Kerry J. Inder

Randomized trial of a hospital-based exercise training program after acute myocardial infarction: Cardiac autonomic effects

OBJECTIVES This study sought to determine whether a moderate intensity supervised exercise training program, performed immediately after an uncomplicated acute myocardial infarction, improves recovery in cardiac autonomic function compared with standard advice about activity at home. BACKGROUND Exercise training has beneficial effects on cardiac autonomic function and may improve prognosis after acute myocardial infarction. METHODS Thirty-nine male and 10 female patients, mean (+/-SE) age 57 +/- 1 years, with an uncomplicated acute myocardial infarction were randomized to either a 6-week moderate intensity supervised hospital-based exercise training program (exercise group) or to an unsupervised low intensity home walking program (control group). Outcome measures included changes in baroreflex sensitivity (phenylephrine bolus method) and heart rate variability (24-h Holter monitoring) and the endurance time at 85% of peak oxygen consumption. RESULTS At baseline, there were no significant differences in left ventricular ejection fraction (57 +/- 2% vs. 53 +/- 2%), frequency of anterior infarction (27% vs. 18%) and peak creatine kinase (1,256 +/- 170 vs. 2,599 +/- 295 IU) between the exercise and control groups. Baroreflex sensitivity (10.5 +/- 1.0 vs. 8.4 +/- 1.2 ms/mm Hg) and time domain measures of heart rate variability were also similar. After completion of the program, the exercise group exercised for a median of 15 min (interquartile range 12 to 25) at a workload of 104 +/- 7 W compared with 7 min (interquartile range 3.5 to 12) at a workload of 89 +/- 8 W in the control group (p < 0.01). There were significant (p < 0.001) improvements in baroreflex sensitivity and heart rate variability for the 49 patients combined but no differences between the exercise and control groups. Baroreflex sensitivity improved by 3.4 +/- 1.0 and 1.7 +/- 1.0 ms/mm Hg and the standard deviation of 24-h RR intervals by 36 +/- 6 and 40 +/- 10 ms, respectively (p > 0.1). CONCLUSIONS A hospital-based exercise training program increased endurance capacity but did not improve recovery of cardiovascular antonomic function after uncomplicated acute myocardial infarction.

Prevalence and risk factors for stunting and severe stunting among under-fives in North Maluku province of Indonesia

BackgroundAdequate nutrition is needed to ensure optimum growth and development of infants and young children. Understanding of the risk factors for stunting and severe stunting among children aged less than five years in North Maluku province is important to guide Indonesian government public health planners to develop nutrition programs and interventions in a post conflict area. The purpose of the current study was to assess the prevalence of and the risk factors associated with stunting and severe stunting among children aged less than five years in North Maluku province of Indonesia.MethodsThe health and nutritional status of children aged less than five years was assessed in North Maluku province of Indonesia in 2004 using a cross-sectional multi-stage survey conducted on 750 households from each of the four island groups in North Maluku province. A total of 2168 children aged 0-59 months were used in the analysis.ResultsPrevalence of stunting and severe stunting were 29% (95%CI: 26.0-32.2) and 14.1% (95%CI: 11.7-17.0) for children aged 0-23 months and 38.4% (95%CI: 35.9-41.0) and 18.4% (95%CI: 16.1-20.9) for children aged 0-59 months, respectively. After controlling for potential confounders, multivariate analysis revealed that the risk factors for stunted children were childs age in months, male sex and number of family meals per day (≤2 times), for children aged 0-23 months, and income (poorest and middle-class family), childs age in months and male sex for children aged 0-59 months. The risk factors for severe stunting in children aged 0-23 months were income (poorest family), male sex and childs age in months and for children aged 0-59 months were income (poorest family), fathers occupation (not working), male sex and childs age in months.ConclusionProgrammes aimed at improving stunting in North Maluku province of Indonesia should focus on children under two years of age, of male sex and from families of low socioeconomic status.

The health services burden of heart failure: an analysis using linked population health data-sets.

