National Health Medical Research Council Research Articles

Are Australian podiatrists meeting best practice in the management of diabetic foot complications?

Background Diabetic foot complications are the leading cause of lower extremity amputation and diabetes-related hospitalisation in Australia. Studies demonstrate significant reductions in amputations and hospitalisation when health professionals implement best practice management. Whilst other nations have surveyed health professionals on specific diabetic foot management, to the best of the authors' knowledge this appears not to have occurred in Australia. The primary aim of this study was to examine Australian podiatrists' diabetic foot management compared with best practice recommendations by the Australian National Health Medical Research Council.

Bioaccumulation of Cd, Cu, Pb, and Zn in Oyster (Saccostrea cucullata) from Qeshm Island Coast in Persian Gulf: Implications of Provisional Maximum Tolerable Daily Intake (PMTDI)

Concentrations of heavy metals (Cd, Cu, Pb, and Zn) were determined in soft tissue of 122 rock oyster (Saccostrea cucullata) collected at seven stations from the coastal zones of Qeshm Island. The exposure of the consumer is compared directly to maximum residue level and provisional maximum tolerable daily intake. Result indicated that levels of Cd, Pb, and Cu were within limits, but the level of Zn exceeded that the limit. Concentrations of Zn (1168.71 μg g−1) and Cu (105.16 μg g−1) were comparatively higher than the level recommended in the international food standards, such as Brazilian Ministry of Health, National Health Medical Research Council, Ministry of Agriculture, Fisheries and Food, and the Tasmania Public Health Regulation. The results, therefore, indicate possible risk in consuming the oysters.

Women with polycystic ovary syndrome have intrinsic insulin resistance on euglycaemic-hyperinsulaemic clamp

What is the prevalence of insulin resistance (IR) and the contributions of intrinsic and extrinsic IR in women diagnosed with polycystic ovary syndrome (PCOS) according to the Rotterdam criteria? We report novel clamp data in Rotterdam diagnosed PCOS women, using World Health Organization criteria for IR showing that women with PCOS have a high prevalence of IR, strengthening the evidence for an aetiological role of IR in both National Institutes of Health (NIH) and Rotterdam diagnosed PCOS in lean and overweight women. PCOS is a complex endocrine condition with a significant increased risk of gestational diabetes and type 2 diabetes. Using a cross-sectional study design, 20 overweight and 20 lean PCOS (Rotterdam criteria), 14 overweight and 19 lean body mass index (BMI)-matched control non-PCOS women underwent clinical measures of IR after a 3-month withdrawal of insulin sensitizers and the oral contraceptive pill. In an academic clinic setting, glucose infusion rate (GIR) on euglycaemic-hyperinsulinaemic clamp was investigated as a marker of insulin sensitivity. PCOS women were more IR than BMI-matched controls (main effect for BMI and PCOS; P < 0.001). IR was present in 75% of lean PCOS, 62% of overweight controls and 95% of overweight PCOS. Lean controls (mean ± SD; GIR 339 ± 76 mg min⁻¹ m⁻²) were less IR than lean PCOS (270 ± 66 mg min⁻¹ m⁻²), overweight controls (264 ± 66 mg min⁻¹ m⁻²) and overweight PCOS (175 ± 96 mg min⁻¹ m⁻²). The negative relationship between BMI and IR reflected by GIR was more marked in PCOS (y = 445.1 - 7.7x, R² = 0.42 (P < 0.0001) than controls (y = 435.5 - 4.6x, R² = 0.04 (P < 0.01)). The study did not use glucose tracer techniques to completely characterize the IR, as well as the lack of matching for body composition and age. IR is exacerbated by increased BMI, supporting intrinsic IR in PCOS. BMI impact on IR is greater in PCOS, than in controls, irrespective of visceral fat, prioritizing lifestyle intervention and the need for effective therapeutic interventions to address intrinsic IR and prevent diabetes in this high-risk population. This investigator-initiated trial was supported by grants from the National Health & Medical Research Council (NHMRC) Grant number 606553 (H.J.T., N.K.S. and S.K.H.) as well as Monash University and The Jean Hailes Foundation. H.J.T. is an NHMRC Research Fellow. N.K.S. is supported through the Australian Government's Collaborative Research Networks (CRN) programme. A.E.J. is a Jean Hailes and NHMRC scholarship holder. The authors declare that there is no conflict of interest associated with this manuscript.

