domain. The scaling success of discriminant validity was around 44–83 per cent for caregivers.
Conclusion
The findings of the study demonstrate a good reliability of a Thai QOL-AD version for both patient and caregiver groups. Validity, especially in the caregiver group, might need to be re-examined.
doi:10.4066/AMJ.2014.2078
PMCID: PMC4082250  PMID: 25031647
Quality of life; Alzheimer’s disease; Thai version; Reliability; Validity
18.  A qualitative study of staff perspectives of patient non-attendance in a regional primary healthcare setting 
The Australasian Medical Journal  2014;7(5):218-226.
Background
Non-attendance at health appointments reduces health service efficiency, is costly to services, and can risk patient health. Reminder systems are widely used to overcome forgetfulness, the most common reason for non-attendance; however, other factors, such as patient demographics and service accessibility, may also affect attendance rates.
Aims
There is limited primary research on the reasons for patient non-attendance in the Australian healthcare setting, although the success of preventative health initiatives requires ongoing monitoring of patients. This study aims to improve our understanding of the Australian experience by examining staff perspectives.
Method
This qualitative study explored staff perspectives of the reasons for non-attendance in a large, regional general practice super clinic, which has a low socioeconomic catchment, and serves a large Aboriginal population.
Results
The practical barriers to attendance of travel, cost, and waiting times had largely been overcome with transport provision, free medical care and responsive appointment times, but paradoxically, these were seen to devalue allocated appointments and reinforce the expectations of “on-demand” health care. For Aboriginal patients specifically, a distrust of authority, combined with poor health literacy was perceived to impact negatively on the uptake of diagnostic tests, filling of prescriptions, health monitoring, and adherence to medication.
Conclusion
The results suggest a complex interplay between poor health literacy and low patient self-worth; a funding system that encourages “five-minute medicine and prevents doctors getting to the root cause of patient problems or having the ability to provide health education.
doi:10.4066/AMJ.2014.2056
PMCID: PMC4051357  PMID: 24944719
Non-attendance; super clinic; Aboriginal; adherence; reminders
19.  A study to assess the feasibility of Text Messaging Service in delivering maternal and child healthcare messages in a rural area of Tamil Nadu, India 
The Australasian Medical Journal  2014;7(4):175-180.
Background
Mobile text messaging is a potentially powerful tool for behaviour change because it is widely available, inexpensive, and instant.
Aims
To evaluate whether mobile Text Messaging Service is a feasible mode of raising knowledge regarding maternal and child health (MCH) and to explore issues related to mobile text messages as a mode of health education.
Method
A community-based intervention study was conducted from January to June 2013 in six randomly selected villages of Vellore district, Tamil Nadu. A multi-stage sampling technique was followed: 120 individuals from 120 households (30 clusters in six villages) were contacted. Data was collected using a pretested questionnaire by house-to-house visits in three phases: 1) baseline assessment of aptitude towards text messages; 2) intervention: sending MCH-related text messages; and 3) end-line assessment to evaluate the increase in knowledge level. Qualitative data regarding mobile text messages as a mode of health education was explored. Quantitative data was analysed using SPSS version 17.0 and qualitative data by Anthropac software.
Results
Of the individuals surveyed, 69.17 per cent and 52.5 per cent were “able to read” and “type and send” text messages, respectively. Seventy per cent of individuals were willing to receive health information via text messages, and 98.33 per cent believed text messages could effectively spread health messages. A significant increase in knowledge was observed following text messages. Male gender and subjects’ ability to read text messages were significantly associated. Factors related to mobile phone use include minimum economic burden, easy availability, portability, and ease of use. Factors related to mobile text messages as a mode of health message delivery include direct receipt of information, mass reach, the absence of regional language font in many handsets, and illiterate individuals being unable to read messages.
Conclusion
In rural areas, mobile text messages have the potential to deliver health messages regarding MCH.
doi:10.4066/AMJ.2014.1916
PMCID: PMC4009878  PMID: 24817911
Health education; maternal and child health; text messages
20.  A study of antibiogram of Salmonella enterica serovar Typhi isolates from Pondicherry, India 
The Australasian Medical Journal  2014;7(4):185-190.
Background
Enteric fever caused by Salmonella enterica serovar Typhi (S. Typhi) is an important public health problem in developing countries like India.1 The emergence of resistance to fluoroquinolones has reduced the therapeutic options available. Currently, the uniform laboratory interpretation of ciprofloxacin and azithromycin susceptibility remains unclear.
Aims
To study the antibiogram of S. Typhi isolates with special emphasis on in-vitro activity of ciprofloxacin and azithromycin.
Method
We evaluated the antimicrobial susceptibility pattern of 16 S. Typhi isolates from January 2012 to June 2013. We also determined by Epsilometer-test (E-test) method, the minimum inhibitory concentration (MIC) of ciprofloxacin and azithromycin against these isolates and compared them with their corresponding disc diffusion sizes.
