Quantitative Detection and Genotyping of Helicobacter pylori from Stool using Droplet Digital PCR Reveals Variation in Bacterial Loads that Correlates with cagA Virulence Gene Carriage.

BACKGROUND: Epidemiologic studies of the carcinogenic stomach bacterium Helicobacter pylori have been limited by the lack of noninvasive detection and genotyping methods. We developed a new stool-based method for detection, quantification, and partial genotyping of H. pylori using droplet digital PCR (ddPCR), which allows for increased sensitivity and absolute quantification by PCR partitioning. MATERIALS AND METHODS: Stool-based ddPCR assays for H. pylori 16S gene detection and cagA virulence gene typing were tested using a collection of 50 matched stool and serum samples from Costa Rican volunteers and 29 H. pylori stool antigen-tested stool samples collected at a US hospital. RESULTS: The stool-based H. pylori 16S ddPCR assay had a sensitivity of 84% and 100% and a specificity of 100% and 71% compared to serology and stool antigen tests, respectively. The stool-based cagA genotyping assay detected cagA in 22 (88%) of 25 stools from CagA antibody-positive individuals and four (16%) of 25 stools from CagA antibody-negative individuals from Costa Rica. All 26 of these samples had a Western-type cagA allele. Presence of serum CagA antibodies was correlated with a significantly higher load of H. pylori in the stool. CONCLUSIONS: The stool-based ddPCR assays are a sensitive, noninvasive method for detection, quantification, and partial genotyping of H. pylori. The quantitative nature of ddPCR-based H. pylori detection revealed significant variation in bacterial load among individuals that correlates with presence of the cagA virulence gene. These stool-based ddPCR assays will facilitate future population-based epidemiologic studies of this important human pathogen.

Evaluation of tcdB real-time PCR in a three-step diagnostic algorithm for detection of toxigenic Clostridium difficile.

Clostridium difficile is the most common infectious cause of diarrhea in hospitalized patients. The optimal approach for the detection of toxigenic C. difficile remains controversial because no single test is sensitive, specific, and affordable. We have developed a real-time PCR method (direct stool PCR [DPCR]) to detect the tcdB gene encoding toxin B directly from stool specimens and have combined it with enzyme immunoassays (EIAs) in a three-step protocol. DPCR was performed on 699 specimens that were positive for C. difficile glutamate dehydrogenase (GDH) by Wampole C Diff Quik Chek EIA (GDH-Q) and negative for toxins A and B by Wampole Tox A/B Quik Chek EIA (AB-Q), performed sequentially. The performance of this three-step algorithm was compared with a modified "gold standard" that combined tissue culture cytotoxicity (CYT) and DPCR. A separate investigation was performed to evaluate the sensitivity of the GDH-Q as a screening test, and toxigenic C. difficile was found in 1.9% of 211 GDH-Q-negative specimens. The overall sensitivity, specificity, and positive and negative predictive values, respectively, were as follows for an algorithm combining GDH-Q, AB-Q, and DPCR: 83.8%, 99.7%, 97.1%, and 97.9%. Those for CYT alone were 58.8%, 100%, 100%, and 94.9%, respectively. In comparison, the sensitivity and specificity of DPCR were estimated to be 97.5% and 99.7%, respectively, using the same modified gold standard. Neither CYT nor toxin EIA was sufficiently sensitive to exclude toxigenic C. difficile, and combining EIAs with CYT in a three-step algorithm failed to substantially improve sensitivity. DPCR is a sensitive and specific method for the detection of toxigenic C. difficile that can provide same-day results at a cost-per-positive test comparable to those of other methods. A three-step algorithm in which DPCR is used to analyze GDH EIA-positive, toxin EIA-negative specimens provides a convenient and specific alternative with rapid results for 87.7% of specimens, although this approach is less sensitive than performing DPCR on all specimens.

Impact of structured education and self management on rural asthma outcomes.

