Missing voices: Profile and extent of acquired communication disorders in Aboriginal and non-Aboriginal adult stroke survivors in Western Australia using linked administrative records.

BACKGROUND: Limited data exist on the extent of specific functional sequelae, including acquired communication disorder, among Aboriginal stroke survivors, making planning of multidisciplinary services difficult. AIMS: To obtain estimates of the extent and profile of acquired communication disorder in Aboriginal and non-Aboriginal adult stroke survivors in Western Australia and investigate potential disparities in receiving in-hospital speech pathology services among survivors with acquired communication disorder. METHODS: Stroke cases surviving their first stroke episode during 2002-2011 were identified using Western Australia-wide person-based linked hospital and mortality data, and their five-year comorbidity profiles determined. The mid-year prevalence of stroke cases with acquired communication disorder was estimated for 2011. Regression methods were used to investigate determinants of receiving speech pathology services among acquired communication disorder cases. RESULTS: Of 14,757 stroke survivors aged 15-79 years admitted in 2002-2011, 33% had acquired communication disorder (22% aphasia/dysphasia) and 777 (5.3%) were Aboriginal. Aboriginal patients were more likely to be younger, live remotely, and have comorbidities. A diagnosis of aphasia was more common in Aboriginal than non-Aboriginal patients 15-44 years (p = 0.003). A minimum of 107 Aboriginal and 2324 non-Aboriginal stroke patients with acquired communication disorder lived in Western Australia in 2011. Aboriginal status was not associated with receiving in-hospital speech services among acquired communication disorder patients in unadjusted or adjusted models. CONCLUSIONS: The relative youth, geographical distribution, high comorbidity prevalence, and cultural needs of Aboriginal stroke patients with acquired communication disorder should inform appropriate service design for speech pathology and rehabilitation. Innovative models are required to address workforce issues, given low patient volumes.

Evidence-based prescribing of drugs for secondary prevention of acute coronary syndrome in Aboriginal and non-Aboriginal patients admitted to Western Australian hospitals.

AIMS: To assess the level of evidence-based drug prescribing for acute coronary syndrome (ACS) at discharge from Western Australian (WA) hospitals and determine predictors of such prescribing in Aboriginal and non-Aboriginal patients. METHODS: All Aboriginal (2002-2004) and a random sample of non-Aboriginal (2003) hospital admissions with a principal diagnosis of ACS were extracted from the WA Hospital Morbidity Data Collection of WA Data Linkage System. Clinical information, history of co-morbidities and drugs were collected from medical notes by trained data collectors. Evidence-based prescribing (EBP) was defined as prescribing of aspirin, statin and beta-blocker or angiotensin-converting enzyme inhibitor/angiotensin II antagonist. RESULTS: Records for 1717 ACS patients discharged alive from hospitals were reviewed. The majority of patients (71%) had EBP, and there was no significant difference between Aboriginal and non-Aboriginal patients (70% vs 71%, P = 0.36). Conversely, a significantly higher proportion of Aboriginal patients had none of the drugs prescribed compared with non-Aboriginal patients (11% vs 7%, P < 0.01). EBP for ACS was independently associated with male sex (odds ratio (OR) 1.63, 95% confidence interval (CI) 1.26-2.11), previous admission for ACS (OR 1.83, 95% CI 1.39-2.42) and diabetes (OR 1.36, 95% CI 1.04-1.79). However, ACS patients living in regional and remote areas, attending district or private hospitals, or with a history of chronic obstructive pulmonary disease were significantly less likely to have ACS drugs prescribed at discharge. CONCLUSIONS: Opportunity exists to improve prescribing of recommended drugs for ACS patients at discharge from WA hospitals in both Aboriginal and non-Aboriginal patients. Attention regarding pharmaceutical management post-ACS is particularly required for patients from rural and remote areas, and those attending district and private hospitals.

Indigenous beliefs about biomedical and bush medicine treatment efficacy for indigenous cancer patients: a review of the literature.

