Telemonitoring or Structured Telephone Support Programmes for Patients with Chronic Heart Failure: Systematic Review and Meta-Analysis

Objective: To determine whether remote monitoring (structured telephone support or telemonitoring) without regular clinic or home visits improves outcomes for patients with chronic heart failure. Data sources: 15 electronic databases, hand searches of previous studies, and contact with authors and experts. Data extraction: Two investigators independently screened the results. Review methods: Published randomised controlled trials comparing remote monitoring programmes with usual care in patients with chronic heart failure managed within the community. Results: 14 randomised controlled trials (4264 patients) of remote monitoring met the inclusion criteria: four evaluated telemonitoring, nine evaluated structured telephone support, and one evaluated both. Remote monitoring programmes reduced the rates of admission to hospital for chronic heart failure by 21% (95% confidence interval 11% to 31%) and all cause mortality by 20% (8% to 31%); of the six trials evaluating health related quality of life three reported significant benefits with remote monitoring, and of the four studies examining healthcare costs with structured telephone support three reported reduced cost and one no effect. Conclusion: Programmes for chronic heart failure that include remote monitoring have a positive effect on clinical outcomes in community dwelling patients with chronic heart failure.

Adherence, adaptation and acceptance of elderly chronic heart failure patients to receiving healthcare via telephone-monitoring

Background: Although the potential to reduce hospitalisation and mortality in chronic heart failure (CHF) is well reported, the feasibility of receiving healthcare by structured telephone support or telemonitoring is not. Aims: To determine; adherence, adaptation and acceptability to a national nurse-coordinated telephone-monitoring CHF management strategy. The Chronic Heart Failure Assistance by Telephone Study (CHAT). Methods: Triangulation of descriptive statistics, feedback surveys and qualitative analysis of clinical notes. Cohort comprised of standard care plus intervention (SC + I) participants who completed the first year of the study. Results: 30 GPs (70% rural) randomised to SC + I recruited 79 eligible participants, of whom 60 (76%) completed the full 12 month follow-up period. During this time 3619 calls were made into the CHAT system (mean 45.81 SD ± 79.26, range 0-369), Overall there was an adherence to the study protocol of 65.8% (95% CI 0.54-0.75; p = 0.001) however, of the 60 participants who completed the 12 month follow-up period the adherence was significantly higher at 92.3% (95% CI 0.82-0.97, p ≤ 0.001). Only 3% of this elderly group (mean age 74.7 ±9.3 years) were unable to learn or competently use the technology. Participants rated CHAT with a total acceptability rate of 76.45%. Conclusion: This study shows that elderly CHF patients can adapt quickly, find telephone-monitoring an acceptable part of their healthcare routine, and are able to maintain good adherence for a least 12 months. © 2007.

[Letter to the Editor] Telemonitoring in Patients with Heart Failure

To the Editor: Chaudhry et al. suggest that enhanced support in the use of a telephone-based interactive voice-response system for patients recently discharged after worsening heart failure does not improve outcomes. This finding is broadly consistent with previous systematic reviews of telephone support1 and contrasts with the substantial effect observed with home telemonitoring of vital signs in similar populations.1 The treatment of patients in the control group was excellent, but unrepresentative of usual clinical care and not inferior to the treatment of patients receiving enhanced support. Monitoring alone is unlikely to improve outcomes but may do so when it improves prescription of or adherence to lifesaving treatments. Given enough resources, traditional methods for delivering care may render an interactive voice-response system or a home telemonitoring system ineffective. Nonetheless, there may be more cost-efficient approaches to ensuring quality care.2 Informal post hoc addition of these data to our recent meta-analysis of telephone support1 does not substantially alter the point estimates for death from any cause or heart-failure−related hospitalizations, but it does nullify the small benefit in hospitalizations for any cause, which may not be reduced by a heart-failure−focused intervention.1 Original article: Telemonitoring in Patients with Heart Failure NEJM. December 9, 2010 | S.I. Chaudhry and Others

Epidemiologic modeling with FluSurge for pandemic (H1N1) 2009 outbreak, Queensland, Australia

At the beginning of the pandemic (H1N1) 2009 outbreak, we estimated the potential surge in demand for hospital-based services in 4 Health Service Districts of Queensland, Australia, using the FluSurge model. Modifications to the model were made on the basis of emergent evidence and results provided to local hospitals to inform resource planning for the forthcoming pandemic. To evaluate the fit of the model, a comparison between the model's predictions and actual hospitalizations was made. In early 2010, a Web-based survey was undertaken to evaluate the model's usefulness. Predictions based on modified assumptions arising from the new pandemic gained better fit than results from the default model. The survey identified that the modeling support was helpful and useful to service planning for local hospitals. Our research illustrates an integrated framework involving post hoc comparison and evaluation for implementing epidemiologic modeling in response to a public health emergency.

