Deborah Askew

Effectiveness of 5-fluorouracil treatment for actinic keratosis - A systematic review of randomized controlled trials

Actinic keratosis (AK) lesions present as dry, rough, yellow– brown, scaly plaques which may become thickened and horny. Most AKs are caused by chronic exposure to ultraviolet (UV) radiation and are therefore most common in middle-aged and elderly fair-skinned individuals. Regions with a higher UV exposure show a higher prevalence, and the incidence rate increases with age. 1 Around 15–25% of lesions resolve spontaneously over a 12-month period, and the risk of a single lesion progressing to an invasive squamous cell carcinoma (SCC) is in the range 0.25–20% per year. 2,3 Opinion differs about the classification of AKs – some argue that they should be classified as in situ SCC because they are histopathologically indistinguishable from SCCs, 3 whereas others argue that the classification of in situ SCC, although histopathologically correct, is liable to misinterpretation by consumers, leading to unnecessary and excessive concerns generated by a diagnosis of cancer and additional costs to already overburdened healthcare systems. 4 Nevertheless, the inability to predict which AK lesions will transform into invasive SCCs means that the treatment of all AKs is indicated. Topical 5-fluorouracil (5-FU) is a well-established treatment for AK. 5-FU is an antineoplastic antimetabolite, which interferes with the synthesis of DNA and RNA, provoking unbalanced cell growth and death. 5-FU enables field therapy for patients with multiple AKs, and may also promote the healing of subclinical lesions. 5 Treatment is lengthy (about 4 weeks) and application site reactions, ranging from redness, soreness and weeping to shallow ulceration and crusting, are a consequence of treatment. Despite the widespread use of 5-FU to treat AK, the evidence supporting its use has not been reviewed systematically or appraised critically, unlike that for imiquimod. 6–8 We therefore reviewed systematically the published literature to address this gap, and to identify areas in which further research is needed.

Building family/general practice research capacity.

To promote the range of interventions for building family/general practice (family medicine) research capacity, we describe successful international examples. Such examples of interventions that build research capacity focus on diseases and illness research, as well as process research; monitor the output of research in family/general practice (family medicine); increase the number of family medicine research journals; encourage and enable research skills acquisition (including making it part of professional training); strengthen the academic base; and promote research networks and collaborations. The responsibility for these interventions lies with the government, colleges and academies, and universities. There are exciting and varied methods of building research capacity in family medicine.

Bullying in the Australian medical workforce: cross-sectional data from an Australian e-Cohort study

OBJECTIVE This study aimed to describe the prevalence of perceived workplace bullying in the Australian medical workforce, and investigate the relationship between workplace bullying and job satisfaction, health status, and current and planned medical workforce participation. METHODS An electronic cross-sectional survey of doctors currently in the paid workforce, conducted between April 2008 and October 2009, was nested within a longitudinal cohort study investigating factors affecting the recruitment and retention of the Australian medical workforce. To address the specific aims of this study, a subset of questions in the survey investigated the prevalence of self-reported bullying; physical and mental health; workforce participation patterns; job satisfaction; and job stressors. RESULTS Seven hundred and forty-seven participants responded to the bullying question and were included in this analysis. Twenty-five percent of participants reported being bullied in the last 12 months. There were no differences in the reported rates of bullying across age groups, sex and country of medical qualification. Bullied doctors were least satisfied with their jobs (P<0.001), had taken more sick leave in the last 12 months (P<0.001), and were more likely to be planning to decrease the number of hours worked in medicine in the next 12 months (P=0.01) or ceasing direct patient care in the next 5 years (independent of their age or the number of hours currently worked in patient care) (P=0.006). CONCLUSIONS Our findings suggest that Australian doctors, independent of age or sex, have experienced workplace bullying, and although no conclusions can be made about causal pathways, there were strong associations between this exposure and poorer health and wellbeing, and on remaining in the medical workforce.

Model of care for the management of complex Type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial.

To evaluate patient outcomes for a novel integrated primary/specialist model of community care for complex Type 2 diabetes mellitus management compared with outcomes for usual care at a tertiary hospital for diabetes outpatients.

Strategies for assessing the degree of photodamage to skin: a systematic review of the literature

As our understanding of the role of ultraviolet (UV) radiation exposure in causing skin cancer continues to be enhanced, it is important that clinicians and researchers are familiar with the various methods for assessing photodamage to skin. This paper provides a systematic review of the published literature on invasive and noninvasive methods used to quantify lifetime UV exposure (‘photoageing’). Clinical examination, histopathology, immunohistochemistry, skin surface topography and ultrasound, in addition to newer technologies such as reflectance confocal microscopy, optical coherence tomography and multiphoton tomography, are reviewed. It is concluded that histopathological solar elastosis alone should not be viewed as a ‘gold standard’ diagnostic test and that there is no single method available to give accurate quantification of the degenerative changes associated with photodamage. Although additional research into sensitivity and specificity is still needed, skin surface topography currently has the most support in the literature as a valid and reliable noninvasive tool for the assessment of photoageing.

