Bonded training places: evidence-based policy or a stab in the dark?
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Australia↗
Biomedical subjects
David Wilkinson
Publications and source records attributed to David Wilkinson.
Rural doctors and rural backgrounds: how strong is the evidence? A systematic review.
OBJECTIVE: We sought to summarise the evidence for an association between rural background and rural practice by systematically reviewing the national and international published reports. DESIGN: A systematic review. SETTING: A search of the national and international published reports from 1973 to October 2001. SUBJECT: The search criteria included observational studies of a case-control or cohort design making a clear and quantitative comparison between current rural and urban doctors, this resulted in the identification of 141 studies for potential inclusion. RESULTS: We systematically reviewed 12 studies. Rural background was associated with rural practice in 10 of the 12 studies, in which it was reported, with most odds ratios (OR) approximately 2-2.5. Rural schooling was associated with rural practice in all 5 studies that reported on it, with most OR approximately 2.0. Having a rural partner was associated with rural practice in 3 of the 4 studies reporting on it, with OR approximately 3.0. Rural undergraduate training was associated with rural practice in 4 of 5 studies, with most OR approximately 2.0. Rural postgraduate training was associated with rural practice in 1 of 2 studies, with rural doctors reporting rural training about 2.5 times more often. CONCLUSIONS: There is consistent evidence that the likelihood of working in rural practice is approximately twice greater among doctors with a rural background. There is a smaller body of evidence in support of the other rural factors studied, and the strength of association is similar to that for rural background.
Attitude of Health Personnel↗
Evidence-based practice in rural and remote clinical practice: where is the evidence?
OBJECTIVE: To critically review the evidence regarding barriers to implementing research findings in rural and remote settings, and the ways those barriers have been addressed. DESIGN: A systematic review that included searching several electronic databases, Internet sites and reference lists of relevant articles, assessment of methodological quality of the studies, and data extraction and analysis where possible. Eligibility for the review was not limited by study design. SETTINGS/PARTICIPANTS: Studies that reported on: (1) barriers to the implementation of evidence by health professionals in rural and remote areas, or (2) interventions for implementing evidence-based practice or an element of evidence-based practice in rural and remote areas. RESULTS: There were no experimental data available on the implementation of research findings in rural and remote clinical settings. The small amounts of empirical research undertaken (surveys) showed that some of the problems experienced by general practitioners were exacerbated by rural and remote location, particularly with relation to isolation, lack of time and locum cover, and poor information technology infrastructure. CONCLUSION: There is a paucity of empirical literature on implementing evidence-based practice in rural and remote settings. This is in contrast to the large amount of literature available on implementing evidence in other clinical settings. A clear finding from the literature was that getting evidence into practice needs to be context-specific and yet very little research has been conducted into the rural and remote context. Research is needed into how evidence can be implemented in contextually specific ways in rural and remote areas.
Data Interpretation, Statistical↗
HIV: opportunistic infections.
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AIDS-Related Opportunistic Infections↗
HIV: prevention of opportunistic infections.
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2-Aminopurine↗
Nonoxynol-9 fails to prevents STDs, but microbicide research continues.
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HIV Infections↗
Trichomonas vaginalis is associated with pelvic inflammatory disease in women infected with human immunodeficiency virus.
We assessed the association between the causative agents of vaginal discharge and pelvic inflammatory disease (PID) among women attending a rural sexually transmitted disease clinic in South Africa; the role played by coinfection with human immunodeficiency virus type 1 (HIV-1) was studied. Vaginal and cervical specimens were obtained to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and bacterial vaginosis. HIV-1 infection was established by use of serum antibody tests. A total of 696 women with vaginal discharge were recruited, 119 of whom had clinical PID. Patients with trichomoniasis had a significantly higher risk of PID than did women without trichomoniasis (P=.03). PID was not associated with any of the other pathogens. When the patients were stratified according to HIV-1 status, the risk of PID in HIV-1-infected patients with T. vaginalis increased significantly (P=.002); no association was found in patients without HIV-1. T. vaginalis infection of the lower genital tract is associated with a clinical diagnosis of PID in HIV-1-infected women.
AIDS-Related Opportunistic Infections↗
Lavender oil as a treatment for agitated behaviour in severe dementia: a placebo controlled study.
