Balakrishnan R Nair

Better Management of Cardiovascular Diseases by Pulse Wave Velocity: Combining Clinical Practice with Clinical Research using Evidence-Based Medicine

Arterial stiffness measured by pulse wave velocity (PWV) is an accepted strong, independent predictor of cardiovascular events and mortality. However, lack of a reliable reference range has limited its use in clinical practice. In this evidence-based review, we applied published data to develop a PWV risk stratification model and demonstrated its impact on the management of common clinical scenarios. After reviewing 97 studies where PWV was measured, 5 end-stage renal disease patients, 5 hypertensives, 2 diabetics, and 2 elderly studies were selected. Pooling the data by the “fixed-effect model” demonstrated that the mortality and cardiovascular event risk ratio for one level increment in PWV was 2.41 (1.81–3.20) or 1.69 (1.35–2.11), respectively. There was a significant difference in PWV between survived and deceased groups, both in the low and high risk populations. Furthermore, risk comparison demonstrated that 1 standard deviation increment in PWV is equivalent to 10 years of aging, or 1.5 to 2 times the risk of a 10 mmHg increase in systolic blood pressure. Evidence shows that PWV can be beneficially used in clinical practice for cardiovascular risk stratification. Furthermore, the above risk estimates could be incorporated into currently used cardiac risk scores to improve their predictive power and facilitate the clinical application of PWV.

Evidence based medicine for older people: available, accessible, acceptable, adaptable?

Despite the wealth of evidence concerning interventions in older people from properly conducted randomised controlled trials the profession has been slow to implement these findings. Gains in life expectancy with resulting greying of the patient base has not been accompanied by interest and motivation to provide the best quality evidence based care for older people.

Is there a problem with the problems in problem-based learning?

To determine the balance between acute and chronic medical problems in the PBL cases at 2 Australian medical schools.

Potential predictors of psychological distress and well-being in medical students: a cross-sectional pilot study

Purpose Research has consistently found that the proportion of medical students who experience high levels of psychological distress is significantly greater than that found in the general population. The aim of our research was to assess the levels of psychological distress more extensively than has been done before, and to determine likely predictors of distress and well-being. Subjects and methods In 2013, students from an Australian undergraduate medical school (n=127) completed a questionnaire that recorded general demographics, hours per week spent studying, in paid work, volunteer work, and physical exercise; past and current physical and mental health, social support, substance use, measures of psychological distress (Kessler Psychological Distress Scale, depression, anxiety, stress, burnout); and personality traits. Results Females were found to have higher levels of psychological distress than males. However, in regression analysis, the effect of sex was reduced to nonsignificance when other variables were included as predictors of psychological distress. The most consistent significant predictors of our 20 indicators of psychological distress were social support and the personality traits of emotional resilience and self-control. Conclusion The findings suggest that emotional resilience skills training embedded into the medical school curriculum could reduce psychological distress among medical students.

The hyponatremic hypertensive syndrome in renal artery stenosis: An infrequent cause of hyponatremia

The hyponatremic hypertensive syndrome is a rare but serious complication of reno-vascular disease. The syndrome is characterized by hypertension and profound natriuresis, leading to body sodium and water depletion. Hypertension is typically refractory to treatment. We report an 82-year-old patient with this syndrome and describe the results of an audit of the clinical records of patients admitted to a teaching hospital over a two-year period with confirmed renal artery stenosis and hyponatremia. The syndrome should be suspected in patients in whom severe hypertension is associated with hyponatremia without other apparent cause, especially in the presence of reno-vascular disease.

Music and dementia

As the population ages, the prevalence of dementia is increasing. Distressing behavioral problems are often part of the illness. This review considers the available evidence for cognitive effects related to music, evidence for the efficacy of music in the management of behavioral problems in dementia, and evidence about the effects of different types of music, their mode of delivery, and any adverse effects. Live music may be more beneficial than recorded. The effect of music may not be lasting, but there is evidence of benefit in studies, which to date are mostly not of high quality.

Improving hospital-based end of life care processes and outcomes: a systematic review of research output, quality and effectiveness

BackgroundAs in other areas of health delivery, there is a need to ensure that end-of-life care is guided by patient centred research. A systematic review was undertaken to examine the quantity and quality of data-based research aimed at improving the (a) processes and (b) outcomes associated with delivering end-of-life care in hospital settings.MethodsMedline, EMBASE and Cochrane databases were searched between 1995 and 2015 for data-based papers. Eligible papers were classified as descriptive, measurement or intervention studies. Intervention studies were categorised according to whether the primary aim was to improve: (a) end of life processes (i.e. end-of-life documentation and discussions, referrals); or (b) end-of-life outcomes (i.e. perceived quality of life, health status, health care use, costs). Intervention studies were assessed against the Effective Practice and Organisation of Care methodological criteria for research design, and their effectiveness examined.ResultsA total of 416 papers met eligibility criteria. The number increased by 13% each year (p < 0.001). Most studies were descriptive (n = 351, 85%), with fewer measurement (n = 17) and intervention studies (n = 48; 10%). Only 18 intervention studies (4%) met EPOC design criteria. Most reported benefits for end-of-life processes including end-of-life discussions and documentation (9/11). Impact on end-of-life outcomes was mixed, with some benefit for psychosocial distress, satisfaction and concordance in care (3/7).ConclusionMore methodologically robust studies are needed to evaluate the impact of interventions on end-of-life processes, including whether changes in processes translate to improved end-of-life outcomes. Interventions which target both the patient and substitute decision maker in an effort to achieve these changes would be beneficial.

A checklist for comprehensive health assessment for the over 70's

Objectives: To describe the development and performance of an instrument for health assessment of older Australian veterans and war widows, including: (a) the underlying dimensions of the assessment instrument, (b) problems identified and (c) associations with health related quality of life. Method: Participants were randomly selected veterans and war widows aged 70 years and over, living independently in 10 regions of NSW and QLD. The intervention consisted of a series of preventive care home visit health assessments by health professionals using a specially developed 113‐item screening checklist, together with targeted health education materials, telephone follow‐up and computer generated reports to the veterans local medical officer. Main outcome measures were underlying facets of the checklist, and associations with self reported quality of life. Results: 904 home visit assessments were conducted using the checklist. Problems identified included having no recent hearing check, poor rate of vaccination against pneumonia and tetanus vaccination, and problems with feet. Exploratory factor analysis of the checklist reported four main factors, explaining 31% of the variance. Three out of four checklist scales were significantly associated with both physical and mental component scores of the SF‐36 quality of life measure.

Workplace-based assessment for international medical graduates: at what cost?

Objective: To estimate the cost of resources required to deliver a program to assess international medical graduates (IMGs) in Newcastle, Australia, known as the Workplace Based Assessment (WBA) Program.

Development and implementation of an innovative intern training programme

The quality of medical education during internship is a cause for concern. This paper describes a structured educational programme for interns that was based around learning modules, clinical attachments and bedside teaching. The programme was incorporated into the term rotation of interns within an Area Health Service, and evaluated. Learning modules were timetabled by a Programme Coordinator and interns were reminded to attend. Clinical attachments were organized by the interns from a list of willing supervisors. Attendance at timetabled learning modules averaged 67%, which was greater than the 27% attendance at clinical attachments. Both sessions received high ratings for quality and clinical relevance. This structured education programme was based upon adult learning methods and was both feasible and well received by interns. Intern training programmes need to be programmed into the working week to ensure attendance, and modified following evaluation by interns. Such programmes should be considered by all hospitals to which interns are allocated.