Impact of parental health literacy on the health outcomes of children with chronic disease globally: A systematic review.

AIM: Health literacy is the ability to understand and interpret health information and navigate the health-care system. Low health literacy is associated with poorer health knowledge and disease management, increased chronic illness, underutilisation of preventative health services and increased hospitalisations. The aim of the study is to review the available literature on the relationship between parental health literacy and health outcomes for children with chronic disease in high-income countries (HIC) and low- and middle-income countries (LMIC). METHODS: We systematically searched Medline, EMBASE and Web of Science, and assessed study quality using the Newcastle Ottawa Scale. We reviewed all relevant studies, and identified themes using thematic analysis. RESULTS: Of 1167 studies assessed, 49 were included in the review. All studies were of adequate quality. Twenty-two were from LMIC and 27 from HIC. Six themes were identified: Parental health literacy, parental education, socio-economic conditions, identity and culture, family factors, and health behaviours. In both HIC and LMIC, lower parental health literacy was associated with poorer child health outcomes. Disease-specific knowledge was found in a number of papers to directly impact parent health behaviour and child health outcomes, and may mitigate the effects of low parental health literacy. CONCLUSION: There is a clear link between parental health literacy, health behaviour and health outcomes for children with chronic disease. Disease-specific knowledge as a target for health-care interventions holds promise for application in low-resourced settings with parents (particularly mothers) who have lower health literacy, where disease-specific education may improve child health outcomes, although more research is required to determine how we can best facilitate these programmes.

How Adolescents Search for and Appraise Online Health Information: A Systematic Review.

OBJECTIVE: To conduct a systematic review of the evidence concerning whether and how adolescents search for online health information and the extent to which they appraise the credibility of information they retrieve. STUDY DESIGN: A systematic search of online databases (MEDLINE, EMBASE, PsycINFO, ERIC) was performed. Reference lists of included papers were searched manually for additional articles. Included were studies on whether and how adolescents searched for and appraised online health information, where adolescent participants were aged 13-18 years. Thematic analysis was used to synthesize the findings. RESULTS: Thirty-four studies met the inclusion criteria. In line with the research questions, 2 key concepts were identified within the papers: whether and how adolescents search for online health information, and the extent to which adolescents appraise online health information. Four themes were identified regarding whether and how adolescents search for online health information: use of search engines, difficulties in selecting appropriate search strings, barriers to searching, and absence of searching. Four themes emerged concerning the extent to which adolescents appraise the credibility of online health information: evaluation based on Web site name and reputation, evaluation based on first impression of Web site, evaluation of Web site content, and absence of a sophisticated appraisal strategy. CONCLUSIONS: Adolescents are aware of the varying quality of online health information. Strategies used by individuals for searching and appraising online health information differ in their sophistication. It is important to develop resources to enhance search and appraisal skills and to collaborate with adolescents to ensure that such resources are appropriate for them.

Use of the EpiNet database for observational study of status epilepticus in Auckland, New Zealand.

The EpiNet project has been established to facilitate investigator-initiated clinical research in epilepsy, to undertake epidemiological studies, and to simultaneously improve the care of patients who have records created within the EpiNet database. The EpiNet database has recently been adapted to collect detailed information regarding status epilepticus. An incidence study is now underway in Auckland, New Zealand in which the incidence of status epilepticus in the greater Auckland area (population: 1.5 million) will be calculated. The form that has been developed for this study can be used in the future to collect information for randomized controlled trials in status epilepticus. This article is part of a Special Issue entitled "Status Epilepticus".

Application of Bayesian techniques to model the burden of human salmonellosis attributable to U.S. food commodities at the point of processing: adaptation of a Danish model.

Mathematical models that estimate the proportion of foodborne illnesses attributable to food commodities at specific points in the food chain may be useful to risk managers and policy makers to formulate public health goals, prioritize interventions, and document the effectiveness of mitigations aimed at reducing illness. Using human surveillance data on laboratory-confirmed Salmonella infections from the Centers for Disease Control and Prevention and Salmonella testing data from U.S. Department of Agriculture Food Safety and Inspection Service's regulatory programs, we developed a point-of-processing foodborne illness attribution model by adapting the Hald Salmonella Bayesian source attribution model. Key model outputs include estimates of the relative proportions of domestically acquired sporadic human Salmonella infections resulting from contamination of raw meat, poultry, and egg products processed in the United States from 1998 through 2003. The current model estimates the relative contribution of chicken (48%), ground beef (28%), turkey (17%), egg products (6%), intact beef (1%), and pork (<1%) across 109 Salmonella serotypes found in food commodities at point of processing. While interpretation of the attribution estimates is constrained by data inputs, the adapted model shows promise and may serve as a basis for a common approach to attribution of human salmonellosis and food safety decision-making in more than one country.

