Performing in the operating theater.
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Clinical Competence↗
Biomedical subjects
Margaret Miller
Publications and source records attributed to Margaret Miller.
Folate intake and the primary prevention of non-neural birth defects.
OBJECTIVES: To investigate whether maternal periconceptional folate intake is associated with a reduction in selected non-neural birth defects in Western Australia (WA). METHODS: Case-control study of folate intake in women whose infants had orofacial clefts (62); congenital heart defects (151); urinary tract defects (117); limb reduction defects (26); or other major birth defects (119); and 578 control women. RESULTS: Neither folic acid supplements nor dietary folate intake in women not using supplements was significantly associated with a reduction in risk in any of the case groups. In contrast to neural tube defects, WA population data for orofacial clefts, heart defects, limb reduction defects and urinary tract defects showed no fall in prevalence since the introduction of folate promotion and voluntary food fortification. CONCLUSIONS: This study provides no evidence of folate being an important factor in the prevention of birth defects other than neural tube defects.
Case-Control Studies↗
Managing asthma in expectant mothers.
Pregnancy does not appear to have a consistent effect on the frequency or severity of asthma. The most common cause of worsening asthma in pregnancy is likely to be noncompliance with medication. Emphasizing to the patient in advance that fetal well-being is dependent on maternal well-being may help prevent this.In general, well controlled asthma is not associated with a higher risk of adverse pregnancy outcomes. Essential to successful asthma management is patient education that helps to ensure effective medication use, avoidance of triggers, and prompt treatment. This education should include measurement of peak expiratory flow rate and a written asthma action plan. Most of the medications that are used to control asthma in the general population can be safely used in pregnant women. Inhaled beta-adrenoceptor agonists (beta-agonists), cromolyn sodium (sodium cromoglycate), and inhaled and systemic corticosteroids all appear to be very well tolerated by the fetus. Budesonide and beclomethasone should be considered as the preferred inhaled corticosteroids for the treatment of asthma in pregnancy. Use of the leukotriene receptor antagonists zafirlukast and montelukast in pregnancy is probably safe but should be limited to special circumstances, where they are viewed essential for asthma control. Zileuton should not be used in pregnancy.Acute asthma exacerbations in pregnant women should be treated in a similar manner to that in non-pregnant patients. Maternal blood glucose levels should be monitored periodically in pregnant women receiving systemic corticosteroids because of the deleterious effects of hyperglycemia upon embryos and fetuses. During pregnancy, maternal arterial oxygen saturations should be kept above 95% if possible for fetal well-being. Ambulatory oxygenation should be checked prior to discharge to ensure that women do not desaturate with their daily activities.Acute exacerbations of asthma during labor and delivery are rare. Dinoprost, ergometrine, and other ergot derivatives can cause severe bronchospasm, especially when used in combination with general anesthesia, and should be avoided in asthmatic patients. Pregnant women who have been treated with corticosteroids in the past year may require stress-dose corticosteroids during labor and delivery. Most asthma medications, including oral prednisone, are considered compatible with breast-feeding.
Adrenal Cortex Hormones↗
Driving strategies used by older adults with macular degeneration: assessing the risks.
Older adults with macular degeneration use multiple driving strategies. A secondary analysis focused on driving strategies was conducted on data from two studies that had explored the experience of visual impairment in older adults diagnosed with macular degeneration. Findings revealed 24 driving strategies. Twelve categories emerged, reflecting two themes: (1) strategies used while performing the task of driving and (2) strategies used to continue driving. By understanding these strategies, nurses can assess the conditions under which these older adults drive and the risks taken. Findings guide nurses to counsel and educate older adults regarding driving.
Activities of Daily Living↗
Analysis of peripheral blood T-cell subsets in active thyroid-associated ophthalmopathy: absence of effect of octreotide-LAR on T-cell subsets in patients with thyroid-associated ophthalmopathy.
