"I'm On My Own, I Need Support": Needs Assessment of Community Aged Care Services.

Introduction: Well-integrated community aged care services empower and enable older people to live and thrive in the community by supporting activities of daily living. To inform integrated community aged care service planning and delivery in South Western Sydney Australia, a needs assessment with consumers (i.e., older people), their caregivers, and healthcare providers was conducted. This study details the comprehensive and inclusive needs assessment process undertaken, with a focus on translating the findings into practice to improve integrated care. Description: Qualitative interviews and community forum-style focus groups engaged 160 stakeholders including GPs, older people, and aged care workers. Transcribed data were thematically coded using an inductive approach. Data were organised into four themes: 1) access to community aged care services; (2) healthcare and medical needs; (3) social concerns and needs; and (4) education and information needs. Discussion: The needs assessment undertaken identified unmet needs, gaps in service provision, and recommendations for improving integrated community aged care services. Conclusion: Findings are novel in the context of South Western Sydney, Australia. The study design, methods employed, and lessons learned can be adapted internationally for future needs assessments to inform policy, strategies, and integrated aged care service delivery.

Dementia risk reduction in practice: the knowledge, opinions and perspectives of Australian healthcare providers.

This study examined Australian primary healthcare providers' knowledge about dementia risk factors and risk reduction and their perspectives on barriers and enablers to risk reduction in practice. Primary healthcare providers were recruited through Primary Health Networks across Australia (n=51). Participants completed an online survey that consisted of fixed-responses and free-text components to assess their knowledge, attitudes and current practices relating to dementia risk factors and risk reduction techniques. The results showed that Australian primary healthcare providers have good knowledge about the modifiable risk factors for dementia; however, face several barriers to working with patients to reduce dementia risk. Commonly reported barriers included low patient motivation and healthcare system level limitations. The most commonly reported recommendations to helping primary healthcare providers to work with patients to reduce dementia risk included increasing resources and improving dementia awareness and messaging. While the results need to be interpreted in the context of the limitations of this study, we conclude that collaborative efforts between researchers, clinicians, policy makers and the media are needed to support the uptake of risk reduction activities in primary care settings.

"We need a one-stop-shop": co-creating the model of care for a multidisciplinary memory clinic with community members, GPs, aged care workers, service providers, and policy-makers.

BACKGROUND: Timely diagnosis of dementia has a wide range of benefits including reduced hospital emergency department presentations, admissions and inpatient length of stay, and improved quality of life for patients and their carers by facilitating access to treatments that reduce symptoms, and allow time to plan for the future. Memory clinics can provide such services, however there is no 'gold standard' model of care. This study involved the co-creation of a model of care for a new multidisciplinary memory clinic with local community members, General Practitioners (GPs), policy-makers, community aged care workers, and service providers. METHODS: Data collection comprised semi-structured interviews (N = 98) with 20 GPs, and three 2-h community forums involving 53 seniors and community/local government representatives, and 25 community healthcare workers. Interviews and community forums were audio-recorded, transcribed verbatim, and coded by thematic analysis using Quirkos. RESULTS: GPs' attitudes towards their role in assessing people with dementia varied. Many GPs reported that they found it useful for patients to have a diagnosis of dementia, but required support from secondary care to make the diagnosis and assist with subsequent management. Community forum participants felt they had a good knowledge of available dementia resources and services, but noted that these were highly fragmented and needed to be easier to navigate for the patient/carer via a 'one-stop-shop' and the provision of a dementia key worker. Expectations for the services and features of a new memory clinic included diagnostic services, rapid referrals, case management, education, legal services, culturally sensitive and appropriate services, allied health, research participation opportunities, and clear communication with GPs. Participants described several barriers to memory clinic utilisation including transportation access, funding, awareness, and costs. CONCLUSION: This study demonstrates the importance of working with stakeholders to co-design models of care for people with dementia that take into account the local communities' needs. Findings pave the way for the development of a potential new "gold standard" memory clinic model of care and operationalise new national clinical guidelines.

Advancing Prenatal Detection of Congenital Heart Disease: A Novel Screening Protocol Improves Early Diagnosis of Complex Congenital Heart Disease.

