Lesley Braun

Oxidative Stress in Surgery in an Ageing Population : Pathophysiology and Therapy

Reactive oxygen species (ROS) play an important role in the regulation of normal cellular function. When ROS are produced in excess they can have detrimental effects, a state known as oxidative stress. Thus ROS play both physiological and pathophysiological roles in the body. In clinical practice oxidative stress and its counterpart, antioxidant capacity can be measured and can guide remedial therapy. Oxidative stress can have a negative impact in all forms of major surgery including cardiac surgery, general surgery, trauma surgery, orthopedic surgery and plastic surgery; this is particularly marked in an ageing population. Many different therapies to reduce oxidative stress in surgery have been tried with variable results. We conclude that in surgical patients the assessment of oxidative stress, improvement of the understanding of its role, both positive and negative, and devising appropriate therapies represent fruitful fields for future research.

Reduction in urinary organophosphate pesticide metabolites in adults after a week-long organic diet

BACKGROUND Conventional food production commonly uses organophosphate (OP) pesticides, which can have negative health effects, while organic food is deemed healthier because it is produced without these pesticides. Studies suggest that organic food consumption may significantly reduce OP pesticide exposure in children who have relatively higher pesticide exposure than adults due to their different diets, body weight, behaviour and less efficient metabolism. OBJECTIVES A prospective, randomised, crossover study was conducted to determine if an organic food diet reduces organophosphate exposure in adults. METHODS Thirteen participants were randomly allocated to consume a diet of at least 80% organic or conventional food for 7 days and then crossed over to the alternate diet. Urinary levels of six dialkylphosphate metabolites were analysed in first-morning voids collected on day 8 of each phase using GC-MS/MS with detection limits of 0.11-0.51 μg/L. RESULTS The mean total DAP results in the organic phase were 89% lower than in the conventional phase (M=0.032 [SD=0.038] and 0.294 [SD=0.435] respectively, p=0.013). For total dimethyl DAPs there was a 96% reduction (M=0.011 [SD=0.023] and 0.252 [SD=0.403] respectively, p=0.005). Mean total diethyl DAP levels in the organic phase were half those of the conventional phase (M=0.021 [SD=0.020] and 0.042 [SD=0.038] respectively), yet the wide variability and small sample size meant the difference was not statistically significant. CONCLUSIONS The consumption of an organic diet for one week significantly reduced OP pesticide exposure in adults. Larger scale studies in different populations are required to confirm these findings and investigate their clinical relevance.

Physical conditioning and mental stress reduction - a randomised trial in patients undergoing cardiac surgery

BackgroundPreoperative anxiety and physical unfitness have been shown to have adverse effects on recovery from cardiac surgery. This study involving cardiac surgery patients was primarily aimed at assessing the feasibility of delivering physical conditioning and stress reduction programs within the public hospital setting. Secondary aims were to evaluate the effect of these programs on quality of life (QOL), rates of postoperative atrial fibrillation (AF) and length of stay (LOS) in hospital.MethodsElective patients scheduled for coronary artery bypass graft and/or valve surgery at a public hospital in Melbourne, Australia were enrolled. Patients were randomized to receive either holistic therapy (HT) or usual care (UC). HT consisted of a series of light physical exercise sessions together with a mental stress reduction program administered in an outpatient setting for the first two weeks after placement on the waiting list for surgery. A self-administered SF-36 questionnaire was used to measure QOL and hospital records to collect data on LOS and rate of postoperative AF.ResultsThe study population comprised 117 patients of whom 60 received HT and 57 received UC. Both programs were able to be delivered within the hospital setting but ongoing therapy beyond the two week duration of the program was not carried out due to long waiting periods and insufficient resources. HT, as delivered in this study, compared to UC did not result in significant changes in QOL, LOS or AF incidence.ConclusionsPreoperative holistic therapy can be delivered in the hospital setting, although two weeks is insufficient to provide benefits beyond usual care on QOL, LOS or postoperative AF. Further research is now required to determine whether a similar program of longer duration, or targeted to high risk patients can provide measurable benefits.Trial registrationThis trial was conducted as part of a larger study and according to the principles contained in the CONSORT statement 2001.