BackgroundThe burden of patients with heart failure on health care systems is widely recognised, although there have been few attempts to quantify individual patterns of care and differences in health service utilisation related to age, socio-economic factors and the presence of co-morbidities. The aim of this study was to assess the typical profile, trajectory and resource use of a cohort of Australian patients with heart failure using linked population-based, patient-level data.MethodsUsing hospital separations (Admitted Patient Data Collection) with death registrations (Registry of Births, Deaths and Marriages) for the period 2000–2007 we estimated age- and gender-specific rates of index admissions and readmissions, risk factors for hospital readmission, mean length of stay (LOS), median survival and bed-days occupied by patients with heart failure in New South Wales, Australia.ResultsWe identified 29,161 index admissions for heart failure. Admission rates increased with age, and were higher for males than females for all age groups. Age-standardised rates decreased over time (256.7 to 237.7/100,000 for males and 235.3 to 217.1/100,000 for females from 2002–3 to 2006–7; p = 0.0073 adjusted for gender). Readmission rates (any cause) were 27% and 73% at 28-days and one year respectively; readmission rates for heart failure were 11% and 32% respectively. All cause mortality was 10% and 28% at 28 days and one year. Increasing age was associated with more heart failure readmissions, longer LOS and shorter median survival. Increasing age, increasing Charlson comorbidity score and male gender were risk factors for hospital readmission. Cohort members occupied 954,888 hospital bed-days during the study period (any cause); 383,646 bed-days were attributed to heart failure admissions.ConclusionsThe rates of index admissions for heart failure decreased significantly in both males and females over the study period. However, the impact on acute care hospital beds was substantial, with heart failure patients occupying almost 200,000 bed-days per year in NSW over the five year study period. The strong age-related trends highlight the importance of stabilising elderly patients before discharge and community-based outreach programs to better manage heart failure and reduce readmissions.

Factors associated with referral to outpatient cardiac rehabilitation services.

BACKGROUND Although practice guidelines and policy statements for cardiac rehabilitation recommend that it be offered to all patients with cardiovascular disease, the participation rates in most Western countries are low. PURPOSE This study aimed to determine the factors associated with referral to outpatient cardiac rehabilitation in the Hunter region of New South Wales, Australia. METHODS The study sample comprised 1933 patients discharged from public hospitals in the Hunter region between March 1, 1998 and February 28, 1999 who were eligible for cardiac rehabilitation, and for inclusion on the Hunter Area Heart and Stroke Register (the Register). Data were obtained from the Register database (gender, age, clinical information) and via a self-completed questionnaire eliciting referral, sociodemographic, and cardiovascular disease risk factor information. Multiple logistic regression analysis was conducted to determine the factors independently associated with referral. RESULTS : Of the respondents (1202/1933), 41% (493/1202; 95% confidence interval, 38-44%) reported that they had been referred to outpatient cardiac rehabilitation. The factors independently associated with referral were age younger than 65 years, previous participation in an outpatient cardiac rehabilitation program, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery. CONCLUSIONS Younger age, previous participation in outpatient cardiac rehabilitation, admission to a hospital that provides outpatient cardiac rehabilitation, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery were associated with referral to cardiac rehabilitation. Research testing strategies designed to increase cardiac rehabilitation referral rates are needed and could include testing the potential role of modern quality management methods.

Touch screen computer health assessment in Australian general practice patients: a cross-sectional study protocol.

Introduction Cardiovascular disease (CVD) and cancer are leading causes of death globally. Early detection of cancer and risk factors for CVD may improve health outcomes and reduce mortality. General practitioners (GPs) are accessed by the majority of the population and play a key role in the prevention and early detection of chronic disease risk factors. This cross-sectional study aims to assess the acceptability of an electronic method of data collection in general practice patients. The study will describe the proportion screened in line with guidelines for CVD risk factors and cancer as well as report the prevalence of depression, lifestyle risk factors, level of provision of preconception care, cervical cancer vaccination and bone density testing. Lastly, the study will assess the level of agreement between GPs and patients perception regarding presence of risk factors and screening. Methods and analysis The study has been designed to maximise recruitment of GPs by including practitioners in the research team, minimising participation burden on GPs and offering remuneration for participation. Patient recruitment will be carried out by a research assistant located in general practice waiting rooms. Participants will be asked regarding the acceptability of the touch screen computer and to report on a range of health risk and preventive behaviours using the touch screen computer. GPs will complete a one-page survey indicating their perception of the presence of risk behaviours in their patients. Descriptive statistics will be generated to describe the acceptability of the touch screen and prevalence of health risk behaviours. Cohens κ will be used to assess agreement between GP and patient perception of presence of health risk behaviours. Ethics and dissemination This study has been approved by the human research committees in participating universities. Findings will be disseminated via peer-reviewed publications, conference presentations as well as practice summaries provided to participating practices.

