Flying Doctor clinic to close in Tennant Creek - ABC Rural (Australian Broadcasting Corporation)

Flying Doctor clinic to close in Tennant Creek - ABC Rural (Australian Broadcasting Corporation)

Title: Baby shower supplies online

Summary: A new website dedicated to baby products has been launched for online shoppers who used to buy from reliable e-commerce websites. This website provides fascinating baby shower supplies online at affordable prices and is christened as “outbackBabyShop”. Easy accessibility and convenience is all the e-commerce buyer needs, the website has been designed by keeping this in mind. Those in need of baby shower shopping will definitely appreciate the convenience.

Content: A new website dedicated to baby products has been launched for online shoppers who used to buy from reliable e-commerce websites. This website provides fascinating baby shower supplies online at affordable prices and is christened as “outbackBabyShop”. Easy accessibility and convenience is all the e-commerce buyer needs, the website has been designed by keeping this in mind. Those in need of baby shower shopping will definitely appreciate the convenience.

Products are categorized on the home page with separate menus for those who want to check out specific items. The site has showcased the wide range of products from the trusted brands.  What you need to do to purchase product from this site:

1)      Visit the store and

2)      Choose your products

3)      Add your favorite items to cart.

4)      Make final payment.

That’s it; soon the product will be delivered at your door step. Especially for busy people and for those with no clue of what to buy, baby shower shopping offers great ideas as well. The website is designed in such a way that an individual need not to get confuse of what to do next. The website is integrated with Amazon to showcase their products and use amazons’ payment gateway, on which user can easily trust. On Amazon various payment modes are available to choose including Credit cards. You can anytime visit the site and buy baby shower supplies online of your choice.

Product category includes:

1)      Baby Essential Products such as Baby Bedding Products , Baby Bathing & Skin Care Products, Baby Feeding Supplies , Baby Potty Training and many more.

2)      Best Baby Brands like Old Varsity Brand, '47 Brand, Chicco, Gerber, Graco, Maclaren, Sassy, Sealy and many more.

3)      Extensive range of baby shower themes, which includes invitations, decorations, gifts, games etc.

4)      Other Baby products such as Bathing & Skin Care Products , Baby Toys and gifts, Baby bedding products, Baby Furniture, Maternity & New Baby products, Baby Health & Care Products , Baby Home Safety, Car seats and many more such products.

Resource Box: In short this site will make you feel homely with providing all the essential <a href="http://www.outbackbabyshop.com/baby_shower.html">baby shower supplies online</a> for your baby at your doorstep. The grand benefit of online <a href="http://www.outbackbabyshop.com/best_baby_brand">baby shower shopping</a> is the wide range of products you can choose from and the ideas you can get.

Keywords:baby shower shopping,baby shower supplies online

Title: Should You Buy Baby Shower Supplies Online?

Title: Should You Buy Baby Shower Supplies Online?

Summary: If you have to deal with the stress of planning a baby shower and hosting it, then you need to think about what decisions you could take in order to make sure that everything is going to turn out just fine. One of the best things that you could do is to do the baby shower shopping online because it is an option that has many advantages. When looking for baby shower supplies online, you can do so in five minutes or in five hours as no one will be rushing you to get out of the store.

Content: If you have to deal with the stress of planning a baby shower and hosting it, then you need to think about what decisions you could take in order to make sure that everything is going to turn out just fine. One of the best things that you could do is to do the baby shower shopping online because it is an option that has many advantages. When looking for baby shower supplies online, you can do so in five minutes or in five hours as no one will be rushing you to get out of the store.

Being online, you can look at all the items that you want and need without worrying that the shop has a closing time or that you need to stay in line. It is stressful enough to do the planning for a soon to be mom, you do not need to run from one shop to another. You should look for baby shower supplies online because you do not need to put in too much effort in this type of shopping. Baby shower shopping online is something that only needs you to know the products that you need and to make a few clicks.

You can read descriptions of the items that you are interested in and you can even sign up for a newsletter and special offers so that when something that you need for the baby shower is at a discounted price, you can buy it right away. This is a fantastic way of staying within your budget and buying necessary products for the baby shower. Also, if you need a specific baby product, you can be sure of the fact that you can find it online.

Resource box:

Doing the <a href="http://www.outbackbabyshop.com/">baby shower shopping online</a> is the best decision that you can make when you need to plan a baby shower. Buying <a href="http://www.outbackbabyshop.com/baby_shower.html">baby shower supplies online</a> will bring you more advantages than you can imagine!