OBJECTIVES: Prenatal diagnosis of complex congenital heart disease (CHD) during routine obstetric ultrasound (US) examinations improves postnatal outcomes, but sensitivity is low (<40%). Our objective was to improve our prenatal detection of complex CHD with implementation of a specific screening protocol. METHODS: From January 2003 to December 2013, 506 consecutive confirmed cases of complex CHD in the province of Manitoba, Canada, were analyzed to compare the sensitivity and positive predictive value of prenatal US detection of complex CHD before and after the introduction of a novel prenatal screening protocol. The intervention was done in October 2004, emphasizing screening and not diagnosis of complex CHD. It involved education, practical scanning tips, a checklist, and feedback on cases. We also assessed the effect of the intervention in different screening settings: community hospitals, tertiary hospitals, and fetal assessment units. RESULTS: The sensitivity for detecting complex CHD increased from 29.8% to 88.3% (P < .0001), while the positive predictive value remained high. The largest improvement in detection was found for US units in community hospitals (52.4% higher; P < .0001), followed by tertiary hospitals (39.9%; P = .0004), and fetal assessment units (7.2%; P = .16). Additionally, there was a significant decrease in the presentation of neonates in critical condition from before to after the implementation (24.3% to 13.1%, respectively; P = .0165). CONCLUSIONS: Implementing a focused routine prenatal screening protocol can vastly improve detection rates of critical cardiac abnormalities. The improvement in community hospitals was particularly important because early detection ensured that the birth was planned to take place in an appropriate facility. Our novel protocol can be performed by all sonographers, regardless of experience, equipment used, and hospital setting.

A new species of treefrog (Litoria) from Cape York Peninsula, Australia.

We describe a new species of treefrog from northern Australia. Litoria bella sp. nov. is morphologically and genetically most similar to frogs in the L. gracilenta and L. chloris groups but is distinguished from all members in these groups by a combination of a moderately large male body size (34.5-41.8 mm SVL), near-immaculate green dorsum, orange venter, bright orange digits and webbing, bluish purple lateral surfaces of the thighs, no pale canthal stripe, white bones, and a highly-pulsed, single-note, male advertisement call with a pulse rate of 56-64 pulses/s and dominant frequency of 2.6-2.8 kHz. Litoria bella sp. nov. has a patchy distribution across the Cape York Peninsula, inhabiting rainforest and monsoon vine thicket in close association with watercourses. The new species' affinities lie with L. auae from southern New Guinea rather than with L. gracilenta from eastern Australia. Molecular data suggest that the L. gracilenta group should be expanded to include L. chloris and L. xanthomera, two moderately large green treefrogs from eastern Australia.

An Ancient Divide in a Contiguous Rainforest: Endemic Earthworms in the Australian Wet Tropics.

Understanding the factors that shape current species diversity is a fundamental aim of ecology and evolutionary biology. The Australian Wet Tropics (AWT) are a system in which much is known about how the rainforests and the rainforest-dependent organisms reacted to late Pleistocene climate changes, but less is known about how events deeper in time shaped speciation and extinction in this highly endemic biota. We estimate the phylogeny of a species-rich endemic genus of earthworms (Terrisswalkerius) from the region. Using DEC and DIVA historical biogeography methods we find a strong signal of vicariance among known biogeographical sub-regions across the whole phylogeny, congruent with the phylogeography of less diverse vertebrate groups. Absolute dating estimates, in conjunction with relative ages of major biogeographic disjunctions across Australia, indicate that diversification in Terrisswalkerius dates back before the mid-Miocene shift towards aridification, into the Paleogene era of isolation of mesothermal Gondwanan Australia. For the Queensland endemic Terrisswalkerius earthworms, the AWT have acted as both a museum of biological diversity and as the setting for continuing geographically structured diversification. These results suggest that past events affecting organismal diversification can be concordant across phylogeographic to phylogenetic levels and emphasize the value of multi-scale analysis, from intra- to interspecies, for understanding the broad-scale processes that have shaped geographic diversity.