Mild Hyponatremia is Associated with Impaired Cognition and Falls in Community‐Dwelling Older Persons

To the Editor: Hyponatremia is a common finding in older persons. Mild hyponatremia was once thought to be asymptomatic, but recent evidence suggests that mild hyponatremia is linked to attention deficits, gait disturbances, and risk of falls. Published studies have examined hospitalized individuals with acute illnesses with the ensuing risk of Berkson’s bias (a form of selection bias). No published study has included asymptomatic community-dwelling older persons or assessed cognition in hyponatremic subjects across multiple domains. It was hypothesized that mild hyponatremia (serum sodium 130–135 mmol/L) is associated with clinically subtle yet significant cognitive deficits, impaired balance, and propensity to fall in communitydwelling older persons. The relationship between mild hyponatremia and cognitive function, two surrogate markers of falls risk (functional reach (FR) and Timed Up and Go test (TUG)), and the incidence of falls was investigated.

Contributors to suicidality in rural communities: beyond the effects of depression

BackgroundRural populations experience a higher suicide rate than urban areas despite their comparable prevalence of depression. This suggests the identification of additional contributors is necessary to improve our understanding of suicide risk in rural regions. Investigating the independent contribution of depression, and the impact of co-existing psychiatric disorders, to suicidal ideation and suicide attempts in a rural community sample may provide clarification of the role of depression in rural suicidality.Methods618 participants in the Australian Rural Mental Health Study completed the Composite International Diagnostic Interview, providing assessment of lifetime suicidal ideation and attempts, affective disorders, anxiety disorders and substance-use disorders. Logistic regression analyses explored the independent contribution of depression and additional diagnoses to suicidality. A receiver operating characteristic (ROC) analysis was performed to illustrate the benefit of assessing secondary psychiatric diagnoses when determining suicide risk.ResultsDiagnostic criteria for lifetime depressive disorder were met by 28% (174) of the sample; 25% (154) had a history of suicidal ideation. Overall, 41% (63) of participants with lifetime suicidal ideation and 34% (16) of participants with a lifetime suicide attempt had no history of depression. When lifetime depression was controlled for, suicidal ideation was predicted by younger age, being currently unmarried, and lifetime anxiety or post-traumatic stress disorder. In addition to depression, suicide attempts were predicted by lifetime anxiety and drug use disorders, as well as younger age; being currently married and employed were significant protective factors. The presence of comorbid depression and PTSD significantly increased the odds of reporting a suicide attempt above either of these conditions independently.ConclusionsWhile depression contributes significantly to suicidal ideation, and is a key risk factor for suicide attempts, other clinical and demographic factors played an important role in this rural sample. Consideration of the contribution of factors such as substance use and anxiety disorders to suicidal ideation and behaviours may improve our ability to identify individuals at risk of suicide. Acknowledging the contribution of these factors to rural suicide may also result in more effective approaches for the identification and treatment of at-risk individuals.

Accuracy of general practitioner unassisted detection of depression.