Keywords:baby shower supplies online,baby shower shopping online

www.outbackbabyshop.com

Review 1- http://www.outbackbabyshop.com/

Title: Baby shop online

Review: When one of your best friends is about to be a mother, the right thing to do is throw her a baby shower. The problem here is the fact that planning such a party will require you to do a lot of things that include inviting guests, ordering a cake, setting up for the party and looking for the right place from where you can order the baby shower items that you need. The best thing that you can do is to order every single thing that you need from a Baby shop online due to the fact that you can make the order in a matter of minutes and get the products that you need for the baby shower in a few days. This means that regardless of the fact that you have had enough time to plan the party or not, it can be a great success. Instead of wasting time looking for the bay shower products that you need in local stores, get the best offers from a Baby shop online.

Joy of baby shower shopping

Title: Joy of baby shower shopping

www.outbackbabyshop.com 

Summary: Do you know what is my favorite event to attend? It’s Baby Shower. The attractive things about it are: full of love and joy, you get to look at sweet baby clothes, amazing baby shower gifts and many more. I think it's really special to celebrate this awesome occasion for every new little one. My days as mother were not much easier as I used to purchase from the local stores for all the essential products for my baby. Online purchasing has made it so simple; just a few clicks and product will be at your doorstep. A baby shop online is at everyone’s fingertips. It surely makes baby shower shopping a lot easier.

Content: Do you know what is my favorite event to attend? It’s Baby Shower. The attractive things about it are: full of love and joy, you get to look at sweet baby clothes, amazing baby shower gifts and many more. I think it's really special to celebrate this awesome occasion for every new little one. My days as mother were not much easier as I used to purchase from the local stores for all the essential products for my baby. Online purchasing has made it so simple; just a few clicks and product will be at your doorstep. A baby shop online is at everyone’s fingertips. It surely makes baby shower shopping a lot easier.

I really enjoy picking hose gifts that I think the mother will enjoy or something that has made my days as a mother more interesting. You can make something for the new baby at your own too.The best part is that you can get inspired from a baby shop online. There are various simple and quick ideas to create your own gifts for mom and baby, regardless of the sex and shower’s theme. If you are not a big fan of baby shower shopping, here is couple of handmade ideas:

A Basket of Essential Baby Products

Choose a large, hollow item to fill with little things, it may be of plastic or any other hard material but wooden item will give the best feel. They are usually inexpensive and work very nicely. For carrying baby’s small bath items you can choose bathroom bucket/caddy. Skin care products and bathing products can be purchased from a baby shop online.

Choosing bath items are always easiest thing to do. It could be a very exciting baby shower shopping experience. Remember look out only for branded products. Here are some examples:

Soap

Lotion

Towels

Wash cloths

Brush

Comb

And many more such items. Some people prefer the health and safety related products for this gift. Here are some other gift items you can choose:

Diapers

Toys

Baby Books

Nursing Pads

Bottles

Bibs

You can also find some nice, baby toys online. A baby shop online provides toys for each chapter in a baby’s life. You can always use a fancy party bag instead of bucket or wooden item. To make your gift more fancy and beautiful, gift wrap individual item, it will take time but will give a different look. You can decorate it with thermocol balls and shiny papers.

Diaper Cake

This product will require little bit of talent, but after creating it one or two times it shouldn't be too difficult! As a result of all this work you will get a delightful looking "cake" made of diapers and toys.

Items you will need:

Diapers (a large pack)

Cardboard

Small gifts such as toys, brushes etc.

Transparent Tape

Rubber bands and Ribbons

A small stuff toy as a cake topper.

Procedure to make a diaper cake:

Use the cardboard as a base

Wrap diapers around cardboard to form the bottom of the cake.

Use transparent tape or rubber bands to keep the base intact.

Now start second layer. Make sure that this will be smaller than the first layer.

In this similar fashion you can create as many layers you need.

Now take your small gifts and tie them with ribbon and fix them into the layers. Gifts should look like part of the cake. Keep the small stuff toy as a cake topper. Now your diaper cake is ready to keep as a center piece at your baby’s shower.

Resource Box: If you have been invited to a baby shower, don’t forget to buy a lovely gift from a <a href="http://www.outbackbabyshop.com/">baby shop online</a>. In fact, <ahref="http://www.outbackbabyshop.com/best_baby_brand">baby shower shopping</a> could turn out to be more interesting than you thought.

Henry Lawson - famous Australian poet

A Mate can do no Wrong

We learnt the creed at Hungerford,

We learnt the creed at Bourke;

We learnt it in the good times

And learnt it out of work.

We learnt it by the harbour-side

And on the billabong:

'No matter what a mate may do,

A mate can do no wrong!' 

He’s like a king in this respect

(No matter what they do),

And, king-like, shares in storm and shine

The Throne of Life with you.

We learnt it when we were in gaol 

And put it in a song:

' No matter what a mate may do,

A mate can do no wrong!'

They’ll say he said a bitter word

When he’s away or dead.

We’re loyal to his memory,

No matter what he said.

And we should never hesitate,

But strike out good and strong,

And jolt the slanderer on the jaw –

A mate can do no wrong ! 