Results
Fifteen (93.75 per cent) isolates were sensitive to chloramphenicol, 14 (87.5 per cent) were sensitive to cotrimoxazole. All isolates were resistant to nalidixic acid. MICs for ciprofloxacin ranged from 6μg/ml to 15μg/ml and corresponding zone diameters ranged from 15mm to 26mm. MIC and zone diameters for ciprofloxacin had significant negative correlation. MICs for azithromycin ranged from 3μg/ml to 24μg/ml, corresponding zone diameters ranged from 13mm to 19mm. However, MIC and zone diameters for azithromycin had no significant negative correlation.
Conclusion
The widespread emergence of resistance to fluoroquinolones and reappearance of sensitivity to firstline drugs has reinforced the need for antibiotic recycling. There is a need to have uniform laboratory testing guidelines for testing susceptibility to ciprofloxacin and azithromycin for S. Typhi isolates.
doi:10.4066/AMJ.2014.2010
PMCID: PMC4009880  PMID: 24817913
Antibiogram; ciprofloxacin; azithromycin; minimum inhibitory concentrations; S. Typhi
21.  Western Australia coastal shark bites: A risk assessment 
The Australasian Medical Journal  2014;7(2):137-142.
Background
As Western Australia’s (WA) government enacts shark bite mitigation, the personal risk of shark bite in WA has not been studied.
Aims
Model the risk of large (>3m) white shark bite (Carcharodon carcharias, LWS) in southwest WA.
Method
An observational study inclusive of 1 January 1974 to 31 December 2013 was conducted. Analysis of prey abundance, location, water temperature, and water activity participation. Shark bite risk was benchmarked against serious or fatal recreational cycling crash risk in WA.
Results
Total and fatal shark bites have grown exponentially over 40 years (3 to 29 total, 0 to 7 fatal per 5 years), correlated with the 10 per cent annual growth in WA humpback whale (Megaptera novaeangliae) abundance (rtotal=0.96 95%CI 0.77–0.99, p<0.001; rfatal=0.96 95%CI 0.81-0.99, p<0.001) but not water activity participation rtotal= 0.25, 95%CI –0.45–0.76, p=0.48). LWS were implicated in 10 of 12 fatalities. Metropolitan Perth beach summer/autumn bathing less than 25m from shore in water less than 5m deep (risk lower than 1 in 20 years) is estimated to be at least 50x safer than cycling. Off-shore diving and surf sports off Perth, during winter/spring have a similar risk to cycling. Winter/spring off- shore diving south of Perth has between 3 and 11 times the cycling risk.
Conclusion
WA’s shark bite risk is likely to increase as whale abundance continues to increase off the WA coast. However, the risk to bathers less than 25m from shore in shallow water during the WA summer, is likely to remain very low, and well below the risk of other recreational activities undertaken in WA.
doi:10.4066/AMJ.2014.2008
PMCID: PMC3941575  PMID: 24611078
shark; injury; risk
22.  Antibiotic screening of urine culture as a tool for interal quality audit 
Background
Microbiologic culture of urine is an important component in the diagnosis of urinary tract infections (UTI). However, confounding factors like the patient’s current history of antibiotic usage can affect the interpretation of urine culture results.
Aims
This study was undertaken to find out the occurrence of unreported antibiotic consumption prior to urine culture and its clinical consequences.
Method
In this descriptive study conducted from February to August 2013, we tested consecutive urine specimens for the presence of antibiotics with a modified urine antibacterial substance assay (UABA) and compared the results obtained with the accuracy of antibiotic data entry on the accompanying request forms. In addition, the consequences of culturing urine specimens with incomplete antibiotic history received in the laboratory were investigated.
Results
Out of 2,040 urine specimens, 721 (35.34 per cent) were UABA positive. Comparison of antibiotic screening of urine with antibiotic data entry from request forms showed 1,299 (63.68 per cent) true-negative, 38 (1.86 per cent) true- positive, 20 (0.98 per cent) false-negative, and 683 (33.48 per cent) false-positive results. The sensitivity and specificity of this test were 65.52 per cent and 65.54 per cent, respectively. The positive and negative predictive values were 5.27 per cent and 98.48 per cent, respectively. The UABA had a positive diagnostic likelihood ratio of 1.901.
Conclusion
This internal audit demonstrates how the accurate history of current antibiotic usage in the request forms impacts the interpretation of urine culture results.
doi:10.4066/AMJ.2014.1956
PMCID: PMC3941580  PMID: 24611076
Antibiotic screening; internal audit; Antibiotic History; Urine culture
23.  Clinical profile of urinary tract infections in diabetics and non-diabetics 
Background
The risk of urinary tract infection (UTI) is higher in diabetics compared to non-diabetics. The aetiology and the antibiotic resistance of uropathogens have been changing over the past years. Hence the study was undertaken to determine if there are differences in clinical and microbiological features of UTI between diabetic and non-diabetic subjects, to study the influence of diabetes mellitus on the uropathogens and antibiotic sensitivity pattern in patients with UTI.