Objective: Primary care is an important setting for the treatment of depression. The aim of the study was to describe the accuracy of unassisted general practitioner judgements of patients’ depression compared to a standardised depression-screening tool delivered via touch-screen computer. Method: English-speaking patients, aged 18 or older, completed the Patient Health Questionnaire-9 (PHQ-9) when presenting for care to one of 51 general practitioners in Australia. General practitioners were asked whether they thought the patients were clinically depressed. General practitioner judgements of depression status were compared to PHQ-9 results. Results: A total of 1558 patients participated. Twenty per cent of patients were identified by the PHQ-9 as being depressed. General practitioners estimated a similar prevalence; however, when compared to the PHQ-9, GP judgement had a sensitivity of 51% (95% CI [32%, 66%]) and a specificity of 87% (95% CI [78%, 93%]). Conclusions: General practitioner unassisted judgements of depression in their patients lacked sensitivity when compared to a standardised psychiatric measure used in general practice.

Factors associated with reported service use for mental health problems by residents of rural and remote communities: cross-sectional findings from a baseline survey

BackgroundThe patterns of health service use by rural and remote residents are poorly understood and under-represented in national surveys. This paper examines professional and non-professional service use for mental health problems in rural and remote communities in Australia.MethodsA stratified random sample of adults was drawn from non-metropolitan regions of New South Wales, Australia as part of a longitudinal population-based cohort. One-quarter (27.7%) of the respondents were from remote or very remote regions. The socio-demographic, health status and service utilization (professional and non-professional) characteristics of 2150 community dwelling residents are described. Hierarchical logistic regressions were used to identify cross-sectional associations between socio-demographic, health status and professional and non-professional health service utilization variables.ResultsThe overall rate of professional contacts for mental health problems during the previous 12 months (17%) in this rural population exceeded the national rate (11.9%). Rates for psychologists and psychiatrists were similar but rates for GPs were higher (12% vs. 8.1%). Non-professional contact rates were 12%. Higher levels of help seeking were associated with the absence of a partner, poorer finances, severity of mental health problems, and higher levels of adversity. Remoteness was associated with lower utilization of non-professional support. A Provisional Service Need Index was devised, and it demonstrated a broad dose–response relationship between severity of mental health problems and the likelihood of seeking any professional or non-professional help. Nevertheless, 47% of those with estimated high service need had no contact with professional services.ConclusionsAn examination of self-reported patterns of professional and non-professional service use for mental health problems in a rural community cohort revealed relatively higher rates of general practitioner attendance for such problems compared with data from metropolitan centres. Using a measure of Provisional Service Need those with greater needs were more likely to access specialist services, even in remote regions, although a substantial proportion of those with the highest service need sought no professional help. Geographic and financial barriers to service use were identified and perception of service adequacy was relatively low, especially among those with the highest levels of distress and greatest adversity.

Construct validity of the Assessment of Quality of Life - 6D (AQoL-6D) in community samples

BackgroundThe Assessment of Quality of Life - 6D scale (AQoL-6D) is a self-report instrument designed to provide a sensitive multidimensional evaluation of health related quality of life. The current paper assesses the construct, concurrent and convergent validity of the AQoL-6D in a combined longitudinal population sample drawn from across urban, regional and remote areas of Australia.MethodsThe AQoL-6D was administered within the Hunter Community Study and the Australian Rural Mental Health Study over time (mean years lag = 3.90, SD = 1.30). Observations with sufficient data were used to confirm the construct validity of the AQoL-6D domains and higher-order structure using confirmatory factor analyses (CFA, N = 7915). The stability of this structure across cohorts and over time was assessed using multi-group CFA. Additionally, the concurrent validity (against the SF-36) and convergent validity of AQoL-6D domains and factors were assessed.ResultsThe construct validity of the AQoL-6D domains was considered satisfactory. Two higher-order factors, representing the physical and psychological components of quality of life were identified (CFA model fit: RMSEA = .07, SRMR = .03; TLI = .96, CFI = .98). These factors displayed group and temporal invariance, as well as concurrent and convergent validity against a range of measures. Recommendations for the derivation of summary scores are provided, together with a provisional set of norms.ConclusionsThe AQoL-6D is a useful tool for assessing quality of life impairment in epidemiological cohort studies, both cross-sectionally and over time. It displays appropriate levels of construct, concurrent and convergent validity. Conceptualisation of higher-order factors as representing the physical and psychological aspects of quality of life impairment may increase the sensitivity and appeal of the AQoL-6D, particularly for studies examining predictors of and changes in social and psychological outcomes.