Health risks from indoor gas appliances.

BACKGROUND: Cooking and heating with gas is common in Australian homes and is a risk factor for several important health problems; however, there is little awareness of these risks among doctors or the public. Gas stove use is estimated to cause 12% of childhood asthma in Australia. OBJECTIVE: The aim of this article is to help general practitioners identify when gas combustion products such as nitrogen dioxide might be contributing to asthma in children and adults and to alert them to the risks of carbon monoxide (CO) poisoning, which can be hard to diagnose. DISCUSSION: There are excellent alternatives to the use of gas in domestic appliances and some simple behavioural changes that can reduce exposure in situations where appliances cannot yet be removed. CO poisoning can be insidious. Mild exposure can cause headache, nausea, vomiting, dizziness, malaise and confusion, so it can be mistaken for common conditions such as influenza or gastroenteritis. The COMA mnemonic is clinically useful. Increased awareness of these issues can provide patients with safer and healthier living environments.

Opportunity to reduce paediatric asthma in New South Wales through nitrogen dioxide control.

OBJECTIVE: The main sources of nitrogen dioxide (NO2 ), road vehicles and electricity generation, are currently in a period of technological change. We assessed the number of cases of childhood asthma in New South Wales that could be avoided by lowering exposure to NO2 by 25% from current levels. METHODS: Health impact assessment calculations for each of the 128 local government areas were based on the population of children aged 2 to 14, the prevalence of asthma derived from the 2017 NSW health survey, NO2 exposure from a land-use regression model using satellite data, and risk estimates derived from two meta-analyses and one Australian study. RESULTS: A 25% reduction in NO2 below current exposure would lead to between 2,597 and 12,286 fewer children with asthma in NSW. The wide range in these estimates reflects the variation in concentration-response functions used. CONCLUSIONS: Even the lowest of these estimates would be a worthwhile reduction in this common childhood illness. Implications for public health: A 25% reduction in NO2 is ambitious, but it is achievable through improved vehicle exhaust standards, increasing electric vehicle numbers, and reform of the electricity sector. Current Australian ambient air quality standards for annual NO2 should be revised downwards.

Predictors of adherence to a physical activity counseling intervention delivered by exercise physiologists: secondary analysis of the NewCOACH trial data.

BACKGROUND: General practitioners (GPs) cite time as a barrier to physical activity counseling. An alternative for time-poor GPs in Australia is the referral of insufficiently active patients to exercise physiologists (EPs). As data on the predictors of adherence to physical activity counseling interventions are limited, this study aimed to identify the sociodemographic, medical, health, and psychological characteristics of insufficiently active primary care patients who adhered to a physical activity counseling intervention delivered by EPs. METHODS: This secondary analysis of data from the NewCOACH randomized trial used logistic regression to identify predictors of adherence, defined as patient participation in at least four of the five physical activity counseling sessions. EPs provided information about the number of sessions, while other potential predictors were obtained from the self-administered baseline questionnaire and medical summary sheets provided by the GPs. RESULTS: Of the 132 patients referred to an EP, 102 (77%) were adherent: 91 (69%) and eleven (8.3%) participated in all, or all but one, of the sessions, respectively. Of the remainder, seven (5.3%) patients participated in three sessions, seven (5.3%) participated in two sessions, five (3.8%) participated in one session, and eleven (8.3%) did not participate in any session. The odds of being adherent were 5.84 (95% CI 1.46-23.4, P≤0.05) times higher among retired participants than in those who were not in paid employment. The odds of being adherent 1) increased as the positive outcome expectation score increased (OR 1.89, 95% CI 1.12-3.18, P≤0.05) and 2) decreased as the duration (days) between referral and the initial counseling session increased (OR 0.95, 95% CI 0.92-0.98, P<0.01). CONCLUSION: More than three quarters of the patients participated in all, or all but one, of the sessions. Being retired, positive outcome expectations, and having a shorter wait between referral and the initial appointment predicted adherence.

Physical activity coaching by Australian Exercise Physiologists is cost effective for patients referred from general practice.

OBJECTIVE: Interventions to promote physical activity for sedentary patients seen in general practice may be a way to reduce the burden of chronic disease. Coaching by an exercise physiologist is publicly funded in Australia, but cost effectiveness has not been documented. METHODS: In a three-arm randomised controlled trial, face-to-face coaching and telephone coaching over 12 weeks were compared with a control group using the outcome of step count for one week at baseline, three months and twelve months. Program costs and time-based costs were considered. Quality of life was measured as a secondary outcome. RESULTS: At 12 months, the intervention groups were more active than controls by 1,002 steps per day (95%CI 244, 1,759). This was achieved at a cost of AUD$245 per person. There was no change in reported quality of life or utility values. CONCLUSION: Coaching achieved a modest increase in activity equivalent to 10 minutes walking per day, at a cost of AUD$245 per person. Face-to-face and telephone counselling were both effective. Implication for public health: Persistence of increases nine months after the end of coaching suggests it creates long-term change and is a good value health intervention.

