Hay fever in a changing climate: linking an Internet-based diary with environmental data.

Investigating the impact of climate change on human health requires the development of efficient tools that link patient symptoms with changing environmental variables. We developed an internet-based hay fever diary linked to simultaneously recorded pollen load and weather variables in Canberra, Australia over spring 2010. We recruited 42 hay fever sufferers to complete a simple online pollen diary daily over a period of 60 days. In conjunction, daily airborne pollen load was counted and meteorological data collected simultaneously. We focused on the relationships between temperature, rainfall, pollen count and rhinoconjunctivitis symptoms. Pollen load increased after a peak rainfall event until the end of the study. Compliance was high, averaging 79% of days per person. Nasal rhinoconjunctivitis symptoms increased in concert with increasing pollen load, and then remained high. Mucosal itching increased more gradually and strongly coincided with increased daily maximum temperature. Our study successfully demonstrated the feasibility of linking pollen load and climate variables to symptoms of rhinoconjunctivitis in the Australian community. However, a larger study would better explore the nature of associations between these variables. Similar online methods could be used to monitor a range of health responses to our changing environment.

Oral folic acid and vitamin B-12 supplementation to prevent cognitive decline in community-dwelling older adults with depressive symptoms--the Beyond Ageing Project: a randomized controlled trial.

BACKGROUND: Evidence remains unclear as to whether folic acid (FA) and vitamin B-12 supplementation is effective in reducing depressive symptoms. OBJECTIVES: The objective was to determine whether oral FA + vitamin B-12 supplementation prevented cognitive decline in a cohort of community-dwelling older adults with elevated psychological distress. DESIGN: A randomized controlled trial (RCT) with a completely crossed 2 × 2 × 2 factorial design comprising daily oral 400 µg FA + 100 µg vitamin B-12 supplementation (compared with placebo), physical activity promotion, and depression literacy with comparator control interventions for reducing depressive symptoms was conducted in 900 adults aged 60-74 y with elevated psychological distress (Kessler Distress 10-Scale; scores >15). The 2-y intervention was delivered in 10 modules via mail with concurrent telephone tracking calls. Main outcome measures examined change in cognitive functioning at 12 and 24 mo by using the Telephone Interview for Cognitive Status-Modified (TICS-M) and the Brief Test of Adult Cognition by Telephone (processing speed); the Informant Questionnaire on Cognitive Decline in the Elderly was administered at 24 mo. RESULTS: FA + vitamin B-12 improved the TICS-M total (P = 0.032; effect size d = 0.17), TICS-M immediate (P = 0.046; d = 0.15), and TICS-M delayed recall (P = 0.013; effect size d = 0.18) scores at 24 mo in comparison with placebo. No significant changes were evident in orientation, attention, semantic memory, processing speed, or informant reports. CONCLUSION: Long-term supplementation of daily oral 400 µg FA + 100 µg vitamin B-12 promotes improvement in cognitive functioning after 24 mo, particularly in immediate and delayed memory performance. This trial was registered at clinicaltrials.gov as NCT00214682.

Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence.

OBJECTIVES: To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety. DATA SOURCES: 25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance. STUDY SELECTION: 19 high-quality studies that assessed outcomes were included. DATA EXTRACTION: All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives. DATA SYNTHESIS: Most evidence supports governance models which use targeted, peer-led feedback on the clinician's own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance. CONCLUSIONS: The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.

Enhancing care, improving quality: the six roles of the general practice nurse.

OBJECTIVE: To describe the evolving roles of practice nurses in Australia and the impact of nurses on general practice function. DESIGN, SETTING AND PARTICIPANTS: Multimethod research in two substudies: (a) a rapid appraisal based on observation, photographs of workspaces, and interviews with nurses, doctors and managers in 25 practices in Victoria and New South Wales, conducted between September 2005 and March 2006; and (b) naturalistic longitudinal case studies of introduced change in seven practices in Victoria, NSW, South Australia, Queensland and Western Australia, conducted between January 2007 and March 2008. RESULTS: We identified six roles of nurses in general practice: patient carer, organiser, quality controller, problem solver, educator and agent of connectivity. Although the first three roles are appreciated as nursing strengths by both nurses and doctors, doctors tended not to recognise nurses' educator and problem solver roles within the practice. Only 21% of the clinical activities undertaken by nurses were directly funded through Medicare. The role of the nurse as an agent of connectivity, uniting the different workers within the practice organisation, is particularly notable in small and medium-sized practices, and may be a key determinant of organisational resilience. CONCLUSION: Nursing roles may be enhanced through progressive broadening of the scope of the patient care role, fostering the nurse educator role, and addressing barriers to role enhancement, such as organisational inexperience with interprofessional work and lack of a career structure. In adjusting the funding structure for nurses, care should be taken not to create perverse incentives to limit nurses' clinical capacity or undermine the flexibility that gives practice nursing much of its value for nurses and practices.