The family costs of attending hospital outpatient appointments via videoconference and in person

We compared the costs incurred by families attending outpatient appointments at the Royal Children's Hospital (RCH) in Brisbane with those incurred by families who had a consultation via videoconference in their regional area. In each category 200 families were interviewed. The median time spent travelling for videoconferences was 30 min compared with 80 min for face-to-face appointments. Families interviewed in the outpatient department had travelled a median distance of 70 km, while those who had a videoconference at the local hospital had travelled only 20 km. It cost these families much more to attend an appointment at the RCH than to attend a videoconference. Ninety-six per cent of families (193) reported at least one of the following types of expense: 150 families had expenses related to parking (median A$10), 156 had fuel expenses (median A$10) and 122 reported costs related to meals purchased at the RCH (median A$10). Only 21 families who had their appointment via local videoconference reported any additional costs. Specialist appointments via videoconference were a more convenient and cheaper option for families living in regional areas of Queensland than the conventional method of attending outpatient appointments at the specialist hospital in Brisbane.

Silica reduces the toxicity of aluminium to a tropical freshwater fish (Mogurnda mogurnda)

The toxicity of aluminium (Al) to fish in acidic waters has been well documented. It was therefore expected that Al toxicity would be significant in fish communities in Gadjarrigamarndah (Gadji) Creek, a seasonally flowing stream in tropical northern Australia. This creek receives acidic groundwater containing elevated concentrations of Al from earlier land irrigation of treated mine tailings water from the former Nabarlek uranium mine. It was hypothesised that Al toxicity was reduced by high levels of silica (Si) in the water, and the subsequent formation of Al-silicate complexes. This prompted a laboratory assessment of the toxicity of Gadji Creek water to sac-fry of the native fish, Mogurnda mogurnda, followed by more detailed investigation of the toxicity of Al and the influence of Si in reducing Al toxicity. No mortality of M. mogurnda sac-fry was observed in two toxicity tests using Gadji Creek water collected in August 1997 and September 1998. The majority of Al (80-95%) was calculated to be complexed with humic substances and sulfate, with <1% being complexed with silicate. Assessment of the influence of silica on the acute toxicity of Al in the absence of natural organic complexants (i.e. in reconstituted freshwater, pH 5) revealed that Si reduced Al toxicity. As the molar ratio of Si:Al was increased, the percent survival of M. mogurnda sac-fry increased until there was no significant (P > 0.05) difference from the controls. However, speciation modelling again predicted that little (<3%) Al complexed with silicate, with the speciation and bioavailability of Al remaining constant as the molar ratio of Si:Al increased. Therefore, the original hypothesis that Al-silicate complexes in solution reduced the toxicity of Al to M. mogurnda could not be supported. This potential mechanism, and an alternative hypothesis, that Si competes with Al for binding sites at the fish gill surface, requires further investigation. Crown Copyright (C) 2002 Published by Elsevier Science Ltd. All rights reserved.

A new analytical solution for water table fluctuations in coastal aquifers with sloping beaches

The Boussinesq equation appears as the zeroth-order term in the shallow water flow expansion of the non-linear equation describing the flow of fluid in an unconfined aquifer. One-dimensional models based on the Boussinesq equation have been used to analyse tide-induced water table fluctuations in coastal aquifers. Previous analytical solutions for a sloping beach are based on the perturbation parameter, epsilon(N) = alphaepsilon cot beta (in which beta is the beach slope, alpha is the amplitude parameter and epsilon is the shallow water parameter) and are limited to tan(-1) (alphaepsilon) much less than beta less than or equal to pi/2. In this paper, a new higher-order solution to the non-linear boundary value problem is derived. The results demonstrate the significant influence of the higher-order components and beach slope on the water table fluctuations. The relative difference between the linear solution and the present solution increases as 6 and a increase, and reaches 7% of the linear solution. (C) 2003 Elsevier Ltd. All rights reserved.

A review of telemedicine and asthma

The literature contains a number of reports of early work involving telemedicine and chronic disease; however, there are comparatively few studies in asthma. Most of the telemedicine studies in asthma have investigated the use of remote monitoring of patients in the home, e.g. transmitting spirometry data via a telephone modem to a central server. The primary objective of these studies was to improve management. A secondary benefit was that patient adherence to prescribed treatment is also likely to be improved. Early results are encouraging; home monitoring in a randomized controlled trial in Japan significantly reduced the number of emergency room visits by patients with poorly controlled asthma. Other studies have described the cost-benefits of a specialist asthma nurse who can manage patients by telephone contact, as well as deliver asthma education. Many web-based systems are available for the general public or healthcare professionals to improve education in asthma, although their quality is highly variable. The work on telemedicine in asthma clearly shows that the technique holds promise in a number of areas. Unfortunately - as in telemedicine generally - most of the literature in patients with asthma refers to pilot trials and feasibility studies, with short-term outcomes. Large-scale, formal research trials are required to establish the cost effectiveness of telemedicine in asthma.