How do clinicians with different training backgrounds manage walk-in patients in the ED setting?

OBJECTIVE: To compare the initial assessment and management of walk-in emergency department (ED) patients between different types of healthcare providers. SETTING: A large teaching hospital with an annual ED census of 140 000 adult patients. METHODS: A random sample of 384 patients who self-presented to the ED was obtained. A detailed analysis of each patient record was performed by two clinicians. Data were obtained on the presenting condition, and disposition of each patient, either into the ED for further assessment, or discharge. RESULTS: GPs were significantly more likely to discharge patients home as compared to emergency nurses. ED senior nurses were more likely than GPs to stream patients into the ED for further assessment. Of the patients referred into the ED for further assessment by senior ED nurses, the majority were discharged home. There were insufficient numbers of emergency physician assessments for meaningful statistical analysis. CONCLUSIONS: The clinician groups studied here demonstrated different patterns of discharge and referral, reflecting their training and experience. When planning operational procedures, the training and background of the staff allocated to each area should be considered.

Is the case-mix of patients who self-present to ED similar to general practice and other acute-care facilities?

OBJECTIVE: To benchmark walk-in presentations to emergency departments (ED) with those presenting to other local acute healthcare facilities. SETTING: A large teaching hospital with an annual ED census of 140, 000 adult patients and surrounding associated acute healthcare providers. METHODS: A random sample of 384 patients who self-presented to the ED was obtained. Benchmarking data were drawn from two general practices; the Tower Hamlets Community Services walk-in centre (co-located on-site with the ED) and the GP-run out-of-hours service. RESULTS: The case-mix presenting to the ED was characterised by a higher proportion of injuries and chest pain, but fewer simple infections and non-traumatic musculoskeletal conditions as compared to other acute care facilities in our region. CONCLUSIONS: Patients with injuries and possible cardiac chest pain were more likely to attend the ED, and those with infection or musculoskeletal problems less likely, as compared with other acute healthcare facilities. The population presenting to the ED is distinct from that presenting to general practice, out-of-hours clinics, or walk-in centres.

Addressing the deficiencies in the evidence-base for primary practice in regional Australia - sentinel practices data sourcing (SPDS) project: a pilot study.

BACKGROUND: Chronic disease risk on a population level can be quantified through health surveys, either continuous or periodic. To date, information gathered from primary care interactions, using sentinel sites, has not been investigated as a potentially valuable surveillance system in Australia. METHODS: A pilot study was conducted in a single General Practice in a regional area of New South Wales, Australia to assess the feasibility of accessing data obtained through a computerised chronic disease management program that has been designed for desktop application (Pen Computer Systems (PCS) Clinical Audit Tool: ™ PCS CAT). Collated patient data included information on chronic disease management and prevention, prevalence of overweight and obesity, mental health indicators, medication profiling and home medicine reviews, as well as uptake of preventive health services (immunisation and cervical cancer screening). RESULTS: Higher than national average estimates were found for the age-adjusted prevalence of chronic diseases such as hypertension (14.3% for sample vs 10.4%, nationally), anxiety disorders (4.4% vs 3.8%) and obesity/overweight (67.1 vs 63.4%). Preventive health assessment items were undersubscribed, ranging from 6-20% in eligible patients. CONCLUSIONS: This pilot study has demonstrated that the scope of data collected by patient visits to their General Practitioners, facilitated through the Medicare-funded primary health care system in Australia, offers a feasible opportunity for monitoring of chronic disease prevalence and its associated risk factors. The inclusion of a larger number of sentinel sites that are generalizable to the population being served would provide an accurate and region-specific system for the purposes of population health planning at the primary care level in order to improve the overall health of the community.

Chytridiomycosis and seasonal mortality of tropical stream-associated frogs 15 years after introduction of Batrachochytrium dendrobatidis.

