Treating children with sleep disorders. Early intervention increases sleep times in young babies.
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Behavior Therapy↗
Biomedical subjects
J Marley
Publications and source records attributed to J Marley.
Selecting medical students: a case report of the need for change.
OBJECTIVES: To review the selection of medical students by academic score alone. SETTING: The University of Adelaide. METHODS: Surveys of students, staff, school counsellors and review of matriculation scores and rankings in the medical course. RESULTS: Staff and school counsellors both rated personal qualities such as problem solving ability and communication skills as highly desirable attributes to be sought, but not rote learning ability. School counsellors reported intense pressure on students and schools to achieve the required high scores, with educationally undesirable narrowing of subject choices and reduced involvement in sport and extra-curricular activities. Matriculation scores did not predict placings in our medical course. Only 52% of students had a clear ambition to do medicine, while parental pressure and a high mark featured strongly as other reasons for entry. Only 11% of students claimed any reasonable knowledge about their chosen career before entry. CONCLUSION: This case report confirmed that selecting medical students by academic score alone was no longer desirable.
Clinical Competence↗
Topical treatment of interdigital tinea pedis: terbinafine compared with clotrimazole.
A multicentre, prospective, randomized, double-blind, parallel group study was undertaken to compare the efficacy and tolerability of topical terbinafine with topical clotrimazole in the treatment of interdigital tinea pedis. Patients were randomized to receive either terbinafine 1% cream twice daily for 1 week, followed by a similar placebo cream for 5 weeks, or clotrimazole 1% cream twice daily for 4 weeks. Outcome measures were: (i) mycological cure (negative culture); (ii) effective treatment (negative culture plus a symptom score of 2 or less out of a maximum score of 18); and (iii) complete cure (negative culture and a symptom score of 0); measured at 1, 4, 8 and 12 weeks after the commencement of the study. One hundred and four of the 217 patients randomized had a culture-confirmed dermatophyte infection at baseline. In these patients, 84.6% in the terbinafine group were culture negative after 1 week, compared with only 55.8% in the clotrimazole group. Both agents were well tolerated. The study showed that terbinafine achieves mycological cure more rapidly than clotrimazole. This may result in improved compliance and better control over transmission of infection.
Administration, Cutaneous↗
Cross-over comparison of nifedipine Oros and felodipine extended release with blind 24 h ambulatory blood pressure assessments.
1. The aim of the present study was to compare the efficacy of nifedipine Oros and felodipine extended release (ER) in controlling 24 h ambulatory blood pressures (ABP) in hypertensive patients. 2. The study was a randomized cross-over design with a 2 week open placebo run-in phase and two observer-blind treatment periods. 3. Subjects were males and females, aged between 18 and 65 years, suffering from mild to moderate essential hypertension with a sitting mean diastolic blood pressure (DBP) within the range of 95-114 mmHg. Twenty-three subjects were randomized to treatment; 15 patients completed the study. 4. Treatment intervention was 2 weeks of placebo followed by either 30 mg nifedipine OROS once daily or 5 mg felodipine ER once daily for 6 weeks, which was titrated up to 60 mg nifedipine OROS daily or 10 mg felodipine ER daily after 2 weeks of treatment on the lower doses if the DBP was > 90 mmHg. The main outcome measure was 24 h ABP after 6 weeks of active treatment, evaluated by an independent observer blinded as to treatment allocation. 5. Compared with placebo, mean (+/- SD) 24 h DBP was reduced by 6.2 +/- 6.8 and 5.2 +/- 5.1 mmHg after nifedipine and felodipine, respectively. The 24 h mean systolic blood pressure (SBP) fell by 11.8 +/- 10.9 and 10.1 +/- 8.2 mmHg for nifedipine and felodipine, respectively, compared with placebo. There were no significant differences between the two active treatments in the reduction of DBP or SBP during the 24 h period, daytime or night-time. 6. Similar antihypertensive effects are achieved with nifedipine Oros and felodipine ER when doses are individually titrated, with no significant differences between the two treatments.
