Sleep influences on cardio-metabolic health in Indigenous populations.

Indigenous populations continue to be among the world's most marginalized population groups. Studies in Indigenous populations from high income countries (including the United States, Canada, Australia, and New Zealand) indicate increased risk of sleep disorders compared to non-Indigenous populations. Poor sleep, whether it be short sleep duration or fragmented sleep, is a well-established risk factor for cardio-metabolic diseases. Given the implications, targeted improvement of poor sleep may be beneficial for the health and well-being of Indigenous people. In this narrative review, we will: (1) discuss the effects of sleep on the cardio-metabolic processes; (2) examine sleep in Indigenous populations; (3) review the association between sleep and cardio-metabolic risk in Indigenous populations; and (4) review the potential role of sleep in cardiovascular disease risk detection and interventions to improve sleep and cardio-metabolic health in Indigenous people. In particular, this review highlights that the assessment of sleep quality and quantity may be a beneficial step toward identifying Indigenous people at risk of cardio-metabolic diseases and may represent a key intervention target to improve cardio-metabolic outcomes.

Efficacy of inspiratory muscle training as a practical and minimally intrusive technique to aid functional fitness among adults with obesity.

OBJECTIVE: To examine the efficacy of inspiratory muscle training (IMT) as a non-intrusive and practical intervention to stimulate improved functional fitness in adults with obesity. As excess adiposity of the chest impedes the mechanics of breathing, targeted re-training of the inspiratory muscles may ameliorate sensations of breathlessness, improve physical performance and lead to greater engagement in physical activity. METHODS: Sixty seven adults (BMI=36±6.5) were randomized into either an experimental (EXP: n=35) or placebo (PLA: n=32) group with both groups undertaking a 4-week IMT intervention, comprising daily use of a inspiratory resistance device set to 55% (EXP), or 10% (PLA) of maximum inspiratory effort. RESULTS: Inspiratory muscle strength was significantly improved in EXP (19.1 cmH20 gain; P<0.01) but did not change in PLA. Additionally, the post training walking distance covered was significantly extended for EXP (P<0.01), but not for PLA. Bivariate analysis demonstrated a positive association between the change (%) of performance in the walking test and BMI (r=0.78; P<0.01) for EXP. CONCLUSION: The findings from this study suggest IMT provides a practical, self-administered intervention for use in a home setting. This could be a useful strategy to improve the functional fitness of obese adults and perhaps lead to better preparedness for engagement in physical activity initiatives.

Utility of field-based techniques to assess Indigenous Australians' functional fitness and sedentary time.

OBJECTIVE: To examine the utility of field-based techniques to assess functional exercise capacity and sedentary time in Indigenous and non-Indigenous regional Australian adults. STUDY DESIGN: Observational, analytic cohort study. METHODS: Ninety six adults residing in regional and remote Australian communities participated in this study (Indigenous n = 61 and non-Indigenous Australians n = 35). Participants undertook a field-based test of functional exercise capacity (6 min walk test; 6 MWT) and wore an accelerometer during waking hours for seven days, provided self-report data on physical activity and sedentary time and rated experiences in regard to the ease of complying with study protocols. RESULTS: There were high levels of compliance in this study (Indigenous: 91% and non-Indigenous: 97%). Functional exercise capacity was lower in Indigenous Australians (P < 0.001), and independently associated with advancing age, higher BMI, and indigeneity, with 45% of variability in the 6 MWT distance explained by these factors. The relationship between accelerometer and self-report measures of sedentary behaviour was significant (P < 0.001) but only explained 17% of the total variation. CONCLUSIONS: This study demonstrated very good compliance for the methods utilised and is the first to report reduced functional exercise capacity in Indigenous people. IMPLICATIONS: The field-based techniques from this study demonstrate good utility for larger scale implementation in regional Indigenous populations.

Predicting coronary heart disease in remote settings: a prospective, cross-sectional observational study.