Henry Lawson

copper wire

After having dug to a depth of 10 feet last year, British scientists found traces of copper wire dating back 200 years and came to the conclusion that their ancestors already had a telephone network more than 150 years ago.  

Not to be outdone by the British, in the weeks that followed, an American archaeologist dug to a depth of 20 feet, and shortly after, a story published in the New York Times: "American archaeologists, finding traces of 250-year-old copper wire, have concluded that their ancestors already had an advanced high-tech communications network 50 years earlier than the British".  

One week later, Australia 's Northern Territory Times reported the following: "After digging as deep as 30 feet in his backyard in Tennant Creek , Northern Territory , Knackers Johnson, a self-taught archaeologist, reported that he found absolutely bugger-all. Knackers has therefore concluded that 250 years ago, Australia had already gone wireless."
  ...Makes ya feel bloody proud to be Australian!

EARTHQUAKE!!!!

Tennant Creek, NT.
Magnitude: 4.2 (ML)
Depth: 10 km
Tsunamigenic: Not available

Date and Time
UTC: 18 July 2013 @ 11:39:11
Sydney Time: 18 July 2013 @ 21:39:11 (AEST)

Location
Coordinates: -19.821, 133.885

Solution status
Last updated: 19 July 2013 @ 09:21:54 (AEST)
Solution finalised: Yes
Source: AUST

Was just going to bed, when suddenly the whole room shook, the bed bounced, the walls vibrated!. It lasted for about 40 secs, fortunatly there was no damage.
An interesting experience, but I would not want to go through a bigger one thats for sure.

An Earthquake also hit New Zealand this morning - no reports of dameage yet, lets hope they dont have any after shocks !!

funny aussie sayings

• By way of personal instinct, I have an inherent distaste for grandiose rhetorical statements, which don’t have any substantive dimension to them – Kevin Rudd prime minister
• Some mistakes are too much fun to only make once – anon
• A truly happy person is one who can enjoy the scenery on a detour – anon
• Before you criticise someone, you should walk a mile in their shoes. That way, when you criticise them, you’re a mile away and have their shoes – anon
• Never complain, never explain personal motto of Kerry Packer – billionaire
• A determined soul will do more with a rusty monkey wrench than a loafer will accomplish with all the tools in a machine shop Robert Hughes – art critic and author
• Winning needs no explanation, losing has no alibi Greg Baum – journalist
• The bigger the hat, the smaller the property – Australian proverb
• A champion team will always beat a team of champions – Early Collingwood Magpies teams
• Unless you’re willing to have a go, fail miserably, and have another go, success won’t happen Phillip Adams – Left-wing journalist
• All our best heroes are losers Richard Glover – radio presenter
• Always back the horse named self-interest, son. It’ll be the only one trying – Jack Lang – Labor premier
• As a work of art, it reminds me of a long conversation between two drunks – Clive James
• I’ve never seen anyone rehabilitated by punishment Henry Lawson – poet
• The true Aussie battler and his wife thrust doggedly onwards: starting again, failing again, implacably thrusting towards success. For success, even if it is only the success of knowing that one has tried to the utmost and never surrendered, is the target of every battler Michael Page & Robert Inapen – authors
• It’s dead easy to die; it’s the keeping on living that’s hard – Douglas Mawson – Scientist and polar survivor

Study designs and research

For each scenario below identify 1) the ideal study design, 2) other potential study designs and 3) the advantages and disadvantages of the nominated study designs.

a) A dietician is interested in identifying the risk factors present in infancy associated with obesity in primary school aged children. 

The ideal study design to answer this question is?

Cohort study, this type of study will look at the associations between the risk factors

and the outcome of interest.  The defined population (infants), that have not yet

experienced the outcome and who have a known or measurable exposure to a

potential risk factor.  The population is observed overtime and there subsequent

outcomes identified (obesity in primary school aged children).

(Doust & Sanders, 2005)

Other potential study designs to answer this question are? 

Case controlled study. This type of study looks at a population with and without a

certain disease or problem (Obesity in primary school aged children) and looks back

to see what they were exposed to (risk factors in infancy that contributed to obesity in

primary school)  (Doust & Sanders, 2005).

What are the advantages and disadvantages of the different study designs to

answer this question?

 The advantages of a cohort study include they are ethically less challenging than

randomised controlled trials (RCT’s), they can sometimes be cheaper and easier than

a RCT, eligibility and outcome criteria can be standardised and the author can

establish the timing between factor and event.  The disadvantages include potential for

losses to follow-up, large sample sizes and long follow-up is needed, there is no

randomisation so there is an increased potential for confounding and selection bias. 

In this case a long follow up is needed with close monitoring of the child’s lifestyle. 

(Doust & Sanders, 2005).