Adolescent↗
Compliance with restrictions on the subsidized use of proton pump inhibitors in Australia.
AIMS: To determine among a cohort of patients newly dispensed a prescription for a proton pump inhibitor (PPI) the extent of prior use of other less expensive agents such as antacids and H2-receptor antagonists as evidence of a 'stepped care' approach to peptic ulcer and oesophageal disease. METHODS: A retrospective drug utilization study was conducted within the Pharmaceutical Benefits Scheme (PBS) claims database in Australia. A cohort of social security recipients, who received approval for PPI supply in the month of October 1996, had no prior PPI approval in the previous 18 months and went on to have the drug dispensed, was assembled. This group of 'new PPI starters' was then examined for supply of less expensive prescription medicines to treat peptic ulcer and oesophageal disease in the 12 months prior to obtaining their PPI approval. RESULTS: In a cohort of 4554 defined new PPI users, 1205 (26.5%) showed no use of H2-receptor antagonists, antacids, cisapride, cytoprotectants or antiregurgitants in the 12 month period prior to commencing the PPI. The major reason for use given by prescribers for PBS supply was 'severe refractory ulcerating oesophagitis'. CONCLUSIONS: Subsidized supply is currently restricted on cost-effectiveness grounds to refractory peptic ulcer disease or severe oesophageal disease. Despite this, utilization and epidemiological data suggest that there is widespread leakage of use outside these indications particularly to less severe forms of oesophageal disease. This patient tracking study has shown within the PBS database that around a quarter of the patients are treated directly with a PPI without being prescribed less expensive agents at least in the preceding 12 months.
Anti-Ulcer Agents↗
Comparison of one week of oral terbinafine (250 mg/day) with four weeks of treatment with clotrimazole 1% cream in interdigital tinea pedis.
Treatment of interdigital tinea pedis often involves long-term therapy with topically applied preparations. Effective oral preparations, such as the allylamine terbinafine (Lamisil), taken over a shorter period, could provide a useful therapeutic alternative. A total of 269 patients from five centres with clinically diagnosed interdigital tinea pedis were entered into this double-blind, randomized, double-dummy, parallel-group study comparing oral terbinafine 250 mg once daily for 1 week with 1% clotrimazole (Canesten) cream applied twice daily for 4 weeks. Of these, 137 patients were evaluable for efficacy (confirmed dermatophyte infection by microscopy and culture): 63 terbinafine and 74 clotrimazole. At week 4, the mycological cure rates (negative culture at week 1 and negative results on microscopy and culture at week 4 onwards) were very similar (71% for clotrimazole and 72% for terbinafine). There was a faster response rate in the terbinafine group with respect to signs and symptoms at week 1. Both treatments were equally well tolerated; adverse events occurred equally in the two groups. In conclusion, oral terbinafine in a single daily dose of 250 mg for 1 week is as effective and as well tolerated as 1% clotrimazole cream applied twice daily for 4 weeks in the treatment of interdigital tinea pedis.
Adolescent↗
Cytokine gene therapy or infusion as treatment for solid human cancer.
In the induction of tissue-directed immune responses, cytokines tend to be released within the affected tissues. We used two strategies to expose tumor tissues to continuous high levels of cytokines: First, a vaccinia interleukin (IL)2 recombinant was injected directly intratumorally 3-weekly at 10(7) pfus/dose in six patients with the solid tumor malignant mesothelioma (MM). No virus excretion was detectable. At each cycle vaccinia-IL-2 mRNA (SQ [semi-quantitative] reverse transcription polymerase chain reaction) was maximal 24-72 h following injection reduced at 8 days and faded by 21 days. No tumor regression occurred. Second, based on the success of granulocyte macrophage colony-stimulating factor (GM-CSF) in gene transfer experiments, we conducted a study using continuous intratumoral GM-CSF infusion in eight patients with MM using a portable pump at doses of 10 micro/cg/24 h over 8 weeks. Systemic neutrophil agglutination and local catheter-related difficulties occurred. Two patients demonstrated tumor necrosis, one of whom had a marked progressive mononuclear cell infiltration of the tumor associated with a partial response (>50% reduction in tumor area). Murine studies using our MM model in CBA and BALB/C mice have demonstrated that B7-1 and allo-class I transfections induce strong tumor-specific cytotoxic T lymphocyte responses: GM-CSF, IL-12, and IL-2 induced mixed nonspecific plus specific responses, whereas B7-2 and class II transfections were not effective. We conclude that increased intratumoral cytokine concentrations can be generated using both gene transfer and cytokine infusion approaches; however, both have their limitations and, at this stage, have not produced dramatic antitumor effects in humans.