Diabetic retinopathy management by Australian optometrists

To survey the current diabetic retinopathy screening and management practices of Australian optometrists following the release of the 1997 National Health Medical Research Council Diabetic Retinopathy Management Guidelines. Cross-sectional national survey, primary care setting. 1000 Australian optometrists across different states. A self-administered questionnaire was sent to 1000 optometrists across all states during 2007/2008. Use of retinal camera, screening practices/attitudes and behaviour in diabetic retinopathy management. 568 optometrists (57%) responded to the survey. Patients' unpreparedness to drive post dilation (51%) and the fear of angle closure glaucoma (13%) were the two main barriers to optometrists not performing dilated ophthalmoscopy. Those who had strong desire to screen for diabetic retinopathy were more likely to use a retinal camera (p<0.005). Use of a retinal camera was significantly associated with an increased confidence in detecting clinical signs of diabetic retinopathy including macular oedema (P<0.001). Optometrists who read the guidelines at least once were 2.5-times (P<0.001) more likely to have confidence in detecting macular oedema than those who had never read the guidelines. Although they may be confident in diagnosis, and may use retinal cameras for screening, nearly 60% of optometrists would not refer patients with macular oedema to an ophthalmologist. Despite their self-reported desire for involvement in diabetic retinopathy, the management of macular oedema by Australian optometrists needs improvement. The use of retinal cameras and promotion of the 2008 NHMRC guidelines should be encouraged to improve overall optometric diabetic retinopathy management, particularly with macular oedema.

Immunohistochemical Expression of Muscarinic Receptors in the Urothelium and Suburothelium of Neurogenic and Idiopathic Overactive Human Bladders, and Changes With Botulinum Neurotoxin Administration

To investigate the possible associations of urothelial and suburothelial muscarinic receptors with human bladder pathophysiology we examined the immunohistochemical expression of muscarinic receptors types 1, 2 and 3 in the bladder urothelium and suburothelium of patients with neurogenic or idiopathic detrusor overactivity compared with that in controls. We also examined associations with patient quantified symptoms and the effect of intradetrusor botulinum neurotoxin type A treatment. We obtained bladder biopsies from 36 patients with detrusor overactivity before, and 4 and 16 weeks after treatment with intradetrusor botulinum neurotoxin type A via flexible cystoscopy. Patients with neurogenic detrusor overactivity were injected with 300 U botulinum neurotoxin type A and those with idiopathic detrusor overactivity received 200 U. Control biopsies were taken from 7 patients during investigation for asymptomatic microscopic hematuria. We studied muscarinic receptor immunohistochemical expression using commercial antibodies to muscarinic receptors 1, 2 and 3 with results quantified by image analysis. We noted decreased suburothelial muscarinic receptor immunoreactivity in detrusor overactivity biopsies vs controls, which were significant for muscarinic receptors 1 and 3. After successful botulinum neurotoxin treatment we noted only increased muscarinic receptor 1 and 2 immunoreactivity. Urothelial muscarinic receptor 1 and 3 immunoreactivity was increased after treatment. We identified no substantial urothelial muscarinic receptor 2 immunoreactivity. Receptor levels showed inverse correlations with patient urgency and frequency. Decreased muscarinic receptor levels in the urothelium and suburothelium of patients with detrusor overactivity were largely restored to control levels after successful treatment with botulinum neurotoxin type A. Correlations of receptor levels with patient symptoms further support a role for urothelial and suburothelial muscarinic receptors in detrusor overactivity in humans.

Protecting healthcare workers from pandemic influenza: N95 or surgical masks?

The successful management of an influenza pandemic will be reliant on the expertise of healthcare workers at high risk for occupationally acquired influenza. Recommended infection control measures for healthcare workers include surgical masks to protect against droplet-spread respiratory transmissible infections and N95 masks to protect against aerosol-spread infections. A literature review was undertaken for evidence of superior protective value of N95 masks or surgical masks for healthcare workers against influenza and extraneous factors influencing conferred protection. Four scientific search engines using 12 search sequences identified 21 mask studies in healthcare settings for the prevention of transmission of respiratory syncytial virus, Bordetella pertussis, and severe acute respiratory syndrome. Each was critically assessed in accordance with Australian National Health Medical Research Council guidelines. An additional 25 laboratory-based publications were also reviewed. All studies reviewed used medium or lower level evidence study design. In the majority of studies, important confounders included the unrecognized impact of concurrent bundling of other infection control measures, mask compliance, contamination from improper doffing of masks, and ocular inoculation. Only three studies directly compared the protective value of surgical masks with N95 masks. The majority of laboratory studies identified both mask types as having a range of filtration efficiency, yet N95 masks afford superior protection against particles of a similar size to influenza. World Health Organization guidelines recommend surgical masks for all patient care with the exception of N95 masks for aerosol generating procedures. Because of the paucity of high-quality studies in the healthcare setting, the advocacy of mask types is not entirely evidence-based. Evidence from laboratory studies of potential airborne spread of influenza from shedding patients indicate that guidelines related to the current 1-meter respiratory zone may need to be extended to a larger respiratory zone and include protection from ocular inoculation.