BACKGROUND: Coronary heart disease (CHD) places a major burden on the Australian health care system. Determining the likelihood of CHD in a patient presenting with chest pain can be particularly difficult in a remote setting where access to transportation and specialised investigations including myocardial stress studies and coronary angiography can be difficult and delayed. The objective is to develop a predictive model for determining the risk of CHD, including the value of high sensitivity C-reactive protein (hsCRP), in patients presenting with chest pain with a particular emphasis on resources and information likely to be available in a remote primary health care setting. METHODS: A prospective, cross-sectional observational study of patients with no prior diagnosis of CHD presenting to a specialist chest pain assessment clinic at Cairns Hospital from November 2012 to May 2013. RESULTS: Out of the 163 participants included in the study analyses, a total of 38 were classified as CHD likely (23.3% (95% CI 17.1-30.6)). Logistic regression modelling identified two factors that were independently associated with likely CHD, namely the presence of typical chest pain (OR 83.7 (95% CI 21.7-322.1)) and an abnormal baseline ECG (OR 12.8 (95% CI 1.9-86.0)). CONCLUSION: In this study, it was demonstrated that the presence of typical chest pain and an abnormal resting ECG, remain the cornerstone of predicting a subsequent diagnosis of CHD. This information is easily accessible in remote primary health care and should be utilised to expedite assessment in patients presenting with symptoms suggestive of CHD.

Variability in disease burden and management of rheumatic fever and rheumatic heart disease in two regions of tropical Australia.

BACKGROUND: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) contribute to Aboriginal Australian and Torres Strait Islander health disadvantage. At the time of this study, specialist ARF/RHD care in the Kimberley region of Western Australia was delivered by a broad range of providers. In contrast, in Far North Queensland (FNQ), a single-provider model was used as part of a coordinated RHD control programme. AIMS: To review ARF/RHD management in the Kimberley and FNQ to ascertain whether differing models of service delivery are associated with different disease burden and patient care. METHODS: An audit of ARF/RHD management. Classification and clinical management data were abstracted from health records, specialist letters, echocardiograms and regional registers using a standardised data collection tool. RESULTS: Four hundred and seven patients were identified, with 99% being Aboriginal and/or Torres Strait Islanders. ARF without RHD was seen in 0.4% of Aboriginal and/or Torres Strait Islander residents and RHD in 1.1%. The prevalence of RHD was similar in both regions but with more severe disease in the Kimberley. More FNQ RHD patients had specialist review within recommended time frames (67% vs 45%, χ(2) , P < 0.001). Of patients recommended benzathine penicillin secondary prophylaxis, 17.7% received ≥80% of scheduled doses in the preceding 12 months. Prescription and delivery of secondary prophylaxis was greater in FNQ. CONCLUSIONS: FNQ's single-provider model of specialist care and centralised RHD control programme were associated with improved patient care and may partly account for the fewer cases of severe disease and reduced surgical procedures and other interventions observed in this region.

Four weeks of inspiratory muscle training improves self-paced walking performance in overweight and obese adults: a randomised controlled trial.

Objective. To examine whether a programme of inspiratory muscle training (IMT) improves accumulative distance of self-paced walking in overweight and obese adults. Methods. A total of 15 overweight and obese adults were randomized into experimental (EXP: n = 8) and placebo (PLA: n = 7) groups. Lung function, inspiratory muscle performance, 6-minute walking test, and predicted [Formula: see text]O(2) max were assessed prior to and following the 4-week IMT intervention. Both groups performed 30 inspiratory breaths, twice daily using a proprietary inspiratory resistance device set to 55% of baseline maximal effort (EXP), or performing the same inspiratory training procedure at the minimum resistive setting (PLA). Results. Lung function was unchanged in both groups after-training; however inspiratory muscle strength was significantly improved in EXP (19 ± 25.2 cm H(2)O gain; P < 0.01) but did not significantly change in PLA. Additionally, the posttraining distance covered in the 6-minute walking test was significantly extended for EXP (62.5 ± 37.7 m gain; P < 0.01), but not for PLA. A positive association was observed between the change (%) of performance gain in the 6-minute walking test and body mass index (r = 0.736; P < 0.05) for EXP. Conclusion. The present study suggests that IMT provides a practical, minimally intrusive intervention to significantly augment both inspiratory muscle performance and walking distance covered by overweight and obese adults in a clinically relevant 6-minute walk test. This indicates that IMT may provide a useful priming (preparatory) strategy prior to entry in a physical training programme for overweight and obese adults.