Quantifying the benefits and harms of various preventive health activities

Background and objective: It is helpful for general practitioners (GPs) and their patients to understand the amount of health benefit expected from different preventive activities to enable a thoughtful choice of which to adopt first. The aim of this article is to illustrate how it might be possible to quantify the mortality benefit for cancer screening, quitting smoking, losing weight and treating lipids, which are preventive activities from The Royal Australian College of General Practitioners' (RACGP's) Guidelines for preventive activities in general practice (Red Book). Methods: A sample of common preventive activities was taken, with an outcome for each selected for fair comparison, and benefits and harms were estimated. Results: For a man aged 50 years, the benefit in terms of reduced risk of dying is greatest for quitting smoking (at 24 fewer deaths/1000/decade), which is approximately 10 times the benefit of lowering lipids in a man with metabolic syndrome and about 50 times greater than from participating in regular colorectal cancer screening. Benefits for women are generally lower, as their baseline risk is lower. Discussion: It is feasible to quantify the benefits of some preventive activities, although estimating them is not straightforward and requires several assumptions. Nevertheless, extending estimates such as these to the items in the RACGP's Red Book would assist GPs and their patients' preventive activity prioritisation.

Referral for Expert Physical Activity Counseling: A Pragmatic RCT.

INTRODUCTION: Primary care physicians are well placed to offer physical activity counseling, but insufficient time is a barrier. Referral to an exercise specialist is an alternative. In Australia, exercise specialists are publicly funded to provide face-to-face counseling to patients who have an existing chronic illness. This trial aimed to (1) determine the efficacy of primary care physicians' referral of insufficiently active patients for counseling to increase physical activity, compared with usual care, and (2) compare the efficacy of face-to-face counseling with counseling predominantly via telephone. STUDY DESIGN: Three-arm pragmatic RCT. SETTING/PARTICIPANTS: Two hundred three insufficiently active (<7,000 steps/day) primary care practice patients (mean age 57 years; 70% female) recruited in New South Wales, Australia, in 2011-2014. INTERVENTION: (1) Five face-to-face counseling sessions by an exercise specialist, (2) one face-to-face counseling session followed by four telephone calls by an exercise specialist, or (3) a generic mailed physical activity brochure (usual care). The counseling sessions operationalized social cognitive theory via a behavior change counseling framework. MAIN OUTCOME MEASURES: Change in average daily step counts between baseline and 12 months. Data were analyzed in 2016. RESULTS: Forty (20%) participants formally withdrew; completion rates at 3 and 6 months were 64% and 58%, respectively. Intervention attendance was high (75% received five sessions). The estimated mean difference between usual care and the combined intervention groups at 12 months was 1,002 steps/day (95% CI=244, 1,759, p=0.01). When comparing face-to-face with predominantly telephone counseling, the telephone group had a non-significant higher mean daily step count (by 619 steps) at 12 months. CONCLUSIONS: Provision of expert physical activity counseling to insufficiently active primary care patients resulted in a significant increase in physical activity (approximately 70 minutes of walking per week) at 12 months. Face-to-face only and counseling conducted predominantly via telephone were both effective. This trial provides evidence to expand public funding for expert physical activity counseling and for delivery via telephone in addition to face-to-face consultations. TRIAL REGISTRATION: This trial is registered at www.anzctr.org.au/ ACTRN12611000884909.

Daily step count and the need for hospital care in subsequent years in a community-based sample of older Australians.

OBJECTIVES: To determine the extent to which physical activity reduces the number of hospital bed-days for Australians over 55, using an objective measure of activity. DESIGN, SETTING AND PARTICIPANTS: 9784 Newcastle residents aged 55 years or more were invited to participate. 3253 responders were eligible and wore pedometers for one week during 2005-2007; their hospital data from recruitment to 31 March 2015 were analysed (mean follow-up time: 8.2 years). Complete data for 2110 people were available for analysis. MAIN OUTCOME MEASURES: Mean annual hospital bed-days, according to individual step count. RESULTS: There was a statistically significant reduction in the number of hospital bed-days associated with higher step counts; the incidence rate ratio per extra 1000 steps per day at baseline was 0.91 (95% CI, 0.90-0.94). The disease-specific reductions were significant for admissions for cancer and diabetes, but not for cardiovascular disease. The difference between 4500 and 8800 steps per day (the upper and lower quartile boundaries for step count) was 0.36 bed-days per person per year, after adjusting for age, sex, number of medications, number of comorbidities, smoking and alcohol status, and education. When analysis was restricted to hospital admissions after the first 2 years of follow-up, the difference was 0.29 bed-days per person per year. CONCLUSIONS: More active people require less hospital care, and an achievable extra 4300 steps per day would result in an average of one less day in hospital for each 3 years of life.