The advantages of case controlled studies are they are reasonably fast and cheap, they

are the only feasible method for very rare disorders, or those with long lags between

exposure and outcome.  The disadvantages include having to rely on recall or records

to determine exposure status, this may lead to measurement bias and inevitable

confounding.   The control group selection can be difficult and may lead to selection

bias.  In this case it may be reasonably fast and cheap to question the parents of obese

primary school children but the authors of the study will have to rely on the parents

memories, as well as the risk of the parents changing some of their answers if they

think it will make them look better (confounding as participants not blinded).  (Doust

& Sanders, 2005).

           

b) The health department is considering the usefulness of needle exchange programs for preventing transmission of blood borne diseases among intravenous drug users. 

The ideal study design to answer this question is?

Randomised Controlled Trials, (RCT’s) because the health department wants to find if

the intervention of a needle exchange programme will be effective in preventing the

transmission of blood borne disease among IV drug users an RCT will be able to

assess the effectiveness of therapy or prevention, it is the only study that can

adequately minimise confounding and therefore validly estimate the effectiveness of

an intervention (Doust & Sanders, 2005).

Other potential study designs to answer this question are? 

Cohort Study, this type of study will look at the associations between the risk factors

and the outcome of interest.  The defined population (IV drug users) that have not yet

experienced the outcome and who have a known or measurable exposure to a

potential risk factor (blood borne diseases).  The population is observed overtime and

there subsequent outcomes identified (did the needle exchange programme reduce the

transmission of blood borne diseases).  Another study design for this question is a

case controlled study. This type of study looks at a population with and without a

certain disease or problem and looks back to see what they were exposed to.  In this

case did the population using the needle exchange programme have a lower incidence

of blood borne diseases than those who were not involved in the programme? (Doust

& Sanders, 2005).

What are the advantages and disadvantages of the different study designs to answer this question?

The advantages of randomised controlled trials (RCT’s) include successful blinding of

subject and/or the investigator if possible, randomisation facilitates unbiased

distribution of confounders.  Eligibility and outcome criteria can be standardised and

the authors are able to establish the timing between cause and effect.  The

disadvantages of RCT’s is they can be ethically problematic at times, RCT’s can be

expensive both in time and place, it can be difficult to enrol a large enough sample,

generalisablity may be limited due to strict eligibility criteria, there is potential for

loses to follow-up which threatens the validity of the study results.  In this case it may

be difficult to keep track of a large group of IV drug users, due to movement, jail,

death and difficultly in obtaining consent, however due to the lack of confounders the

establishment of timing between the cause and effect this study is a good way to see if

needle exchange programmes are an effective intervention (Doust & Sanders, 2005).

The advantages of a cohort study include they are ethically less challenging than

randomised controlled trials (RCT’s), they can sometimes be cheaper and easier than

a RCT, eligibility and outcome criteria can be standardised, the author can establish

the timing between factor and event.  The disadvantages include potential for losses to

follow-up, large sample sizes and long follow-up is needed, there is no randomisation

so there is an increased potential for confounding and selection bias.  May be difficult

to follow-up due to movement, death, imprisonment, lack of interest by participants. 

(Doust & Sanders, 2005).

The advantages of case controlled studies are they are reasonably fast and cheap; they

are the only feasible method for very rare disorders, or those with long lag between

exposure and outcome.  The disadvantages include having to rely on recall or records

to determine exposure status may lead to measurement bias, inevitable confounding,

and the control group selection can be difficult and may lead to selection bias. This

may be quite difficult due to the unreliability of most drug users in terms of memory

(Doust & Sanders, 2005).

c) A woman whose partner has been hospitalised with influenza is prescribed an antiviral and is advised to take it prophylactically.  The drug (a neuraminidase inhibitor) is expensive and she wonders how effective it is at preventing influenza. 

The ideal study design to answer this question is?

RCT’s.  In this type of study the purpose of randomisation is to evenly distribute the

individual characteristics or variables (confounding factors) making both groups as

similar as possible, if one group was sicker than the other at the start of the study it

might make one treatment look better or worse when in reality there is no real

difference between the treatments.  A RCT is able to give the best evidence for the

effectiveness of a therapy or in this case the antiviral prescribed above (Doust &

Sanders, 2005).

Other potential study designs to answer this question are?

Cohort Study, this type of study will look at the associations between the risk factors

and the outcome of interest.  The defined population that have not yet experienced the

outcome and who have a known or measurable exposure to a potential risk factor. 

The population is observed overtime and there subsequent outcomes identified (did

the antiviral reduce the incidence of influenza?).  Another study design for this

question is a case controlled study. This type of study looks at a population with and

without a certain disease or problem and looks back to see what they were exposed to

(Doust & Sanders, 2005).

What are the advantages and disadvantages of the different study designs to answer this question?