BACKGROUND: Australia's indigenous people suffer from higher cancer mortality than non-indigenous Australians, a discrepancy partly caused by differences in beliefs about treatment efficacy between Indigenous patients and their non-indigenous healthcare providers. This paper critically reviews the literature associated with Indigenous beliefs about cancer treatment, both 'bush medicine' and biomedical, in order to provide recommendations to healthcare providers about accommodating indigenous beliefs when treating cancer. METHODS: A search was undertaken of peer-reviewed journal papers using electronic databases and citation snowballing. Papers were selected for inclusion based upon relevance to themes that addressed the research questions. RESULTS: Literature suggests that indigenous beliefs about treatment efficacy for cancer involve five themes: (i) concerns about the toxicity of treatment; (ii) disconnect with the physician; (iii) fears about absence from home during treatment; (iv) different beliefs about disease aetiology; (v) biomedical cancer treatments failing to address holistic health. CONCLUSIONS: Although some information is known about indigenous Australian healing beliefs and practices associated with cancer treatment, few studies have addressed ways in which indigenous and biomedical approaches to cancer treatment might be integrated. Some recent work has examined the role of belief in cancer treatment, specifically bush medicine, but more research is required.

Time to bring down the twin towers in poor Aboriginal hospital care: addressing institutional racism and misunderstandings in communication.

Improvements in Aboriginal health have been slow. Research demonstrates ongoing discrimination towards Aboriginal Australians based on race, including in health services, leads to poor health outcomes. Using an eclectic methodology based on observations and discussions with health practitioners experienced in working with Aboriginal patients, this paper identifies how cross-cultural misunderstandings undermine the quality of care to Aboriginal patients in hospital and offers suggestions for improving practice. It also explores the concept of institutional racism and challenges doctors to reflect on their role in perpetuating power imbalances. We argue that physicians and healthcare providers need to do more than just deliver evidence-based interventions, by critically reflecting on their own attitudes to and practices with Aboriginal Australians and work collectively to effect systemic change which creates a more inclusive and safe environment for all people accessing healthcare.

Intraventricular insulin suppresses the acoustic startle response in rats.

We and others have previously reported that the hormone insulin alters brain noradrenergic function at the synaptic and molecular levels. In the present study, we examined the in vivo effect of insulin (administered chronically via osmotic minipumps at a dose of 5 mU/day into the third cerebral ventricle) on the acoustic startle response. Rats receiving chronic intraventricular insulin had a significantly reduced startle response relative to vehicle-treated controls (i.e., 47 +/- 21% of baseline control startle response). Because our previous findings suggest that on an acute basis, insulin may enhance endogenous noradrenergic activity by inhibiting norepinephrine reuptake, we speculate here that the chronic effect of insulin is similar to that of the noradrenergic reuptake blocker, desipramine, which has been reported to decrease baseline startle performance.

The impact of diagnosis of hepatitis C virus on quality of life.

The aim of this study was to examine the effects of diagnosis of hepatitis C virus (HCV) infection on quality of life in a cohort admitted to Fairfield Infectious Diseases Hospital with acute hepatitis from 1971 to 1975. Sera stored from the original admission were tested for antibody to HCV. Systematic approaches were used to locate anti-HCV-positive individuals and outcomes assessed by the Short Form 36 (SF-36) scale and a study-specific questionnaire as well as clinical review. Study subjects' SF-36 scores were compared with Australian population norms. Anti-HCV and HCV-RNA positive individuals (n = 15) aware of their serostatus rated significantly worse on 7 of 8 SF-36 scales compared with population norms. However, HCV-seropositive and RNA-positive individuals unaware of their HCV serostatus (n = 19) scored significantly worse in only 3 scales. Those aware of their serostatus did not differ sociodemographically, clinically, virologically, or serologically from those who were unaware, nor was there a link between quality of life (QOL) scores and objective measures of ill health. All subjects had injected drugs in the past. In conclusion, HCV-RNA and anti-HCV-positive individuals in our study have significantly poorer subjective health status 26 years after original infection compared with population norms. QOL measures were significantly worse for HCV-seropositive individuals aware of their serostatus compared with those unaware. We feel that the reduced QOL in the diagnosed group may be partially an effect of labeling and that the impact of the diagnostic process per se on QOL in individuals with HCV requires further evaluation.

