Mapping of host-parasite-microbiome interactions reveals metabolic determinants of tropism and tolerance in Chagas disease.

Chagas disease (CD) is a parasitic disease caused by Trypanosoma cruzi protozoa, presenting with cardiomyopathy, megaesophagus, and/or megacolon. To determine the mechanisms of gastrointestinal (GI) CD tissue tropism, we systematically characterized the spatial localization of infection-induced metabolic and microbiome alterations, in a mouse model of CD. Notably, the impact of the transition between acute and persistent infection differed between tissue sites, with sustained large-scale effects of infection in the esophagus and large intestine, providing a potential mechanism for the tropism of CD within the GI tract. Infection affected acylcarnitine metabolism; carnitine supplementation prevented acute-stage CD mortality without affecting parasite burden by mitigating infection-induced metabolic disturbances and reducing cardiac strain. Overall, results identified a previously-unknown mechanism of disease tolerance in CD, with potential for new therapeutic regimen development. More broadly, results highlight the potential of spatially resolved metabolomics to provide insight into disease pathogenesis and infectious disease drug development.

A study of dysphagia symptoms and esophageal body function in children undergoing anti-reflux surgery.

BACKGROUND: The role of high-resolution esophageal impedance manometry (HRIM) for establishing risk for dysphagia after anti-reflux surgery is unclear. We conducted a prospective study of children with primary gastroesophageal reflux (GER) disease, for whom symptoms of dysphagia were determined pre-operatively and then post-operatively and we examined for features that may predict post-operative dysphagia. METHODS: Thirteen children (aged 6.8-15.5 years) undergoing work-up prior to 360o Nissen fundoplication were included in the study. A dysphagia score assessed symptoms at pre-operative study and post-operatively (mean 1.4 years). A HRIM procedure recorded 5-ml liquid, 5-ml viscous and 2-cm solid boluses. We assessed esophageal motility, esophago-gastric junction (EGJ) morphology, EGJ contractility and pressure-flow variables indicative of bolus distension pressures and bolus clearance pressures. A composite pressure-flow index score was also derived. RESULTS: Pre-operative pressure-flow index was positively correlated with post-operative dysphagia score (viscous bolus r = 0.771, p < 0.005). Of three variables that comprise the pressure-flow index, the ramp pressure measured during bolus clearance was the main driver of the effect seen (viscous bolus r = 0.819, p < 0.005). CONCLUSIONS: In order to mitigate symptoms in relation to anti-reflux surgery, dysphagia symptoms and esophageal function need to be pre-operatively assessed. In patients with normal motility, an elevated pressure-flow index may predict post-operative dysphagia.

Upper Gastrointestinal Function in Morbidly Obese Adolescents Before and 6 Months After Gastric Banding.

BACKGROUND: The effects of laparoscopic adjustable gastric band (LAGB) placement on upper gastrointestinal tract function in obese adolescents are unknown. Therefore, our aim was to determine the short-term effects of LAGB on esophageal motility, gastroesophageal reflux, gastric emptying, appetite-regulatory hormones, and perceptions of post-prandial hunger and fullness. METHODS: This study was part of a prospective cohort study (March 2009-December 2015) in one tertiary referral hospital. The study included obese adolescents (14-18 years) with a body mass index (BMI) > 40 (or ≥ 35 with comorbidities). Gastric emptying was assessed by 13C-octanoic acid breath test, pharyngeal, and esophageal motor function by high-resolution manometry with impedance (HRIM), and appetite and other perceptions using 100-mm visual analogue scales. Dysphagia symptoms were scored using a Dakkak questionnaire. Data were compared pre- and post-LAGB placement and at a 6-month follow-up. RESULTS: Based upon analysis of 15 adolescents, at the 6-month follow-up, LAGB placement: (i) led to a significant reduction in weight and BMI; (ii) increased fullness and decreased hunger post-meal; (iii) increased symptoms of dysphagia after solid food; and, despite these effects, (iv) caused little or no changes to appetite hormones, while (v) effects on gastric emptying, esophageal motility, esophageal bolus transport, and esophageal emptying were not significant. CONCLUSION: In adolescents, LAGB improved BMI and altered the sensitivity to nutrients without significant effects on upper gastrointestinal tract physiology at the 6-month follow-up.

Applying the Chicago Classification criteria of esophageal motility to a pediatric cohort: effects of patient age and size.