Measuring sensorineural disability in preterm children using a public health screening strategy: A randomised controlled trial

To assess the efficacy of a preterm-targeted screening programme against the routine Australian National Health Medical Research Council (NHMRC) universal child health screening programme to detect disability in a general practice setting in children born < or =31 weeks gestation at 12-months of age. Multi-centred trial involving 202 preterm children randomised to receive the preterm-targeted or NHMRC programme. Primary outcome, correct identification of neurosensory disability by general practitioners assessed against gold standard paediatric assessments. Sensitivity analysis estimated interrater agreement and screening accuracy. Secondary outcomes, post natal depression (PND), parental stress, health service use, screening programme helpfulness and correct identification of levels of disability severity. Of the 195 infants with data on the primary outcome in the preterm-targeted group, their general practitioners correctly identified the disability status of 61/93 (65.6%) children, as compared with 69/102 (67.6%) in the NHMRC group (odds ratios (OR) 0.91 95% confidence interval (CI) 0.50, 1.65). Responses where general practitioners were unsure of a child's disability status were coded as incorrect and not paired for sensitivity analysis. Sensitivity analysis for 180 diagnostic pairs showed fair interrater agreement for both groups (preterm-targeted k = 0.30 vs. NHMRC k = 0.29) with screening test results favouring the preterm-targeted group with greater sensitivity (73% vs. 33%) but lower specificity (70% vs. 92%) resulting in more over referrals (30% vs. 8%); however, these had a significantly lower mean Developmental Quotient (DQ) score compared with non-disabled children. PND scores were higher in preterm-targeted group (OR 1.33 95% CI 0.01, 2.66). The preterm-targeted programme used by general practitioners: (i) did not improve overall identification of disability status compared to the NHMRC universal programme (Australian New Zealand Clinical Trails Registry number, ACTRN 12606000472572); however (ii) it did demonstrate greater efficacy as a screening tool in accurately identifying disabled children.

RhD Antenatal Prophylaxis - The Pathology Laboratory Perspective

Stage 1 of routine antenatal RhD immunoglobulin prophylaxis was recommended in late 2002, for RhD negative women having their first child. This was as a result of a 1999 National Health Medical Research Council [NHMRC] recommendation as best practice to further reduce the incidence of HDN due to anti-D. Revised guidelines were released in 2003 by the National Blood Authority with NHMRC endorsement. It is likely that stage 2 [for all pregnancies in RhD negative women] will be in place by early 2005. The introduction of antenatal prophylaxis has raised a number of issues for pathology laboratories: a) frequency of antenatal testing within this new program b) laboratory protocols where the presence of RhD immunoglobulin is confirmed or suspected c) reporting formats in such circumstances d) inventory and supply issues including product traceability e) testing of maternal and cord samples at delivery in women who have received antenatal prophylaxis The Australian & New Zealand Society of Blood Transfusion released revised antenatal testing guidelines in early 2004 to assist laboratories in dealing with some of these issues. Collaboration with ARCBS, CSL and RANZCOG has also resulted in useful information being made available covering other aspects of this new initiative. The presentation will explore some of the above issues leading to more general discussion during the symposium.

Helicobacter Pylori: A Nobel Pursuit?

<i>Helicobacter Pylori</i>: A Nobel Pursuit?

