The effect of lengthening life expectancy on future pension and long-term care expenditure in England, 2007 to 2032.

BACKGROUND: The aim of this analysis is to examine the effect of different assumptions about future trends in life expectancy (LE) on the sustainability of the pensions and long-term care (LTC) systems. The context is the continuing debate in England about the reform of state pensions and the reform of the system for financing care and support. METHODS: Macro and micro simulation models are used to make projections of future public expenditure on LTC services for older people and on state pensions and related benefits, making alternative assumptions on increases in future LE. The projections cover the period 2007 to 2032 and relate to England. RESULTS: Results are presented for a base case and for specified variants to the base case. The base case assumes that the number of older people by age and gender rises in line with the Office for National Statistics' principal 2006-based population projection for England. It also assumes no change in disability rates, no changes in patterns of care, no changes in policy and rises in unit care costs and real average earnings by 2 per cent per year. Under these assumptions public expenditure on pensions and related benefits is projected to rise from 4.7 per cent of Gross Domestic Product (GDP) in 2007 to 6.2 per cent of GDP in 2032 and public expenditure on LTC from 0.9 per cent of GDP in 2007 to 1.6 per cent of GDP in 2032. Under a very high LE variant to the GAD principal projection, however, public expenditure on pensions and related benefits is projected to reach 6.8 per cent of GDP in 2032 and public expenditure on LTC 1.7 per cent of GDP in 2032. CONCLUSIONS: Policymakers developing reform proposals need to recognise that, since future LE is inevitably uncertain and since variant assumptions about future LE significantly affect expenditure projections, there is a degree of uncertainty about the likely impact of demographic pressures on future public expenditure on pensions and LTC.

Building capacity for acute care in developing countries.

The article provides a 'short journey' to neighbours in the Australasian region to highlight some innovation in health policy, rural health education, and professional teams, in developing countries. The innovations are described and challenges discussed.

Acquired heart disease in low-income and middle-income countries.

The burden of illness associated with acquired cardiac disease in children in low-income and middle-income countries (LMIC) is significant and may be equivalent to that of congenital heart disease. Rheumatic heart disease, endomyocardial fibrosis, cardiomyopathy (including HIV cardiomyopathy) and tuberculosis are the most important causes. All are associated with poverty with the neediest children having the least access to care. The associated mortality and morbidity is high. There is an urgent need to improve cardiac care in LMIC, particularly in sub-Saharan Africa and parts of Southeast Asia where the burden is highest.

Noggin inhibits postoperative resynostosis in craniosynostotic rabbits.

UNLABELLED: Inhibition of bone formation after surgery to correct craniosynostosis would alleviate the need for secondary surgeries and decrease morbidity and mortality. This study used a single dose of Noggin protein to prevent resynostosis and improve postoperative outcomes in a rabbit model of craniosynostosis. INTRODUCTION: Craniosynostosis is defined as the premature fusion of one or more of the cranial sutures, which causes secondary deformations of the cranial vault, cranial base, and brain. Current surgical intervention involves extirpation of the fused suture to allow unrestricted brain growth. However, resynostosis of the extirpated regions often occurs. Several bone morphogenetic proteins (BMPs), well-described inducers of ossification, are involved in bone healing. This study tested the hypothesis that a postoperative treatment with Noggin, an extracellular BMP inhibitor, can inhibit resynostosis in a rabbit model of human familial nonsyndromic craniosynostosis. MATERIALS AND METHODS: Thirty-one New Zealand white rabbits with bilateral coronal suture synostosis were divided into three groups: (1) suturectomy controls (n = 13); (2) suturectomy with BSA in a slow-resorbing collagen vehicle, (n = 8); and (3) suturectomy with Noggin in a slow-resorbing collagen vehicle (n = 10). At 10 days of age, a 3 x 15-mm coronal suturectomy was performed. The sites in groups 2 and 3 were immediately filled with BSA-loaded gel or Noggin-loaded gel, respectively. Serial 3D-CT scan reconstructions of the defects and standard radiographs were obtained at 10, 25, 42, and 84 days of age, and the sutures were harvested for histological analysis. RESULTS: Radiographic analysis revealed that Noggin-treated animals had significantly greater coronal suture marker separation by 25 days and significantly greater craniofacial length at 84 days of age compared with controls. 3D-CT analysis revealed that Noggin treatment led to significantly greater defect areas through 84 days and to increased intracranial volumes at 84 days of age compared with other groups. Histological analysis supported CT data, showing that the untreated and BSA-treated groups had significant healing of the suturectomy site, whereas the Noggin-treated group had incomplete wound healing. CONCLUSIONS: These data support our hypothesis that inhibition of BMP activity using Noggin may prevent postoperative resynostosis in this rabbit model. These findings also suggest that Noggin therapy may have potential clinical use to prevent postoperative resynostosis in infants with craniosynostosis.