BACKGROUND: Applying the 2012 Chicago Classification (CC) of esophageal motility disorders to pediatric patients is problematic as it relies upon adult-derived criteria. As shorter esophageal length and smaller esophago-gastric junction (EGJ) diameter may influence CC metrics, we explored the potential for age- and size-adjustment of diagnostic criteria. METHODS: We evaluated 76 high-resolution solid state impedance-manometry recordings in children referred for manometry (32M; mean age 9 ± 1 years) and 25 recordings from healthy adult subjects (7M; mean age 36 ± 2 years). CC metrics; integrated relaxation pressure (IRP4s, mmHg), contractile front velocity (CFV, cm/s), distal contractile integral (DCI, mmHg cm/s), distal latency (DL, s), and peristaltic break size (BS, cm) were derived for 10 liquid swallows using CC analysis software. Effects of age and size were examined using regression analysis. KEY RESULTS: Younger patient age and shorter size correlated significantly with greater IRP4s (p < 0.05), shorter DL (p < 0.001) and smaller BS (p < 0.05). Standard diagnostic CC criteria were adjusted using the slope of the linear regression equation to define the age/size-related trend. Sixty-six percent of the pediatric cohort showed abnormal motility when applying standard CC criteria. Adjustment for age and size reduced this to 50% and 53% respectively, with the largest reduction being in the IRP4s- and DL-dependent disorders EGJ outflow obstruction and diffuse esophageal spasm (13% to 7% and 5% and 14% to 1 and 5%, respectively). CONCLUSIONS & INFERENCES: CC metrics, particularly IRP4s and DL, are age and size dependent, and therefore, require adjustment to improve accuracy of diagnosis of esophageal motility disorders in children.

Saudi Arabian nurses' experiences of studying Masters degrees in Australia.

AIM: This paper presents findings from a study which explored a group of Saudi Arabian nurses' experiences of studying for a Masters degree in Australia. BACKGROUND: Arab states in the Middle East, Saudi Arabia in particular, have high expatriate nursing populations, and governments in the region have allocated considerable funding to up-skilling their health workforce, often at Western universities. However, there has been little research into the learning experiences of nursing students from Middle East nations. METHODS: A descriptive qualitative study design was used. Middle Eastern students undertaking Masters courses in a School of Nursing and Midwifery at one Australian university were invited to participate in a semi-structured interview. Ten Saudi students participated and data were analysed using content analysis. FINDINGS: Students experienced challenges related to the transition to very different forms of study; to managing relationships and family. They were resourceful, employing strategies to manage multiple demands, including differences in culture, and stressed the significance of strong personal relationships with staff. Students acknowledged being changed, even transformed, by their experience, and saw themselves as future change agents. CONCLUSION: Highly skilled local nursing professionals are being sought in many Middle Eastern countries and may undertake post-graduate studies in Western contexts quite different from their own. Students reported that, in spite of difficulties, their experience prompted transformational change: intellectually, psychologically and developmentally. It is necessary for staff to understand expectations and learning preferences of these students to ensure fruitful learning outcomes and benefits to nursing in their home countries.

An evaluation of a public health nutrition workforce development intervention for the nutrition and dietetics workforce.

BACKGROUND: Workforce development is a key element for building the capacity to effectively address priority population nutrition issues. On-the-job learning and mentoring have been proposed as strategies for practice improvement in public health nutrition; however, there is limited evidence for their effectiveness. METHODS: An evaluation of a mentoring circle workforce development intervention was undertaken. Thirty-two novice public health nutritionists participated in one of three mentoring circles for 2 h, every 6 weeks, over a 7-month period. Pre- and post-intervention qualitative (questionnaire, interview, mentor diary) and quantitative (competence, time working in public health nutrition) data were collected. RESULTS: The novice public health nutritionists explained the intervention facilitated sharing of ideas and strategies and promoted reflective practice. They articulated the important attributes of the mentor in the intervention as having experience in and a passion for public health, facilitating a trusting relationship and providing effective feedback. Participants reported a gain in competency and had an overall mean increase in self-reported competence of 15% (range 3-48% change; P < 0.05) across a broad range of competency elements. Many participants described re-orienting their practice towards population prevention, with quantifiable increases in work time allocated to preventive work post-intervention. CONCLUSIONS: Mentoring supported service re-orientation and competency development in public health nutrition. The nature of the group learning environment and the role and qualities of the mentor were important elements contributing to the interventions effects. Mentoring circles offer a potentially effective strategy for workforce development in nutrition and dietetics.

Impact of Master of Family Medicine degree by distance learning on general practitioners' career options.