Method
A total of 181 diabetics (83 males and 98 females) and 124 non-diabetic subjects (52 males and 72 females) with culture positive UTI were studied. Patients with negative urine culture (n= 64), those diagnosed and treated outside (n= 83) and not willing to participate in the study (n= 24) were excluded.
Results
Almost 30 per cent of the patients (both diabetics and nondiabetics) presented with asymptomatic bacteriuria and the prevalence of pyelonephritis was significantly higher (p= 0.04) in diabetics compared to non-diabetic patients. The majority of the diabetics with UTI (87.14 per cent) had glycosylated haemoglobin (HbA1c) > 6.5 per cent with p < 0.001. The isolation rate of Escherichia coli (E. coli) from urine culture was higher (64.6 per cent) among diabetic patients followed by Klebsiella (12.1 per cent) and Enterococcus (9.9 per cent). The prevalence of extendedspectrum beta-lactamase (ESBL) producing E.coli was significantly higher in diabetics (p= 0.001) compared to nondiabetics. E.coli showed maximum sensitivity to carbapenems in both diabetic and non-diabetic subjects and least susceptibility to ampicillin.
Conclusion
The prevalence of pyelonephritis is significantly higher in diabetics than in non-diabetic subjects, with E. coli being the most common isolate. Elevated glycosylated hemoglobin (HbA1c) predisposes diabetics to UTI. Investigation of bacteriuria in diabetic patients for urinary tract infection is important for treatment and prevention of renal complications.
doi:10.4066/AMJ.2014.1906
PMCID: PMC3920469  PMID: 24567764
Urinary tract infection; Asymptomatic bacteriuria; Uropathogens; Diabetic patients; E. coli
24.  Pharmacy practice and its challenges in Yemen 
Background
Pharmacy practice in Yemen was established in 1875 in Aden.
Objectives
To describe pharmacy practice as it currently exists in Yemen, the challenges the profession faces, and to recommend changes that will improve pharmaceutical care services.
Methods
This study has two parts. Part 1 comprised a literature search performed between May and July 2011 to identify published studies on pharmacy practice in Yemen. Full text papers, abstracts, and reports in Arabic or English between 1970 and 2011 were reviewed. Part 2 consisted of a qualitative study with face-to-face interviews with a representative sample of pharmacists, staff from the Ministry of Public Health and Population (MoPHP), and patients.
Results
The analysis revealed several issues that plague pharmacy practice in Yemen:
Fewer than 10 per cent of pharmacists working in pharmacies and drug stores are graduates of governmentrecognised colleges.
Most Yemeni pharmacists are dissatisfied with their work conditions and opportunities.
Medicines are expensive and hard to access in Yemen, and counterfeit medicines are a serious problem.
Few regulations and standards exist for pharmacists and pharmaceutical care.
Pharmaceutical marketing plays an important role in marketing and selling products in Yemen.
A dearth of standards, regulations, and laws are hurting pharmacy practice in the country and potentially endangering peoples’ lives.
Conclusion
In order to improve pharmacy practice in Yemen, many changes are needed, including updating the pharmacy curriculum taught, implementing industry standards for pharmacy practice, implementing and reinforcing laws, and integrating pharmacists more fully in the healthcare industry. Additionally, the quality of the pharmacy workforce needs to be improved, and there needs to be increased awareness by the public, physicians, other healthcare professionals, and policy makers about the value of pharmacists.
doi:10.4066/AMJ.2014.1890
PMCID: PMC3920470  PMID: 24567762
Pharmacy practice; workforce; satisfaction; challenges; recommendations and Yemen
25.  Hepatitis C, a silent threat to the community of Haryana, India: a community-based study 
Background
Hepatitis C is a global public health problem. As many as 12 million people may be chronically infected in India and most are unaware of it.
Aims
To determine the incidence of hepatitis C in the Ratia block of the Fatehabad district, Haryana, India.
Method
This cross-sectional study was carried out by house-tohouse visits over 2 weeks. After obtaining written consent, a blood sample was drawn from suspected cases by a laboratory technician maintaining all necessary safety precautions and sterilization.
Results
Of the samples, 1,630 (22.3 per cent) were found to be positive for hepatitis C by ELISA, 253 (15.5 per cent) patients were previously hepatitis C positive, and adults (21–60 years) were affected maximally (70.0 per cent).
Conclusion
The study emphasises the need for public awareness campaigns at various levels and prevention of HCV infection. It also suggests the need to develop and strengthen evaluation methodology for the Integrated Disease Surveillance Project (IDSP).
doi:10.4066/AMJ.2014.1883
PMCID: PMC3920471  PMID: 24567761
Hepatitis C; HCV; community

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