Promoting independence in frail older people: a randomised controlled trial of a restorative care service in New Zealand.

BACKGROUND: frail older people often require tailored rehabilitation in order to remain at home, especially following a period of hospitalisation. Restorative care services aim to enhance an older person's ability to remain improve physical functioning, either at home or in residential care but evidence of their effectiveness is limited. OBJECTIVE: to evaluate the effectiveness of a restorative care service on institutional-free survival and health outcomes in frail older people referred for needs assessment in New Zealand. METHODS: a randomised controlled trial of restorative care or usual care in 105 older people at risk of permanent residential who were follow-up over 24 months. The restorative care service was delivered in short-stay residential care facilities and at participants' residences with the aim of reducing the requirement for permanent residential care. It included a comprehensive geriatric assessment and care plan developed and delivered, initially by a multi-disciplinary team and subsequently by home care assistants. RESULTS: compared with usual care, there was a non-significant absolute risk reduction of 14.3% for death or permanent residential care (8.8% for residential care and 7.2% for death alone) for the restorative care approach. There was no difference in levels of burden among caregivers. CONCLUSIONS: restorative care models that utilise case management and multi-disciplinary care may positively impact on institutional-free survival for frail older people without adversely impacting on the health of caregivers.

A Retrospective Study of Macropod Progressive Periodontal Disease ("Lumpy Jaw") in Captive Macropods Across Australia and Europe: Using Data from the Past to Inform Future Macropod Management.

Macropod Progressive Periodontal Disease (MPPD) is a well-recognised disease that causes high morbidity and mortality in captive macropods worldwide. Epidemiological data on MMPD are limited, although multiple risk factors associated with a captive environment appear to contribute to the development of clinical disease. The identification of risk factors associated with MPPD would assist with the development of preventive management strategies, potentially reducing mortality. Veterinary and husbandry records from eight institutions across Australia and Europe were analysed in a retrospective cohort study (1995 to 2016), examining risk factors for the development of MPPD. A review of records for 2759 macropods found incidence rates (IR) and risk of infection differed between geographic regions and individual institutions. The risk of developing MPPD increased with age, particularly for macropods >10 years (Australia Incidence Rate Ratio (IRR) 7.63, p < 0.001; Europe IRR 7.38, p < 0.001). Prognosis was typically poor, with 62.5% mortality reported for Australian and European regions combined. Practical recommendations to reduce disease risk have been developed, which will assist zoos in providing optimal long-term health management for captive macropods and, subsequently, have a positive impact on both the welfare and conservation of macropods housed in zoos globally.

Is inequality at the heart of it? Cross-country associations of income inequality with cardiovascular diseases and risk factors.

Despite a number of cross-national studies that have examined the associations between income inequality and broad health outcomes such as life expectancy and all-cause mortality, investigations of the cross-country relations between income inequality and cardiovascular disease (CVD) morbidity, mortality, and risk factors are sparse. We analyzed the cross-national relations between income inequality and age-standardized mean body mass index (BMI), serum total cholesterol, systolic blood pressure (SBP), obesity prevalence, smoking impact ratio (SIR), and age-standardized and age-specific disability-adjusted life-years (DALYs) and mortality rates from coronary heart disease (CHD) and stroke, controlling for multiple country-level factors and specifying 5- to 10-year lag periods. In multivariable analyses primarily limited to industrialized countries, countries in the middle and highest (vs. lowest) tertiles of income inequality had higher absolute age-standardized obesity prevalences in both sexes. Higher income inequality was also related to higher mean SBP in both sexes, and higher SIR in women. In analyses of larger sets of countries with available data, positive associations were observed between higher income inequality and mean BMI, obesity prevalence, and CHD DALYs and mortality rates. Associations with stroke outcomes were inverse, yet became positive with the inclusion of eastern bloc and other countries in recent economic/political transition. China was also identified to be an influential data point, with the positive associations with stroke mortality rates becoming attenuated with its inclusion. Overall, our findings are compatible with harmful effects of income inequality at the national scale on CVD morbidity, mortality, and selected risk factors, particularly BMI/obesity. Future studies should consider income inequality as an independent contributor to variations in CVD burden globally.

