Coronary events and exposure to environmental tobacco smoke: a case-control study from Australia and New Zealand

Objectives-To estimate the relative risk of coronary heart disease (CHD) associated with exposure to environmental tobacco smoke (ETS). Design-Population-based case-control study. Subjects-Cases were 953 people identified in a population register of coronary events, and controls were 3189 participants in independent community-based risk factor prevalence surveys from the same study populations. Setting-Newcastle, Australia and Auckland, New Zealand. Main outcome measures-Acute myocardial infarction or coronary death. Results-After adjusting for the effects of age, education, history of heart disease, and body mass index, women had a statistically significant increased risk of a coronary event associated with exposure to ETS (relative risk (RR) = 1.99; 95% confidence interval (CI)= 1.40-2.81). There was little statistical evidence of increased risk found in men (RR = 1.02, 95% CI = 0.81-1.28). Conclusion-Our study found evidence for the adverse effects of exposure to ETS on risk of coronary heart disease among women, especially at home. For men the issue is unclear according to the data from our study. Additional studies with detailed information on possible confounders and adequate statistical power are needed. Most importantly, they should use methods for measuring exposure to ETS that are sufficiently accurate to permit the investigation of dose-response relationships.

Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome

The purpose of this study was to investigate the relationship between self-awareness, emotional distress, motivation, and outcome in adults with severe traumatic brain injury. A sample of 55 patients were selected from 120 consecutive patients with severe traumatic brain injury admitted to the rehabilitation unit of a large metropolitan public hospital. Subjects received multidisciplinary inpatient rehabilitation and different types of outpatient rehabilitation and community-based services according to availability and need, Measures used in the cluster analysis were the Patient Competency Rating Scale, Self-Awareness of Deficits Interview, Head Injury Behavior Scale, Change Assessment Questionnaire, the Beck Depression Inventory, and Beck Anxiety Inventory; outcome measures were the Disability Rating Scale, Community Integration Questionnaire, and Sickness Impact Profile. A three-cluster solution was selected, with groups labeled as high self-awareness (n = 23), low self-awareness (n = 23), and good recovery (n = 8). The high self-awareness cluster had significantly higher levels of self-awareness, motivation, and emotional distress than the low self-awareness cluster but did not differ significantly in outcome. Self-awareness after brain injury is associated with greater motivation to change behavior and higher levels of depression and anxiety; however, it was not clear that this heightened motivation actually led to any improvement in outcome. Rehabilitation timing and approach may need to be tailored to match the individual's level of self-awareness, motivation, and emotional distress.

Rapid reduction in coronary risk for those who quit cigarette smoking

The objective of this study was to determine the rate of the decline in risk of a major coronary event after quitting cigarette smoking. It was a population-based case-control study of men and women aged 35 to 69 years in Newcastle, Australia, and men and women aged 35 to 64 years in Auckland, New Zealand, between 1986 and 1994. Cases were 5,572 people identified in population registers of coronary events and controls were 6,268 participants in independent community-based risk factor prevalence surveys from the same study populations. There was a rapid reduction in risk after quitting cigarette smoking. The risk of suffering a major coronary event for men who were current cigarette smokers was 3.5 (95% CI 3.0-4.0) times higher than the risk for never smokers but this fell to 1.5 (95% CI 1.1-1.9) for men who had quit for 1-3 years. Women who were current cigarette smokers were 4.8 (95% CI 4.0-5.9) times more likely to suffer a major coronary event than never smokers and this fell to 1.6 (95% CI 1.0-2.5) for women who had quit for 1-3 years. Those who had quit cigarette smoking for 4-6 years or more had a similar risk to never smokers. These results reinforce the importance of smoking cessation. The public health message is that the benefit of giving up smoking occurs rapidly.

Conservation farming projects in the Philippine uplands: Rhetoric and reality

The phenomenon of agricultural land degradation in the Philippine uplands has been regarded by scientists and policy-makers as a major environmental and rural development problem. Numerous conservation farming projects have been implemented in the past two decades to address this problem, apparently with little success. Most of these projects have espoused the currently fashionable principles of community-based sustainable development. This paper examines case histories of three completed upland conservation projects. The aim is to compare the rhetoric of project documents and evaluations with the reality of on-going land management practices as seen from the perspective of the land managers themselves. (C) 2000 Elsevier Science Ltd. All rights reserved.