The prevalence and experience of Australian naturopaths and Western herbalists working within community pharmacies

BackgroundNaturopaths and Western herbal medicine (WHM) practitioners were surveyed to identify their extent, experience and roles within the community pharmacy setting and to explore their attitudes to integration of complementary medicine (CM) practitioners within the pharmacy setting.MethodPractising naturopaths and WHM practitioners were invited to participate in an anonymous, self-administered, on-line survey. Participants were recruited using the mailing lists and websites of CM manufacturers and professional associations.Results479 practitioners participated. 24% of respondents (n = 111) reported they had worked in community pharmacy, three-quarters for less than 5 years. Whilst in this role 74% conducted specialist CMs sales, 62% short customer consultations, 52% long consultations in a private room and 51% staff education. This was generally described as a positive learning experience and many appreciated the opportunity to utilise their specialist knowledge in the service of both customers and pharmacy staff. 14% (n = 15) did not enjoy the experience of working in pharmacy at all and suggested pharmacist attitude largely influenced whether the experience was positive or not. Few practitioners were satisfied with the remuneration received. 44% of the total sample provided comment on the issue of integration into pharmacy, with the main concern being the perceived incommensurate paradigms of practice between pharmacy and naturopathy. Of the total sample, 38% reported that they would consider working as a practitioner in retail pharmacy in future.ConclusionsThe level of integration of CM into pharmacy is extending beyond the mere stocking of supplements. Naturopaths and Western Herbalists are becoming utilised in pharmacies

OA09.03. Stress reduction using massage in cardiac surgery patients

Purpose The primary aim of the study was to determine the effects of massage therapy, delivered to post-surgery cardiothoracic patients, on pain, anxiety, relaxation and muscular tension at two different time points and compare it to an equivalent period of rest time. The secondary aims were to explore the effects of massage on heart rate, respiratory rate and blood pressure, feasibility of treatment delivery in a busy ward and staff acceptance of the new therapy and therapists. Methods A randomised study conducted at the Alfred hospital compared massage therapy to an equivalent period of rest time. Visual analogue scales measured pain, anxiety, relaxation, muscular tension and satisfaction. Heart rate, respiratory rate and blood pressure were measured preand post-treatment by a cardiac nurse. Focus groups, staff and therapist feedback were utilised to collect qualitative data about clinical significance and feasibility of delivering the treatment. Results One hundred and fifty-two (99% response rate) patients participated. Compared to rest time, massage therapy produced a significantly greater reduction in pain (p=0.001), anxiety (p<0.0001), muscular tension (p=0.002) and increases in relaxation (p<0.0001) and satisfaction (p=0.016). No significant differences were seen for heart rate, respiratory rate and blood pressure. The effects at different time points were also compared between the groups. Pain significantly reduced after massage on day 3/4 (p<0.0001) and day 5/6 (p=0.003) whereas controls experienced no significant change at either time point. At both time points, massage significantly reduced anxiety (p<0.0001) and muscular tension (p<0.0001). Relaxation significantly improved on day 3/4 for both groups (massage p<0.0001; rest time p=0.006) but only massage was effective on day 5/6 (p<0.0001). Nurses and physiotherapists confirmed patient improvements and helped facilitate delivery of the treatment. Conclusion Post-surgery massage therapy significantly improved pain, anxiety, muscular tension and relaxation amongst cardiothoracic surgery patients, was well accepted and feasible to deliver.

An interpretive review of consensus statements on clinical guideline development and their application in the field of traditional and complementary medicine

BackgroundDespite ongoing consumer demand and an emerging scientific evidence-base for traditional and complementary medicine (T&CM), there remains a paucity of reliable information in standard clinical guidelines about their use. Often T&CM interventions are not mentioned, or the recommendations arising from these guidelines are unhelpful to end-users (i.e. patients, practitioners and policy makers). Insufficient evidence of efficacy may be a contributing factor; however, often informative recommendations could still be made by drawing on relevant information from other avenues. In light of this, the aim of this research was to review national and internationally endorsed consensus statements for clinical guideline developers, and to interpret how to apply these methods when making recommendations regarding the use of T&CM.MethodThe critical interpretive review method was used to identify and appraise relevant consensus statements published between 1995 and 2015. The statements were identified using a purposive sampling technique until data saturation was reached. The most recent edition of a statement was included in the analysis. The content, scope and themes of the statements were compared and interpreted within the context of the T&CM setting; including history, regulation, use, emerging scientific evidence-base and existing guidelines.ResultsEight consensus statements were included in the interpretive review. Searching stopped at this stage as no new major themes were identified. The five themes relevant to the challenges of developing T&CM guidelines were: (1) framing the question; (2) the limitations of using an evidence hierarchy; (3) strategies for dealing with insufficient, high quality evidence; (4) the importance of qualifying a recommendation; and (5) the need for structured consensus development.ConclusionEvidence regarding safety, efficacy and cost effectiveness are not the only information required to make recommendations for clinical guidelines. Modifying factors such as burden of disease, magnitude of effect, current use, demand, equity and ease of integration should also be considered. Uptake of the recommendations arising from this review are expected to result in the development of higher quality clinical guidelines that offer greater assistance to those seeking answers about the appropriate use of T&CM.