Thyroid-associated ophthalmopathy (TAO) is thought to be a T-cell-mediated autoimmune disorder. We sought to characterize abnormalities in the peripheral blood T-cell subsets in patients with TAO, and examine whether the long-acting somatostatin analogue, octreotide-LAR, treatment affects these cells. We analyzed peripheral blood T-cell subsets by flow cytometry in 26 euthyroid patients with moderately severe active TAO and 24 controls. Twenty-five of the patients with TAO were enrolled in a randomized trial to receive either 30 mg of octreotide-LAR (n = 11) or placebo (n = 14) every 4 weeks for 16 weeks; all 25 patients subsequently received octreotide-LAR 30 mg every 4 weeks from week 16 to 32. T-cell subsets were analysed at baseline, week 16, and week 32. At baseline, the relative percentage of CD4+ helper T-cells (p = 0.0003) and the CD4+/CD8+ ratio (p = 0.008) were significantly higher in patients with TAO compared to controls. Patients with TAO had higher naïve active T cells (CD45RA+, CD45RA+ CD4+) and lower memory T cells (CD45RO+, CD45RO+ CD4+) than controls. At weeks 16 and 32, there were no significant differences in any T-cell subsets between the octreotide-LAR-treated and placebo groups. These results support a role of T cell in the pathogenesis of TAO, and show that octreotide-LAR has no effect on T-cell subsets during 32-weeks of treatment.
CD4-CD8 Ratio↗
Florence Nightingale as the symbol of nursing.
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Humans↗
Promotion of folate for the prevention of neural tube defects: who benefits?
Since the publication of randomised trials showing firm evidence of prevention of neural tube defects with periconceptional folic acid, there have been population health promotion programmes to encourage women to take folic acid supplements, and the introduction of voluntary fortification of some foods with folic acid in Australia. In order to evaluate these two strategies, we collected data by self-administered questionnaire from a random sample of recently pregnant women in Western Australia between September 1997 and March 2000. Response to health promotion was measured in three ways: (1) knowledge of the association between periconceptional folate and prevention of spina bifida (the 'correct message'); (2) use of periconceptional vitamin supplements of folic acid daily in the periconceptional period; and (3) daily folate intake from fortified foods in the 6 months before pregnancy. We examined the relationship of maternal demographic and behavioural characteristics with these three measures. Overall, 62.3% of women were aware of the correct message before pregnancy, 28.5% reported taking 200 microg or more of folic acid from supplements daily in the periconceptional period and 56.6% of women obtained 100 microg or more of folic acid from fortified foods. Women who first became aware of the correct message during pregnancy or who were unaware of the correct message before or during pregnancy were more likely than women aware before pregnancy to be younger, having their first pregnancy, be single or in a de facto relationship, have no tertiary education, and be a public patient. Similar associations were seen for women taking either no folic acid or < 200 microg of folic acid in supplements daily in the periconceptional period. There were no significant associations between these demographic variables and amount of folate obtained from fortified foods. Women who were unaware of the correct message and did not take folic acid supplements were more likely to have smoked, not to have engaged in exercise, and not to have planned their pregnancy, whereas there was no association with these behavioural characteristics and intake of folate from fortified foods. These results indicate that health promotion strategies have not reached all segments of the target population equally, but there is no such disparity with folate-fortified foods, and they suggest that mandatory fortification of a staple food is likely to reach all women regardless of demographic and behavioural characteristics, and hence provide improved opportunity for prevention of neural tube defects in Australia.
Adult↗
Health working with industry to promote fruit and vegetables: a case study of the Western Australian Fruit and Vegetable Campaign with reflection on effectiveness of inter-sectoral action.
OBJECTIVE: In 1990, the Department of Health in Western Australia (DOH) initiated a five-year campaign to increase awareness of the need to eat more fruit and vegetables and to encourage increased consumption. This paper describes aspects of the campaign and reviews the strengths and weaknesses of health and fruit and vegetable industry alliances to extend and sustain the campaign. METHOD: The fruit and vegetable industry was engaged through information sharing, consultation, working groups and joint promotions. The partnership was examined in terms of six inter-sectoral action dimensions (necessity; opportunity and capacity to work together; established relationships for goal achievement; degree of planning; potential for evaluation; and sustainability of action). RESULTS AND CONCLUSIONS: There were both need and opportunity for each sector to work together. Health had commitment, expertise and resources to plan, implement and evaluate the campaign. Industry had established channels of communication within the supply chain. Sustained health sector presence provided incentive, endorsement and policy direction. Resources and infrastructure limited partnership sustainability. Greatest potential for success occurred when participants' contributions were closely aligned to their core business and there was a body responsible for co-ordinating action.