Protocol and baseline data from The Inala Chronic Disease Management Service evaluation study: a health services intervention study for diabetes care

BackgroundType 2 Diabetes Mellitus is one of the most disabling chronic conditions worldwide, resulting in significant human, social and economic costs and placing huge demands on health care systems. The Inala Chronic Disease Management Service aims to improve the efficiency and effectiveness of care for patients with type 2 diabetes who have been referred by their general practitioner to a specialist diabetes outpatient clinic. Care is provided by a multidisciplinary, integrated team consisting of an endocrinologist, diabetes nurse educators, General Practitioner Clinical Fellows (general practitioners who have undertaken focussed post-graduate training in complex diabetes care), and allied health personnel (a dietitian, podiatrist and psychologist).Methods/DesignUsing a geographical control, this evaluation study tests the impact of this model of diabetes care provided by the service on patient outcomes compared to usual care provided at the specialist diabetes outpatient clinic. Data collection at baseline, 6 and 12-months will compare the primary outcome (glycaemic control) and secondary outcomes (serum lipid profile, blood pressure, physical activity, smoking status, quality of life, diabetes self-efficacy and cost-effectiveness).DiscussionThis model of diabetes care combines the patient focus and holistic care valued by the primary care sector with the specialised knowledge and skills of hospital diabetes care. Our study will provide empirical evidence about the clinical effectiveness of this model of care.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12608000010392.

Retinal photography for diabetic retinopathy screening in Indigenous primary health care: the Inala experience

Objective: We aimed to determine the impact of clinic based retinal photography on access to appropriate screening for diabetic retinopathy (DR).

Preventing obesity in infants: the Growing healthy feasibility trial protocol

Introduction Early childhood is an important period for establishing behaviours that will affect weight gain and health across the life course. Early feeding choices, including breast and/or formula, timing of introduction of solids, physical activity and electronic media use among infants and young children are considered likely determinants of childhood obesity. Parents play a primary role in shaping these behaviours through parental modelling, feeding styles, and the food and physical activity environments provided. Children from low socio-economic backgrounds have higher rates of obesity, making early intervention particularly important. However, such families are often more difficult to reach and may be less likely to participate in traditional programs that support healthy behaviours. Parents across all socio-demographic groups frequently access primary health care (PHC) services, including nurses in community health services and general medical practices, providing unparalleled opportunity for engagement to influence family behaviours. One emerging and promising area that might maximise engagement at a low cost is the provision of support for healthy parenting through electronic media such as the Internet or smart phones. The Growing healthy study explores the feasibility of delivering such support via primary health care services. Methods This paper describes the Growing healthy study, a non-randomised quasi experimental study examining the feasibility of an intervention delivered via a smartphone app (or website) for parents living in socioeconomically disadvantaged areas, for promoting infant feeding and parenting behaviours that promote healthy rather than excessive weight gain. Participants will be recruited via their primary health care practitioner and followed until their infant is 9 months old. Data will be collected via web-based questionnaires and the data collected inherently by the app itself. Ethics and dissemination This study received approval from the University of Technology Sydney Ethics committee and will be disseminated via peer-reviewed publications and conference presentations.

What sort of evidence do we need in primary care

General practitioners need evidence from and about the patients they see I n this weeks BMJ (p 635), Mant and colleagues raise again the question of whether large scale randomised controlled trials provide evidence relevant to primary care.1 In a cross sectional study they question whether the UK national clinical guidelines for stroke are applicable to primary care patients. These guidelines, largely based on the PROGRESS trial,1 recommend a target blood pressure of 140/85 mm Hg, with further lowering beyond this target desirable through use of a thiazide diuretic and an angiotensin converting enzyme inhibitor.2 Mant and colleagues critiqued the applicability of these guidelines to primary care patients by comparing the characteristics of patients in English general practice who had confirmed stroke with participants in the PROGRESS trial. They concluded that these populations were not sufficiently similar to warrant widespread use …

It puts a human face on the researched--A qualitative evaluation of an Indigenous health research governance model.

Objective: To describe the Inala Aboriginal and Torres Strait Islander Community Jury for Health Research, and evaluate its usefulness as a model of Indigenous research governance within an urban Indigenous primary health care service from the perspectives of jury members and researchers.