Prevalence of Vitamin D Deficiency Prior to Cardiothoracic Surgery

BACKGROUND Vitamin D deficiency is one of the most common chronic medical conditions in the world and also prevalent in Australia. A growing body of evidence suggests that low vitamin D also has adverse effects on cardiovascular health, including coronary risk factors and adverse cardiovascular outcomes such as myocardial infarction, cardiac failure and stroke. There is some evidence suggesting that a greater proportion of people with cardiovascular disease have low vitamin D compared to the general population. We examined the prevalence of vitamin D deficiency and insufficiency in elective cardiothoracic surgical patients presenting to the Alfred Hospital in Melbourne, Australia and compared this to recent Victorian statistics for people of the same age group. METHODS Consecutive adult elective cardiothoracic surgical patients listed for either coronary artery bypass graft surgery or heart valve repair or replacement surgery attending The Alfred Hospital, Melbourne between July 2011 and October 2012 were invited to participate. This ensured that patients were enrolled over all four seasons. Fasting serum samples were taken on the day of surgery, immediately after admission. Eighty volunteers participated in the study. Of the group, 40% were due to have coronary artery bypass graft surgery, 35% valve surgery and 25% a combination of the two; 74% reported having hypertension, 69% hyperlipidaemia, 26% diabetes and 39% had a BMI >30 kg/m(2). RESULTS Test results revealed that 92.5% of patients had Vitamin D levels < 75 nmol/L, 67.5% had levels < 60 nmol/L, 52.5% had levels between 30-59 nmol/L and 15% had levels < 30 nmol/L. Inadequate vitamin D levels were found in 80% of obese patients (BMI > 30 kg/m(2)) compared to 59% of non-obese patients. CONCLUSIONS Based on our small screening study, a substantial proportion of elective cardiothoracic surgical patients have less than optimal serum vitamin D3 levels prior to surgery. We found two-thirds of patients had serum vitamin D levels below 60 nmol/L, placing them at higher risk of falls. This finding is of concern as these patients would have received multiple consultations with various medical practitioners prior to hospital admission and yet their inadequate vitamin D status remained. Failing to identify patients with low vitamin D and correcting it with supplementation places older adults at unnecessary risk, especially of falls, which are associated with a high risk of mortality. In an ageing population with CVD, vitamin D status needs to be assessed and any inadequacy corrected. Whether low vitamin D status prior to cardiac surgery affects post-surgery outcomes, is another issue which deserves future investigation.

Complementary medicine use by people living with HIV in Australia - a national survey.

Little is known about the use of complementary medicines by people living with HIV in Australia since the advent of more effective combination antiretroviral therapy. We conducted an anonymous survey of 1211 adult patients receiving combination antiretroviral therapy from one of eight specialist HIV clinics across Australia, aiming to identify the current patterns of use of ingestible complementary medicines. Data collected included reasons for use, information sources and rates of disclosure of use of complementary medicines to medical practitioners and pharmacists. Ingestible complementary medicine was used by up to 53% of the 1037 patients returning a survey. Complementary medicine was commonly used for general health, to boost immune function and, to a lesser extent, to address co-morbidities. Disclosure of complementary medicines use to doctors was far higher than to pharmacists. Given the potential for interactions, pharmacists should be more aware of patients’ complementary medicines use.

P04.25. Complementary medicine use and potential adverse reactions amongst HIV-positive people

Purpose Relatively little is known about the patterns of complementary medicine (CM) use by HIV-positive people in the last decade, since the introduction of contemporary antiretroviral therapy (ART), or their information requirements. As ART use has evolved, CM use is likely to have also changed over time, however this has yet to be established. This is of relevance to health care providers, partly because of potential risks including drug interactions, but also to understand reasons for use and intended benefits, such as managing antiretroviral therapy (ART) side effects and/or addressing existing disease symptoms. The primary aim of this study is to establish the current patterns of use of CMs by HIV-positive people in Australia. Secondary aims are to identify their main information sources and the prevalence of potential drug interactions and suspected adverse reactions to CMs.