Assessing the effects of diseases on wildlife populations can be difficult in the absence of observed mortalities, but it is crucial for threat assessment and conservation. We performed an intensive capture-mark-recapture study across seasons and years to investigate the effect of chytridiomycosis on demographics in 2 populations of the threatened common mist frog (Litoria rheocola) in the lowland wet tropics of Queensland, Australia. Infection prevalence was the best predictor for apparent survival probability in adult males and varied widely with season (0-65%). Infection prevalence was highest in winter months when monthly survival probabilities were low (approximately 70%). Populations at both sites exhibited very low annual survival probabilities (12-15%) but high recruitment (71-91%), which resulted in population growth rates that fluctuated seasonally. Our results suggest that even in the absence of observed mortalities and continued declines, and despite host-pathogen co-existence for multiple host generations over almost 2 decades, chytridiomycosis continues to have substantial seasonally fluctuating population-level effects on amphibian survival, which necessitates increased recruitment for population persistence. Similarly infected populations may thus be under continued threat from chytridiomycosis which may render them vulnerable to other threatening processes, particularly those affecting recruitment success.

Investigation of the anxiolytic effects of naringenin, a component of Mentha aquatica, in the male Sprague-Dawley rat.

This was a prospective, randomized, between-subjects experimental study to investigate the anxiolytic effects of naringenin, a component of mentha aquatica, and its potential interaction with the benzodiazepine binding site on the γ-aminobutyric acid (GABAA) receptor in the rat. Fifty-five rats were assigned to one of 5 groups with 11 rats per group: control, naringenin, midazolam, midazolam with naringenin, and flumazenil with naringenin. The elevated plus maze measured the behavioral components of anxiety and motor movements. Our data suggest that naringenin does not produce anxiolysis by modulation of the GABAA receptor; however, the findings indicate that naringenin decreases motor movements (P < .05).

Environmental refuge from disease-driven amphibian extinction.

Species that are tolerant of broad environmental gradients may be less vulnerable to epizootic outbreaks of disease. Chytridriomycosis, caused by the fungus Batrachochytrium dendrobatidis, has been linked to extirpations and extinctions of amphibian species in many regions. The pathogen thrives in cool, moist environments, and high amphibian mortality rates have commonly occurred during chytridiomycosis outbreaks in amphibian populations in high-elevation tropical rainforests. In Australia several high-elevation species, including the armored mist frog (Litoria lorica), which is designated as critically endangered by the International Union for the Conservation of Nature (IUCN), were believed to have gone extinct during chytridiomycosis outbreaks in the 1980s and early 1990s. Species with greater elevational ranges disappeared from higher elevations, but remained common in the lowlands. In June 2008, we surveyed a stream in a high-elevation dry sclerophyll forest and discovered a previously unknown population of L. lorica and a population of the waterfall frog (Litoria nannotis). We conducted 6 additional surveys in June 2008, September 2008, March 2009, and August 2009. Prevalences of B. dendrobatidis infection (number infected per total sampled) were consistently high in frogs (mean 82.5%, minimum 69%) of both species and in tadpoles (100%) during both winter (starting July) and summer (starting February). However, no individuals of either species showed clinical signs of disease, and they remained abundant (3.25 - 8.75 individuals of L. lorica and 6.5-12.5 individuals of L. nannotis found/person/100 m over 13 months). The high-elevation dry sclerophyll site had little canopy cover, low annual precipitation, and a more defined dry season than a nearby rainforest site, where L. nannotis was more negatively affected by chytridiomycosis. We hypothesize this lack of canopy cover allowed the rocks on which frogs perched to warm up, thereby slowing growth and reproduction of the pathogen on the hosts. In addition, we suggest surveys for apparently extinct or rare species should not be limited to core environments.

Enhancing palliative care in rural Australia: the residential aged care setting.