Hepatitis infection among adolescents resident in Melbourne Juvenile Justice Centre: risk factors and challenges.

OBJECTIVE: To describe patterns of infection with, and risks for, hepatitis A, B and C viruses (HAV, HBV, and HCV) in male adolescents detained in the Melbourne Juvenile Justice Centre (MJJC). METHODS: A cross-sectional serosurvey for HAV, HBV, and HCV among 90 male adolescents aged 15-18 years who were resident in MJJC for more than 1 week in 1996. RESULTS: Nine percent had been exposed to HAV, 8% were positive or equivocal for exposure to HBV, and 21% were antibody positive for HCV. All those with hepatitis markers except one positive for HAV had been injection heroin users for more than 1 year. Of those who were not HBcAb positive, only 28% were immune to HBV. For most respondents, sexual and drug-using risks began in the early teens and were associated with leaving school prematurely. CONCLUSIONS: Respondents were vulnerable to exposure to blood-borne viruses from an early age, posing a challenge for health education programs. An opportunity exists for harm minimization and prevention of spread of blood-borne viruses within the first year of injection drug use in this population.

Assessment of long-term outcomes of hepatitis C virus infection in a cohort of patients with acute hepatitis in 1971-1975: results of a pilot study.

BACKGROUND: To examine the long-term effects of hepatitis C virus (HCV) infection in a cohort of patients admitted to Fairfield Hospital with hepatitis from 1971 to 1975. The availability of stored sera from this time enabled testing to identify those who were anti-HCV positive on admission. METHODS: Sixteen per cent (n = 230) of the cohort tested positive for HCV antibody (anti-HCV). The 'unexposed' group was selected from those who were anti-HCV negative. Systematic approaches were used to locate the cohort and health outcomes assessed by a study specific questionnaire and clinical review with repeat serology and liver function tests. RESULTS: Complete follow up has been achieved on a subset of 35 HCV-seropositive and 70 seronegative individuals. The seropositive group was significantly more likely to have given a history of injecting drug use, the presumed route of infection. The seropositive group was also more likely to have elevated serum alanine aminotransferase levels, but only two (6%) were known to have progressed to cirrhosis. DISCUSSION: The anti-HCV-positive individuals followed up to date are at increased risk of liver-related pathology, but few had progressed to cirrhotic liver disease. This differs from findings of transfusion-related studies and suggests, within the limitations of the study, that the natural history of community acquired HCV may be more benign.

Hepatitis B vaccination of personnel employed in Victorian hospitals: are those at risk adequately protected?

OBJECTIVE: To examine the policies and practices in hospitals within the state of Victoria, Australia, with respect to vaccination of staff against hepatitis B infection. DESIGN: A written self-administered questionnaire to be completed by the infection control officer (or designated officer for hepatitis B vaccination) within each hospital. SETTING: Public (teaching and nonteaching) and private hospitals, including metropolitan and rural institutions in Victoria. PARTICIPANTS: A random sample of 30% of Victorian hospitals were asked to participate in the survey. Of 78 eligible institutions, 69 (88%) completed and returned questionnaires. RESULTS: There was no consistent hepatitis B prevention policy in place across Victoria. Of the 69 responding hospitals, 63 (91%) offered hepatitis B vaccination to staff, and 58 (84%) of these also paid all costs of vaccination. Of the 63 hospitals offering vaccination to staff, 39 offered vaccination to all staff, 23 offered vaccination based on job title, and one offered vaccination based on anticipated exposure. In many institutions, postexposure protocols were recalled more readily than preexposure vaccination guidelines. Numerous respondents indicated a need for clear guidelines on policy and clarification on practical matters of management, such as acceptable immune levels, management of nonresponders to the primary series, and the need for, and timing of, booster doses of vaccine. Eleven (18%) of the 63 hospitals offering hepatitis B vaccination to staff undertook routine prevaccination screening, a practice not generally regarded as cost-effective in Australia. Fifty-five of these hospitals (91%) also undertook postvaccination screening. CONCLUSIONS: It is evident from this study that a considerable number of potentially susceptible healthcare personnel in Victorian hospitals remain unprotected against hepatitis B infection. A more reliable and consistent approach to preexposure hepatitis B vaccination is recommended.