Promoting physical activity among middle-aged and older adults in health care settings

Physical inactivity continues to be a significant public health issue for middle-aged and older adults. This review focuses on physical activity interventions targeting older adults in health care settings. The literature in this area is limited and the results to date disappointing. Much remains to be done to develop effective interventions targeting older adults, especially those from underserved groups. Attention also needs to be paid to maintenance of initial treatment gains and to linking primary-care-based physical activity interventions to community-based resources. Recognition in the social and behavioral sciences of the importance of social-environmental influences on health and health behaviors mandates both a multidisciplinary and a multilevel intervention approach to the problem of physical inactivity.

Prior calcium channel blockade and short-term survival following acute myocardial infarction

There is concern over the safety of calcium channel blockers (CCBs) in acute coronary disease. We sought to determine if patients taking calcium channel blockers (CCBs) at the time of admission with acute myocardial infarction (AMI) had a higher case-fatality compared with those taking beta-blockers or neither medication. Clinical and drug treatment variables at the time of hospital admission predictive of survival at 28 days were examined in a community-based registry of patients aged under 65 years admitted to hospital for suspected AMI in Perth, Australia, between 1984 and 1993. Among 7766 patients, 1291 (16.6%) were taking a CCB and 1259 (16.2%) a betablocker alone at hospital admission. Patients taking CCBs had a worse clinical profile than those taking a beta-blocker alone or neither drug (control group), and a higher unadjusted 28-day mortality (17.6% versus 9.3% and 11.1% respectively, both P < 0.001). There was no significant heterogeneity with respect to mortality between nifedipine, diltiazem, or verapamil when used alone, or with a beta-blocker. After adjustment for factors predictive of death at 28 days, patients taking a CCB were found not to have an excess chance of death compared with the control group (odds ratio [OR] 1.06, 95% confidence interval [CI]; 0.87, 1.30), whereas those taking a beta-blocker alone had a lower odds of death (OR 0.75, 95% CI; 0.59, 0.94). These results indicate that established calcium channel blockade is not associated with an excess risk of death following AMI once other differences between patients are taken into account, but neither does it have the survival advantage seen with prior beta-blocker therapy.

Exploratory research: Citizen participation, local government and sustainable development in Australia

Exploratory research reported in this paper was undertaken in Adelaide, Australia during 1998/99. The purpose of the research is to explore local development practice as evidenced through the experiences and actions of local citizens, community based groups and local government (Neuman, 1994). Results from this first stage research suggest that sustainability initiatives in Australia might best be implemented through a collaborative approach at the local community level involving local citizens working in partnership with local government. Copyright (C) 2002 John Wiley & Sons, Ltd and ERP Environment.

Improving maximum walking distance in early peripheral arterial disease: Randomised controlled trial

The purpose of this study was to determine the impact of increased physical activity and cessation of smoking on the natural history of early peripheral arterial disease, We conducted a randomised controlled trial in Perth, Western Australia, involving 882 men with early peripheral arterial disease identified via population-based screening using the Edinburgh Claudication Questionnaire and the ankle:brachial index. Members of the control group (n = 441) received usual care from their general practitioner while members of the intervention group (n = 441) were allocated to a stop smoking and keep walking regime - a combined community-based intervention of cessation of smoking (where applicable) and increased physical activity. Postal follow-up occurred at two and 12 months post-entry into the trial. The main outcome of interest was maximum walking distance. There were no statistically significant differences in the characteristics of the intervention and usual care groups at recruitment. Follow-up information at two and 12 months was available for 85% and 84% of participants, respectively. At 12 months, more men allocated to the intervention group had improved their maximum walking distance (23% vs 15%; chi(2) = 9.74, df = 2, p = 0.008). In addition, more men in the intervention group reported walking more than three times per week for recreation (34% vs 25%, p = 0.01). Although not statistically significant, more men in the intervention group who were smokers when enrolled in the trial had stopped smoking (12% vs 8%, p = 0.43). It is concluded that referral of older patients with intermittent claudication to established physiotherapy programs in the community can increase levels of physical activity and reduce disability related to peripheral arterial disease. A combination of simple and safe interventions that are readily available in the community through physiotherapists and general practitioners has the potential to improve early peripheral arterial disease.