OBJECTIVE: To determine whether aromatherapy with lavender oil is effective in the treatment of agitated behaviour in patients with severe dementia. DESIGN: A placebo controlled trial with blinded observer rater. SETTING: A long-stay psychogeriatric ward. PATIENTS: Fifteen patients meeting ICD-10 diagnostic criteria for severe dementia and suffering from agitated behaviour defined as a minimum score of three points on the Pittsburgh Agitation Scale (PAS). INTERVENTION: A 2% lavender oil aromatherapy stream was administered on the ward for a two hour period alternated with placebo (water) every other day for a total of ten treatment sessions. ASSESSMENTS: For each subject 10 total PAS scores were obtained. Five during treatment and five during placebo periods. RESULTS: Nine patients (60%) showed an improvement, five (33%) showed no change and one patient (7%) showed a worsening of agitated behaviour during aromatherapy compared with placebo. A comparison of the group median PAS scores during aromatherapy showed a significant improvement in agitated behaviour during aromatherapy compared with placebo (median PAS scores 3 c.f. 4; Wilcoxon Signed-Ranks test p = 0.016 (one-tailed)). CONCLUSIONS: Lavender oil administered in an aroma stream shows modest efficacy in the treatment of agitated behaviour in patients with severe dementia.
Aged↗
Prophylactic therapy with lithium in elderly patients with unipolar major depression.
OBJECTIVES: To compare the relapse rate of elderly depressed patients taking low dose lithium as an additional therapy with antidepressant medication to those receiving antidepressant medication alone. METHODS: Fifty elderly subjects recovering from a major depressive illness taking continuation antidepressants were randomised, in a double blind study, to receive additional lithium carbonate or placebo and followed up over a two year period for evidence of relapse. RESULTS: Relapse rate was significantly greater in those subjects taking antidepressant medication alone compared to subjects taking additional lithium therapy. After six months four (17%) subjects taking antidepressant medication alone had relapsed, whereas none of the subjects taking additional lithium had relapsed. After two years eight (33%) subjects taking antidepressant medication alone had relapsed, whereas only one (4%) of the subjects taking additional lithium had relapsed. CONCLUSION: This preliminary study suggests that long-term low dose lithium therapy is well tolerated and protects elderly patients from a relapse of depressive illness.
Aged↗
Nonoxynol-9 spermicide for prevention of vaginally acquired HIV and other sexually transmitted infections: systematic review and meta-analysis of randomised controlled trials including more than 5000 women.
We aimed to determine the effectiveness of the vaginally administered spermicide nonoxynol-9 (N-9) among women for the prevention of HIV and other sexually transmitted infections (STIs). We did a systematic review of randomised controlled trials. Nine such trials including 5096 women, predominantly sex workers, comparing N-9 with placebo or no treatment, were included. Primary outcomes were new HIV infection, new episodes of various STIs, and genital lesions. Five trials included HIV and nine included STI outcomes, and all but one (2% of the data) contributed to the meta-analysis. Overall, relative risks of HIV infection (1.12, 95% confidence interval 0.88-1.42), gonorrhoea (0.91, 0.67-1.24), chlamydia (0.88, 0.77-1.01), cervical infection (1.01, 0.84-1.22), trichomoniasis (0.84, 0.69-1.02), bacterial vaginosis (0.88, 0.74-1.04) and candidiasis (0.97, 0.84-1.12) were not significantly different in the N-9 and placebo or no treatment groups. Genital lesions were more common in the N-9 group (1.18, 1.02-1.36). Our review has found no statistically significant reduction in risk of HIV and STIs, and the confidence intervals indicate that any protection that may exist is likely to be very small. There is some evidence of harm through genital lesions. N-9 cannot be recommended for HIV and STI prevention.
Adult↗
Increasing rural activity and curriculum content in the Adelaide University Medical School.
This study aimed to document the level of rural activity and curriculum content in the Adelaide University Medical School. A questionnaire was distributed to all heads of departments within the Medical School and additional information was obtained from reports and discussions with key personnel. There has been an increase in the proportion of students with a rural background enrolled from 9% in 1994 to 22% in 2000. There has also been an increase in the number of weeks available for rural placements from 12 (mostly optional) to 29 weeks (some mandatory), and an increase in the number of departments offering rural placements. There has also been improved academic support to rural practitioners and many departments directly provide services in rural communities. A new combined University Department of Rural Health (UDRH)/Rural Clinical School associated with the Adelaide University Medical School aims to provide at least half of all clinical training to 25% of all medical students of Australian origin.