INTRODUCTION: This study investigated the impact of a Master of Family Medicine degree (via distance education) on GPs' career options, and in particular, whether they were more likely to adopt university positions after the course. A secondary aim was to examine whether those who undertook a research project as part of their Masters took up different career options than Masters graduates who undertook a more clinically orientated course. METHODS: A questionnaire survey was posted to all 192 graduates of the Master of Family Medicine degree. Approximately one fifth of these resided overseas, with the majority in Hong Kong. RESULTS: The response rate was 68%. Graduates stated that they benefited from the course, particularly in the areas of clinical knowledge and improvement in 'academic' skills. Changes in careers, with increases in non-clinical appointments, did occur after the course for both the Research and Clinical Masters graduates. DISCUSSION: Responses to the survey indicated that graduates benefited in completing the course and changes in their career direction following graduation. However, whether the Masters course provided new skills to enable career change, or the GPs were in the process of change anyway, cannot be determined with certainty. Further studies, including interviews, are required to establish the impact of a distance education higher degree. CONCLUSION: The research output of general practice remains behind that of its specialist colleagues. Higher degrees for GPs might encourage them to undertake more academic pursuits, but the precise relationship still remains uncertain.

The patient perspective survey. Can consultations for complex health problems be enhanced?

BACKGROUND: Patients with complex health problems pose particular difficulties due to the interaction between psychosocial factors and physical disease. The aim of this study is to investigate the usefulness of a paper based instrument (the Patient Perspective Survey, or PPS) to enhance general practitioner-patient communication and patients' self reported coping skills. METHODS: A previously validated questionnaire was modified and distributed to a self selected group of 21 GPs. They recruited 77 patients with complex health problems and asked them to complete a PPS questionnaire. The patients then returned for an extended consultation to discuss the results of the questionnaire with the GP. Patients and GPs subsequently completed PPS evaluation forms. RESULTS: The PPS was useful for patients with chronic conditions with mixed physical and psychological components. It appeared to enhance the GP-patient relationship and gave patients a better understanding of their coping skills. DISCUSSION: Patients with complex health problems can use paper based questionnaires to improve the quality of communication between themselves and their GPs.

A comparative study of venlafaxine with a focused education and psychotherapy program versus venlafaxine alone in the treatment of depression in general practice.

The efficacy of a focused education and psychotherapy program (FEPP) plus antidepressant was compared with that of usual psychosocial treatment and antidepressant in a general practice setting. The FEPP comprised interpersonal counselling (IPC) delivered in a modified way to suit the general practice setting, together with patient education and selected cognitive behavioural techniques. All patients were treated with venlafaxine-XR. Thirty-one patients entered the study, three withdrawing before completion of the 12 week trial. Both treatments produced a statistically significant reduction in BDI and POMS scores from baseline, with greater improvement evident in the FEPP plus antidepressant group. Copyright 2001 John Wiley & Sons, Ltd.

Explaining levels of within-group wage inequality in U.S. labor markets.

Most research on earnings inequality has focused on the growing gap between workers of different races and at different education, age, and income levels, but a large portion of the increasing inequality has actually occurred within these groups. This article focuses on the extent and sources of "within-group" wage inequality in more than 500 labor markets in the United States in 1990. In addition to documenting that within-group wage inequality across regions varies more widely today than over the past several decades, the analysis reveals that two frequently cited explanations of rising wage inequality over time have little impact on within-group wage inequality when measured at the local labor market level: (1) industrial shifts and (2) increased technology and trade. By contrast, flexible and insecure employment conditions (e.g., unemployment, contingent work, and immigration) are associated strongly with high local levels of within-group wage inequality, especially among women.

Distance education. Part 1. Conceptualization and development.

INTRODUCTION: The Graduate Diploma/Masters in Family Medicine were developed at Monash University as distance education courses from a previous on-campus version of a Masters course in response to real and perceived needs for more flexible forms of delivery. METHOD: Conceptualization and development involved consultation with experts in distance education and the application of adult learning principles, phenomenology and constructivism in course design. CONCLUSION: Despite initial difficulties and delays, course objectives were met through the application of standardised distance learning and teaching methods applied to four core and 15 clinical elective subjects. These were developed within a three year period for delivery in a predominantly paper based format.

Distance education. Part 4. Supervision of family medicine research at a distance. A formative evaluation.

INTRODUCTION: A survey on supervision of research projects was undertaken among current general practitioner students, recent graduates and supervisors of a Masters of Family Medicine degree. The aim was to describe and compare the experience of the three groups and, in particular, to identify the problems associated with distance supervision. METHODS: A self-administered questionnaire survey was distributed to current students (n = 21), graduates (n = 16) and current supervisors (n = 7). RESULTS: Forty out of 44 doctors returned completed questionnaires. Distance was a relatively minor barrier to successful supervision, provided that the student and supervisor established good communication patterns and were able to respond to each other with minimal delay. The commencement of the study and its final write-up were critical phases in the supervision process. DISCUSSION: Communication, including emotional and psychological support, was at least as important as expert opinion in helping Masters students to successfully complete their research projects. Attention must be paid to establishing good understanding and regular means of communication at the beginning of the supervisory process.