The prevalence of hepatitis C in patients admitted with acute hepatitis to Fairfield Infectious Diseases Hospital, 1971-1975.

OBJECTIVE: To identify and determine trends in the prevalence of hepatitis C virus (HCV) antibody in stored sera from 1971 to 1975 and to determine associations with HCV seropositivity, including markers for other hepatitis infections and possible routes of transmission. DESIGN: A retrospective cross-sectional study. PATIENTS AND SETTING: 1511 adults admitted to Fairfield Infectious Diseases Hospital, Victoria, with a clinical and biochemical diagnosis of hepatitis between 1 January 1971 and 31 December 1975. MAIN OUTCOME MEASURES: Prevalence over study period of hepatitis A virus antibody (anti-HAV) IgM, hepatitis B core antibody (anti-HBc), hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (anti-HCV) in stored sera; sociodemographic data and risk factors for blood-borne viruses documented in original medical records. RESULTS: Anti-HCV was detected in 17% of adults admitted with hepatitis from 1971 through 1975. Prevalence increased significantly over this period. Most cases were in young men who had a history of injecting drug use. HCV seropositivity was also significantly associated with markers for hepatitis B infection. CONCLUSIONS: Given the 20-30-year period between infection with hepatitis and the development of liver disease, our findings predict significant liver-related morbidity in Australia in the next decade. The increase in prevalence over the five years studied suggests rapid spread of HCV through susceptible populations, principally injecting drug users.

Juvenile offenders and hepatitis B: risk, vaccine uptake and vaccination status.

OBJECTIVE: To determine the hepatitis B vaccination status of juvenile offenders in a custodial setting, their perceived risk of hepatitis B infection, and factors influencing vaccine uptake. DESIGN: 130 males aged 14-17 years resident at the Melbourne Juvenile Justice Centre for at least one week between mid-January and mid-December 1996 were invited to participate; 90 (69%) completed a doctor-administered questionnaire, and blood for serological testing was obtained from 83 of these participants. MAIN OUTCOME MEASURES: Whether hepatitis B vaccine had been offered; whether hepatitis B vaccine had been given; the presence of antibodies to hepatitis B and C; risk factors and self-perceived risk of hepatitis B. RESULTS: About a quarter of participants (22/83) had protective levels of antibody to hepatitis B surface antigen (anti-HBs). Forty (44%) participants reported having been offered hepatitis B vaccine; they were more likely to be vaccinated and have protective levels of anti-HBs. Perceived risk for bloodborne virus infection was low, although two-thirds of participants were at high risk of hepatitis B infection. On serological testing, 6.4% (5/78) were positive for antibody to hepatitis B core antigen (anti-HBc), and a further 2.6% (2) had equivocal antibody levels. Of the 71 who were negative for anti-HBc, 51 (71.8%) were negative for anti-HBs. CONCLUSIONS: The targeted hepatitis B vaccination program has not adequately protected this group at high lifetime risk of hepatitis B. Failure to deliver vaccine may reflect lack of contact with healthcare services, oversight in offering vaccine and reluctance of youth to participate in preventive healthcare measures, often through not seeing themselves to be at risk. Universal approaches to vaccination may be more successful in vaccinating this group.

Immunogenicity and reactogenicity of a combined hepatitis A-hepatitis B vaccine in adolescents.