Efficacy of GP referral of insufficiently active patients for expert physical activity counseling: protocol for a pragmatic randomized trial (The NewCOACH trial).

BACKGROUND: Physical inactivity is fourth in the list of risk factors for global mortality. General practitioners are well placed to offer physical activity counseling but insufficient time is a barrier. Although referral to an exercise specialist is an alternative, in Australia, these allied health professionals are only publicly funded to provide face-to-face counseling to patients who have an existing chronic illness. Accordingly, this trial aims to determine the efficacy of GP referral of insufficiently active patients (regardless of their chronic disease status) for physical activity counseling (either face-to-face or predominately via telephone) by exercise specialists, based on patients' objectively assessed physical activity levels, compared with usual care. If the trial is efficacious, the equivalence and cost-effectiveness of face-to-face counseling versus telephone counseling will be assessed. METHODS: This three arm pragmatic randomized trial will involve the recruitment of 261 patients from primary care clinics in metropolitan and regional areas of New South Wales, Australia. Insufficiently active (less than 7000 steps/day) consenting adult patients will be randomly assigned to: 1) five face-to-face counseling sessions, 2) one face-to-face counseling session followed by four telephone calls, or 3) a generic mailed physical activity brochure (usual care). The interventions will operationalize social cognitive theory via a behavior change counseling framework. Participants will complete a survey and seven days of pedometry at baseline, and at three and 12 months post-randomization. The primary analyses will be based on intention-to-treat principles and will compare: (i) mean change in average daily step counts between baseline and 12 months for the combined intervention group (Group 1: face-to-face, and Group 2: telephone) and usual care (Group 3); (ii) step counts at 3 months post-randomization. Secondary outcomes include: self-reported physical activity, sedentary behavior, quality of life, and depression. DISCUSSION: If referral of primary care patients to exercise specialists increases physical activity, this process offers the prospect of systematically and sustainably reaching a large proportion of insufficiently active adults. If shown to be efficacious this trial provides evidence to expand public funding beyond those with a chronic disease and for delivery via telephone as well as face-to-face consultations. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12611000884909 .

How many steps are enough? Dose-response curves for pedometer steps and multiple health markers in a community-based sample of older Australians.

BACKGROUND: Although an overall public health target of 10,000 steps per day has been advocated, the dose-response relationship for each health benefit of physical activity may differ. METHODS: A representative community sample of 2458 Australian residents aged 55-85 wore a pedometer for a week in 2005-2007 and completed a health assessment. Age-standardized steps per day were compared with multiple markers of health using locally weighted regression to produce smoothed dose-response curves and then to select the steps per day matching 60% or 80% of the range in each health marker. RESULTS: There is a linear relationship between activity level and markers of inflammation throughout the range of steps per day; this is also true for BMI in women and high density lipoprotein in men. For other markers, including waist:hip ratio, fasting glucose, depression, and SF-36 scores, the benefit of physical activity is mostly in the lower half of the distribution. CONCLUSIONS: Older adults have no plateau in the curve for some health outcomes, even beyond 12,000 steps per day. For other markers, however, there is a threshold effect, indicating that most of the benefit is achieved by 8000 steps per day, supporting this as a suitable public health target for older adults.

Discomfort sharing the general practice waiting room with mentally ill patients: a cross-sectional study.

BACKGROUND: Most mental illness is managed in general practice rather than specialist psychiatric settings. Management of mental illness in general practice is advocated as being less stigmatizing than psychiatric settings. Thus, other patients' discomfort with sharing the waiting room with the mentally ill may be problematic. OBJECTIVES: To examine prevalence and associations of discomfort of general practice waiting room patients with fellow patients with mental illness and the implications for practices of these attitudes. We sought attitudes reflecting social distance, a core element of stigmatization. METHODS: A cross-sectional waiting room questionnaire-based study in 15 Australian general practices. Outcome measures were discomfort sharing a waiting room with patients with mental illness, likelihood of changing GP practice if that practice provided specialized care for patients with mental illness, and the perception that general practice is a setting where patients with mental illness should be treated. RESULTS: Of 1134 participants (response rate 78.5%), 29.7% and 12.2%, respectively, reported they would be uncomfortable sharing a waiting room with a patient with schizophrenia or severe depression/anxiety. Only 29.9% and 48.8%, respectively, felt that general practice was an appropriate location for treatment of schizophrenia or severe depression/anxiety. Ten per cent would change their current practice if it provided specialized care for mentally ill patients. CONCLUSIONS: This desire of general practice patients for social distance from fellow patients with mental illness may have implications for both the GPs with a particular interest in mental disorders and the care-seeking and access to care of patients with mental illness.