The advantages of randomised controlled trials (RCT’s) include successful blinding of

subject and/or the investigator if possible, randomisation facilitates unbiased

distribution of confounders, eligibility and outcome criteria can be standardised and

the authors are able to establish the timing between cause and effect.  The

disadvantages of RCT’s is they can be ethically problematic at times, RCT’s can be

expensive both in time and place, it can be difficult to enrol a large enough sample,

generalisablity may be limited due to strict eligibility criteria, there is potential for

loses to follow-up which threatens the validity of the study results (Doust & Sanders,

2005).

The advantages of a cohort study include they are ethically less challenging than

randomised controlled trials (RCT’s), they can sometimes be cheaper and easier than

a RCT, eligibility and outcome criteria can be standardised, the author can establish

the timing between factor and event.  The disadvantages include potential for losses to

follow-up, large sample sizes and long follow-up is needed, there is no randomisation

so there is an increased potential for confounding and selection bias (Doust &

Sanders, 2005).

The advantages of case controlled studies are they are reasonably fast and cheap; they

are the only feasible method for very rare disorders, or those with long lag between

exposure and outcome.  The disadvantages include having to rely on recall or records

to determine exposure status may lead to measurement bias, inevitable confounding,

and the control group selection can be difficult and may lead to selection bias (Doust

& Sanders, 2005).

d) A child health nurse is pregnant with her second child and has maternal hypothyroidism (an under active thyroid).  She has heard that this can have an affect on her child’s development and wonders what the available evidence suggests. 

The ideal study design to answer this question is?

Cohort study, this type of study will look at the associations between the risk factors

and the outcome of interest.  The defined population that have not yet experienced the

outcome and who have a known or measurable exposure to a potential risk factor

(Doust & Sanders, 2005).

Other potential study designs to answer this question are?

 Case- Control study, this type of study looks at a population with and without a

certain disease or problem and looks back to see what they were exposed to (Doust &

Sanders, 2005).

What are the advantages and disadvantages of the different study designs to answer this question?

The advantages of a cohort study include they are ethically less challenging than

randomised controlled trials (RCT’s), they can sometimes be cheaper and easier than

a RCT, eligibility and outcome criteria can be standardised and the author can

establish the timing between factor and event.  The disadvantages include potential for

losses to follow-up, large sample sizes and long follow-up is needed, there is no

randomisation so there is an increased potential for confounding and selection bias

(Doust & Sanders, 2005).

The advantages of case controlled studies are they are reasonably fast and cheap; they

are the only feasible method for very rare disorders, or those with long lag between

exposure and outcome.  The disadvantages include having to rely on recall or records

to determine exposure status may lead to measurement bias, inevitable confounding,

and the control group selection can be difficult and may lead to selection bias (Doust

& Sanders, 2005).

e) A GP is wondering whether waist circumference is a useful measure for identifying patients who need weight management programs.

The ideal study design to answer this question is?

Cross-sectional study, a cross-sectional measures both factors of interest and

outcomes at one point in time (Doust & Sanders, 2005).

Other potential study designs to answer this question are?

 Case-control study this type of study looks at a population with and without a certain

disease or problem and looks back to see what they were exposed to  (Doust &

Sanders, 2005).

What are the advantages and disadvantages of the different study designs to answer this question?

The advantages of a cross sectional study include they are relatively fast and cheap,

the authors can collect accurate baseline data, may be able to suggest an association

between exposure and outcome.  The disadvantages include the group sizes will be

unequal in a ‘free living’ population, confounders will be unequally distributed, the

study does not readily establish causality (Doust & Sanders, 2005).

The advantages of case controlled studies are they are reasonably fast and cheap; they

are the only feasible method for very rare disorders, or those with long lag between

exposure and outcome.  The disadvantages include having to rely on recall or records

to determine exposure status may lead to measurement bias, inevitable confounding,

and the control group selection can be difficult and may lead to selection bias  (Doust

& Sanders, 2005).

Consider each study excerpt below and identify the study design (2 marks for each question).

a) Excerpt 1

Method: Subjects were 39 adolescents who stutter, between ages 13 and 18 years (mean AGE=14.4 years), and 39 adolescents who did not stutter (mean AGE=14.6 years), all of whom were currently enrolled in school.  Control subjects were recruited from local school districts and matched for same grade, ethnicity, gender, and approximate age. Information about the demographic characteristics of the subjects and the onset, duration, perceptions, and chronicity of stuttering were obtained. Information was also collected about familial history of stuttering, types and duration of treatment, and concomitant speech, language, or associated problems. Significantly higher levels of communication apprehension and poorer scores on self-perceived communication competence were found in adolescents who stutter when compared with adolescents who do not stutter. Subscore test data revealed that adolescents who stutter had significantly greater fears about speaking in Group Discussions and Interpersonal Conversations than they had about Public Speaking and talking during Meetings, when compared with students who do not stutter. They also had significantly poorer perceptions about their own communication competence on the Talking to Strangers subscore test when compared with students who do not stutter. A significant positive relationship among stuttering severity, communication apprehension, and self-perceived communication competence total scores was found. Students who stutter severely had greater fears about speaking in group discussions and interpersonal conversations.