Cooperative Behavior↗
Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists.
OBJECTIVE: To describe a group of patients who were treated with tumor necrosis factor alpha (TNF alpha) antagonists and who developed coccidioidomycosis, and to test the hypothesis that patients with inflammatory arthritis receiving TNF alpha antagonist therapy are at higher risk for developing symptomatic coccidioidomycosis. METHODS: Cases of coccidioidomycosis were identified and reviewed from among patients receiving TNF alpha antagonist therapy from May 1998 through February 2003 in 5 practices within the areas endemic for coccidioidomycosis (Arizona, California, and Nevada). In addition, the relative risk of developing symptomatic coccidioidomycosis was calculated in patients with inflammatory arthritis who were receiving treatment with infliximab, in comparison with patients with inflammatory arthritis who were not receiving infliximab, from January 2000 to February 2003 in a single medical center. RESULTS: Thirteen cases of documented coccidioidomycosis were associated with TNF alpha antagonist therapy. Twelve cases were associated with the use of infliximab and 1 case with etanercept. Among the cohort of patients from a single medical center, 7 of the 247 patients receiving infliximab and 4 of the 738 patients receiving other therapies developed symptomatic coccidioidomycosis (relative risk 5.23, 95% confidence interval 1.54-17.71; P < 0.01). CONCLUSION: Patients with inflammatory arthritis who are undergoing treatment with infliximab appear to be at higher risk for developing symptomatic coccidioidomycosis as compared with those not receiving infliximab.
Acute Disease↗
The effect of echinacea (Echinacea purpurea root) on cytochrome P450 activity in vivo.
BACKGROUND: Echinacea is a widely available over-the-counter herbal remedy. Tinctures of echinacea have been shown to inhibit cytochrome P450 (CYP) in vitro. The effect of echinacea (Echinacea purpurea root) on CYP activity in vivo was assessed by use of the CYP probe drugs caffeine (CYP1A2), tolbutamide (CYP2C9), dextromethorphan (CYP2D6), and midazolam (hepatic and intestinal CYP3A). METHODS: Twelve healthy subjects (6 men) completed this 2-period, open-label, fixed-schedule study. Caffeine, tolbutamide, dextromethorphan, and oral and intravenous midazolam were administered before and after a short course of echinacea (400 mg 4 times a day for 8 days) to determine in vivo CYP activities. RESULTS: Echinacea administration significantly increased the systemic clearance of midazolam by 34%, from 32 +/- 7 L/h to 43 +/- 16 L/h (P =.003; 90% confidence interval [CI], 116%-150%), and significantly reduced the midazolam area under the concentration-time curve by 23%, from 127 +/- 36 microg. h/L to 102 +/- 43 microg. h/L (P =.024; 90% CI, 63%-88%). In contrast, the oral clearance of midazolam was not significantly altered (P =.655; 90% CI, 75%-124%), 137 +/- 19 L/h compared with 146 +/- 71 L/h. The oral availability of midazolam after echinacea dosing was significantly increased (P =.028; 90% CI, 108%-153%), from 0.23 +/- 0.06 to 0.33 +/- 0.13. Hepatic availability (0.72 +/- 0.08 versus 0.61 +/- 0.16; P =.006; 90% CI, 73%-90%) and intestinal availability (0.33 +/- 0.11 versus 0.61 +/- 0.38; P =.015; 90% CI, 125%-203%) were significantly altered in opposite directions. Echinacea dosing significantly reduced the oral clearance of caffeine, from 6.6 +/- 3.8 L/h to 4.9 +/- 2.3 L/h (P =.049; 90% CI, 58%-96%). The oral clearance of tolbutamide was reduced by 11%, from 0.81 +/- 0.18 L/h to 0.72 +/- 0.19 L/h, but this change was not considered to be clinically relevant because the 90% CIs were within the 80% to 125% range. The oral clearance of dextromethorphan in 11 CYP2D6 extensive metabolizers was not affected by echinacea dosing (1289 +/- 414 L/h compared with 1281 +/- 483 L/h; P =.732; 90% CI, 89%-108%). CONCLUSIONS: Echinacea (E purpurea root) reduced the oral clearance of substrates of CYP1A2 but not the oral clearance of substrates of CYP2C9 and CYP2D6. Echinacea selectively modulates the catalytic activity of CYP3A at hepatic and intestinal sites. The type of drug interaction observed between echinacea and other CYP3A substrates will be dependent on the relative extraction of drugs at hepatic and intestinal sites. Caution should be used when echinacea is coadministered with drugs dependent on CYP3A or CYP1A2 for their elimination.