Telemedicine - the way ahead for medicine in the developing world

An e-mail link with the facility to send high-resolution digital images is a cheap and uncomplicated telemedicine method. The Swinfen Charitable Trust helped establish such a link in Patan Hospital Kathmandu, Nepal in March 2000. Over 12 months using this link 42 telemedicine referrals were sent to specialists throughout the world. Referrals were: 36% respiratory medicine; 21% neurology, 21% dermatology; 14% cardiology; 5% nephrology; and 3% radiology - 28 had digital pictures attached, of which 96% were of high enough quality on which specialists were able to comment. Thirty-nine replies were received. The average time for a specialist reply was 2 days, and 45% were answered within 24 hours. All replies were judged by independent assessors to be helpful or very helpful for diagnosis, management and education. The assessors decided that in 50% of cases the advice if acted upon would have shortened hospital stay. This pilot study has shown that a low-cost telemedicine link is technically feasible and can be of significant benefit for diagnosis, management and education in a developing world setting.

Estimates of global and regional potential health gains from reducing multiple major risk factors

Background Estimates of the disease burden due to multiple risk factors can show the potential gain from combined preventive measures. But few such investigations have been attempted, and none on a global scale. Our aim was to estimate the potential health benefits from removal of multiple major risk factors. Methods We assessed the burden of disease and injury attributable to the joint effects of 20 selected leading risk factors in 14 epidemiological subregions of the world. We estimated population attributable fractions, defined as the proportional reduction in disease or mortality that would occur if exposure to a risk factor were reduced to an alternative level, from data for risk factor prevalence and hazard size. For every disease, we estimated joint population attributable fractions, for multiple risk factors, by age and sex, from the direct contributions of individual risk factors. To obtain the direct hazards, we reviewed publications and re-analysed cohort data to account for that part of hazard that is mediated through other risks. Results Globally, an estimated 47% of premature deaths and 39% of total disease burden in 2000 resulted from the joint effects of the risk factors considered. These risks caused a substantial proportion of important diseases, including diarrhoea (92%-94%), lower respiratory infections (55-62%), lung cancer (72%), chronic obstructive pulmonary disease (60%), ischaemic heart disease (83-89%), and stroke (70-76%). Removal of these risks would have increased global healthy life expectancy by 9.3 years (17%) ranging from 4.4 years (6%) in the developed countries of the western Pacific to 16.1 years (43%) in parts of sub-Saharan Africa. Interpretation Removal of major risk factors would not only increase healthy life expectancy in every region, but also reduce some of the differences between regions, The potential for disease prevention and health gain from tackling major known risks simultaneously would be substantial.

Using a problem detection study (PDS) to identify and compare health care provider and consumer views of antihypertensive therapy

The objectives of this study were to ascertain consumer knowledge and behaviour about hypertension and treatment and to compare these with health care providers' perceptions (of 'most' consumers). The design for the study was a problem detection study (PDS): focus groups and then survey. Focus groups and survey participants were convenience samples of consumers, doctors, nurses and pharmacists. The main outcome measures were agreement on a 5-point Likert scale with statements about consumers' knowledge and behaviour about high blood pressure and medication. The survey identified areas of consensus and disagreement between consumers and health providers. While general knowledge and concordance with antihypertensive therapy among consumers was good, consequences such as eye and kidney disease, interactions with herbal medicines, and how to deal with missing a dose were less well known. Side effects were a problem for over one-quarter of participants, and cost was a problem in continuing therapy. Half the consumers had not received sufficient written information. Providers overall disagreed that most consumers have an adequate understanding of the condition. They agreed that most consumers adhere to therapy and can manage medicines; and about their own profession's role in information provision and condition management. Consumers confirmed positive provider behaviour, suggesting opportunities for greater communication between providers about actions taken with their consumers. In conclusion, the PDS methodology was useful in identifying consumer opinions. Differences between consumer and provider responses were marked, with consumers generally rating their knowledge and behaviour above providers' ratings of 'most' consumers. There are clear gaps to be targeted to improve the outcomes of hypertension therapy.