Estimation on disease burden related to hepatitis B virus infection in Shandong province of China [山东省乙型肝炎病毒感染所致相关疾病的疾病负担研究]

Objective: To comprehensively measure the burden of hepatitis B, liver cirrhosis and liver cancer in Shandong province, using disability-adjusted life years (DALYs) to estimate the disease burden attribute to hepatitis B virus (HBV)infection. Methods: Based on the mortality data of hepatitis B, liver cirrhosis and liver cancer derived from the third National Sampling Retrospective Survey for Causes of Death during 2004 and 2005, the incidence data of hepatitis B and the prevalence and the disability weights of liver cancer gained from the Shandong Cancer Prevalence Sampling Survey in 2007, we calculated the years of life lost (YLLs), years lived with disability (YLDs) and DALYs of three diseases following the procedures developed for the global burden of disease (GBD) study to ensure the comparability. Results: The total burden for hepatitis B, liver cirrhosis and liver cancer were 211 616 (39 377 YLLs and 172 239 YLDs), 16 783 (13 497 YLLs and 3286 YLDs) and 247 795 (240 236 YLLs and 7559 YLDs) DALYs in 2005 respectively, and men were 2.19, 2.36 and 3.16 times as that for women, respectively in Shandong province. The burden for hepatitis B was mainly because of disability (81.39%). However, most burden on liver cirrhosis and liver cancer were due to premature death (80.42% and 96.95%). The burden of each patient related to hepatitis B, liver cirrhosis and liver cancer were 4.8, 13.73 and 11.11 respectively. Conclusion: Hepatitis B, liver cirrhosis and liver cancer caused considerable burden to the people living in Shandong province, indicating that the control of hepatitis B virus infection would bring huge potential benefits.

Hot temperatures and morbidity : a systematic review and meta–analysis

Extreme temperatures have been shown to have a detrimental effect on health. Hot temperatures can increase the risk of mortality, particularly in people suffering from cardiorespiratory diseases. Given the onset of climate change, it is critical that the impact of temperature on health is understood, so that effective public health strategies can correctly identify vulnerable groups within the population. However, while effects on mortality have been extensively studied, temperature–related morbidity has received less attention. This study applied a systematic review and meta–analysis to examine the current literature relating to hot temperatures and morbidity.

Cultural challenges to secondary prevention: Implications for Saudi women

Like other highly developed countries, cardiovascular disease (CVD) and coronary heart disease (CHD) are major health problems in Saudi Arabia. The aetiology of cardiovascular disease (CVD) burden within the Saudi population is similar to Western countries with atherosclerosis, hypertension, ischemic heart disease and diabetes highly prevalent with the main risk factors being smoking, obesity and inactivity. There are differences between Saudi men and women in epidemiology, risk factors and health service provision for CHD. These sex and gender based factors are important in considering the health and well-being of Saudi women. Currently, there is limited focus on the cardiovascular health of Saudi women. The aim of this paper is to examine culturally specific issues for Saudi women and the implications for secondary prevention.

Where not to have a Heart Attack in Australia!: The Cardiac ARIA Index

Background/aims: Access to appropriate health care following an acute cardiac event is important for positive outcomes. The aim of the Cardiac ARIA index was to derive an objective, comparable, geographic measure reflecting access to cardiac services across Australia. Methods: Geographic Information Systems (GIS) were used to model a numeric-alpha index based on acute management from onset of symptoms to return to the community. Acute time frames have been calculated to include time for ambulance to arrive, assess and load patient, and travel to facility by road 40–80 kph. Results: The acute phase of the index was modelled into five categories: 1 [24/7 percutaneous cardiac intervention (PCI) ≤1 h]; 2 [24/7 PCI 1–3 h, and PCI less than an additional hour to nearest accident and emergency room (A&E)]: 3 [Nearest A&E ≤3 h (no 24/7 PCI within an extra hour)]: 4 [Nearest A&E 3–12 h (no 24/7 PCI within an extra hour)]: 5 [Nearest A&E 12–24 h (no 24/7 PCI within an extra hour)]. Discharge care was modelled into three categories based on time to a cardiac rehabilitation program, retail pharmacy, pathology services, hospital, GP or remote clinic: (A) all services ≤30 min; (B) >30 min and ≤60 min; (C) >60 min. Examples of the index indicate that the majority of population locations within capital cities were category 1A; Alice Springs and Byron Bay were 3A; and the Northern Territory town of Maningrida had minimal access to cardiac services with an index ranking of 5C. Conclusion: The Cardiac ARIA index provides an invaluable tool to inform appropriate strategies for the use of scarce cardiac resources.