Administration, Oral↗
Folate promotion in Western Australia and the prevention of neural tube defects.
OBJECTIVES: We conducted a case-control study to investigate the effectiveness of efforts to increase folate intake in Western Australia (WA) for the prevention of neural tube defects (NTD). METHODS: Case (36) and control (578) mothers completed questionnaires, from which their intake of folate from supplements and food (including fortified foods) was estimated. RESULTS: Almost one-third of women took folic acid supplements periconceptionally. Supplement use was associated with a non-significant 4% reduction in risk. For women not taking supplements, dietary sources of folate were protective, and most women obtained at least some folate from fortified food. CONCLUSIONS: For the two-thirds of WA women not taking supplements, fortified food is an important source of folate for the prevention of NTD. IMPLICATIONS: Greater promotion of foods currently allowed to be fortified with folate, or mandatory fortification, is needed to maximise prevention of NTD in Australia.
Adolescent↗
The tooty fruity vegie project: changing knowledge and attitudes about fruits and vegetables.
OBJECTIVES: The Tooty Fruity Vegie (TFV) project was a multi-strategic, school-based intervention aimed at preventing the large decline in fruit and vegetable intake that typically starts during primary school. METHODS: During 1999 and 2000, TFV was implemented in 10 volunteer primary schools across the Northern Rivers region of New South Wales. Surveys were conducted, in late 2000, with children, parents, teachers and principals across nine intervention and three matched control schools. Intervention schools' management teams also completed strategy implementation indexes indicating how often, how well and with how many people each major strategy was implemented. RESULTS: Completed surveys from 613 parents (59%), 392 older children (65%), 50 teachers (81%) and all 10 intervention principals and school management teams showed the project was well implemented, achieved high reach and was very positively received. The project enhanced the quality, diversity and frequency of classroom fruit and vegetable-promoting activities, substantially increasing children's involvement and enjoyment levels. It significantly improved children's fruit and vegetable knowledge, attitudes, access and preparation skills; parents' knowledge and involvement in fruit and vegetable-promoting activities in schools and beyond; and teachers' perceived support for doing fruit and vegetable promotions. CONCLUSION: Despite some methodological limitations, which may limit confidence in our findings, survey results across all target groups consistently indicated that primary schools can be supported to establish, implement and sustain highly acceptable and effective fruit and vegetable-promoting programs.
Child↗
Double-blind, placebo-controlled trial of octreotide long-acting repeatable (LAR) in thyroid-associated ophthalmopathy.