Waiting room ambience and provision of opioid substitution therapy in general practice.

OBJECTIVE: To assess whether patients receiving opioid substitution therapy (OST) in general practice cause other patients sufficient distress to change practices--a perceived barrier that prevents general practitioners from prescribing OST. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional questionnaire-based survey of consecutive adult patients in the waiting rooms of a network of research general practices in New South Wales during August-December 2009. MAIN OUTCOME MEASURES: Prevalence of disturbing waiting room experiences where drug intoxication was considered a factor, discomfort about sharing the waiting room with patients being treated for drug addiction, and likelihood of changing practices if the practice provided specialised care for patients with opiate addiction. RESULTS: From 15 practices (eight OST-prescribing), 1138 of 1449 invited patients completed questionnaires (response rate, 78.5%). A disturbing experience in any waiting room at any time was reported by 18.0% of respondents (203/1130), with only 3.1% (35/1128) reporting that drug intoxication was a contributing factor. However, 39.3% of respondents (424/1080) would feel uncomfortable sharing the waiting room with someone being treated for drug addiction. Respondents were largely unaware of the OST-prescribing status of the practice (12.1% of patients attending OST-prescribing practices [70/579] correctly reported this). Only 15.9% of respondents (165/1037) reported being likely to change practices if theirs provided specialised care for opiate-addicted patients. In contrast, 28.7% (302/1053) were likely to change practices if consistently kept waiting more than 30 minutes, and 26.6% (275/1033) would likely do so if consultation fees increased by $10. CONCLUSIONS: Despite the frequency of stigmatising attitudes towards patients requiring treatment for drug addiction, GPs' concerns that prescribing OST in their practices would have a negative impact on other patients' waiting room experiences or on retention of patients seem to be unfounded.

How many steps/day are enough? For older adults and special populations.

Older adults and special populations (living with disability and/or chronic illness that may limit mobility and/or physical endurance) can benefit from practicing a more physically active lifestyle, typically by increasing ambulatory activity. Step counting devices (accelerometers and pedometers) offer an opportunity to monitor daily ambulatory activity; however, an appropriate translation of public health guidelines in terms of steps/day is unknown. Therefore this review was conducted to translate public health recommendations in terms of steps/day. Normative data indicates that 1) healthy older adults average 2,000-9,000 steps/day, and 2) special populations average 1,200-8,800 steps/day. Pedometer-based interventions in older adults and special populations elicit a weighted increase of approximately 775 steps/day (or an effect size of 0.26) and 2,215 steps/day (or an effect size of 0.67), respectively. There is no evidence to inform a moderate intensity cadence (i.e., steps/minute) in older adults at this time. However, using the adult cadence of 100 steps/minute to demark the lower end of an absolutely-defined moderate intensity (i.e., 3 METs), and multiplying this by 30 minutes produces a reasonable heuristic (i.e., guiding) value of 3,000 steps. However, this cadence may be unattainable in some frail/diseased populations. Regardless, to truly translate public health guidelines, these steps should be taken over and above activities performed in the course of daily living, be of at least moderate intensity accumulated in minimally 10 minute bouts, and add up to at least 150 minutes over the week. Considering a daily background of 5,000 steps/day (which may actually be too high for some older adults and/or special populations), a computed translation approximates 8,000 steps on days that include a target of achieving 30 minutes of moderate-to-vigorous physical activity (MVPA), and approximately 7,100 steps/day if averaged over a week. Measured directly and including these background activities, the evidence suggests that 30 minutes of daily MVPA accumulated in addition to habitual daily activities in healthy older adults is equivalent to taking approximately 7,000-10,000 steps/day. Those living with disability and/or chronic illness (that limits mobility and or/physical endurance) display lower levels of background daily activity, and this will affect whole-day estimates of recommended physical activity.

A self-controlled case series to assess the effectiveness of beta blockers for heart failure in reducing hospitalisations in the elderly.