Curriculum↗
Uptake of health assessments, care plans and case conferences by general practitioners through the Enhanced Primary Care program between November 1999 and October 2001.
We aimed to describe the uptake of the Enhanced Primary Care (EPC) item numbers listed on the Medicare Benefits Schedule for health assessment (HA), care plan (CP) and case conference (CC) between November 1999 (when these items first became available) and October 2001. We used data provided by the Commonwealth Department of Health and Ageing. General practitioners rendered 371,409 EPC services in all. Most services were HA (225,353; 61%), most of the remainder were CP (134,688; 36%), and CC comprised the rest (11,368; 3%). The number of HA done increased steadily and has stabilised at around 13,000 HA per month. Most CP done (80%) were in the community and with the GP preparing the plan. From a slow start, the number of CP done increased rapidly in 2001 to about 15,000 per month. There has been a slow and steady increase in the number of CC done each month, reaching 8-900 per month. Uptake of the EPC item numbers in the first two years of their availability has been rapid and has reached substantial levels, especially for HA and CP. The uptake of CC has been slower.
Aged↗
Issues and challenges facing rural hospitals.
Australia's rural hospitals face most of the same issues and challenges faced by metropolitan hospitals. However they also face additional challenges around geographic isolation, their iconic status and role as major employers in local communities, and their close relationship with community based health services. Future opportunities include more formal integration with community service through multipurpose service arrangements, regional networking with urban centers, expanded us of IT linkages, and with the expanding rural academic networks. Rural hospitals' roles as key aged care providers in the country is a particular challenge.
Australia↗
Variation in levels of uptake of enhanced primary care item numbers between rural and urban settings, November 1999 to October 2001.
We aimed to report on variation in levels of uptake of enhanced primary care item numbers between rural and urban Divisions of General Practice between November 1999 and October 2001. Most providers of EPC services and most services (close to 70%) are located in capital cities and other metropolitan centres. The average number of health assessments done per provider was slightly lower (8-14) in remote than urban and rural (20-30) areas. A similar pattern was observed for care plans, but rates of case conferences were similar in rural and urban areas. However, adjusted for population aged 75 years and over, in all jurisdictions except South Australia, between 30% and 144% more health assessments were done per full time equivalent general practitioner (FTE GP) in rural divisions. For rural and urban Divisions of General Practice, there is a wide range in the rate of services provided, between and within Divisions. However, overall, more services are provided per FTE GP in rural Divisions.
Aged↗
Signalling between the hindbrain and paraxial tissues dictates neural crest migration pathways.
Cranial neural crest cells are a pluripotent population of cells derived from the neural tube that migrate into the branchial arches to generate the distinctive bone, connective tissue and peripheral nervous system components characteristic of the vertebrate head. The highly conserved segmental organisation of the vertebrate hindbrain plays an important role in patterning the pathways of neural crest cell migration and in generating the distinct or separate streams of crest cells that form unique structures in each arch. We have used focal injections of DiI into the developing mouse hindbrain in combination with in vitro whole embryo culture to map the patterns of cranial neural crest cell migration into the developing branchial arches. Our results show that mouse hindbrain-derived neural crest cells migrate in three segregated streams adjacent to the even-numbered rhombomeres into the branchial arches, and each stream contains contributions of cells from three rhombomeres in a pattern very similar to that observed in the chick embryo. There are clear neural crest-free zones adjacent to r3 and r5. Furthermore, using grafting and lineage-tracing techniques in cultured mouse embryos to investigate the differential ability of odd and even-numbered segments to generate neural crest cells, we find that odd and even segments have an intrinsic ability to produce equivalent numbers of neural crest cells. This implies that inter-rhombomeric signalling is less important than combinatorial interactions between the hindbrain and the adjacent arch environment in specific regions, in the process of restricting the generation and migration of neural crest cells. This creates crest-free territories and suggests that tissue interactions established during development and patterning of the branchial arches may set up signals that the neural plate is primed to interpret during the progressive events leading to the delamination and migration of neural crest cells. Using interspecies grafting experiments between mouse and chick embryos, we have shown that this process forms part of a conserved mechanism for generating neural crest-free zones and contributing to the separation of migrating crest populations with distinct Hox expression during vertebrate head development.
Animals↗
Opportunistic infections and HIV.
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AIDS-Related Opportunistic Infections↗