The delivery of palliative care in residential aged care communities is challenging, even more so in rural areas due to workforce ageing and shortages. The objectives of the present study were to: (i) assess the needs of, and quality of palliative care delivered to residents of 16 residential aged care facilities in rural southern Australia; and (ii) identify the needs of care staff to facilitate the delivery of quality palliative care. A cross-sectional survey of all residents, assessing the degree of functional limitation, stage of palliative care, and the presence of several quality indicators was conducted. Separate focus groups of care staff and relatives of residents sought information on the quality of care delivered, perceived strengths and weaknesses of the care delivered, and education and training needs. Quality palliative care in residential aged care facilities (RACFs) is hampered by workforce shortages, with low ratios of registered nurses, limited access to general practitioners after hours, and some communication difficulties. Some staff reported low confidence in technical and psychosocial aspects of care, especially for relatives. Relatives described mostly appropriate care, while acknowledging workload constraints. Most residents whose condition was unstable, deteriorating or terminal received advance care planning, though family expectations and unwillingness to discuss end-of-life care did tend to delay planning. Unstable residents with a reasonable prognosis were more likely to be transferred to hospital than terminally ill residents. Palliative care in participating RACFs appears to be adequate. Provision of targeted education for health care providers and implementation of protocols for advance care planning and end-of life care pathways will enhance this care.

Application of the survey protocol for chytridiomycosis to Queensland, Australia.

Spread of the amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd), which causes chytridiomycosis, has resulted in the extinction of frogs, but the distribution of Bd is incompletely known. We trialled the survey protocol for Bd by attempting to systematically map its distribution in Queensland, Australia. Bd was easily detected in known infected areas, such as the Wet Tropics and South East Queensland. It was not detected in bioregions adjacent to, but inland from or to the north of, infected regions: Einasleigh Uplands and Cape York adjacent to the infected Wet Tropics; and Brigalow Belt South adjacent to the infected South East Queensland bioregion. These regions where Bd was not detected have bordered infected regions for between 15 yr (in northern Queensland) and 30 yr (in southern Queensland), and so they define the geographical limits of Bd with regard to the long-term environmental conditions in Queensland. The Gulf Plains, a bioregion distant from infected bioregions, was also negative. Bd was confined to rainforest and bordering habitats, such as wet eucalypt forests. Infections were largely confined to permanent water-associated species, consistent with this being an important cause of this group having the greatest declines. Our data supports biogeographic climatic models that show much of inland and northern Australia to be too hot and dry to support Bd. As there is limited opportunity for Bd to spread further in Queensland, the priority for management is reducing the impact of Bd in affected populations and assisting frogs to disperse into their former distributions. Given that the survey protocol has been applied successfully in Australia it may be useful for mapping the distribution of Bd in other parts of the world.

Survey protocol for detecting chytridiomycosis in all Australian frog populations.

Spread of the amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd) has caused the decline and extinction of frogs, but the distribution of Bd is not completely known. This information is crucial to implementing appropriate quarantine strategies, preparing for outbreaks of chytridiomycosis due to introduction of Bd, and for directing conservation actions towards affected species. This survey protocol provides a simple and standard method for sampling all frog populations in Australia to maximise the chances of detecting Bd. In order to structure and prioritise the protocol, areas are divided by bioregion and frog species are allocated depending on the water bodies they utilize into 3 groups representing different levels of risk of exposure to Bd. Sixty individuals per population need to be tested to achieve 95% certainty of detecting 1 positive frog, based on the minimum apparent prevalence of > or =5% in infected Australian frog populations and using a quantitative real-time TaqMan PCR test. The appropriate season to sample varies among bioregions and will ideally incorporate temperatures favourable for chytridiomycosis (e.g. maximum air temperatures generally <27 degrees C). Opportunistic collection and testing of sick frogs and tadpoles with abnormal mouth-parts should also be done to increase the probability of detecting Bd. The survey priorities in order are (1) threatened species that may have been exposed to Bd, (2) bioregions surrounding infected bioregions/ecological groups, and (3) species of frogs of unknown infection status in infected bioregions. Within these priority groups, sampling should first target ecological groups and species likely to be exposed to Bd, such as those associated with permanent water, and areas within bioregions that have high risk for Bd as indicated by climatic modelling. This protocol can be adapted for use in other countries and a standard protocol will enable comparison among amphibian populations globally.

Optimizing allocation of management resources for wildlife.