BACKGROUND: This study trialled the outcome for asthma patients of a brief, nurse led, patient education session with general practice review of an Asthma Action Plan. METHODS: Prospective cohort with before-after measures conducted in six rural general practices. Outcome measures were changes over 12 months in self reported asthma control, quality of life, device use, and unscheduled general practice and emergency department visits for asthma exacerbation. RESULTS: Eighty-three patients participated. Mean asthma control score decreased but did not reach statistical significance (p=0.124). Quality of life improved for adults (Wilcoxon rank signed test for two related samples p<0.001). The proportion of patients who had one or more unscheduled visits to their general practitioner over 12 months decreased from 23% to 13% (p=0.178) and emergency department presentations decreased from 9% to 4% (p=0.102). DISCUSSION: Structured general practice based education appears to be an effective preventive health care program, with the potential to reduce expensive unscheduled use of health services.

Does teaching an entire nursing degree rurally have more workforce impact than rural placements?

Education plays a key role in recruitment of health workforce to rural and remote locations. In Australia, Schools of Nursing have set up a variety of educational programmes to encourage rural workforce choices. These programmes include rural campuses and short-term rural placement programmes out of urban campuses. This study compares the relative workforce impacts of rural campus versus short-term rural placements out of urban campus. The single outcome measure - rural or urban location after graduation - showed that the rural school graduated a significantly higher proportion of rural-working graduates (chi(2) 4.46, p = 0.04). However there was no difference in the rural workforce choices of students from rural backgrounds, irrespective of their university location (chi(2) = 1.45, p = 0.23). We conclude that both rural universities and affirmative action for selecting rural students into nursing programmes are effective workforce strategies, but that rural campuses have the added benefit of encouraging under-represented rural students to access university education.

Improving GP diabetes management - A PDSA audit cycle in Western Australia.

BACKGROUND: Tight glucose, blood pressure and lipid control in patients with diabetes can reduce morbidity and mortality from macro- and micro-vascular complications. However, treatment targets are not being met in a large proportion of patients. Clinical audit involves cycles of evaluation of current activity against standards. It allows problems to be identified and action to be taken to address them. METHODS: Annual retrospective audits over 3 years of random samples of up to 20 patient medical records from 13 general practitioners in the midwest region of Western Australia (n=807). Statistical tests compared the second and third audits with the first in regard to completeness of screening, health indicators, and the proportion of patients within The Royal Australian College of General Practitioners and Diabetes Australia guidelines targets. RESULTS: While there was a significant improvement in lipid monitoring over the study period (p<0.001), monitoring of HbA1c and blood pressure (BP) remained unchanged. Between the first and third audits, a reduction in mean HbA1c (p<0.001), mean total cholesterol (p=0.017), mean LDL cholesterol (p=0.014) and mean systolic BP (p=0.002) was seen. There was an improvement in the proportion of patients achieving cholesterol goals (measured by LDL and reaching a target of HbA1c <7%) between the first and third audits; however the proportion with BP within target declined. In the third audit, 11% of patients on diet alone, 36% on an oral hypoglycaemic agent, 90% on three oral hypoglycaemic agents and 84% of those on insulin were outside the target HbA1c. In the same audit, of those outside target BP, 53% were on no treatment and 65% were only on one type of medication. Eighty-seven percent of patients outside target cholesterol levels had not been prescribed a statin. DISCUSSION: Many of the audited GPs in our study undertreated BP, HbA1c and cholesterol. Improvement in some areas was seen over the study period, which may have been due to the quality assurance activities undertaken. These results reveal a therapeutic opportunity for reducing cardiovascular events in patients with diabetes. More aggressive management of BP and lipids by GPs may see rewards in terms of reducing cardiovascular events in patients with diabetes.

Rural health in a time of cataclysm.

How can the academic discipline of rural health position itself to be relevant in a global environment dominated by financial crisis and climate change? This commentary by Rural and Remote Health Australasian regional editors looks beyond the present time of gloom to opportunities for this young academic discipline to flourish and increase in impact. Steps towards solutions for each of these major global challenges may well be made in the coming years by rural health research conducted in regional and remote Australia.

Effects of purification on the bioavailability of botulinum neurotoxin type A.

Botulinum neurotoxins (BoNTs) are among the most potent biological toxins for humans. They are primarily produced by the gram-positive, anaerobic spore-forming bacterium, Clostridium botulinum. In bacterial cultures, secreted BoNTs are associated with non-toxic accessory proteins forming large complexes. Neurotoxin-associated proteins have been shown to play an important role in the oral toxicity of BoNTs by protecting them from degradation and digestion by gastric acid and enzymes. Most toxicity studies using BoNTs have been performed using highly purified toxin. In this study, the toxicities of purified and crude BoNT/A toxin preparations were compared. Protein components secreted into culture supernatants along with BoNT/A were identified by mass spectrometry and the contribution of extra proteins found in the soluble crude toxin extracts to the toxicity of BoNTs was determined in mouse models of oral and parenteral botulinum intoxication. Analysis of crude toxin composition permitted assessment of the impact of accessory proteins on the oral bioavailability of BoNT/A toxin in food matrices.