Acute rheumatic fever and rheumatic heart disease--priorities in prevention, diagnosis and management. A report of the CSANZ Indigenous Cardiovascular Health Conference, Alice Springs 2011.

Three priority areas in the prevention, diagnosis and management of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) were identified and discussed in detail: 1. Echocardiography and screening/diagnosis of RHD ­ Given the existing uncertainty it remains premature to advocate for or to incorporate echocardiographic screening for RHD into Australian clinical practice. Further research is currently being undertaken to evaluate the potential for echocardiography screening. 2. Secondary prophylaxis ­ Secondary prophylaxis (long acting benzathine penicillin injections) must be seen as a priority. Systems-based approaches are necessary with a focus on the development and evaluation of primary health care-based or led strategies incorporating effective health information management systems. Better/novel systems of delivery of prophylactic medications should be investigated. 3. Management of advanced RHD ­ National centres of excellence for the diagnosis, assessment and surgical management of RHD are required. Early referral for surgical input is necessary with multidisciplinary care and team-based decision making that includes patient, family, and local health providers. There is a need for a national RHD surgical register and research strategy for the assessment, intervention and long-term outcome of surgery and other interventions for RHD.

Community-acquired pneumonia in the central desert and north-western tropics of Australia.

BACKGROUND: Community-acquired pneumonia (CAP) results in significant morbidity in central and north-western Australia. However, the nature, management and outcome of CAP are poorly documented. The aim of the study was to describe CAP in the Kimberley and Central Desert regions of Australia. METHODS: Prospective and retrospective cohort studies of inpatient management of adults with CAP at Alice Springs Hospital and six Kimberley hospitals were carried out. We documented demographic data, comorbidities, investigations, causes, CAP severity, outcome and concordance between prescribed and protocol-recommended antibiotics. RESULTS: Two hundred and ninety-three subjects were included. Aboriginal Australians were overrepresented (relative risk 8.1). Patients were notably younger (median age 44.5 years) and disease severity lower than in urban Australian settings. Two patients died within 30 days of admission compared with expected mortality based on Pneumonia Severity Index predictions of seven deaths (chi(2), P= 0.09). Disease severity and outcome did not differ between regions. Management differences were identified, including significantly more investigations, higher rates of critical care and broader antibiotic cover in Central Australia compared with the Kimberley. Sputum culture results showed Gram-negative organisms in both regions. However, Streptococcus pneumoniae was the most frequent organism isolated in the Kimberley and Haemophilus influenzae in Central Australia. CONCLUSION: CAP in this setting is an Aboriginal health issue. The low mortality observed and results of microbiology investigations support the use of existing antibiotic protocols. Larger studies investigating CAP aetiology are warranted. Addressing social and environmental disadvantage remains the key factors in dealing with the burden of CAP in this setting.

Pulmonary tuberculosis, impaired lung function, disability and quality of life in a high-burden setting.

SETTING: Tuberculosis treatment clinic in Papua, Indonesia. OBJECTIVE: To document the impact of pulmonary tuberculosis (PTB) on lung function, exercise tolerance and quality of life (QOL). DESIGN: A prospective cohort study of 115 patients with smear-positive PTB followed for 6 months. Demographics, disease history, sputum microbiology, spirometry, 6-minute weight.walk distance (6MWWD) and QOL (modified St George's Respiratory Questionnaire) were measured at diagnosis and at 2 and 6 months. Analysis was restricted to the 69/115 (60%) subjects who attended all follow-up visits. RESULTS: Subjects who attended all visits were less likely than the full cohort to be of Papuan ethnicity (P < 0.05), were more likely to be cured (P < 0.001) and had better lung function at diagnosis (P < 0.05). Significant lung function impairment (forced expiratory volume in 1 second [FEV(1)] <60% predicted) was found in 27/69 (39%) at diagnosis. Although this fell during treatment (P < 0.01), 17/69 (24.6%) had persisting significant lung function impairment at treatment completion. As lung function recovered, exercise tolerance (6MWWD) rose by 12.3% (P < 0.001) and QOL improved (P < 0.001). CONCLUSION: In a high-burden setting, PTB causes prolonged, significant impairment of lung function, exercise tolerance and QOL. Current measures of disease burden are likely to underestimate the true impact of disease. Earlier diagnosis and disease-modifying treatments may reduce the long-term impact of PTB.