This is a case controlled study because the authors gathered subjects (not randomly)

who stutter and matched them to a control case (no stuttering).  The authors then

looked back at exposure to see what the outcome of stuttering had on people (Doust &

Sanders, 2005).

b) Excerpt 2

SUBJECTS: Twenty-seven people with 42 chronic leg ulcers participated in the study. METHODS: The subjects were separated into subgroups according to primary etiology of the wound (diabetes, arterial insufficiency, venous insufficiency) and then randomly assigned to receive either HVPC (100 microseconds, 150 V, 100 Hz) or a sham treatment for 45 minutes, 3 times weekly, for 4 weeks. Wound surface area and wound appearance were assessed during an initial examination, following a 1- to 2-week period during which subjects received only conventional wound therapy, after 4 weeks of sham or HVPC treatment, and at 1 month following treatments.

This study is a Randomised controlled study, as the patients were randomly assigned

to a treatment (Doust & Sanders, 2005).

c) Excerpt 3

METHOD: The authors reviewed the charts of 59 female patients with anorexia nervosa who were transferred from 24-hour inpatient care to an eating disorder day hospital program. They evaluated the prognostic significance of a variety of anthropometric, demographic, illness history, and psychometric measures. RESULTS: Greater risk of day hospital program treatment failure and inpatient readmission was associated with longer duration of illness (for patients who had been ill for more than 6 years, risk ratio = 2.7), amenorrhea (for patients who had this symptom for more than 2.5 years, risk ratio = 5.7), or lower body mass index at the time of inpatient admission (for patients with a body mass index of 16.5 or less, risk ratio = 9.6; for those with a body mass index 75% or less than normal, risk ratio = 7.2) or at the time of transition to the day hospital program (for patients with a body mass index of 19 or less, risk ratio = 3.9; for those with a body mass index 90% or less than normal, risk ratio = 11.7). CONCLUSIONS: Inpatients with anorexia nervosa who have the poor prognostic indicators found in this study are in need of continued inpatient care to avoid immediate relapse and higher cost and longer duration of treatment.

Cross-sectional study because the authors measured both the factors of interest

and the outcomes at the same time (Doust & Sanders, 2005).

d) Excerpt 4

An advertisement for an over the counter product has data of the effect of the oil on the appearance of scars.  Please go to the following website and determine what type of study this is: "http://www.bio-oil.info/australia/user_trials.php"

This is a Cohort study because the identified population was observed over a period of

time to see what the effects of the exposure (Bio-oil) had on the appearance of scars

(Doust & Sanders, 2005, http://www.bio-oil.info/australia/users_trials.php)

Consider the questions below.  What evidence source/s would you look in first?  (Assume, for the purposes of this assignment, that you have access to all the evidence sources discussed in the course material). (5 marks for each question)

a) In an outpatient setting, what is the accuracy of a brief screening instrument that uses self-report for detecting migraine headaches?

The best study design would be cross sectional or cohort.  Synopses would be a great

place to start; a synopsis contains the minimum information needed to make a clinical

decision without having to access the full article. The Cochrane library uses DARE

which has access to nearly 3000 systematic reviews.  Other evidence-based medical

and nursing resources are a good place to look such as Cinahl or online journals such

as evidence based nursing available through the UQ Cybrary.  If the question cannot

be answered this way the next place to look is syntheses, they collate, appraise and

summarise the available primary studies to answer a specific question.  A great

resource for these is the Cochrane Database of systematic Reviews as well as DARE

in the Cochrane library.  If still unable to find the answer to the question the next step

is to access the primary research study, this can be done through search engines such

as PubMed, Medline either Webspires or Ovid, Central (Cochrane library) or the

internet. (Doust & Sanders, 2005; http://www.thecochranelibrary.com.au,

www.thecochranelibrary.com.au)

b) Among adults with an acute sore throat, how effective are antibiotics at reducing symptoms?

A systematic review of randomised trials is the best place to start this can be done

through the Cochrane Library; other research sources include Clinical Evidence,

available through UQ Cybrary and Bandolier and Up To Date, available through the

Internet.  Because this is a relatively new system not every question may be answered

this way.  If this is the case Synopsis (They contain the minimum information needed

to make a clinical decision) is the next best place to look they can be found in online

evidence based journals available through UQ Cybrary or DARE in the Cochrane

Library.   If the question still cannot be answered this way the next place to look is

syntheses, they collate, appraise and summarise the available primary studies to

answer a specific question.  A great resource for these is the Cochrane Database of

Systematic Reviews as well as DARE in the Cochrane library.  If still unable to find

the answer to the question the next step is to access the primary research study, this

can be done through search engines such as PubMed, Medline either Webspires or

Ovid, Central (Cochrane library) or the Internet. (Doust & Sanders, 2005).