Health for all beyond 2000: the demise of the Alma-Ata Declaration and primary health care in developing countries

Access to basic health services was affirmed as a fundamental human right in the Declaration of Alma-Ata in 1978. The model formally adopted for providing healthcare services was primary health care (PHC), which involved universal, community-based preventive and curative services, with substantial community involvement. PHC,did not achieve its goals for several reasons, including the refusal of experts and politicians in developed countries to accept the principle that communities should plan and implement their own heathcare services. Changes in economic philosophy led to the replacement of PHC by Health Sector Reform, based on market forces and the economic benefits of better health. It is time to abandon economic ideology and determine the methods that will provide access to basic healthcare services for all people.

Palliative care at home: general practitioners working with palliative care teams

Home care is the preferred option for most people with a terminal illness. Providing home care relies on good community-based services, and a general practice workforce competent in palliative care practice and willing to accommodate patients' needs. Structured palliative care training of general practitioners is needed at undergraduate and postgraduate level, with attention to barriers to teamwork and communication. Good palliative care-can be delivered to patients at home by GPs (supported by specialist palliative care teams) and community nurses, with access to an inpatient facility when required. To optimise patient care, careful planning and good communication between all members of the healthcare team is crucial.

Achieving the millennium development goals for health - Cost effectiveness analysis of strategies for. maternal and neonatal health in developing countries

Objective To determine the costs and benefits of interventions for maternal and newborn health to assess the appropriateness of current strategies and guide future plans to attain the millennium development goals. Design Cost effectiveness analysis. Setting Two regions classified by the World Health Organization according to their epidemiological grouping: Afr-E, those countries in sub-Saharan Africa with very high adult and high child mortality, and Sear-D, comprising countries in South East Asia with high adult and high child mortality. Data sources Effectiveness data from several sources, including trials, observational studies, and expert opinion. For resource inputs, quantifies came from WHO guidelines, literature, and expert opinion, and prices from the WHO choosing interventions that are cost effective database. Main outcome measures Cost per disability adjusted life year (DALY) averted in year 2000 international dollars. Results The most cost effective mix of interventions was similar in Afr-E and Sear-D. These were the community based newborn care package, followed by antenatal care (tetanus toxoid, screening for pre-eclampsia, screening and treatment of asymptomatic bacteriuria and syphilis); skilled attendance at birth, offering first level maternal and neonatal care around childbirth; and emergency obstetric and neonatal care around and after birth. Screening and treatment of maternal syphilis, community based management of neonatal pneumonia, and steroids given during the antenatal period were relatively less cost effective in Sear-D. Scaling up all of the included interventions to 95% coverage would halve neonatal and maternal deaths. Conclusion Preventive interventions at the community level for newborn babies and at the primary care level for mothers and newborn babies are extremely cost effective, but the millennium development goals for maternal and child health will not be achieved without universal access to clinical services as well.

Anthropometric measures in relation to Basal Cell Carcinoma: a longitudinal study

Background: The relationship between anthropometric indices and risk of basal cell carcinoma ( BCC) is largely unknown. We aimed to examine the association between anthropometric measures and development of BCC and to demonstrate whether adherence to World Health Organisation guidelines for body mass index, waist circumference, and waist/ hip ratio was associated with risk of BCC, independent of sun exposure. Methods: Study participants were participants in a community- based skin cancer prevention trial in Nambour, a town in southeast Queensland ( latitude 26 degrees S). In 1992, height, weight, and waist and hip circumferences were measured for all 1621 participants and weight was remeasured at the end of the trial in 1996. Prevalence proportion ratios were calculated using a log- binomial model to estimate the risk of BCC prior to or prevalent in 1992, while Poisson regression with robust error variances was used to estimate the relative risk of BCC during the follow- up period. Results: At baseline, 94 participants had a current BCC, and 202 had a history of BCC. During the 5- year follow- up period, 179 participants developed one or more new BCCs. We found no significant association between any of the anthropometric measures or indices and risk of BCC after controlling for potential confounding factors including sun exposure. There was a suggestion that short- term weight gain may increase the risk of developing BCC for women only. Conclusion: Adherence to World Health Organisation guidelines for body mass index, waist circumference and waist/ hip ratio is not significantly associated with occurrence of basal cell carcinomas of the skin.