BACKGROUND: To determine the suitability of using the self-controlled case series design to assess improvements in health outcomes using the effectiveness of beta blockers for heart failure in reducing hospitalisations as the example. METHODS: The Australian Government Department of Veterans' Affairs administrative claims database was used to undertake a self-controlled case-series in elderly patients aged 65 years or over to compare the risk of a heart failure hospitalisation during periods of being exposed and unexposed to a beta blocker. Two studies, the first using a one year period and the second using a four year period were undertaken to determine if the estimates varied due to changes in severity of heart failure over time. RESULTS: In the one year period, 3,450 patients and in the four year period, 12, 682 patients had at least one hospitalisation for heart failure. The one year period showed a non-significant decrease in hospitalisations for heart failure 4-8 months after starting beta-blockers, (RR, 0.76; 95% CI (0.57-1.02)) and a significant decrease in the 8-12 months post-initiation of a beta blocker for heart failure (RR, 0.62; 95% CI (0.39, 0.99)). For the four year study there was an increased risk of hospitalisation less than eight months post-initiation and significant but smaller decrease in the 8-12 month window (RR, 0.90; 95% CI (0.82, 0.98)). CONCLUSIONS: The results of the one year observation period are similar to those observed in randomised clinical trials indicating that the self-controlled case-series method can be successfully applied to assess health outcomes. However, the result appears sensitive to the study periods used and further research to understand the appropriate applications of this method in pharmacoepidemiology is still required. The results also illustrate the benefits of extending beta blocker utilisation to the older age group of heart failure patients in which their use is common but the evidence is sparse.

Flow-cycled versus time-cycled synchronized ventilation for neonates.

BACKGROUND: Synchronized ventilation of neonates is standard care in industrialized countries. Both flow-cycled and time-cycled modes of synchronized ventilation are in widespread use for assisted ventilation of neonates. OBJECTIVES: To determine the effect of flow-cycled versus time-cycled synchronized ventilation on the risk of bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (PMA) in neonates requiring assisted ventilation. SEARCH STRATEGY: We used the standard methods of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 4, 2009, PubMed (January 1966 to October 2009), EMBASE (January 1974 to October 2009) and CINAHL (January 1982 to October 2009). We checked references and cross-references from identified studies. Abstracts from the proceedings of the Pediatric Academic Societies Meetings (from January 1990 to October 2009) were handsearched. We placed no restrictions on language. SELECTION CRITERIA: Randomized or quasi-randomized clinical trials comparing flow-cycled with time-cycled synchronized endotracheal ventilation in neonates, reporting on at least one outcome of interest were eligible for inclusion in the review. DATA COLLECTION AND ANALYSIS: One author (SMS) searched the literature as described above. Selection of studies and data extraction were done separately by two authors (SMS and SKP). Any disagreements were resolved by discussion involving all authors. MAIN RESULTS: Only two small, short-term, randomized, individual cross-over trials involving a total of 19 preterm neonates met the inclusion criteria of this review. Both trials reported on lung mechanics and short-term respiratory physiology outcomes but not on clinical morbidities or mortality. AUTHORS' CONCLUSIONS: There is insufficient evidence to determine the safety and efficacy of flow-cycled compared to time-cycled synchronized ventilation in neonates. Large randomized clinical trials using a parallel-group design and reporting on clinically important outcomes are warranted.

Association between Participation in Outpatient Cardiac Rehabilitation and Self-Reported Receipt of Lifestyle Advice from a Healthcare Provider: Results of a Population-Based Cross-Sectional Survey.

We test the hypothesis that the odds of self-reported receipt of lifestyle advice from a health care provider will be lower among outpatient cardiac rehabilitation (OCR) nonattendees and nonreferred patients compared to OCR attendees. Logistic regression was used to analyse cross-sectional data provided by 65% (4971/7678) of patients aged 20 to 84 years discharged from public hospitals with a diagnosis indicating eligibility for OCR between 2002 and 2007. Among respondents, 71% (3518) and 55% (2724) recalled advice regarding physical activity and diet, respectively, while 88% (592/674) of smokers recalled quit advice. OCR attendance was low: 36% (1764) of respondents reported attending OCR, 11% (552) did not attend following referral, and 45% (2217) did not recall being invited. The odds of recalling advice regarding physical activity and diet were significantly lower among OCR nonattendees compared to attendees (OR 0.34, 95% CI 0.21, 0.56 and OR 0.33, 95% CI 0.25, 0.44, resp.) and among nonreferred respondents compared to OCR attendees (OR 0.10, 95% CI 0.07, 0.15 and OR 0.17, 95% CI 0.14, 0.22, resp.). Patients hospitalised for coronary heart disease should be referred to OCR or a suitable alternative to improve recall of lifestyle advice that will reduce the risk of further coronary events.