Enumeration of Escherichia coli cells on chicken carcasses as a potential measure of microbial process control in a random selection of slaughter establishments in the United States.

To evaluate whether the number of Escherichia coli bacteria in carcass rinses from chicken slaughter establishments could be monitored for the purpose of microbial process control, we drew a random sample from 20 of 127 large USDA-inspected operations. In 2005, every 3 months, two sets of 10 carcass rinses, 100 ml each, were collected from establishments, netting 80 sample sets from the rehang and postchill stages. E. coli and Campylobacter numbers and Salmonella prevalence were measured. Mixed-effect models were used to estimate variance of mean log(10) E. coli cell numbers of 10-carcass rinse sample sets. Relationships between E. coli and Campylobacter and Salmonella were examined. For 10-carcass rinse sets, at both the rehang and postchill stages the mean log(10) E. coli CFU/ml fit the logistic distribution better than the normal distribution. The rehang overall mean log(10) E. coli was 3.3 CFU/ml, with a within-sample set standard deviation of 0.6 CFU/ml. The overall postchill mean log(10) E. coli was 0.8 CFU/ml, with 13 establishments having mean log(10) E. coli CFU/ml values of less than 1.0 and 7 having mean values of 1.2 or more. At the midpoint separating these establishments, a mean log(10) E. coli CFU/ml of 1.1, the within-sample set standard deviation was 0.5 CFU/ml, with smaller standard deviations as means increased. Postchill sample sets with mean log(10) E. coli counts less than or equal to 1.1 CFU/ml had lower overall prevalence of Salmonella and mean log(10) Campylobacter CFU/ml than sample sets with higher means. These findings regarding reductions in E. coli numbers provide insight relevant to microbial process control.

Not all patients with atrial fibrillation-associated ischemic stroke can be started on anticoagulant therapy.

BACKGROUND AND PURPOSE: Ischemic stroke patients in atrial fibrillation (AF) have a 10% to 20% risk of recurrent stroke. Warfarin reduces this risk by two thirds. However, warfarin is underutilized in this patient group. We performed a prospective study to determine the reasons why warfarin is not started in these patients. METHODS: All patients with AF-associated ischemic stroke over a 12-month period were identified. Demographic and other data, including whether warfarin was commenced or recommended at discharge, and if not why not, were recorded. RESULTS: Ninety-three of 412 (23%) ischemic stroke patients had paroxysmal or permanent AF. Of these patients, 17 (18%) died, 48 (52%) were discharged home, and 28 (30%) were discharged to institutional care. Only 13 of 64 (20%) patients with known AF were taking warfarin at stroke onset. Warfarin was started (or recommended) in 35 of 76 (46%) survivors. Of those not commenced on warfarin, 32 (78%) were dependent (P<0.001) and 23 (56%) were discharged to institutional care (P<0.001). Warfarin was not started because of severe disability and frailty in 13 (32%), risk of falls in 12 (30%), and limited life expectancy in 4 (10%). CONCLUSIONS: In this cohort of patients with AF, warfarin was primarily underutilized before stroke onset, and it was too late to use anticoagulation, in approximately half, once a stroke had occurred. The decision to start or continue anticoagulation requires clinical judgment and should be made on a case by case basis after a complete risk benefit assessment.

Mitochondrial genomic contribution to mitochondrial dysfunction in Alzheimer's disease.

Although mitochondrial dysfunction and increased oxidative stress are found in Alzheimer's disease (AD), the origin(s) of the mitochondrial dysfunction, its causal relationship to oxidative stress and the mechanisms of their downstream effects to yield synaptic dysfunction and neuronal death are not known with certainty. The discovery of "classic" mitochondrial diseases where bioenergetic deficiencies were associated with causal mutations or deletions in mitochondrial DNA (mtDNA) generated a search for similar abnormalities in AD samples. At least three-dozen studies since 1992 have failed to find consistent mutational abnormalities in AD mtDNA beyond those associated with aging, with most studies carried out in postmortem brain. Historically, the publication of a new mutation or deletion is followed by other studies that fail to confirm the initial finding. Promising recent findings include heteroplasmic mutations in the D-loop control region. AD brain mtDNA consistently has more oxidative damage beyond that due to aging, providing the potential for generation of mutations/deletions and postgenomic problems with transcriptional regulation. To date no AD brain studies have examined individual neurons to search for clonal expansions of deleted mtDNA's like two recent reports in Parkinson's disease substantia nigra. Cybrid (cytoplasmic hybrid) models, in which mitochondrial DNA (mtDNA) from accessible tissue (platelets) of living AD patients is expressed in replicating human neural cells initially devoid of their own endogenous mtDNA (rho(0) cells) revealed that decreased cytochrome oxidase (CO) activity, increased oxidative stress, increased beta amyloid production, activation of detrimental intracellular signaling and caspases, accelerated mtDNA proliferation, and abnormal mitochondrial morphology and transport can be transmitted through expression of mtDNA from living AD patients. Carrying these cybrid observations into AD brain is necessary to demonstrate any causality of brain mtDNA to contribute to pathogenesis. A novel protein transfection technology that allows transfer of mtDNA into mitochondria of cells ("protofection") will allow this question to be examined. The contribution of altered mtDNA to pathogenesis and progression of AD is suggestive, not proven, and likely very heterogenous.