OBJECTIVE: To evaluate the immunogenicity and reactogenicity of two lots of a combined hepatitis A-hepatitis B vaccine (HAV, HBV) in healthy 15 to 18 year olds. DESIGN: This was a double-blind, randomized clinical study. Vaccine was administered into the deltoid at 0, 1, and 6 months. Immunogenicity was assessed by anti-HAV and anti-HBs antibody levels at 2, 6, and 7 months after the first vaccine dose. Reactogenicity was assessed through use of 3-day diary cards following each vaccination, plus recording other unsolicited reactions. RESULTS: A total of 160 adolescents were vaccinated; 155 who were seronegative for hepatitis A and B at baseline and who completed the study were included in the immunogenicity analysis. The vaccine was well tolerated; most side effects were local, of low intensity and short duration. Good immunogenicity was determined by antibody titers. High rates of seropositivity (99.4%) were achieved after two doses against HAV, and after three doses for anti-HBs (seroprotection = 98.7%). CONCLUSIONS: This combination vaccine will be useful for immunizing selected high-risk groups in developed countries. In countries where endemicity is low for both diseases, targeting students prior to risk of acquisition would be a feasible preventive strategy.

HIV positive tests at Coronial Services in Victoria 1989-1996: lessons for HIV surveillance.

Results of routine testing at other sites can supplement surveillance of the HIV epidemic in Australia which is largely based upon voluntary testing. Since 1989, systematic onsite HIV testing has been undertaken on all bodies taken to the Victorian Institute of Forensic Medicine (VIFM). Information was collected on all cases of HIV infection detected at VIFM between 1989 and 1996, and matched to surveillance databases. In 8 years, 75 people were diagnosed with HIV; all except one were male. The age range was 14-70 years, mean 37.4 years. The major causes of death were suicide 35%, AIDS 21%, drug toxicity 16%, natural causes 12% and injury 7%. The major exposure categories were male homosexual 51%, male bisexual 11%, homosexual/bisexual IDU 16%, IDU other 8%, and haemophiliac 7%. For only two was exposure information unavailable. Seropositivity for anti-HCV and HBsAg was 37% and 11% respectively. The deceased was recorded as having HIV/AIDS on the police report in 73% of cases, and at least 90% of subjects had been diagnosed with HIV prior to their death. The study suggests there is relatively little undiagnosed HIV infection in Victoria, that HIV infection has not moved outside traditional risk groups, and that many tests for HIV are undertaken using false namecodes. Many patients could not be matched on the HIV/AIDS databases, identifying a problem with HIV surveillance systems in Victoria, and the need to capture all information on HIV positives detected at VIFM.

Serostatus for vaccine-preventable diseases in residents at Melbourne Juvenile Justice Centre.

There are concerns in Australia about inadequate rates of childhood immunisation, an important preventive measure to reduce infectious diseases. The population passing through the Melbourne Juvenile Justice Centre (MJJC) comes from a background at high risk for inadequate immunisation and outbreaks can occur in residential institutions. MJJC residents were invited to participate in a study by completing a medical officer-administered risk behaviour questionnaire and/or giving a blood sample. Ninety residents completed the questionnaire; 83 gave blood samples. Sera were tested for measles, mumps, rubella and hepatitis A, B and C markers using standard commercial assays. Diphtheria and tetanus were tested with an ELISA in a public health laboratory familiar in the technique. Sixty four per cent (53/83) of participants were non-immune to at least one component of MMR and 44.6% (37/83) non-immune to either tetanus or diphtheria. Despite 61.1% of participants reporting injecting drug use, only 28.2% had protective levels of anti-HBs, 6.1% were positive for anti-HBc (2.4% equivocal), 22.9% were anti-HCV positive and 9.6% had markers of exposure to hepatitis A virus. These results show suboptimal levels of immunity in this institutional setting with the potential for disease outbreaks. Many residents miss adolescent school-based programs for immunisation because of truancy and early school leaving. Despite considerable risk of blood-borne viruses, many MJJC residents are inadequately vaccinated against hepatitis B.