A community-based TB drug susceptibility study in Mimika District, Papua Province, Indonesia.

SETTING: A district level tuberculosis (TB) control programme in Papua Province, Indonesia. OBJECTIVE: To determine the nature and extent of drug-resistant TB in newly diagnosed sputum smear-positive patients. METHODS: Sputum was collected from previously untreated smear-positive pulmonary TB patients diagnosed in the district over a 10-month period. Sputum specimens were processed and inoculated into a BACTEC MGIT960 tube. Isolates were identified by Ziehl-Neelsen staining, hybridisation with nucleic acid probes and biochemical investigations. Susceptibility testing was performed using the radiometric proportion method. Pyrazinamide testing was performed using the Wayne indirect method. RESULTS: One hundred and seven patients had sputum sent to a reference laboratory; 101 (94.4%) were culture-positive for Mycobacterium tuberculosis, with 87 (86.1%) fully sensitive to first-line anti-tuberculosis drugs. Two per cent were multidrug-resistant (MDR-TB) and 12 (11.9%) had other drug resistance. Each of the MDR-TB isolates was susceptible to amikacin, capreomycin, ciprofloxacin and para-aminosalicylic acid (PAS), but were resistant to rifabutin. One isolate was also resistant to ethionamide. CONCLUSIONS: MDR-TB is present in Indonesia but is not a major problem for TB control in this district. Generalisability to other districts in Indonesia, particularly large urban areas, needs to be confirmed by future studies.

An alternative method for sputum storage and transport for mycobacterium tuberculosis drug resistance surveys.

SETTING: A district level tuberculosis (TB) programme in Indonesia. OBJECTIVE: To evaluate whether a single sputum specimen could be stored by refrigeration for an extended period of time, then transported to a reference laboratory and successfully cultured for Mycobacterium tuberculosis. METHODS: Single sputum specimens were collected from newly diagnosed smear-positive pulmonary TB patients, refrigerated at the study site without addition of 1% cetylpyridinium chloride, batched and sent to the reference laboratory, where they were decontaminated and inoculated into BACTEC MGIT 960 liquid media. RESULTS: One hundred and seven patients were enrolled. The median specimen storage time was 12 days (range 1-38) and median transportation time was 4 days (2-12). The median time from specimen collection until processing was 18 days (4-42). Only 4 (3.7%) specimens failed to grow Mycobacterium species and M. tuberculosis was isolated from 101 (94.4%) specimens. Six specimens with breakthrough contamination successfully grew M. tuberculosis after a second decontamination procedure. CONCLUSIONS: Single sputum specimens collected at a remote setting, refrigerated for relatively long periods without preservatives and transported without refrigeration to a reference laboratory can yield a high positive culture rate. These findings offer potential logistic simplification and cost savings for drug resistance surveys in low-resource countries.

Treatment of venous thromboembolism.

Venous thromboembolism (VTE) is a disease entity composed of pulmonary embolism (PE) and deep vein thrombosis (DVT). Anticoagulation, initiated as soon as the diagnosis is suspected, is the treatment of choice. Traditionally, anticoagulation is started with intravenous heparin, and changed to warfarin for long-term treatment. The introduction of unmonitored, subcutaneously administered, low molecular weight heparin has resulted in shorter hospitalizations, reduced the incidence of major bleeding as a complication, and shifted the treatment of VTE for selected patients to the outpatient setting. Thrombolytic therapy has been recommended for patients with life-threatening PE. Technologic advances in catheter embolectomy and fragmentation permit clot resolution in patients in whom thrombolytic therapy is contraindicated. Inferior cava filters can be placed percutaneously in patients at high risk for VTE or those in whom anticoagulation is contraindicated. Because VTE is often clinically silent, prevention of VTE is therefore the most effective means to reduce associated morbidity and mortality. Strategies to prevent VTE have been studied and validated for specific clinical circumstances.

Attitudes of respiratory care practitioners and students regarding pulmonary prevention.