Cytokines↗
Undergraduate education in anaesthesia: the influence of role models on skills learnt and career choice.
Undergraduate teaching of anaesthesia occurs in about two-thirds of Australian departments of anaesthesia: however, student contact hours are limited compared with those of other disciplines. Seventy-five directors of anaesthesia were surveyed by written questionnaire concerning the time devoted in their department to undergraduate study and teaching of practice/skills to undergraduate students (40 responded). One hundred and sixty final year students were surveyed regarding career choice, anaesthesia skills taught them and role models identified during their training (101 responded). Most final year students had been taught and had learnt the basic skills of life support such as bag and mask ventilation, cardiopulmonary resuscitation and intravenous cannulation. However, fewer were taught more specialized skills such as induction of anaesthesia and spinal anaesthesia. Positive role models in teaching anaesthetists were identified by 66% of students, more commonly if they were taught advanced skills, and were significantly associated with satisfaction with theoretical and practical training. For those students intending a career in anaesthesia (18%), 94% identified a positive role model compared to 65% who did not (P = 0.03).
Anesthesiology↗
The impact of depression on the physical health of family members.
BACKGROUND: Depressive illness is common. Depression in one family member is associated with an increased incidence of psychopathology in other family members. There are no data on the physical well being of the families of depressed individuals. AIM: To compare physical morbidity of family members of depressed patients with that of family members of comparison patients. METHOD: A comparative follow-up study from case notes. Two hundred and one subjects from 88 families with an index family member diagnosed with depression ('depression families') were compared with 200 subjects from 88 families with a matched index subject without depression ('comparison families'), using the Duke University Illness Severity Scores (ISS) to assess burden of illness experienced by both groups. RESULTS: The cumulative incidence of depression over 11 months in depression families was 8.9% compared to 1.4% in the Family Practice Unit as a whole. Members of depression families had significantly greater ISS than members of comparison families (difference in means = 0.164; 95% confidence interval (CI) 0.113-0.215; P < 0.001). Excluding family members with depression (in addition to the index subject), ISS of members of depression families remained significantly greater than the comparison group (difference in means = 0.136; 95% CI 0.083-0.189; P < 0.001). Among depression families, mean ISS was significantly higher after presentation of depression in index subjects compared with before (difference in means = 0.155; 95% CI 0.115-0.194; P < 0.0001). No significant difference was seen between ISS of depression and comparison families before presentation of depression (difference in means = 0.008; 95% CI -0.004-0.058; P = 0.74). CONCLUSION: Depression in patients is associated with increased physical morbidity in their families.
Adult↗
Does the management of hypertension in general practice conform with guidelines?
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Family Practice↗
Stimulation of auricular acupuncture points in weight loss.