The impact of diabetes on survival among patients with first myocardial infarction

OBJECTIVE - The purpose of this paper is to estimate the impact of diabetes on survival among patients with first acute myocardial infarction, using data from the World Health Organization (WHO) Monitoring Trends and Determinants of Cardiovascular Disease (MONICA) Project in Newcastle, New South Wales, Australia. RESEARCH DESIGN AND METHODS - The WHO MONICA Project is a community-based surveillance system that monitors coronary heart disease morbidity and mortality. All patients with suspected coronary events were observed for 28 days after the onset of symptoms. RESULTS - Of 5,322 patients with acute myocardial infarction and no previous history of ischemic heart disease (3,643 men and 1,679 women), 333 men (9%) and 224 women (13%) had a history of diabetes. The age-adjusted 28-day case fatality for women with diabetes (25%) was significantly higher than for women without diabetes (16%); relative risk 1.56 (95% CI: 1.19-2.04). The difference for men was also significant (25% with diabetes and 20% without diabetes); relative risk 1.25 (95% CI: 1.02-1.53). Age-specific case fatality increased significantly with age in both men and women without diabetes, but systematic age effects were not so apparent in patients with diabetes. Case fatality significantly decreased over the study period in patients without diabetes, but not among the diabetic patients. CONCLUSIONS - The increased risk of death in the diabetic patients remained after accounting for their poorer risk factor profiles; even if they reached the hospital alive, diabetic patients were also less likely to survive than nondiabetic patients. The relative impact of diabetes on survival is greater in women than in men.

Whose diet has changed?

The same questions about diet were asked in two community-based surveys conducted in the Hunter Region of New South Wales in 1983 and 1994. There were substantial changes in diet over the period; for example, the proportion of respondents who reported using low-fat or skim milk increased from 25 per cent to 51 per cent, the proportion eating meat fewer than five times a week doubled from 21 per cent to 42 per cent and the proportion eating fewer than three eggs per week increased from 55 per cent to 80 per cent. In both surveys, women reported eating a healthier diet than men, and older people and those of higher socioeconomic status reported better diets than younger people or people with less education or lower status occupations. The surprising finding was that over the 11-year period the changes in patterns of food consumption were remarkably similar across all strata of the population. The conclusions are that wide-spread dietary change is possible. However, the changes in the last decade related mainly to reducing the risk of cardiovascular disease; similar behavioural changes to reduce the risk of diet-related cancer are required.

A 1-year longitudinal study of severe traumatic brain injury in Australia using the Sickness Impact Profile

Objective: To document outcome and to investigate patterns of physical and psychosocial recovery in the first year following severe traumatic brain injury (TBI) in an Australian patient sample. Design: A longitudinal prospective study of a cohort of patients, with data collection at 3, 6, 9, and 12 months post injury. Setting: A head injury rehabilitation unit in a large metropolitan public hospital. Patients: A sample of 55 patients selected from 120 consecutive admissions with severe TBI. Patients who were more than 3 months post injury on admission, who remained confused, or who had severe communication deficits or a previous neurologic disorder were excluded. Interventions: All subjects participated in a multidisciplinary inpatient rehabilitation program, followed by varied participation in outpatient rehabilitation and community-based sen ices. Main Outcome Measures: The Sickness impact Profile (SIP) provided physical, psychosocial, and total dysfunction scores at each follow-up. Outcome at 1 year was measured by the Disability Rating Scale. Results: Multivariate analysis of variance indicated that the linear trend of recovery over time was less for psychosocial dysfunction than for physical dysfunction (F(1,51) = 5.87, P < .02). One rear post injury, 22% of subjects had returned to their previous level of employability, and 42% were able to live independently. Conclusions: Recovery from TBI in this Australian sample followed a pattern similar to that observed in other countries, with psychosocial dysfunction being more persistent. Self-report measures such as the SIP in TBI research are limited by problems of diminished self-awareness.