Prison health and public health responses at a regional prison in Western Australia.

OBJECTIVE: To describe the health of inmates in a Western Australian regional prison and evaluate the coverage of public health interventions. DESIGN: Cross-sectional audit of all paper-based and electronic medical notes of inmates at one regional prison in Western Australia. SETTING: A mixed medium-security prison in regional Western Australia. PARTICIPANTS: 185 prisoners, 170 men and 15 women. MAIN RESULTS: The prisoners were mainly young (70% < 35 years of age) and Indigenous (84%). Fifty two percent of prisoners had at least one chronic health condition. There was a significantly higher prevalence of diabetes to that found in the general Indigenous population (15% vs 6% p=0.001), and a significantly lower prevalence hepatitis C (4.5%) compared with both national (29-61%) and State (20%) data. Screening for sexually transmitted infections and blood borne viruses within the first month of incarceration was achieved for 43% of inmates. Vaccination coverage for influenza (36%) and pneumococcal disease (12%) was low. CONCLUSION: This study makes visible the burden of disease and reach of public health interventions within a largely Indigenous regional prisoner population. Our study demonstrates that the additional risks associated with being Indigenous remain in a regional Australian prison but also shows that interventions can be delivered equitably to Indigenous and non-Indigenous inmates. IMPLICATIONS: Ongoing monitoring of prisoner health is critical to take advantage of opportunities to improve public health interventions with timely STI and BBV screening and increased vaccinations rates.

It's enough to make you sick: the impact of racism on the health of Aboriginal Australians.

BACKGROUND: Experience of interpersonal racism has been neglected as a mechanism by which inequalities between Aboriginal and non-Aboriginal people are created and maintained. METHODS: Cross-sectional survey of randomly selected residents of a rural Australian town (n=639). Interpersonal racism was measured by two questions on experiences in the past four weeks of negative racially based treatment that evoked an emotional or physical response. Health was measured with the mental and physical health component scores of the Short-Form 12 and self-reported fair or poor general health. Linear and logistic regressions modelled the effects of interpersonal racism on health, controlling for age, sex, socio-economic status and Aboriginality. FINDINGS: The 183 Aboriginal respondents had lower health component scores, were more than twice as likely to report fair-to-poor general health (34% compared with 17%, p<0.001), and 2.6 to 5.0 times more likely to report negative racially based treatment. Demographic and socio-economic characteristics were not associated with reporting negative racially based treatment. After controlling for other variables, Aboriginal respondents who reported negative treatment were more likely to have poor health on all three measures. Non-Aboriginal respondents who reported experiencing negative treatment had lower mental health component scores. IMPLICATIONS: Experiencing racist treatment should be recognised as a social determinant of health. Improved health care and other initiatives may not eliminate health inequalities in the absence of fundamental changes in how non-Aboriginal people behave towards Aboriginal people.

Initiating a PDSA cycle--improving management of diabetes in rural WA.

Diabetes affects 1 million Australians and is the seventh leading cause of death in Australia. General practitioners play an important role in the management of diabetes, especially in rural areas where there is limited access to specialist providers and services.

Rural health's demographic destiny.

Demography is the study of the size and composition of populations. Populations change size through births, deaths and net-migration. Over time, mortality, fertility and migration patterns create populations that may be large or small, young or old, growing or declining. Rural and remote Australia has a unique demography that determines its health problems and health service needs. The tendency of young adults to leave rural and remote areas for cities means that they leave behind communities which are, on average, older than those found in the cities. Rural and remote women have slightly more children at significantly younger ages, but because of out-migration, the actual number of babies born outside of the cities is smaller than would be expected. Most rural and remote areas already have a high proportion of their population over 65 years old. Many communities with an older population are declining in absolute numbers but the need for health services may be greater than required for smaller, younger communities. In contrast to the trends in total population, the rural and remote Aboriginal and Torres Strait Islander population is growing rapidly. This is the result of a higher proportion of young people, higher fertility rates and lower rates of moving to cities. The health characteristics of rural and remote Australia increasingly reflects the higher morbidity of Indigenous and older people. Responding to this demographic destiny is the present and future challenge.