Decolonising research: a shift toward reconciliation

Although awareness of cultural differences that distinguish Indigenous peoples has increased worldwide following attention from international human rights bodies, Indigenous cultural values have had little influence in shaping research agendas or methods of inquiry. Self-determination and reconciliation policies have been part of the decolonisation agenda of governments for several decades; however, these have not, until recently, been considered of relevance to research. Indigenous peoples feel that they are the most studied population in Australia, to the point where even the word research arouses feelings of suspicion and defensive attitudes. Indigenous people are generally cynical about the benefits of research and cautious toward what many perceive to be the colonial mentality or 'positional superiority' ingrained in the psyche of western researchers. This article examines the characteristics and colonising effects of traditional research methods and describes an alternative, decolonising approach. Decolonising research methodology is congruent with Indigenous epistemology and is guided by the values and research agenda of Indigenous people. The Guidelines for ethical conduct in Aboriginal and Torres Strait islander health research, developed by the National Aboriginal and Islander Health Organisation (NAIHO) with the National Health & Medical Research Council (NHMRC) in 2003 are examined, as they exemplify a decolonising paradigm for researchers.

Use of homework by mental health case managers in the rehabilitation of persistent and recurring psychiatric disability

Background: Homework refers to between-session activities that are tied to therapeutic goals. Homework has been suggested as being an important clinical adjunct to case management practices, however, to date, research has not examined case managers' use of homework.Aims: To identify the degree that case managers use homework within their clinical practice and explore the way it is administered with people diagnosed with a persistent and recurring psychiatric illness.Method: A survey was completed by 122 case managers (63% of those approached) comprising nurses, psychologists, social workers, occupational therapists and welfare/support workers.Results: Ninety-three percent of case managers implement homework, but only 15% regularly use a systematic approach to homework administration. Seventy-six percent of case managers reported people in recovery had a positive attitude towards the use of homework, yet 72% felt that homework completed was of a low quality.Conclusions: Suggestions are made for improving the systematic use of homework by case managers.Declaration of interest: The study was supported by a grant from the National Health Medical Research Council (NHMRC, #219327), through the Health Partnership Grant Scheme.

Pharmacokinetics of sevoflurane uptake into the brain

Two recent studies have examined the pharmacokinetics of sevoflurane in adults. Lu et al.(Pharmacokinetics of sevoflurane uptake into the brain and body, Anaesthesia 2003; 58: 951-6) observed that jugular bulb sevoflurane concentration initially rose unexpectedly rapidly and then approached arterial concentrations unexpectedly slowly, suggesting that a blood-brain diffusion barrier exists. They also observed a large alveolar-arterial sevoflurane gradient, suggesting that an alveolar-arterial diffusion barrier exists. Nakamura et al. (Predicted sevoflurane partial pressure in the brain with an uptake and distribution model: Comparison with the measured value in internal jugular vein blood. Journal of Clinical Monitoring and Computing 1999; 15: 299-305) found no diffusion barriers. We used a computer model to analyse both data sets and show that the observations of Lu et al. can be explained by contamination of jugular samples with extracerebral blood. It is possible that the alveolar-arterial gradients observed by Lu et al. are due to discrepancies in conversions between blood concentrations and gas partial pressures. Our study suggests that there is no blood-brain diffusion barrier for sevoflurane and that the data of Lu et al. must be interpreted with caution.

Twin concordance for a binary trait: III. A bivariate analysis of hay fever and asthma

Self-reported histories of hay fever and asthma were obtained from 3,808 pairs of adult twins 18 years and over registered with the Australian National Health Medical Research Council Twin Registry (1232 MZF, 567 MZM, 751 DZF, 352 DZM, 906 DZO). The prevalence of hay fever and asthma was 0.32 and 0.13, respectively, with little variation with zygosity, sex, and age. The associations between twin pairs for these two traits were analysed, under the assumption of constant prevalences, as a special case of a log-linear model for binary traits in pedigrees using the statistical package GLIM. The model assumption that there are no second- or higher-order interactions was tested in the 2 X 2 X 2 X 2 table of twin by disease outcomes without revealing strong evidence of departure, even in this large data set. The log-linear modelling showed that only three first-order interactions, namely 1) between hay fever in a twin pair, 2) asthma in a twin pair, and 3) hay fever and asthma in the same twin, were necessary to describe the data. The first two interaction terms were significantly larger in identical pairs; the third was independent of zygosity. Under this parsimonious model, there was a significant difference between identical and fraternal pairs in marginal correlation, both in asthma and hay fever, and in the cross-correlation between hay fever in one twin and asthma in the other. This suggests that genetic factors are implicated in both hay fever and asthma and that some of these genetic factors are common (at least among a subgroup of individuals) to both traits.