Foot care: prevention of problems for optimal health.

Problems of the feet generally cause pain but are not life threatening. By making information available regarding ill-fitting shoes and the conditions linked to poor shoe wear, the awareness of our clients can be raised. Home health nurses can contribute to the educational process that may reduce foot problems associated with improper shoe wear. As the foot ages, the normal plantar fat pad begins to atrophy. During the initial visit, foot health should be integrated into health promotion. This article seeks to provide an overview of common foot problems that are not related to diabetes mellitus.

Mothers' decisions to change from formula to mothers' milk for very-low-birth-weight infants.

OBJECTIVE: The purpose of this study was to examine maternal decisions about providing milk for a very-low-birth-weight (VLBW) infant, when the initial maternal intent was to formula-feed. DESIGN: Using prospective, purposive sampling, semistructured interviews were conducted with 21 of 23 eligible mothers over a 9-month period. Audio-recorded data were transcribed verbatim, coded, categorized, and subjected to dimensional analysis. SETTING: The study took place in a 52-bed, tertiary urban neonatal intensive-care unit. PATIENTS/PARTICIPANTS: Mean maternal age was 26.5 years (range = 18-38), and mean infant birth weight and gestational age were 705.4 g (range = 504-1,310), and 25.8 weeks (range = 23-33), respectively. Of the 21 mothers, 76% were African American or Latina; 62% were low income. MAIN OUTCOME MEASURES: We evaluated mothers' initial reasons for selecting formula and changing the decision to provide their milk, whether they were made to feel guilty or coerced, the processes of establishing and maintaining lactation, and breastfeeding outcomes at 1-month postbirth. RESULTS: Mothers initially chose formula because they had no breastfeeding role models and were fearful of pain and lifestyle modifications. They changed this decision after the nurse or physician talked with them about the health benefits for their infant. Of the 21 women, all denied feeling pressured, coerced, or guilty about the decision change, and all identified rewards to themselves and their infants. All mothers provided milk for greater than or equal to 30 days, 19 went on to feed at breast, and 2 became certified breastfeeding peer counselors for the Rush Mothers' Milk Club. CONCLUSION: These findings underscore the role of nurses and physicians in providing evidence-based information about mothers' milk and indicate that sharing this knowledge does not make mothers of VLBW infants feel pressured, coerced, or guilty.

Acute stroke services in New Zealand.

AIMS: To obtain an overall picture of the organisation of acute stroke management in hospitals throughout New Zealand. METHODS: A questionnaire was sent to all New Zealand hospitals. The survey included questions about access to organised stroke care, the presence of designated areas for stroke patient management, guidelines for stroke management and audit. RESULTS: Responses were received from all hospitals surveyed, with 41 admitting stroke patients acutely. Five hospitals (four regional and one large urban) had organised inpatient care. Five hospitals (three regional and two large urban) had stroke physicians. Only 40-60% of the New Zealand population had access to hospitals with guidelines for the management of complications following stroke or secondary prevention. Only fifteen of 41 hospitals had audited local stroke care. There were few differences in the management of stroke patients between urban and regional centres, but care in some regional hospitals was 'better' than that in most large urban hospitals. CONCLUSIONS: The development of an organised approach to inpatient stroke care in New Zealand and the training of general physcians, geriatricans and neurologists in stroke medicine must be seen as a priority.

Changes in the provision of transient ischaemic attack services in New Zealand 2008 to 2013.