Clarifying the relationships between health and residential mobility.

Health-selective migration within countries has been implicated as one of the mechanisms by which spatial disadvantage is created and maintained. However, there is conflicting evidence on the nature of the relationship between health and mobility, caused in part by diverse definitions, and age and sex differences. This paper uses the first two waves of data for the middle-aged cohort (aged 45-50 in 1996) of the Australian Longitudinal Study on Women's Health to investigate the relationship between four sets of health variables with subsequent local moves (within the same postcode), longer distance moves (between postcodes) and inter-regional migration from rural and remote areas 'up' the urban hierarchy. After adjusting for socio-economic and marital status, short and longer distance mobility among these middle-aged Australian women was positively associated with long-term and chronic poor health and being a smoker. Moves between postcodes and rural-to-urban migration were positively associated with multiple recent visits to a medical specialist. Our findings are consistent with UK and US studies that have found mobility to be more strongly associated with poor health than good health in mature adults. As the population ages, the health of receiving areas may be adversely affected by relatively unhealthy in-migrants seeking amenities not provided in their former place of residence.

The effect of proximity on park and beach use and physical activity among rural adolescents.

BACKGROUND: Associations between access to environments and levels of physical activity (PA) among adolescents have been established; however the influence of neighborhood design barriers (eg, major roads) on these relationships is less understood. METHODS: In 2006, adolescents (n = 1304) in rural Western Australia completed the Up4it Physical Activity Survey measuring frequency and duration of organized and nonorganized physical activity by season. Geographic Information Systems (GIS) were used to objectively measure distance to nearest park and beach and busy road barriers en route to these destinations. RESULTS: Proximity to parks and beaches was associated with use of these environments for PA among adolescents, but this relationship attenuated after adjustment for presence of a major road. Park and beach use was positively associated with achieving recommended levels of PA. Paradoxically, proximity to these environments was not associated with achieving recommended levels of PA. Results suggest access to parks and beaches is necessary but may be insufficient to achieve recommended levels of PA. These relationships varied by season. CONCLUSIONS: Strategies should be put in place to encourage use of proximate supportive environments. Planning neighborhoods to reduce barriers to access and interventions to overcome seasonal variations in behavior may improve participation levels among adolescents.

Going country: rural student placement factors associated with future rural employment in nursing and allied health.

OBJECTIVE: To measure the rate and predictors of health science graduates joining the rural health workforce following a rural placement. DESIGN: Longitudinal survey including the years immediately prior to and post graduation. SETTING: Western Australian health sciences graduates contacted by email and/or phone. PARTICIPANTS: Allied health and nursing students from urban campuses of three Western Australian universities who had taken a rural placement in their final year of study between 2000 and 2003. MAIN OUTCOME MEASURES: Location of employment six months or more after graduation. RESULTS: Of 429 participating allied health and nursing graduates, 25% had entered the rural workforce. Factors with a positive bivariate association with rural employment were: rural background, health discipline, self-reported value of placement, non-compulsory rural placement, and placements of four weeks or less. After controlling for rural background, the value and duration of the placement were significantly associated with rural employment. CONCLUSIONS: This study augments previous work showing that any prior rural background is a significant predictor of rural work. Rural practitioners of both urban and rural origin who undertake voluntary rural placements are more likely to enter rural practice and consequently mandatory placements may not be helpful to increasing the rural workforce. The quality of a placement is a highly significant factor associated with future workplace choice, the details of which need to be further investigated.

Small-area estimates of general practice workforce shortage in rural and remote Western Australia.

