Efficacy of brief behavioral counselling by allied health professionals to promote physical activity in people with peripheral arterial disease (BIPP): study protocol for a multi-center randomized controlled trial

Background: Physical activity is recommended for people with peripheral arterial disease (PAD), and can improve walking capacity and quality of life; and reduce pain, requirement for surgery and cardiovascular events. This trial will assess the efficacy of a brief behavioral counselling intervention delivered by allied health professionals to improve physical activity in people with PAD. Methods: This is a multi-center randomised controlled trial in four cities across Australia. Participants (N = 200) will be recruited from specialist vascular clinics, general practitioners and research databases and randomised to either the control or intervention group. Both groups will receive usual medical care, a written PAD management information sheet including advice to walk, and four individualised contacts from a protocol-trained allied health professional over 3 months (weeks 1, 2, 6, 12). The control group will receive four 15-min telephone calls with general discussion about PAD symptoms and health and wellbeing. The intervention group will receive behavioral counselling via two 1-h face-to-face sessions and two 15-min telephone calls. The counselling is based on the 5A framework and will promote interval walking for 3 × 40 min/week. Assessments will be conducted at baseline, and 4, 12 and 24 months by staff blinded to participant allocation.Objectively assessed outcomes include physical activity (primary), sedentary behavior, lower limb body function, walking capacity, cardiorespiratory fitness, event-based claudication index, vascular interventions, clinical events, cardiovascular function, circulating markers, and anthropometric measures. Self-reported outcomes include physical activity and sedentary behavior, walking ability, pain severity, and health-related quality of life. Data will be analysed using an intention-to-treat approach. An economic evaluation will assess whether embedding the intervention into routine care would likely be value for money. A cost-effectiveness analysis will estimate change in cost per change in activity indicators due to the intervention, and a cost-utility analysis will assess change in cost per quality-adjusted life year. A full uncertainty analysis will be undertaken, including a value of information analysis, to evaluate the economic case for further research. Discussion: This trial will evaluate the efficacy and cost-effectiveness of a brief behavioral counselling intervention for a common cardiovascular disease with significant burden. Trial registration: ACTRN 12614000592640 Australian New Zealand Clinical Trials Registry. Registration Date 4 June 2014

Unravelling quality culture in higher education:a realist review

There is a growing belief that higher education institutions should nurture a 'quality culture' in which structural/managerial and cultural/psychological elements act in synergy to continuously improve education. Notwithstanding the positive connotation of the 'quality culture' concept, its exact configuration remains subject to debate. A realist review was conducted to identify inhibiting and promoting organisational context elements impacting quality culture, its working mechanisms and associated outcomes. Leadership and communication were identified as being of key importance in binding structural/managerial and cultural/psychological elements. Leaders are central 'drivers' of quality culture development through their ability to influence resource allocation, clarify roles and responsibilities, create partnerships and optimise people and process management. Adequate communication is considered a prerequisite to diffuse quality strategies and policies, evaluate results and identify staff values and beliefs. It is proposed that the working mechanisms of quality culture comprise increased staff commitment, shared ownership, empowerment and knowledge. Associated outcomes related to these mechanisms are positive effects on staff and student satisfaction, continuous improvement of the teaching-learning process and student and teacher learning and development. Institutions striving for the development of a quality culture should best operate from a contingency approach, i.e. make use of quality management intervention approaches which are tailored to the organisational context

Reinforcing pillars for quality culture development: a path analytic model

To this date, research on the interplay between organisational structure/managerial and organisational value/psychological elements which impact on educational quality is scarce and fragmented. As a consequence of a lack of knowledge in this area, institutions often address these elements in isolation, moving past integral approaches, which reinforce the organisations' quality culture. In order to examine interrelationships between context characteristics, work-related psychological attitudes of staff and enhancement practices, a path analysis was performed on data collected from academics with teaching coordination roles. The findings highlight the paramount importance of a 'human relation' value orientation; this orientation influences empowerment, commitment and communication satisfaction. Rational goal values and ownership are positively related to quality enhancement practices. It is advocated that institutional policies and strategies directed at educational quality enhancement should leave discretionary space for the availing of academics' expertise. Nurturing collaborative teaching/learning communities with explicit concern for morale, involvement and development, deserves further cultivation.</p

Q fever (Coxiella burnetii) causing an infected thoracoabdominal aortic aneurysm

We report a patient, which we believe is the first, with a thoracoabdominal aortic aneurysm, Crawford type IV, caused by Q fever (Coxiella burnetii). Treatment consisted of antibiotic therapy started preoperatively and continued postoperatively and an open repair, including resection of the infected aneurysm, replacement with a rifampin-soaked polyester graft, and an omental wrap covering the grafts. After 13 months of follow-up, the patient had no signs of infection, and results of laboratory findings were normal

Applicability of the ankle-brachial-index measurement as screening device for high cardiovascular risk: an observational study

BACKGROUND: Screening with ankle-brachial index (ABI) measurement could be clinically relevant to avoid cardiovascular events in subjects with asymptomatic atherosclerosis. To assess the practical impact of guidelines regarding the use of ABI as a screening tool in general practice, the corresponding number needed to screen, including the required time investment, and the feasibility of ABI performance, was assessed. METHODS: An observational study was performed in the setting of 955 general practices in the Netherlands. Overall, 13,038 subjects of ≥55 years presenting with symptoms of intermittent claudication and/or presenting with ≥ one vascular risk factor were included. Several guidelines recommend the ABI as an additional measurement in selected populations for risk assessment for cardiovascular morbidity. RESULTS: Screening of the overall population of ≥50 years results in ≈862 subjects per general practice who should be screened, resulting in a time-requirement of approximately 6 weeks of full time work. Using an existing clinical prediction model, 247 patients per general practice should be screened for PAD by ABI measurement. CONCLUSION: Screening the entire population of ≥50 years will in our opinion not be feasible in general practice. A more rationale and efficient approach might be screening of subsets of the population of ≥55 years based on a clinical prediction model

A clinical prediction model for the presence of peripheral arterial disease - the benefit of screening individuals before initiation of measurement of the ankle-brachial index: an observational study

Measurement of the ankle-brachial index (ABI) can provide important information about the presence of subclinical atherosclerosis. Performing the ABI in the overall population is not feasible, but it can be used in a selected population. A simple prediction rule could be of much use to estimate the risk of an abnormal ABI. This was designed as an observational study in the setting of 955 general practices in The Netherlands. A total of 7454 patients aged >= 55 years presenting with at least one vascular risk factor (smoking, hypertension, diabetes, and hypercholesterolemia) and no complaints of intermittent claudication were included. Patients were selected by the general practitioner during visiting hours and from medical records. Main outcome measures included the prevalence of PAD, defined as an ABI below 0.9, which was related to vascular risk factors using regression analyses on which the PREVALENT clinical prediction model was developed. The overall prevalence of PAD was 18.4%. Since the treatment of individuals with a history of coronary heart disease and cerebrovascular disease will not be influenced by the finding of asymptomatic PAD, these individuals were not taken into account for the development of the clinical prediction model. Analyses showed a significantly increased risk for PAD with increasing age, smoking, and hypertension. The clinical prediction model giving risk factor points per factor (age: 1 point per 5 years starting at 55 years; ever smoked: 2 points; currently smoking: 7 points; and hypertension: 3 points), showed a proportional increase of the PAD prevalence with each increasing risk profile (range: 7.0-40.6%). In conclusion, based on the PREVALENT clinical prediction model, the general practitioner is able to identify a high-risk population in which measurement of ABI is usefu