What explains the association between socioeconomic status and depression among Vietnamese adults?

Background Depression is a major public health problem worldwide and is currently ranked second to heart disease for years lost due to disability. For many decades, international research has found that depressive symptoms occur more frequently among low socioeconomic (SES) individuals than their more-advantaged peers. However, the reasons as to why those of low socioeconomic groups suffer more depressive symptoms are not well understood. Studies investigating the prevalence of depression and its association with SES emanate largely from developed countries, with little research among developing countries. In particular, there is a serious dearth of research on depression and no investigation of its association with SES in Vietnam. The aims of the research presented in this Thesis are to: estimate the prevalence of depressive symptoms among Vietnamese adults, examine the nature and extent of the association between SES and depression and to elucidate causal pathways linking SES to depressive symptoms Methods The research was conducted between September 2008 and November 2009 in Hue city in central Vietnam and used a combination of qualitative (in-depth interviews) and quantitative (survey) data collection methods. The qualitative study contributed to the development of the theoretical model and to the refinement of culturally-appropriate data collection instruments for the quantitative study. The main survey comprised a cross-sectional population–based survey with randomised cluster sampling. A sample of 1976 respondents aged between 25-55 years from ten randomly-selected residential zones (quarters) of Hue city completed the questionnaire (response rate 95.5%). Measures SES was classified using three indicators: education, occupation and income. The Center for Epidemiologic Studies-Depression (CES-D) scale was used to measure depressive symptoms (range0-51, mean=11.0, SD=8.5). Three cut-off points for the CES-D scores were applied: ‘at risk for clinical depression’ (16 or above), ‘depressive symptoms’ (above 21) and ‘depression’ (above 25). Six psychosocial indicators: life time trauma, chronic stress, recent life events, social support, self esteem, and mastery were hypothesized to mediate the association between SES and depressive symptoms. Analyses The prevalence of depressive symptoms were analysed using bivariate analyses. The multivariable analytic phase comprised of ordinary least squares regression, in accordance with Baron and Kenny’s three-step framework for mediation modeling. All analyses were adjusted for a range of confounders, including age, marital status, smoking, drinking and chronic diseases and the mediation models were stratified by gender. Results Among these Vietnamese adults, 24.3% were at or above the cut-off for being ‘at risk for clinical depression’, 11.9% were classified as having depressive symptoms and 6.8% were categorised as having depression. SES was inversely related to depressive symptoms: the least educated those with low occupational status or with the lowest incomes reported more depressive symptoms. Socioeconomicallydisadvantaged individuals were more likely to report experiencing stress (life time trauma, chronic stress or recent life events), perceived less social support and reported fewer personal resources (self esteem and mastery) than their moreadvantaged counterparts. These psychosocial resources were all significantly associated with depressive symptoms independent of SES. Each psychosocial factor showed a significant mediating effect on the association between SES and depressive symptoms. This was found for all measures of SES, and for males and females. In particular, personal resources (mastery, self esteem) and chronic stress accounted for a substantial proportion of the variation in depressive symptoms between socioeconomic groups. Social support and recent life events contributed modestly to socioeconomic differences in depressive symptoms, whereas lifetime trauma contributed the least to these inequalities. Conclusion This is the first known study in Vietnam or any developing country to systematically examine the extent to which psychosocial factors mediate the relationship between SES and depression. The study contributes new evidence regarding the burden of depression in Vietnam. The findings have practical relevance for advocacy, for mental health promotion and health-care services, and point to the need for programs that focus on building a sense of personal mastery and self esteem. More broadly, the work presented in this Thesis contributes to the international scientific literature on the social determinants of depression.

Loss and grief at the heart of text messages [REVIEW]

WHAT if you lost someone you loved? What if you had to let go for the sake of your own sanity? Lachlan Philpott's Colder and Dennis Kelly's Orphans, playing as part of La Boite's and Queensland Theatre Company's independents programs, are emotionally and textually dense theatrical works...