Allocating money for species conservation on the basis of threatened species listings is not the most cost-effective way of promoting recovery or minimizing extinction rates. Using ecological and social factors in addition to threat categories, we designed a decision-support process to assist policy makers in their allocation of resources for the management of native wildlife and to clarify the considerations leading to a priority listing. Each species is scored on three criteria at the scale of the relevant jurisdiction: (1) threat category, (2) consequences of extinction, and (3) potential for successful recovery. This approach provides opportunity for independent input by policy makers and other stakeholders (who weight the relative importance of the criteria) and scientists (who score the species against the criteria). Thus the process explicitly separates societal values from the technical aspects of the decision-making process while acknowledging the legitimacy of both inputs. We applied our technique to two Australian case studies at different spatial scales: the frogs of Queensland (1,728,000 km(2); 116 species) and the mammals of the Wet Tropics bioregion (18,500 km(2); 96 species). We identified 7 frog and 10 mammal species as priorities for conservation. The frogs included 1 of the 9 species classified as endangered under Queensland legislation, 3 of the 10 species classified as vulnerable, 2 of the 22 species classified as rare, and 1 of the 75 species classified as least concern. The mammals identified included 3 of the 6 species classified as endangered, 1 of the 4 species classified as vulnerable, 5 of the 11 species classified as rare, and 1 of the 75 species classified as least concern. The methods we used to identify species were robust to comparisons across the two taxonomic groups. We concluded that (1) our process facilitates comparisons of data required to make transparent, cost-effective, and strategic management decisions across taxonomic groups and (2) the process should be used to short-list species for further discussion rather than for allocating resources per se.

Implementation of the Adelaide Hills Palliative Care project.

The Rural Palliative Care Program (RPCP) is currently being implemented in eight pilot sites across Australia, under the banner of the National Palliative Care Program. It is one of a number of initiatives commissioned by the Department of Health and Ageing that are designed to achieve the goals of the National Palliative Care Strategy. Specifically the RPCP is testing service components that aim to improve access to palliative care for people living in rural and remote communities. With facilitation from the Australian Divisions of General Practice (ADGP), each project and the program as a whole, is undergoing a formal evaluation by the Centre for Health Service Development (CHSD), University of Wollongong. A key question being investigated is whether any systemic improvements in palliative care delivery are sustainable beyond completion of the 3-year program. This paper gives the background to the RPCP. The Adelaide Hills Palliative Care Project is discussed as an example of how strategies are derived and applied in order to test key service components pertinent to the delivery of palliative care in a rural setting.

Reinforcement drives rapid allopatric speciation.

Allopatric speciation results from geographic isolation between populations. In the absence of gene flow, reproductive isolation arises gradually and incidentally as a result of mutation, genetic drift and the indirect effects of natural selection driving local adaptation. In contrast, speciation by reinforcement is driven directly by natural selection against maladaptive hybridization. This gives individuals that choose the traits of their own lineage greater fitness, potentially leading to rapid speciation between the lineages. Reinforcing natural selection on a population of one of the lineages in a mosaic contact zone could also result in divergence of the population from the allopatric range of its own lineage outside the zone. Here we test this with molecular data, experimental crosses, field measurements and mate choice experiments in a mosaic contact zone between two lineages of a rainforest frog. We show that reinforcing natural selection has resulted in significant premating isolation of a population in the contact zone not only from the other lineage but also, incidentally, from the closely related main range of its own lineage. Thus we show the potential for reinforcement to drive rapid allopatric speciation.

The Griffith area palliative care service: a pilot project.

In September 2000 the Commonwealth released, as part of its National Palliative Care Strategy under the Australian Health Care Agreements, a National Framework for Palliative Care Service Development. The new National Framework stressed an important set of values to guide models of palliative care delivery. It notes that the challenge is to secure the place of palliative care as an integral part of health care across Australia, routinely available within local communities to those people who need it. Care and support for people who are dying and their families need to be built not only into health care services, but also into the fabric of communities and their support networks. While few would disagree with this, little is known about how best to achieve it in rural Australia. The Griffith Area Palliative Care Service (GAPS) is a two-year pilot project delivering a palliative care service through a truly integrated approach to care for patients, their carers and families within the Griffith Local Government Area and Carrathool Shire areas. This paper describes how GAPS is successfully meeting the challenges of service provision to rural and remote areas.