OBJECTIVE: To trial a measure of rural and remote GP access for small areas. DESIGN: A cross-sectional study using geographical information systems software to calculate GP to population rates with a floating catchment of 100 km radius around census collection districts (CCDs). SETTING: Non-metropolitan Western Australia. PARTICIPANTS: The locations and full-time equivalents of GPs and other primary-care doctors were identified through a GP workforce survey. MAIN OUTCOME MEASURES: GP to population ratios for each CCD were classified as being above or below a benchmark of adequate GP access. CCDs with no GP sessions reported within 100 km were identified separately. These categories were investigated by divisions of general practice and by indigenous status, age and employment characteristics of the population. RESULTS: Small-area estimates detected greater variation in access than depicted by conventional methods. Sixty-four per cent of the non-metropolitan population live in CCDs with adequate GP access. Forty-five per cent of indigenous people and 52% of people working in rural industries live in CCDs with access below the benchmark. CONCLUSIONS: The floating catchment method is a powerful tool to identify small areas of inadequate service. It can be applied to measure access to other professionals, medical equipment or facilities.

From workshop to work practice: An exploration of context and facilitation in the development of evidence-based practice.

BACKGROUND: This article examines the process of translating evidence into practice using a facilitation model developed by the Western Australian Centre for Evidence Based Nursing and Midwifery. AIMS: Using the conceptual framework Promoting Action on Research Implementation in Health Services (PARIHS), the aims of the study were (1) to explore the relative and combined importance of context and facilitation in the successful implementation of a new evidence-based clinical practice protocol and (2) to examine the establishment of more lasting change to individuals and organizations that resulted in greater incorporation of the principles of evidence-based practice (EBP). METHODS: A pre-workshop, semi-structured telephone survey with 16 nurse managers in six rural hospitals; a summative evaluation immediately post-workshop with 54 participants; and follow-up, semi-structured interviews with 23 workshop participants. FINDINGS: The contexts in each of the participating hospitals were very different; of the six hospitals, only one had not implemented the new protocol. Five had reviewed their practices and brought them in line with the protocol developed at the workshop. The rate of adoption varied considerably from 2 weeks to months. The participants reported being better informed about EBP in general and were positive about their ability to improve their practice and search more efficiently for best practice information. Underlying motivations for protocol development should be included in the PARIHS framework. IMPLICATIONS FOR EDUCATION: Good facilitation appears to be more influential than context in overcoming the barriers to the uptake of EBP.

Sustainable chronic disease management in remote Australia.

The Sharing Health Care Initiative (SHCI) demonstration project, which aimed to improve management of chronic diseases, was implemented in four small remote communities in the Katherine region which are serviced by the Katherine West Health Board, a remote Aboriginal-community-controlled health organisation in the Northern Territory. We reviewed the project proposal, final report, evaluation reports and transitional funding proposal, and supplemented these with in-depth interviews with key individuals. We determined factors critical to the sustainability of the SHCI project in relation to context, community engagement, systems flexibility and adaptability, the availability and effect of information systems, and the human nature of health care and policy. The project had a significant impact on community awareness of chronic disease and an improvement in clinic processes. We found that a number of interrelated factors promoted sustainability, including: An implementation strategy sufficiently flexible to take account of local conditions; A high level of community engagement; Appropriate timeframes, timing and congruence between national policy and local readiness to implement a chronic disease project; Effective communication between participating organisations; Project champions (key individuals) in participating organisations; Effective use of monitoring and evaluation data; and Adequate and ongoing funding. The absence of a number of these factors, such as poor communication, inhibited sustainability. Other factors could both promote and inhibit. For example, the impact of key individuals was important, but could be idiosyncratic and have negative effects.

Towards a health career for rural and remote students: cultural and structural barriers influencing choices.

OBJECTIVE: To promote tertiary health careers to rural and remote young people. DESIGN: Qualitative research using large and small group discussions and semistructured interviews. SETTING: Fifteen secondary schools in rural and remote Western Australia including five senior secondary schools and 10 district high schools. SUBJECTS: One hundred and twenty students from eight year 10 groups, 35 students from three year 11 groups, 54 students from five year 12 groups, 52 parents, 10 grandparents, 76 teachers and four Aboriginal and Islander Education Officers (AIEO). RESULTS: Students prefer information about the range of health careers to be delivered interactively. Choices to follow a health career at tertiary level were constrained by structural and cultural issues including geographical isolation, financial cost, stereotyping of health professions, insufficient information about the diversity of health careers, obligation to family, community and place and a devalued rural culture. CONCLUSIONS: The under representation of rural and remote students in health related university courses needs to be addressed by long-term strategies taking into account both structural and cultural barriers when making career choices. Health policies should include the provision of financial support for rural and remote students and promote a broad range of health careers as challenging and rewarding life choices that offer much needed services to rural communities.