Inequitable provision of optimal services for patients with chronic heart failure: a national geo-mapping study

OBJECTIVE: To compare the location and accessibility of current Australian chronic heart failure (CHF) management programs and general practice services with the probable distribution of the population with CHF. DESIGN AND SETTING: Data on the prevalence and distribution of the CHF population throughout Australia, and the locations of CHF management programs and general practice services from 1 January 2004 to 31 December 2005 were analysed using geographic information systems (GIS) technology. OUTCOME MEASURES: Distance of populations with CHF to CHF management programs and general practice services. RESULTS: The highest prevalence of CHF (20.3-79.8 per 1000 population) occurred in areas with high concentrations of people over 65 years of age and in areas with higher proportions of Indigenous people. Five thousand CHF patients (8%) discharged from hospital in 2004-2005 were managed in one of the 62 identified CHF management programs. There were no CHF management programs in the Northern Territory or Tasmania. Only four CHF management programs were located outside major cities, with a total case load of 80 patients (0.7%). The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median, 163 km; range, 0.15-3246 km). In rural areas, where the burden of CHF management falls upon general practitioners, the mean distance to general practice services was 37 km (median, 20 km; range, 0-656 km). CONCLUSION: There is an inequity in the provision of CHF management programs to rural Australians.     

An exploration of the health and social wellbeing needs of looked after young people--a multi-method approach

This study, which was undertaken in Northern Ireland, aimed to identify how the promotion of the health and social wellbeing of looked after young people could be enhanced using a four-stage triangulated research design employing qualitative and quantitative elements. Stage 1 sought to identify relevant health issues from a representative sample of case files and found low uptake of statutory medical assessments, relatively few physical health problems and higher levels of mental health and behavioural problems including self-esteem and self-image issues. Stage 2 sought to ascertain, through two focus groups, the views of those caring for looked after young people foster carers and residential social workers. Findings showed that both groups perceive themselves in a health promoting role with the main issues encountered being the need for support in issues such as sex education and access to sources of help and aids to health promotion. Stage 3 sought to listen to the needs and concerns of the young people and their parents through a series of semi-structured interviews. These revealed the need of parents for involvement with their child's care and identification of the social worker as holding primary responsibility for health. Young people had positive views of health, identified stressors and perceived that too much help was given in relation to health issues; social workers were preferred for discussion of sensitive subjects. It was concluded that the multiple needs of young people give excellent opportunities for the development of interdisciplinary working in the context of multi-sectoral involvement to support effective health promotion interventions.     

Effects of incremental levels of continuous positive airway pressure on cerebral blood flow velocity in healthy adult humans

Sleep disordered breathing is common in patients with cerebrovascular disease, and could exacerbate the cerebral damage in acute stroke. Data about the effects of continuous positive airway pressure (CPAP) upon cerebral perfusion are conflicting. We investigated whether increasing levels of CPAP may affect cerebral haemodynamics, assessed by transcranial Doppler (TCD) in normal humans. A group of 25 healthy young volunteers were evaluated before (CPAP0-pre), during (CPAP5, CPAP10 and CPAP15, denoting CPAP at 5, 10 and 15 cmH(2)O respectively) and after (CPAP0-post) application of incremental levels of CPAP delivered through a mouthpiece. The mean cerebral blood flow velocity (CBFV) and the pulsatility index (PI; an indirect measure of cerebrovascular resistance) in the middle cerebral artery were measured with TCD. Respiratory rate, heart rate, end-tidal carbon dioxide pressure (PETCO(2)), transcutaneous haemoglobin oxygen saturation (SpO(2)), mean arterial blood pressure and anxiety score were also recorded. Compared with CPAP0-pre, CBFV was significantly decreased as higher levels of CPAP were applied (P <0.0001). CPAP15 increased PI (P <0.05), ETCO(2) was reduced by CPAP10 and CPAP15 (P <0.0001), and anxiety score and SpO(2) increased at all levels of CPAP (P <0.05). Heart rate, respiratory rate and mean arterial pressure did not change. The decrease in CBFV was correlated with the fall in P ETCO(2) (CPAP15) and the increase in PI (CPAP10, CPAP15) (P <0.05). In conclusion, even low levels of CPAP delivered through a mouthpiece in awake, young volunteers led to a decrease in CBFV, measured by TCD. This fall in CBFV was associated with hypocapnia and with an increase in both cerebrovascular resistance and anxiety due to breathing against positive pressure. As the negative consequences of a fall in CBFV may outweigh the therapeutic effects of CPAP in the post-stroke setting, further studies of the cerebrovascular effects of CPAP with different interfaces in elderly patients with and without stroke are needed before intervention trials can be performed safely.     