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.

IMProving Adherence using Combination Therapy (IMPACT): design and protocol of a randomised controlled trial in primary care.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death, and principal reason for the large difference in life expectancy between indigenous Maori and the non-indigenous population in New Zealand. CVD guidelines recommend that people who are at high risk or who have had previous CVD should be offered aspirin, blood pressure lowering and lipid lowering therapies. However, prescribing and adherence rates are low and CVD events remain high. AIM: To assess whether a medication strategy using a fixed dose combination pill ('polypill') could improve prescribing and adherence to recommended medications, lower blood pressure and improve lipids compared with current care over 12 months. METHODS: IMProving Adherence using Combination Therapy (IMPACT) is an open-label randomised controlled trial comparing a once-daily polypill containing four preventive medications with usual care. Six hundred participants who have had previous CVD events or are at high risk of CVD will be enrolled, including 300 Maori. Participants are identified, enrolled and prescribed either the polypill or current medications at their usual primary health care practice, with medications (including the polypill) dispensed through local community pharmacies. The polypill contains 75 mg aspirin, 40 mg simvastatin, 10mg lisinopril and either 12.5mg hydrochlorothiazide or 50mg atenolol. Primary outcomes are adherence to guidelines-recommended medications and changes in systolic blood pressure and low density lipoprotein at 12 months. Secondary outcomes include other lipids, medication dispensing, barriers to adherence, CVD and other serious adverse events, quality of life and prescriber acceptability. The trial is registered with the Australian New Zealand Clinical Trial Registry (ACTRN12606000067572).

Estimating energy expenditure with the RT3 triaxial accelerometer.

The RT3 is a relatively new triaxial accelerometer that has replaced the TniTrac. The aim of this study was to validate the RT3 against doubly labeled water (DLW) in a free-living, mixed weight sample of adults. Total energy expenditure (TEE) was measured over a 15-day period using DLW Activity-related energy expenditure (AEE) was estimated by subtracting resting energy expenditure and thermic effect of feeding from TEE. The RT3 triaxial accelerometer was worn over 14 consecutive days. TEE and AEE were estimated using the RT3 proprietary equation. Thirty-six adults ages 18-56 years (56% women) with an average weight of 75.9 kg (SD = 14.8) completed all measurements. Compared to DLW the RT3 underestimated TEE by 539 kJ (4%) and AEE by 485 kJ (15%) on average. The RT3 provided a relatively accurate assessment of free-living activity-related energy expenditure at the group level and generally underestimated total and activity-related energy expenditure compared to DLW

Nutrition and the burden of disease in New Zealand: 1997-2011.

OBJECTIVE: To estimate the burden of disease due to selected nutrition-related risk factors (high total blood cholesterol, high systolic blood pressure, high body mass index (BMI) and inadequate vegetable and fruit intake) in 1997, as well as the burden that could potentially be avoided in 2011 if small, favourable changes in the current risk factor distribution were to occur. DESIGN: Data on risk factor levels, disease burden and risk associations were combined using comparative risk assessment methodology, a systematic approach to estimating both attributable and avoidable burden of disease. Disease outcomes assessed varied according to risk factor and included ischaemic heart disease, stroke, type 2 diabetes mellitus and selected cancers. SETTING: New Zealand. RESULTS: Approximately 4500 deaths (17% of all deaths) in 1997 were attributable to high cholesterol, 3500 (13%) to high blood pressure, 3000 (11%) to high BMI and 1500 (6%) to inadequate vegetable and fruit intake. Taking prevalence overlap into account, these risk factors were estimated jointly to contribute to approximately 11 000 (40%) deaths annually in New Zealand. Approximately 300 deaths due to each risk factor could potentially be avoided in 2011 if modest changes were made to each risk factor distribution. CONCLUSIONS: High cholesterol, blood pressure and BMI, as well as inadequate vegetable and fruit intake, are major modifiable causes of death in New Zealand. Small changes in the population distribution of these risk factors could have a major impact on population health within a decade.