STUDY OBJECTIVES: (1) To examine attitudes of respiratory care practitioners (RCPs) and RCP students toward pulmonary disease prevention behaviors and their role in promoting them. (2) To compare RCPs' attitudes regarding pulmonary prevention with existing medical student survey data. DESIGN: Cross-sectional survey. SETTING: Three sites (Valhalla, NY; Winston-Salem, NC; Houston, TX). PARTICIPANTS: One hundred ninety RCPs and 164 RCP students compared with 5,744 medical students. MEASUREMENT AND RESULTS: Subjects completed a 35-item RCP Preventive Pulmonary Attitude (PPA) Survey using a five-point scale (1 = strongly disagree to 5 = strongly agree). A higher score indicates a more positive attitude toward prevention. RCP total scores averaged 117.6 (SD, 15.7; range, 52 to 160). RCP student total scores were significantly higher than RCP practitioners. No significant differences were observed by gender or by type of patient served (pediatric vs adult). RCPs with a history of tobacco smoking had significantly lower scores than RCPs who had never smoked. Most, but not all, respondents acknowledged the importance of patients with chronic lung disease receiving a yearly influenza vaccination. Total PPA scores for medical students were significantly lower than scores for both RCPs and RCP students. Significant differences were noted for a number of individual items. CONCLUSIONS: In general, RCPs had positive attitudes regarding the importance of prevention counseling and their role in providing this to patients. This is important given their potential as a resource in pulmonary prevention efforts. More attention to inclusion of training and evaluation of RCP effectiveness in promoting respiratory health is needed.

Persistent somatization in cancer: a controlled follow-up study.

Nature and frequency of somatic complaints, severity of anxiety and depression, and nature of psychiatric symptoms and disorders were evaluated in 81 adequately treated cancer patients, disease-free or with residual disease, using a controlled, prospective follow-up design. Patients were included in the index group (n=60) if they had persistent somatic complaints or unexplained nature or severity of somatic complaints, or the control group (n=21), if they did not report somatic complaints. Instruments used for evaluation were the Scale for Assessment of Somatic Symptoms, Hospital Anxiety and Depression Scale, Psychiatric Assessment Schedule, and DSM-III-R. Common somatic complaints in the index group were pain (19%), fatigue (17%), sensory symptoms (30%), and mixed symptoms (27%). Subjects in the index group significantly (p<0.001) more often had depressive or anxiety disorder (19%) and atypical somatoform disorder (15%). Patients were treated appropriately with psychotropic medications and counseling. Follow-up at 4-6 months revealed a significant reduction in the number of somatic symptoms (p<0.001) and anxiety (p<0.001) and depression (p<0.05) scores. The observations confirm that somatic symptoms may persist in cancer patients, which are related to concomitant psychopathology, and require psychiatric intervention.

Patients prefer sedation for fibreoptic bronchoscopy.

This study was carried out in order to determine if intravenous (i.v.) sedation with diazepam, at the time of procedure, made fibreoptic bronchoscopy more tolerable and if these perceptions persisted on later questioning. Methodology consisted of a sequential, parallel group design comparing sedation with no sedation for bronchoscopy in a tertiary referral hospital. Patient comfort and sedation desired for hypothetical repeat bronchoscopy were assessed both immediately and after at least 1 month. Patients who received sedation rated bronchoscopy as more comfortable (P = 0.01). Those who received sedation were also more likely to want no change in sedation if the bronchoscopy were repeated (P < 0.01). These differences were more evident at later questioning. Sedation was not associated with an increased complication rate but was associated with a prolonged recovery room stay (no sedation, 19.2 min (SEM 3.8) compared with sedation, 76.1 min (5.4), P < 0.001). In contrast to previous studies, our patients found bronchoscopy more comfortable with i.v. diazepam sedation. This was supported by patients who received sedation being less likely to want any change in future sedation if a repeat bronchoscopy were required. The benefit seen with sedation was more marked at later questioning supporting a previously postulated amnesic effect. However, sedation was associated with a prolonged room stay and potentially greater attendant cost.

Clinical experience and outcomes of community-acquired and nosocomial methicillin-resistant Staphylococcus aureus in a northern Australian hospital.