Rural hospital generalist and emergency medicine training in Papua New Guinea.

The present paper describes the role of the hospital generalist in rural Papua New Guinea (PNG) and the contribution of emergency medicine training to that practice. Generalist practice in Tinsley District Hospital in Western Highlands Province is described, with emphasis on emergency surgery and anaesthesia. The potential of the PNG emergency medicine training programme for preparing generalists is discussed. Tinsley Hospital served a population of 40,000 people, with 4000 admissions and 300-400 operations performed annually. Two doctors and 50 nurses and community health workers provided care with minimal resources. The doctors provided supervision and teaching for nurses, community health workers, hospital administrators and primary health carers, including on long range medical patrols. Over 16 months, doctors performed 243 emergency surgical procedures including orthopaedics, general surgery, obstetrics and gynaecology. The generalist in rural hospitals is required to perform a wide variety of medical tasks in isolated settings yet there is no active postgraduate training programme. The Master of Medicine, Emergency Medicine programme includes rotations through the major disciplines of surgery, anaesthesia, internal medicine, paediatrics, obstetrics and gynaecology. It has the potential to train doctors in PNG for a generalist role as graduates will learn the foundations of the required skills.

Responding to the Boxing Day tsunami disaster in Aceh, Indonesia: Western and South Australian contributions.

OBJECTIVE: To describe the Western and South Australian response to the Boxing Day tsunami disaster in Aceh, Indonesia. METHOD: Reports from three of the responders. RESULTS: Comment has been made on organising a response, the first team to Banda Aceh, the second team to Banda Aceh, and lessons learned. CONCLUSIONS: These experiences have identified areas in which we could be better prepared for the next international disaster response.

Time to analgesia in an emergency department in Eastern Nepal.

OBJECTIVES: Nepal is a least developed country, with limited healthcare resources. An 18 month Fellowship in Emergency Medicine has contributed some improvements to care. This study assessed time to first analgesia in higher and lower acuity patients. METHODS: A prospective observational study of 101 patients in each of the Australasian Triage Scale (ATS) 2, 3 and 100 in ATS 4 was undertaken at B.P. Koirala Institute of Health Sciences. Convenience sampling was used coinciding with researcher's duty hours. Pain scores and time to analgesia were recorded. RESULTS: A total of 302 patients were included. The doctors identified pain in 274 (90%, 95% confidence interval [CI] 86.74-93.65), severity recorded in 92 (30.5%, 95% CI 25-36). Median time from triage to analgesia was 30 min (interquartile range [IQR] 15-60) for ATS 2 patients, 60 min (IQR 40-70) for ATS 3 and 69 min (IQR 45-116) for ATS 4. Tramadol was the analgesic used most commonly (33%), followed by diclofenac (25%), morphine (16%), paracetamol (14%) and ketamine (2%). Analgesia was provided to 212 (70%, 95% CI 64.6-75.2), 65 (30.66%, 95% CI 24.5-37.3) with ATS 2, 85 (40%, 95% CI 33.4-47) with ATS 3 and 62 (29.2%, 95% CI 23.2-35.8) with ATS 4. A total of 44 patients (20.7%, 95% CI 15.5-26.8) with mild, 101 (47.6%, 95% CI 40.7-54.6) with moderate and 60 (28.3%, 95% CI 22.3-34.8) with severe pain received analgesics. CONCLUSION: Time to analgesia for triage score 2 is lower compared to higher triage score. However, a large proportion of patients still do not receive analgesia. This is likely addressed by using a combination of strategies.

HIV antibody seroprevalence in the emergency department at Port Moresby General Hospital, Papua New Guinea.

OBJECTIVE: To determine the prevalence of HIV antibody in patients presenting to the ED at Port Moresby General Hospital in Papua New Guinea. METHOD: Three hundred patients in whom blood samples were taken for investigation of illness or injury between April and July 2003 were surveyed for HIV antibodies. Sex, age and presenting illness were recorded. RESULTS: Fifty-four tests (18%, 95% confidence interval [CI] 14-23%) were positive. Forty-seven per cent were men and 53% were women. The most common presenting illnesses were respiratory tract infections (37%) and gastrointestinal tract infections (26%). Because of resource constraints results were not linked to patients and there was no follow up. CONCLUSION: These limited data support the prediction that the developing HIV/AIDS epidemic in Papua New Guinea will be serious.

The first year of a formal emergency medicine training programme in Papua New Guinea.