A case of Pasteurella multocida peritoneal dialysis-associated peritonitis and review of the literature.

OBJECTIVES: Two episodes of peritoneal dialysis-associated peritonitis, which occurred four months apart and were both due to Pasteurella multocida, were noted in a 73 year old woman. This report aims to describe the clinical history of these episodes and the microbiological investigations that were undertaken. The relevant literature will also be discussed. METHODS AND RESULTS: Basic microbiological tests identified the organism as Pasteurella multocida, and further work at a specialist laboratory classified it as Pasteurella multocida subsp. multocida. Pulsed field gel electrophoresis confirmed that the strains isolated from the two clinical episodes originated from the same clone. A literature search was performed, looking particularly for patients who experienced more than one episode of peritonitis caused by Pasteurella spp, whether due to recurrence or re-infection. CONCLUSIONS: It is likely that the infection resulted from a domestic cat, as there was evidence of a cat bite to the dialysis tubing in the period between the two episodes. Re-infection with two identical strains of pasteurella is more probable than relapse, for reasons discussed. Strict hygiene and avoiding contact between dialysis tubing and domestic animals must be emphasised to try to prevent pasteurella and other animal-associated infections in this already vulnerable population.     

Modernizing the treatment of venous thoracic outlet syndrome

This study aims to quantify the management and outcomes of patients treated for venous thoracic outlet syndrome (vTOS) over a seven-year period. A retrospective case-note review of all patients undergoing first rib resection at a regional vascular unit between January 1, 2002 and December 31, 2009 was performed. Treatment pathways and outcomes recorded as freedom from symptoms and venous patency were analyzed. Thirty-five patients were identified with vTOS. Ninety-one percent of patients had patent veins at discharge from clinical follow-up and were symptom-free at a median of 44 months. Patients treated within seven days of symptoms (94.7 versus 85.7, P = 0.060), with catheter-directed thrombolysis (94 versus 87.5% P = 0.702) and excision of first rib in less than 30 days (100 versus 85.7%, P = 0.002), had improved symptom-free rates. In conclusion, early referral, immediate catheter-directed thrombolysis, perioperative balloon venoplasty and early thoracic outlet decompression may provide a suitable model for improving outcomes in vTOS.     

Interprofessional working in the context of newborn hearing screening: Education and Social Services compare challenges

This article presents data from a study undertaken as part of the national evaluation of the introduction of the newborn hearing screening programme (NHSP) in England. It considers the impact on Education and Social Services of NHSP from the perspective of how each agency perceives each other's role in circumstances where NHSP is requiring a greater focus on interagency and interprofessional working. The qualitative interview study involved 27 education and 15 social services respondents from phase 1 NHSP sites. It reveals considerable agreement on the poorly developed nature of joint working but considerable disagreement about the roots of such. Education is more likely to focus on issues of role, value and skills; social services on conflicts of ethos and culture. The problem of social services' capacity to respond to referrals concerning deaf children was common to both. The findings are placed in the context of government guidance, in particular Early Support and Children's Trusts, both of which support a strategic and statutory basis for interprofessional working in this context.     

Cohousing for older people: housing innovation in the Netherlands and Denmark

Objective: The aim of this paper is to elucidate cohousing for older people. Method: The research is based on a literature review and interviews (in English) with residents of seven schemes in the Netherlands and Denmark, a social housing organisation and several researchers in the field (in 1995 and 2002). Results and Conclusions: Cohousing for older people is now well established in its countries of origin – Denmark and the Netherlands – as a way for older people to live in their own house or unit, with a self‐chosen group of other older people as neighbours, with shared space and facilities they collectively determine or control. As more such housing is built and occupied it has become easier to choose and assess this option. It remains to be seen how widespread its appeal will be, but cohousing for older people is now a valued housing niche.