OBJECTIVE: Many overweight people are aware that diets can help with weight loss but have difficulty in suppressing their appetite. Acupuncture stimulates the auricular branch of the vagal nerve and raises serotonin levels, both of which have been shown to increase tone in the smooth muscle of the stomach, thus suppressing appetite. The aim of this study was to determine the effectiveness of transcutaneous electrical nerve stimulation of specific auricular acupuncture points on appetite suppression. METHODS: Sixty overweight subjects, randomly divided into an active and a control group, used the AcuSlim device twice daily for four weeks. The active group attached the AcuSlim to the acupuncture ear points shenmen and stomach, whereas the control group attached the device to their thumb where there are no acupuncture points. The goal of a 2 kg weight loss was set and changes in appetite and weight were reported after four weeks. RESULTS: Of those who responded, 95% of the active group noticed suppression of appetite, whereas none of the control group noticed such a change. None of the control group lost the required 2 kg, with only 4 subjects losing any weight at all. Both the number of subjects who lost weight and the mean weight loss were significantly higher in the active group (p < 0.05). CONCLUSION: Frequent stimulation of specific auricular acupuncture points is an effective method of appetite suppression which leads to weight loss.
Acupuncture Therapy↗
Feasibility of conducting cardiovascular outcome research in Australian general practice: results from the ANBP2 pilot study. Australian National Blood Pressure Study.
1. The present study aimed to determine the feasibility of conducting a 5 year cardiovascular outcome trial of the treatment of 6000 elderly hypertensive patients in Australian general practices. 2. General practitioners (GPs) were invited to participate by mail and personal follow-up. Patient records were reviewed to identify subjects for a blood pressure (BP) screening programme. Blood pressure was measured on three occasions and eligible subjects were included if the average BP was > or = 160 mmHg systolic or > or = 90 mmHg diastolic if systolic BP was > or = 140 mmHg. 3. Seven hundred and forty-one GPs were approached and 89 were enrolled in the study (12% of mail invites and 75% of those receiving a personal contact). In 16 practices where screening was completed, 82,000 records were reviewed to identify 4% patients eligible for screening. Twenty-two per cent of eligible subjects attended screening. Of 1938 subjects screened, 180 (9%) had BP > or = 160/90 mmHg. Forty-seven per cent of subjects (n = 916) were receiving antihypertensive therapy and 184 (20%) were withdrawn from therapy. One hundred and sixteen (63%) of these subjects had BP return to study entry levels within 6 weeks. Fifty-seven newly diagnosed and 81 previously treated subjects were randomized (7% of the screened population). 4. Based on the high participation rate of GPs, the response rate of patients to attend a BP screening programme and the 7% randomization to screening ratio for entry into the study, the ANBP2 pilot study has demonstrated that it is feasible to recruit subjects from Australian general practices to a cardiovascular outcome trial.
Aged↗
Attitudes of rural general practitioners towards undergraduate medical student attachments.
OBJECTIVE: Increasing exposure of undergraduate medical students to rural practice is a key component of the national effort in Australia to redress the rural workforce shortage. For this exposure to be successful, willing cooperation of current rural general practitioners is essential. To date there has been no formal assessment of rural general practitioners' attitudes to having undergraduate medical students attached to their practice. METHOD: A descriptive survey, using a mailed questionnaire was sent to all 316 general practitioners currently practising in rural areas of South Australia, as identified from the database maintained by the South Australian Rural Practice Training Unit. RESULTS: A 71.5% response rate (n = 225) was achieved, of which 203 were eligible for inclusion. Of these, 176 doctors had medical student attachments in their practice on at least one occasion; 74.4% of whom (n = 131) perceived the attachments to have a positive experience on their continuing medical education experience, and 81.1% (n = 142) described a positive experience on their professional development. However, 52.6% (n = 92) felt the attachments had a negative effect on their income. Almost all the doctors who were included in the survey (94.6%, n = 192) were willing to have students attached to their practice in the future for between one to two weeks. Of these, 169 wanted quality assurance points, 112 wanted financial reimbursement, and 108 wanted 'academic status' with a university. CONCLUSION: The results suggest that rural general practitioners are willing to have students attached to their practice for periods between one to two weeks, providing they receive quality assurance points, and to a lesser extent, financial reimbursement and academic status.
Attitude of Health Personnel↗
Illness behavior and somatization in general practice.