OBJECTIVE: To describe a programme catalyzing the development of emergency medicine in Papua New Guinea (PNG). METHODS: Five emergency physicians rotated through a new position of Senior Lecturer in Emergency Medicine in the University of PNG during 2003. The position was established as a consequence of emergency physician input supported by AusAID in 2002. RESULTS: Fifth (final)-year medical students and medical officers in the Emergency Department at Port Moresby General Hospital undertook formal and bedside problem based learning. The first trainees for a Master of Medicine in Emergency Medicine programme were inducted and supported. Emergency department management was provided with specialist input. Research projects were initiated, dealing with snakebite, chloroquine toxicity and HIV/AIDS. The first year of an emergency nursing curriculum was supported. CONCLUSIONS: There is now considerable enthusiasm for the development of emergency medicine as the hospital generalists' specialty. Emergency nursing training has also made a start. Limitations on resources will require flexibility to sustain the project. Further support by emergency physicians will be needed.

Capacity building for emergency care: Training the first emergency specialists in Myanmar.

OBJECTIVES: The Myanmar Ministry of Health has formed a partnership with Australasian professional colleges and international medical specialists to deliver a comprehensive programme for emergency care training and development. We describe this programme, emphasising the training of the first emergency specialists for Myanmar. METHODS: Eighteen junior specialists (EM18) joined a new postgraduate diploma in emergency medicine (Dip EM) through the University of Medicine (1) (UM1), Yangon. Diploma content included an introductory course, clinical rotations, 2 months in the emergency receiving centre (ERC) of the Yangon General Hospital (YGH) supervised by a volunteer Australasian emergency physician (FACEM), several short courses and an educational visit to Hong Kong. Curriculum and assessments comprising written and oral exams were devised and delivered by volunteer FACEMs and Hong Kong specialists. RESULTS: All EM18 completed the 18 month programme and passed the final assessments to graduate in February 2014. Course strengths included the supervised clinical rotation to the ERC and short course teaching on emergency medical, surgical, trauma, paediatric and disaster topics. The educational visit to Hong Kong enabled the EM18 to visualise more advanced EM systems that could be adapted to the Myanmar context. The participating international clinicians provided expert strategic advice on ED design, staffing, equipment, nursing and pre-hospital systems to leaders within universities, hospitals and the Ministry of Health. CONCLUSION: The first Myanmar postgraduate diploma in EM provides an example of collaborative and responsive clinical health capacity building in a context of very limited resources.

A perspective on developing emergency medicine as a specialty.

AIMS: A rapidly increasing number of countries are developing their capacities to respond to acute illness and injury and organizing emergency medicine training programs. This article offers some insight into the way emergency medicine has undergone development in the Australasian region. METHODS: The perspective is built from experience in Australia, New Zealand and Papua New Guinea. CONCLUSION: The challenges are many, but with persistence can be surmounted. Lessons derived from these diverse environments are presented.

Postoperative anti-Tgf-beta2 antibody therapy improves intracranial volume and craniofacial growth in craniosynostotic rabbits.

Postoperative resynostosis and secondary craniofacial growth abnormalities are common sequelae after craniofacial surgery. It has been suggested that an overexpression of transforming growth factor-beta2 (Tgf-beta2) may be related to craniosynostosis and contribute to postoperative resynostosis. Interference with Tgf-beta2 function using neutralizing antibodies may inhibit resynostosis and improve postoperative craniofacial growth; the present study was designed to test this hypothesis. Twenty-nine New Zealand white rabbits with bilateral coronal suture synostosis were used: 1) suturectomy controls (n=9); 2) suturectomy with nonspecific, control IgG antibody (n=9); and 3) suturectomy with anti-Tgf-beta2 antibody (n=11). At 10 days of age, a 3 mm x 15-mm coronal suturectomy was performed. The sites in groups 2 and 3 were immediately filled with 0.1 cc of a slow resorbing collagen gel mixed with either IgG (100 microg/suture) or anti-Tgf-beta2 (100 microg/suture). Three-dimensional computed tomography scan reconstructions of the skulls and cephalographs were obtained at 10, 25, 42, and 84 days of age. Computed tomography scan data revealed patent suturectomy sites and significantly (P<0.05) greater intracranial volumes by 84 days of age in rabbits treated with anti-Tgf-beta2 compared with controls. Cephalometric analysis revealed significant (P<0.05) differences in craniofacial, cranial vault, and cranial base growth by 84 days of age in rabbits treated with anti-Tgf-beta2 compared with controls. These data support the initial hypothesis that interference with Tgf-beta2 function inhibited postoperative resynostosis and improved cranial vault growth in this rabbit model. Thus, this biologically based therapy may be a potential surgical adjunct in the treatment of infants with craniosynostosis.