Distance education. Part 5. Family medicine research at a distance. Guidelines for supervisors.

INTRODUCTION: This paper recommends guidelines for the supervision of Masters degrees or similar postgraduate courses, in which research projects are supervised at a distance. METHODS: The guidelines are based on the experiences of the authors with a five year old Masters of Family Medicine degree and a formative evaluation conducted by questionnaire survey among its students, graduates and supervisors. RESULTS: It is important to establish ground rules for communication at an early point in the supervisory process. Supervisors need to take into account psychosocial, pedagogical and organisational aspects of their mentorship of students. DISCUSSION: These guidelines are relevant to courses where there remains a strong one-to-one relationship between supervisors and students. In these cases, 'distance' need not be a barrier provided that both sides are aware of and committed to maintaining good patterns of communications with each other.

Distance education. Part 3. Assessment of and feedback to students at a distance.

INTRODUCTION: Assessment of students at distance, in a course with over 20 units (subjects), provides special challenges in providing timely, accurate and detailed feedback both formatively and summatively. METHOD: A description of assessment practices including reflective journals, essays, critical appraisal of literature, case studies or teaching presentations in video and written format, clinical audits, and large research projects is provided. The impact of a multitude of criterion-referenced methods of students, teachers and administrative services as well as quality assurance issues are measured. CONCLUSION: Students preferred multiple levels of formative and summative assessment using criterion referencing to exams. These methods were thought to be contextually relevant to clinical practice and examined knowledge, cognition and performance appropriately. Length of assessment task, difficulty with English as a second language and lack of detail or clarity on written feedback posed problems for a number of students. Quality assurance procedures have been put into place to rectify some of these problems.

Distance education. Part 7. Evaluation of the Graduate Diploma of Family Medicine. Does a distance education course for GPs influence their reported clinical and professional practice?

INTRODUCTION: Course evaluation is essential for continuous enhancement of teaching. This evaluation aimed to assess the impact of the Graduate Diploma of Family Medicine on the clinical practices, community activities, learning styles and personal lives of its graduates. METHODS: Cross-sectional postal questionnaire survey of all 1993 to 1997 graduates of the Graduate Diploma in Family Medicine (n = 233). RESULTS: A response rate of 70% was achieved. Male respondents felt that they treated a greater variety of conditions (p = 0.04), had undertaken more procedural work (p = 0.03), and had increased procedural confidence (p = 0.009) compared to female respondents, while the female respondents referred more (p = 0.03). Solo practitioners tended to look for evidence in clinical decision making (p = 0.006) and applied critical appraisal techniques when reading medical information provided by pharmaceutical representatives (p = 0.04). Group practitioners tended to participate in more research projects (other than drug trials) than solo practitioners (p = 0.03). There was a difference between full and part time general practitioners, even after controlling for gender, with the former more certain that general practice is where they wanted to be (p = 0.005), they also felt more competent in interpreting data, e.g. ECGs (p = 0.013). More male students indicated they preferred a reflective learning style than females (p = 0.04). CONCLUSION: The clinical electives of the Graduate Diploma in Family Medicine had the most significant impact on the clinical practices of full time GPs who were predominantly male graduates. Gender differences were apparent in styles of practice as males tended to conduct more procedural work, while female graduates preferred the gatekeeper role and referred more. The course also impacted on the students' approach to evidence in their clinical decision making. They were more critical of medical information provided by pharmaceutical representatives who are one of the major sources of CME for many GPs. Future evaluations should be based on experimental and quasi-experimental designs in order to measure changes in student perceptions and clinical practice, as well as more objective measures of learning styles.

Distance education. Part 6. Evaluation of a core subject within the Graduate Diploma/Masters in Family Medicine. Principles of general practice.