Practical physical activity measurement in youth : a review of contemporary approaches

Background: The accurate evaluation of physical activity levels amongst youth is critical for quantifying physical activity behaviors and evaluating the effect of physical activity interventions. The purpose of this review is to evaluate contemporary approaches to physical activity evaluation amongst youth. Data sources: The literature from a range of sources was reviewed and synthesized to provide an overview of contemporary approaches for measuring youth physical activity. Results: Five broad categories are described: self-report, instrumental movement detection, biological approaches, direct observation, and combined methods. Emerging technologies and priorities for future research are also identified. Conclusions: There will always be a trade-off between accuracy and available resources when choosing the best approach for measuring physical activity amongst youth. Unfortunately, cost and logistical challenges may prohibit the use of "gold standard" physical activity measurement approaches such as doubly labelled water. Other objective methods such as heart rate monitoring, accelerometry, pedometry, indirect calorimetry, or a combination of measures have the potential to better capture the duration and intensity of physical activity, while self-reported measures are useful for capturing the type and context of activity.

The heart of quality teaching : a values-based pedagogy for pre-service teacher education

In an ever changing world the adults of the future will be faced with many challenges. To cope with these challenges it seems apparent that values education will need to become paramount within a child.s education. A considerable number of research studies have indicated that values education is a critical component within education (Lovat & Toomey, 2007b). Building on this research Lovat (2006) claimed that values education was the missing link in quality teaching The concept of quality teaching had risen to the fore within educational research literature in the late 20th century with the claim that it is the teacher who makes the difference in schooling (Hattie, 2004). Thus, if teachers make such a difference to student learning, achievement and well-being, then it must hold true that pre-service teacher education programmes are vital in ensuring the development of quality teachers for our schools. The gap that this current research programme addressed was to link the fields of values education, quality teaching and pre-service teacher education. This research programme aimed to determine the impact of a values-based pedagogy on the development of quality teaching dimensions within pre-service teacher education. The values-based pedagogy that was investigated in this research programme was Philosophy in the Classroom. The research programme adopted a nested case study design based on the constructivist-interpretative paradigm in examining a unit within a pre-service teacher education programme at a Queensland university. The methodology utilised was qualitative where the main source of data was via interviews. In total, 43 pre-service teachers participated in three studies in order to determine if their involvement in a unit where the focus was on introducing pre-service teachers to an explicit values-based pedagogy impacted on their knowledge, skills and confidence in terms of quality teaching dimensions. The research programme was divided into three separate studies in order to address the two research questions: 1. In what ways do pre-service teachers perceive they are being prepared to become quality teachers? 2. Is there a connection between an explicit values-based pedagogy in pre-service teacher education and the development of pre-service teachers. understanding of quality teaching? Study One provided insight into 21 pre-service teachers. understandings of quality teaching. These 21 participants had not engaged in an explicit values-based pedagogy. Study Two involved the interviewing of 22 pre-service teachers at two separate points in time . prior to exposure to a unit that employed a values-explicit pedagogy and post this subject.s lecture content delivery. Study Three reported on and analysed individual case studies of five pre-service teachers who had participated in Study Two Time 1 and Time 2, as well as a third time following their field experience where they had practice in teaching the values explicit pedagogy. The results of the research demonstrate that an explicit values-based pedagogy introduced into a teacher education programme has a positive impact on the development of pre-service teachers. understanding of quality teaching skills and knowledge. The teaching and practice of a values-based pedagogy positively impacted on pre-service teachers with increases of knowledge, skills and confidence demonstrated on the quality teaching dimensions of intellectual quality, a supportive classroom environment, recognition of difference, connectedness and values. These findings were reinforced through the comparison of pre-service teachers who had participated in the explicit values-based pedagogical approach, with a sample of pre-service teachers who had not engaged in this same values-based pedagogical approach. A solid values-based pedagogy and practice can and does enhance pre-service teachers. understanding of quality teaching. These findings surrounding the use of a values-based pedagogy in pre-service teacher education to enhance quality teaching knowledge and skills has contributed theoretically to the field of educational research, as well having practical implications for teacher education institutions and teacher educators.

Challenges to environmental toxicology and epidemiology : where do we stand and which way do we go?

Modern toxicology investigates a wide array of both old and new health hazards. Priority setting is needed to select agents for research from the plethora of exposure circumstances. The changing societies and a growing fraction of the aged have to be taken into consideration. A precise exposure assessment is of importance for risk estimation and regulation. Toxicology contributes to the exploration of pathomechanisms to specify the exposure metrics for risk estimation. Combined effects of co-existing agents are not yet sufficiently understood. Animal experiments allow a separate administration of agents which can not be disentangled by epidemiological means, but their value is limited for low exposure levels in many of today’s settings. As an experimental science, toxicology has to keep pace with the rapidly growing knowledge about the language of the genome and the changing paradigms in cancer development. During the pioneer era of assembling a working draft of the human genome, toxicogenomics has been developed. Gene and pathway complexity have to be considered when investigating gene–environment interactions. For a best conduct of studies, modern toxicology needs a close liaison with many other disciplines like epidemiology and bioinformatics.