Conduct a search in the Cochrane Library for evidence to answer the following questions.  Report the exact search terms used and present the reference of the best study to answer each question.

a) What effect does attendance at childcare during infancy and early childhood have on a child’s performance and behaviour at school? 

As this question type is ‘prognosis’ the best type of study to answer this question is a

Systematic review of cohort studies, this can be done by accessing the Cochrane

library of systematic reviews (systematic reviews locate and evaluate all available

evidence).  The first step is to look at the question using the PICO formula: P = early

childhood, I = attendance at childcare, C = no attendance at childcare, O = child’s

behaviour and performance at school.  After accessing The Cochrane library, click on

Cochrane advanced search, this brings up a list of all the search types you can conduct

on Cochrane including, DARE (abstracts of systematic reviews), Central (abstracts of

trials) and Cochrane systematic reviews.  Click on Cochrane Systematic Reviews to

limit the search to this section of the library. In the first search box type in ‘early

childhood’ ensuring ‘search all text’ is marked next to it, in the second search box

ensuring ‘AND’ was marked not ‘OR’ or ‘NOT’ type in ‘child care attendance’

ensuring ‘search all text’ is marked and not ‘author’ etcetera, in the third search box

once again ensuring ‘AND’ and ‘search all text’ is marked type in performance and

behaviour and clicked on search.  11 articles appeared such as ‘thioridazine for

schizophrenia’, ‘screening children in the first four years of life to undergo early

treatment for otitis media with effusion’ and ‘male circumcision for prevention of

heterosexual acquisition of HIV in men’.  There was one article called ‘Day care for

pre-school children’ (Zoritch B, Roberts I, Oakley A. Day care for pre-school

children. The Cochrane Database of Systematic Reviews 2000, issue 3. Art. No.:

CD000564.DOI:10.1002/14651858.CD000564) that answered the above question. It

is a systematic review conducted to assess the effects of day-care on children and

families.  The results of the review show that children who attend day care have better

behaviour when older than those children who didn’t.  There is even evidence to

suggest that children who attend day-care are less likely to develop criminal

behaviour in later years.  The review also discusses other advantages and

disadvantages of sending children to day care.  Interestingly when ‘attendance at

childcare’ ‘AND’ ‘early child care’ ‘AND’ ‘performance and behaviour at school’

was typed into the search boxes no articles appeared in the results list.    (Doust &

sanders, 2005; http://www.thecochranelibrary.com.au, 

www.thecochranelibrary.com.au).

b) In people with chronic, low back pain, does sleeping on a firm mattress help to reduce pain and disability?

This question is looking at treatment; the best way to answer this question is with a

systematic review of randomised trials.  The first step is to look at the question using

the PICO formula, P = people with chronic low back pain, I = firm mattress, C = other

type of mattress, O = reduced pain and disability.  After accessing the Cochrane

Library click on advanced search and request a search of all Cochrane Library as

when the results are brought up each system is represented with the number of results

it contains for a particular search (DARE, CENTRAL, MeSH, Systematic Reviews

etc).  This is particularly handy in saving time.  Ensuring that the search boxes had

‘search all text’ and ‘AND’ marked next to them type in ‘back pain’ ‘AND’ ‘mattress’

this brings up 6 Cochrane Reviews (systematic reviews) such as Position in second

stage labour for women without epidural anaesthesia and repositioning for pressure

ulcer prevention and 11 articles in the CENTRAL database (containing abstracts of

trials) including Short term outcomes of chronic back pain patients on an air mattress

verus a innerspring mattress and Associations between back pain, quality of sleep and

quality of mattress, double blind pilot study.  Some of these articles talked about

sleeping on various mattresses and the effects on back pain.  To refine the search

further to see if there were articles that specifically talked about firm mattresses and

lower back pain, type in ‘low back pain’ ‘AND’ ‘firm mattress’ into the search engine

using the same limiters as before and the search produced three Cochrane reviews and

two CENTRAL articles I looked at the Cochrane reviews first but this search

produced articles such as Support surfaces for pressure ulcers.  Under Central there

were two articles both answering the question and both suggesting that a more firm

mattress will reduce back pain, however the article entitled  ‘effect of firmness of

mattress on chronic non-specific low back pain: randomised, double blind, controlled,

multicentre trial (Kovacs FM, Abraira V, Pena A, Martin-Rodriguez JG, Sanchez-

Vera M, Ferrer E, Ruano D, Gullen P, Gestoso M, Muriel A, Zamora J, Gil del Real

MT, Mufraggi N, 2003. Vol362, 936: 1599-1604), answers the question the best.  It

has a wider group of people, longer time frame and it is a randomised controlled trial. 

The article suggests that a medium firm mattress is effective in reducing non-specific

low back pain (Doust & Sanders, 2005: http://www.thecochranelibrary.com.au 

www.thecochranelibrary.com.au).