AIM: To evaluate 'Principles of General Practice' (formerly known as the Academic Basis of General Practice), a core unit of the Graduate Diploma/Masters in Family Medicine. METHOD: Content analysis of feedback sheets and transcripts from teleconferences were analysed to facilitate the process evaluation of this core unit. Content analysis of qualitative responses to the question: 'What did you learn?' at the end of the course formed the impact evaluation. RESULTS: GPs who participated in the evaluation of the Principles of General Practice highlighted four learning outcomes in response to the question: 'What did you learn?' Categories included discipline specific and patient specific. Personal and professional outcomes were further divided into the following subcategories: affirmation of current practice; confidence in dealing with uncertainty; engaging in reflective practice; overcoming professional isolation; and providing opportunities for career change. CONCLUSIONS: The most cited reasons for participating in this course were the professional and personal. Students found that the course clarified their roles, raised self-esteem and confidence, and provided them with a sense of pride in their profession. The reflective learning style resulted in students gaining insight into themselves and their therapeutic roles, with reported changes in clinical practice, including more confidence in dealing with uncertainty. In addition to meeting course objectives there were a number of unanticipated outcomes identified. The most surprising was the recognition that general practice was a medical specialty, supported by a body of literature. For some, this assisted them to overcome feelings of professional isolation and alienation. A number of students saw this course as a stimulus to blending their clinical work with a teaching role to enhance professional growth and satisfaction.

Distance education. Part 2. Student characteristics, program characteristics, administration and future direction.

INTRODUCTION: A descriptive analysis of student and program characteristics was undertaken. METHOD: Data were obtained using student enrollment forms, periodic surveys and regular feedback which formed part of the formative evaluation. RESULTS: In the five year period 1992-1996, 433 doctors enrolled in the Graduate Diploma, of which 56 proceeded onto Masters. Of the 433, 60% were male. The mean age of students was 41 years, with rural (49%) and solo (45%) practitioners over-represented; 20% held the FRACGP and 15% resided outside Australia. Around 20% deferred or withdrew during the five year period. Of the 56 Masters enrollments, 16 had completed the degree in minimum time, with a further 30 completing within two years. Reasons for enrollment were largely professional with many students expressing the need to overcome isolation and gain intellectual stimulation. CONCLUSION: This Diploma/Masters course which has a strong clinical component has attracted considerable interest among established general practitioners. The program appears to have succeeded because of its flexible delivery, lack of exclusive research orientation and its firm grounding in general practice.

Preventive health behaviour among general practitioners in Victoria.

UNLABELLED: This study describes the preventive health behaviour of general practitioners in Victoria, with particular emphasis on hepatitis B prevention, and their use of medical services, and seeks to explain these behaviours. METHODS: Cross sectional postal questionnaire survey of a 10% random sample (n = 544) of all GPs in Victoria, Australia. RESULTS: A valid response rate of 58.5% was achieved. Only 4% of the sample smoked, 93% had a blood pressure check in the past 3 years, and 64% had a cholesterol check in the past 3 years. About half followed a 'healthy' diet and 20% took a high level of physical exercise. With regard to hepatitis B prevention, 87% had completed vaccination, and 49% had confirmed immunity. Needlestick injuries had been suffered by 49% in the previous year, and half of the respondents would take no action after such an event. Over two-thirds (69%) reported having no GP. Psychological factors were associated with preventive health behaviour independent of age and gender. Internal locus of control and health value were positively associated with whether the doctor would take any action after needlestick injury, had a blood pressure or cholesterol test in the past 3 years or had their own GP. CONCLUSION: This study shows that GPs in Victoria have a relatively high level of preventive health activity although they have a low level of utilisation of their GP colleagues in service provision. There are measurable differences in psychological variables between doctors that are associated with their level of preventive care. Plans to improve their personal health care should concentrate on psychological well being.

Targeting the right journal.

While research is scientific, publication is a mixture of science and political pragmatism. Targeting the right journal is influenced by the following factors: the discipline that best represents the subject; the purpose of the message; the audience who are to be recipients of the message; the realities of geographic parochialism; the desire of authors to maximise personal and professional opportunities. If the originally targeted journal rejects the article, authors should have alternative publication strategies that give them professional recognition without requiring them to compromise the message or their ethics.

Gastroesophageal reflux and quality of life. Patient's knowledge, attitudes and perceptions.

INTRODUCTION: Gastroesophageal reflux (GER) is one of the most common conditions seen in general practice. The objective of this study was to determine patients' knowledge and attitudes about GER and its effects on their stated quality of life. METHODS: A cross sectional survey using a self administered questionnaire of a random sample of 400 patients, from the principal author's practice in outer western Sydney. RESULTS: GER affected 53% of this sample of patients with Asians and manual workers being overrepresented. In 62% of these, GER was shown to adversely affect quality of life. Most patients in this study (70%) were unaware of the potentially serious complications of GER. CONCLUSION: The prevalence of GER and the impact of the condition on sufferers' quality of life is generally unknown but requires further research. A history of cough and hoarse voice with no known cause, should be investigated for GER. Most patients are unaware of the serious complications of GER and should be educated about these.