Several uncontrolled studies suggest octreotide is beneficial in thyroid-associated ophthalmopathy (TAO); however, the natural tendency of TAO to improve mandates randomized, controlled trials. We report results of a double-blind, placebo-controlled trial of octreotide long-acting repeatable (LAR). Fifty euthyroid patients (11 males, 39 females; age 22-74 yr, median 50 yr) with active TAO [clinical activity score (CAS) > or =3, NOSPECS (no signs or symptoms; only signs, no symptoms; signs only; proptosis; eye muscle involvement; corneal involvement; sight visual acuity reduction) 2a-5a] of median duration 0.9 yr received either 30 mg LAR or placebo every 4 wk for 16 wk; both groups then received 30 mg LAR for wk 16-32 and were followed up without treatment for a further 24 wk. Objective assessments included all individual parameters of TAO, CAS, and derived scores for soft tissue inflammation (STI) and ophthalmopathy index (OI). During wk 0-16 there was significant reduction in STI, subjective diplopia, and CAS in LAR-treated patients; STI and CAS were also reduced with placebo. The OI reduced by -1.12 in LAR (P = 0.0017) vs. -0.23 in placebo (P = 0.33), giving a barely significant treatment effect by Wilcoxon (P = 0.043), but analysis of covariance failed to confirm this (P = 0.16). During wk 16-32 there was no significant change in OI in either group. The overall results (wk 0-32) showed reduction in STI and CAS in both groups. In this double-blind, placebo-controlled trial, no significant therapeutic effect of octreotide LAR was seen in patients with moderately severe TAO. The improvements in both treated and placebo groups emphasize that the results of open studies must be viewed with caution.
Adult↗
Primary lymphangiectasia in a dingo (Canis familiaris dingo).
A 3-yr-old intact male dingo (Canis familiaris dingo) presented with a 3-mo history of diarrhea. The diarrhea did not resolve with antibiotics or intestinal protectants. Fecal examination for parasites, fecal cultures, physical examination, and radiographs were unremarkable. Enteroscopic duodenal biopsies showed dilated lacteals without inflammation. Results of serum folate, cobalamin, and trypsin-like immunoreactivity were normal. Low serum total protein and albumin combined with increased fecal levels of alpha-1 protease inhibitor suggested the diagnosis of lymphangiectasia. Full-thickness intestinal biopsies of the duodenum, jejunum, and ileum revealed dilated mucosal and submucosal lacteals without associated inflammation, confirming the diagnosis of primary lymphangiectasia. Currently, the dingo is being maintained with nutritional management.
Animal Feed↗
The interaction between St John's wort and an oral contraceptive.
OBJECTIVES: The popular herbal remedy St John's wort is an inducer of cytochrome P450 (CYP) 3A enzymes and may reduce the efficacy of oral contraceptives. Therefore we evaluated the effect of St John's wort on the disposition and efficacy of Ortho-Novum 1/35 (Ortho-McNeil Pharmaceutical, Inc, Raritan, NJ), a popular combination oral contraceptive pill containing ethinyl estradiol (INN, ethinylestradiol) and norethindrone (INN, norethisterone). METHODS: Twelve healthy premenopausal women who were using oral contraception (>3 months) received a combination oral contraceptive pill (Ortho-Novum 1/35) for 3 consecutive 28-day menstrual cycles. During the second and third cycles, the participants received 300 mg St John's wort 3 times a day. The serum concentrations of ethinyl estradiol (day 7), norethindrone (day 7), follicle-stimulating hormone (days 12-16), luteinizing hormone (days 12-16), progesterone (day 21), and intravenous and oral midazolam (days 22 and 23) were determined in serial blood samples. The incidence of breakthrough bleeding was quantified during the first and third cycles. RESULTS: Concomitant use of St John's wort was associated with a significant (P <.05) increase in the oral clearance of norethindrone (8.2 +/- 2.7 L/h to 9.5 +/- 3.4 L/h, P =.042) and a significant reduction in the half-life of ethinyl estradiol (23.4 +/- 19.5 hours to 12.2 +/- 7.1 hours, P =.023). The oral clearance of midazolam was significantly increased (109.2 +/- 47.9 L/h to 166.7 +/- 81.3 L/h, P =.007) during St John's wort administration, but the systemic clearance of midazolam was unchanged (37.7 +/- 11.3 L/h to 39.0 +/- 10.3 L/h, P =.567). Serum concentrations of follicle-stimulating hormone, luteinizing hormone, and progesterone were not significantly affected by St John's wort dosing (P >.05). Breakthrough bleeding occurred in 2 of 12 women in the control phase compared with 7 of 12 women in the St John's wort phase. The oral clearance of midazolam after St John's wort dosing was greater in women who had breakthrough bleeding (215.9 +/- 66.5 L/h) than in those who did not (97.5 +/- 37.2 L/h) (P =.005). CONCLUSION: St John's wort causes an induction of ethinyl estradiol-norethindrone metabolism consistent with increased CYP3A activity. Women taking oral contraceptive pills should be counseled to expect breakthrough bleeding and should consider adding a barrier method of contraception when consuming St Johns wort.