In recent years, there has been considerable controversy over the possible association between non-steroidal anti-inflammatory drugs (both Cox II and non-selective NSAIDs) and the risk of myocardial infarction.  Below are extracts from a study trying to identify the association between non-selective NSAIDs and myocardial infarction.  Read the excerpt and answer the questions below:

Excerpt from study of NSAIDs and risk of myocardial infarction

We identified, through a computer search of the General Practice Research Database, potential cases of a first-time acute myocardial infarction between January 1995 and April 2001 in patients aged 89 years or younger. Subjects with a database history of less than 3 years before the index date (the date of the acute myocardial infarction) were excluded.  We reviewed the computer records of all potential cases, blinded to any information on NSAID exposure.

According to previous validation studies, a high percentage (> 90%) of selected potential cases with acute myocardial infarction can be confirmed by the presence of specific diagnostic criteria in hospital discharge letters.27–29 Because of this fact, we included all potential cases after identifying them by manual review of patient profiles.

Control Subjects

Four control subjects (i.e., patients without acute myocardial infarction) were identified at random and matched to a case patient on age (± 1 yr), sex, general practice attended, number of years of recorded history in the database, and calendar time (by using the same index date— i.e., the date of the acute myocardial infarction diagnosis in the corresponding case patient). Control subjects with a history of less than 3 years in the database were excluded.

What type of study design is this?

   Case control study because the authors found people with and with out the outcome,

in this case myocardial infarction (MI) and looked back to see if they had been

exposed to a NSAID or not and if it made a difference to the risk of having an MI. 

Even though the authors were blinded to what NSAID the subjects were taking they

were not randomly allocated to the exposure – NSAID, they were already taking when

the study commenced.

b) Do the results in Table 2 indicate that NSAID use is associated with an increased or a reduced risk of myocardial infarction?

According to the study the use of NSAID is associated with an increased risk of

myocardial infarct, although as can be seen by the odds ratio not all NSAID show a

high risk of contributing to MI.  Napoxen, Piroxican, Ketoprofen, Nabumetone,

Flurbiprofen and Tiaprofenic acid show odds of less than one indicating protection.

c) Are there any differences between the different types of NSAID?       

Yes, most of the NSAID listed above work by producing anti-inflammatory and

analgesic effects possibly inhibiting the prostaglandin synthesis, however they have

different side effects for example Diclofenic, and Indomethacin, can cause heart

failure, oedema, and hypertension, where as Naproxen and Ketoprofen have no direct

cardio vascular adverse reactions, each drug may also have different drug interactions

(Dwyer, Ed, 1999).

d) What types of factors might be used to adjust the odds ratio in the last column?

Whether the person was taking other medications such as aspirin, their predisposing

factors, such as general health, smoking, family history and obesity.

e) The adjusted odds ratio for patients using aspirin and without any other NSAID exposure was 0.87 (95% CI 0.75-1.00).  The adjusted odds ratio for patients using both aspirin and a NSAID was 0.74 (95% CI 0.57-0.97). 

What do these numbers imply?

  The odds ratio refers to the relative risk, that is the likelihood of an event in the

intervention group compared with the control group.  A score of more than one

indicates risk, a score of less than one usually indicates protection.  People who are

taking aspirin and a NSAID have a slightly more reduced risk of having an MI than

those just taking aspirin (Doust & Sanders, 2005)

f) Based on this data, do you believe that NSAIDs increase or decrease the risk of myocardial infarction?  What else might you like to know about the study?  Would you like more data?  If so, what type of data would you like?

I believe some NSAIDs increase the chance of having an MI and some don’t, as can

be seen by the odds ratio.  I could not make a decision without seeing the whole study,

what are the confounders if any, what is the background, is there more information on

the people in the trials, are they likely to have an MI regardless of NSAID use?  More

information on NSAIDs used in the study is needed.  I would like to see a RCT on

this subject, were there any confounders or selection bias.

Think of a health care question related to your current working environment.  Formulate the question using the PICO format.  Where might you search for answers to this question?  What type of study design would be ideal to answer your question?

     What is the best treatment for chronic otitis media of aboriginal children living

     in outback communities?

P = Aboriginal children with chronic otitis media

I  = Best treatment

C = No treatment or the current treatment of amoxicillin

O = Effective treatment of chronic otitis media

The type of study design ideal for this question on treatment is a randomized control

trial; the best source of these is the Cochrane library.  If there are currently no

systematic reviews then other sources include CENTRAL and DARE or other

databases such as Medline and cinahl.  Cohort and case-control studies will also be

able to answer the question.

Doust & Sanders, 2005. Evidence Based Health Care. The University of Queensland.

Dwyer (Ed), 1999.

Australasia Nursing Drug Handbook. Springhouse Corporation, Pennsylvania.