Methicillin-resistant Staphylococcus aureus (MRSA) is a well-recognized cause of hospital-acquired sepsis. We reviewed the clinical features of a new variant of community-acquired MRSA originally described from the Kimberley region of northern Western Australia (WA MRSA). This strain has become an increasing cause of community- and hospital-acquired sepsis at Royal Darwin Hospital (RDH) in the Northern Territory, especially in Aboriginal Australians from remote communities. Fifty percent of WA MRSA was community-acquired, with 76% in Aboriginals. Like the MRSA from eastern Australia (EA MRSA), WA MRSA commonly caused skin sepsis but was less likely to cause respiratory or urinary infections compared with EA MRSA. Twelve out of 125 (9.6%) WA MRSA and 7/93 (7.5%) EA MRSA infections were septicaemias. Septicaemia due to WA MRSA occurred in adult medical patients, especially those with temporary haemodialysis catheters, while EA MRSA septicaemia occurred throughout the hospital. Aboriginal people were more likely to develop both community- and hospital-acquired WA MRSA septicaemia [overall relative risk (RR) 12.3 (95% CI 3.7-40.7)]. Control of WA MRSA requires policies to reduce transmission in both hospitals and communities. Community-based control programmes need support for individual patient management, improved housing and hygiene, control of skin sepsis and appropriate use of antibiotics, especially in rural Aboriginal communities in northern Australia.

New World cutaneous leishmaniasis imported into Australia.

A case of cutaneous leishmaniasis in a traveller from Belize, Central America is reported. Leishmaniasis presents rarely in Australia and delays in diagnosis and treatment often occur. A high index of suspicion in a patient who has returned from an endemic region is required. Subsequent confirmation of a diagnosis of cutaneous leishmaniasis is best achieved by demonstration of the organism on skin biopsy, aspiration or smear. The histology is variable and depends on geographic, parasite species and host factors. Speciation of New World disease as either Leishmania braziliensis or Leishmania mexicana is important to determine the risk of later development of mucosal disease, which normally only occurs with L. braziliensis infection, and for optimal treatment. Several different modes of treatment have been suggested, but antimonials, such as sodium stibogluconate, remain the treatment of choice in New World cutaneous leishmaniasis.

Emerging epidemic of community-acquired methicillin-resistant Staphylococcus aureus infection in the Northern Territory.

OBJECTIVE: To investigate the epidemiology of WA MRSA (the recently recognised Western Australian strains of methicillin-resistant Staphylococcus aureus) in the north of the Northern Territory (NT). DESIGN: Retrospective survey of data from hospital records. SETTING: Royal Darwin Hospital (a tertiary referral hospital that serves the north of the NT) between January 1991 and July 1995. SUBJECTS: All inpatients with clinical MRSA infection. OUTCOME MEASURES: Incidence of MRSA infection, classification of MRSA as WA or EA (Eastern Australian) based on antibiotic susceptibility, patient demographic details (age, sex, ethnicity, region of residence), source of infection (nosocomial or community-acquired). RESULTS: There were 125 WA MRSA and 93 EA MRSA infections, comprising 7% of all S. aureus infections. The incidence of WA MRSA infections consistently increased, while that of EA MRSA initially fell and then increased. All EA MRSA infections were nosocomial, while 50% of WA MRSA infections were community-acquired. Rates of WA MRSA infections were highest in patients from the west region of the NT, adjacent to the Kimberley region of Western Australia (WA). Community-acquired WA MRSA infections were more likely to affect Aboriginals than non-Aboriginals (relative risk [RR], 25.86; 95% confidence interval [CI], 12.51-53.47, based on population data; RR, 15.43; 95% CI, 7.85-30.32, based on admission data), as were nosocomial EA MRSA infections (RR, 2.54; 95% CI, 1.44-4.47, based on population data; RR, 2.30; 95% CI, 1.52-3.46, based on admission data). CONCLUSIONS: Changes in the epidemiology of MRSA infection in the north of the NT are consistent with the hypothesis that community-acquired WA MRSA spread into and across the NT from the Kimberley region of WA. Alternatively, crowded living conditions, hygiene difficulties and increasing use of broad spectrum antibiotics may have led to independent emergence of WA MRSA in both regions. Current infection control policies and their use in rural Aboriginal communities must be reassessed.