Administration, Oral↗
Older men's experiences of living with severe visual impairment.
BACKGROUND: Little is known about how men react to their health and illness experiences. Lack of information about the lives of older men is unfortunate considering the anticipated growth of the older male sector of society and the fact that older men age differently than older women. One health-related experience common to many older men is severe visual impairment caused by macular degeneration, a chronic eye disease that affects central vision. Understanding the health experiences of older men is imperative if nurses are to provide quality care to this growing segment of society. AIM: The purpose of this study was to gain an understanding of the experience of severe visual impairment from the perspective of older men with macular degeneration. METHOD: A phenomenological approach was used to investigate the experience of severe visual impairment in eight older men with macular degeneration. Data were gathered through audiotaped interviews and analysed using a modified Giorgi method. FINDINGS: The resultant general structural description revealed six central themes: (1) older men's lives were circumscribed by what they could and could not see and could and could not do, (2) cherishing of independence, (3) creation of strategies, (4) acknowledgment of the progression of visual impairment, (5) confrontation of uncertainties, skepticism, and fears about their diagnosis and treatment, and (6) persistence with hope and optimism. CONCLUSIONS: A thorough nursing history and assessment must be completed, including information about the progression of the visual impairment, strategies used for living with visual loss, and presence of other health problems that may complicate life with visual impairment. Nurses must be aware that older men with macular degeneration are often sceptical about their diagnosis and treatment. Therefore, careful education and clear communication are essential.
Activities of Daily Living↗
Effectiveness of smoking cessation interventions: review of evidence and implications for best practice in Australian health care settings.
OBJECTIVE: To review the evidence of the effectiveness of various smoking cessation methods and appropriateness for use in Australian health care settings. METHODS: Cochrane and other existing reviews and meta-analyses of evidence were the basis for the review. Systematic literature searches were also conducted to identify relevant controlled trials published internationally between January 1999 and May 2002. The main inclusion criteria for studies were use of a controlled evaluation design and an outcome measure of continuous abstinence from smoking for at least five months. A three-tiered grading system for strength of evidence was used. RESULTS: Clinic and hospital systems to assess and document tobacco use and routine provision of cessation advice can double long-term quit rates. While brief intervention can achieve a significant effect at population level, at individual level there is a strong dose response between the number and length of sessions of tobacco cessation counselling and its effectiveness. Effective behavioural interventions can increase cessation rates by 50-100% compared with no intervention. Some pharmacotherapies are safe and also help to substantially increase cessation rates. CONCLUSIONS: Effective behavioural and pharmacological methods of tobacco cessation are available. IMPLICATIONS: Every smoker should be offered evidence-based advice and treatment to quit smoking. This includes pharmacotherapy, unless contra-indicated. Health professionals and health care settings can play a significant role in motivating and assisting smokers to quit.
Acupuncture↗
Trends in neural tube defects in Western Australia.
OBJECTIVE: To report on trends in neural tube defects in Western Australia, in relation to folate promotion, periconceptional use of folic acid supplements and food fortification with folate. METHODS: Data on neural tube defects from the Western Australian Birth Defects Registry. RESULTS: A 30% fall in neural tube defects was documented from 1996 to 2000. CONCLUSIONS AND IMPLICATIONS: The sustained fall in neural tube defects is thought to be due to increased periconceptional folate intake in response to health promotion campaigns and fortification of selected foods. There is room for further improvement.
Anencephaly↗