Hemochromatosis and alcoholic liver disease

The close association of excessive alcohol consumption and clinical expression of hemochromatosis has been of widespread interest for many years. In most populations of northern European extraction, more than 90% of patients with overt hemochromatosis are homozygous for the C282Y mutation in the HFE gene. Nevertheless, the strong association of heavy alcohol intake with the clinical expression of hemochromatosis remains. We (individually or in association with colleagues from our laboratories) have performed three relevant studies in which this association was explored. In the first, performed in 1975 before the cloning of the HFE gene, the frequency of clinical symptoms and signs was compared in patients with classical hemochromatosis who consumed 100 g or more of alcohol per day versus in nondrinkers or moderate drinkers who consumed less than 100 g of alcohol per day. The results showed no difference between the two groups except for features of complications of alcoholism in the first group, especially jaundice, peripheral neuritis, and hepatic failure. Twenty-five percent of those with heavy alcohol consumption showed histologic features of alcoholic liver disease (including cirrhosis) together with heavy iron overload. It was concluded that these patients had the genetic disease complicated by alcoholic liver disease. In the second study (2002), 206 subjects with classical HFE-associated hemochromatosis in whom liver biopsy had been performed were evaluated to quantify the contribution of excess alcohol consumption to the development of cirrhosis in hemochromatosis. Cirrhosis was approximately nine times more likely to develop in subjects with hemochromatosis who consumed more than 60 g of alcohol per day than in those who drank less than this amount. In the third study (2002), 371 C282Y-homozygous relatives of patients with HFE-associated hemochromatosis were assessed. Eleven subjects had cirrhosis on liver biopsy and four of these drank 60 g or more of alcohol per day. The reason why heavy alcohol consumption accentuates the clinical expression of hemochromatosis is unclear. Increased dietary iron or increased iron absorption is unlikely. The most likely explanation would seem to be the added co-factor effect of iron and alcohol, both of which cause oxidative stress, hepatic stellate cell activation, and hepatic fibrogenesis. In addition, the cumulative effects of other forms of liver injury may result when iron and alcohol are present concurrently. Clearly, the addition of dietary iron in subjects homozygous for hemochromatosis would be unwise. (C) 2003 Elsevier Inc. All rights reserved.

Listening to young people's voices: Youth sports leaders' advice on facilitating participation in sport

This article reports on a study that accepts the proposal that we listento the voices of young people in relation to sport and physical recreation.The study sought the advice of young sports leaders on what can be done to facilitate young people’s involvement in sport. The study used group interviews (Nominal Group Technique) with over 600 14–18-year-olds toelicit responses to a single question, ‘What can be done to help young people participate in sport?’ This article focuses on young people’s views on issues to do with climate and conditions. We argue that, while their advice offers support for some current initiatives in youth sport, it also provides new insights and challenges and suggests a reordering of existing priorities for youth sport and leisure provision.

Social positioning and the construction of a youth sports club

This article uses the concept of social positioning to explore the construction of a youth sports club by young people, their parents and coaches. The year-long ethnography of Forest Athletics Club (FAC) identified two athlete positions of Samplers and Beginning Specializers. Four parents’ positions were identified, those of Non-Attenders, Spectators, Helpers and Committed Members. One coach position was the Committed Volunteer. Each of these positions was interdependent. Particular expectations, practices and values were attached to these positions. It is argued that the club operates according to multiple agendas and that FAC is a complex and dynamic social phenomenon that is practised differently by the three groups of key players.

Referral to rehabilitation following traumatic brain injury: a model for understanding inequities in access

Identifying inequities in access to health care requires critical scrutiny of the patterns and processes of care decisions. This paper describes a conceptual model. derived from social problems theory. which is proposed as a useful framework for explaining patterns of post-acute care referral and in particular, individual variations in referral to rehabilitation after traumatic brain injury (TBI). The model is based on three main components: (1) characteristics of the individual with TBI, (2) activities of health care professionals and the processes of referral. and (3) the contexts of care. The central argument is that access to rehabilitation following TBI is a dynamic phenomenon concerning the interpretations and negotiations of health care professionals. which in turn are shaped by the organisational and broader health care contexts. The model developed in this paper provides opportunity to develop a complex analysis of post-acute care referral based on patient factors, contextual factors and decision-making processes. It is anticipated that this framework will have utility in other areas examining and understanding patterns of access to health care. (C) 2002 Elsevier Science Ltd. All rights reserved.