In the primary care setting, the early recognition that a patient has psychological problems is frequently hindered by the deceptive mode of presentation known as somatization. In a cross-sectional survey of patients attending suburban General Practitioners in a large metropolitan city, the General Health Questionnaire-30 (GHQ-30) and the Illness Behavior Questionnaire (IBQ) were completed by 201 patients. A comparison was made between somatizing and nonsomatizing patients with new inceptions of illness in terms of the risk of the presence of a mild nonpsychotic psychiatric illness and aspects of illness behavior. For the group as a whole, somatizing patients were more likely to be older and female. Male somatizers differed from male nonsomatizers by showing greater disease conviction and affective disturbance and more readiness to acknowledge difficulties in their lives other than health problems. No differences were found between female somatizing and nonsomatizing patients. We conclude that, while male patients who somatize psychological distress may be distinguished from male nonsomatizers early in their illness, in terms of their illness behavior, these differences are not seen as early distinguishing characteristics in female patients who present to their General Practitioners with physical problems for which no organic cause can be established.
Adult↗
Famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia. A randomized, double-blind, placebo-controlled trial. Collaborative Famciclovir Herpes Zoster Study Group.
OBJECTIVE: To document the effects of treatment with famciclovir on the acute signs and symptoms of herpes zoster and postherpetic neuralgia. DESIGN: A randomized, double-blind, placebo-controlled, multicenter trial. SETTING: 36 centers in the United States, Canada, and Australia. PATIENTS: 419 immunocompetent adults with uncomplicated herpes zoster. INTERVENTION: Patients were assigned within 72 hours of rash onset to famciclovir, 500 mg; famciclovir, 750 mg; or placebo, three times daily for 7 days. MEASUREMENTS: Lesions were assessed daily for as long as 14 days until full crusting occurred and then weekly until the lesions healed. Viral cultures were obtained daily while vesicles were present. Pain was assessed at each of the visits at which lesions were examined and then monthly for 5 months after the lesions healed. Safety was assessed throughout the study. RESULTS: Famciclovir was well tolerated, with a safety profile similar to that of placebo. Famciclovir accelerated lesion healing and reduced the duration of viral shedding. Most importantly, famciclovir recipients had faster resolution of postherpetic neuralgia (approximately twofold faster) than placebo recipients; differences between the placebo group and both the 500-mg famciclovir group (hazard ratio, 1.7 [95% CI, 1.1 to 2.7]) and the 750-mg famciclovir group (hazard ratio, 1.9 [CI, 1.2 to 2.9]) were statistically significant (P = 0.02 and 0.01, respectively). The median duration of postherpetic neuralgia was reduced by approximately 2 months. CONCLUSIONS: Oral famciclovir, 500 mg or 750 mg three times daily for 7 days, is an effective and well-tolerated therapy for herpes zoster that decreases the duration of the disease's most debilitating complication, postherpetic neuralgia.
2-Aminopurine↗
Terbinafine in onychomycosis of the toenail: a novel treatment protocol.
BACKGROUND: Current treatment of onychomycosis of the toenail is poor and relapse is common. OBJECTIVE: Our purpose was to assess the efficacy and safety of oral terbinafine and placebo in onychomycosis of the toenail with the use of a novel treatment protocol. METHODS: This was a randomized, double-blind, 48-week study. Twelve weeks of terbinafine (250 mg daily) or placebo was followed by 12 weeks of observation. Responders received no further treatment and nonresponders were offered 12 weeks of terbinafine (250 mg daily) from week 28. RESULTS: Of 111 evaluable patients, 88% (49 of 56) of the patients given terbinafine and 29% (16 of 55) of the patients given placebo had a negative mycologic culture at week 24 (p < 0.001), 57% (32 of 56) of the terbinafine group and 6% (3 of 55) of the placebo group were responders (p < 0.001). By week 48, after the terbinafine nonresponders were given a second 12-week course of terbinafine, the overall mycologic cure rate for the patients given terbinafine was 94%. CONCLUSION: High mycologic cure rates in onychomycosis of the toenail can be achieved by terbinafine by this novel treatment regimen.
Adolescent↗
Undergraduate perceptions of country practice.
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Adult↗