Primary and secondary control over age-related changes in physical appearance.

Beliefs about appearance-related changes due to aging were used to test the effects of perceived control and secondary control (acceptance) in a sample of 412 young, early-middle-age, and late-middle-age college-educated adults. Mean difference in aging-related appearance control and hypotheses regarding the adaptiveness of primary and secondary control were examined. Primary control over aging-related appearance was lower in older adults and secondary control was higher. In addition, the results indicated support for the Primacy/Back-Up Model that primary perceived control is important at all levels of actual control. Those with stronger beliefs in their primary control were less distressed. Secondary control served a back-up function in that it was related to less distress only for those who had medium or lower beliefs in primary control. The implications of these findings, that primary control may be advantageous even in low-control circumstances, are discussed.

Documentation of children's vaccination status in child care centres in Victoria.

OBJECTIVE: To assess the record-keeping of child care centres in Victoria with respect to children's vaccination status. METHODOLOGY: A random sample of 113 centres from a list of over 800 registered Victorian child care centres received a mailed questionnaire on characteristics and policies of the centre, including documentation of attending children's vaccination status. RESULTS: The response rate was 86.7%; more than 95% of centres had children under two in care. Only 85% of centres kept any record of children's immunisation status, with smaller centres and class 2 centres (occasional care centres) significantly less likely to keep records. Records were updated irregularly. Fewer than half of the centres studied kept a record of whether children had been vaccinated against Haemophilus influenzae type b. CONCLUSIONS: Despite the importance of documenting children's vaccination status, many child care centres have failed to develop adequate systems to record or update records of children's immunisation. This makes exclusion during outbreaks of a vaccine-preventable disease difficult. The ongoing process of accreditation may eventually improve performance, but both legislation and a better educational strategy to improve practice in this area are needed.

Illusions of control, underestimations, and accuracy: a control heuristic explanation.

The illusions of control area is reviewed, and 5 conditions that influence control judgments are identified: skill-related factors, success or failure emphasis, need for the outcome, mood, and the intrusion of reality. It is proposed that individuals use a control heuristic that includes perceptions of intentionality and connection. Judgments of intentionality are based on foreseeability, ability to produce the effect, and valence of the outcome. Judgments of connection are based on the perceived association between the action and the outcome, which includes temporal, shared meaning, and predictive association. Effects of motives to overestimate, underestimate, and have accurate assessments of control are explained, using the concepts of hindsight bias, connection, and counterfactuals. In addition, the relation between the control heuristic and illusory correlation research and applications of the control heuristic to coping with chronic illness are explored.

Hepatitis A vaccination of child care workers in Victoria: are recommendations being implemented?

This study examined the self-reported hepatitis A and B immunisation status of child care workers, the level of awareness among child care workers of the NHMRC recommendation for immunisation against hep. A and centre practices. A confidential mail survey was conducted in June 1996 with workers and co-ordinators from 113 randomly selected child care centres. Co-ordinators completed a questionnaire on the centre's characteristics and immunisation policy. Child care workers completed a second questionnaire on their immunisation knowledge or beliefs and immunisation status. Ninety-five centres (85%) and 607 (74%) workers participated. Only 11% of workers were vaccinated against hep. A, although the majority of child care worker respondents believed their occupation placed them at increased risk. Those vaccinated were more likely to be aware of the availability of hep. A vaccine, of the NHMRC recommendation for hep. A vaccination, and to have been vaccinated for hep. B. Centres in which co-ordinators perceived hep. A vaccination as important, and those which recorded staff immunisation, particularly hep. A, were more likely to have child care workers who were vaccinated against hep. A. In contrast, nearly two-thirds of child care workers reported that they were vaccinated against hep. B, although hep. B is not routinely recommended by the NHMRC for child care workers. These findings show a need for further policy and educational initiatives in the implementation of an immunisation strategy for child care workers.