BACKGROUND: Urgent assessment and management of patients with transient ischaemic attack (TIA) reduces the early risk of stroke. In 2008 an audit was conducted of TIA services in New Zealand and a substantial discrepancy was found between clinical practice and recommendations in TIA guidelines. We aimed to re-evaluate the situation again in 2013 to determine if there had been any change in provision of TIA services. METHODS: A brief written questionnaire, based on the 2008 survey, was sent to lead stroke clinicians at all district health boards. Questions were asked about the provision of services, including investigation and management of patients with TIA. RESULTS: The questionnaire was completed by all DHBs. The number of DHBs with a dedicated TIA clinic has increased from 3 in 2008 to 15 in 2013 and the number with a clinical pathway for assessment of patients with TIA has increased from 5 to 17. Brain and carotid imaging is usually available within 48h for patients assessed as having high stroke risk. Delays for other patients remain frequent for brain imaging in 14 DHBs and for carotid imaging in 16 DHBs. There was a decrease in the number of DHBs with a wait of more than a week for carotid endarterectomy when indicated from 16 in 2008 to 4 in 2013. CONCLUSION: There have been significant improvements in the provision of TIA services over the last 5 years. However in order to reduce the burden of stroke, DHBs need to consider further investments into adequately resourced TIA services as a priority.

Transient ischaemic attack services in New Zealand.

BACKGROUND: We conducted an audit of transient ischaemic attack (TIA) services in New Zealand to determine how current practice compares to best practice recommendations. METHODS: A brief written questionnaire was sent to all district health boards (DHBs) concerning service provision, clinical management and clinical audit activity related to patients with TIA. RESULTS: Questionnaires were completed by all 21 DHBs. In 18 of 21 (71%) DHBs, most TIA patients were managed by acute services; 3 (14%) DHBs routinely admit most patients and 15 (72%) see most patients in hospital emergency departments or acute assessment units. Three (14%) DHBs see most TIA patients in outpatient clinics, with a usual wait to be seen of more than 1 week. Delays of more than a week were common for carotid ultrasound scans (10 DHBs, 48%) and carotid endarterectomy when indicated (16 DHBs, 76%). Only 4 (19%) DHBs had audited TIA management at a patient level and 3 (14%) at a service level. CONCLUSIONS: There are major discrepancies between current management of TIA patients and best practice recommendations in national and international guidelines. Significant regional variations in models of care and access to investigations exist. The provision of dedicated appropriately resourced TIA services within an organised stroke service should be seen as a priority.

Rehabilitation after stroke: changes between 2002 and 2007 in services provided by district health boards in New Zealand.

AIM: To determine changes between 2002 and 2007 in stroke rehabilitation services provided by district health boards (DHBs) in New Zealand (NZ). METHOD: A questionnaire about organisation of stroke rehabilitation services and use of recommended guidelines was sent to hospitals in all 21 DHBs. RESULTS: Seven DHBs serving 49% of the NZ population provided a designated inpatient area for stroke rehabilitation in 2007 compared with one DHB serving 10% of the population in 2002 (p<0.001). In six DHBs (37%), this designated area was within a general rehabilitation unit. Only one DHB (12%) had a dedicated stroke rehabilitation unit. DHBs with a designated stroke rehabilitation area (SRA) were more likely to have multidisciplinary teams that spent more than half of the time with stroke patients (94% population with SRA versus 22% without SRA; p<0.001), audit their services (90% vs 39%; p<0.001), and provide education sessions for patients/families (82% vs 55%; p 0.004). However, many DHBs did not have guidelines for the management of common aspects of stroke care. CONCLUSION: Stroke rehabilitation services have improved since 2002 but concerns exist about the variability and quality of services provided. A consistent national approach to implementation of guideline recommendations and audit of services is required.

Acute stroke services in New Zealand: changes between 2001 and 2007.

AIM: To determine changes in the organisation of acute stroke management in New Zealand between 2001 and 2007. METHOD: A questionnaire was sent to 58 New Zealand hospitals; it included questions about access to organised stroke care, the presence of designated areas for stroke patient management, guidelines for stroke management, and audit. RESULTS: Responses were received from all hospitals surveyed, with 46 admitting stroke patients either acutely or for stroke rehabilitation. Sixteen District Health Boards (DHBs) covering 88% of the population have a physician who provides overall leadership for stroke services. Seven of 46 hospitals, covering 48% of the population, had areas designated for acute management of stroke patients. Rehabilitation for patients older than 65 years was carried out in designated areas for patients with stroke in seven hospitals, covering 49% of the population. Only 13 hospitals (serving 60% of the population) had audited local inpatient stroke care at the patient level and 10 (45% of the population) at the service level. CONCLUSION: While there have been improvements in the development of an organised approach to acute inpatient acute stroke care in New Zealand there remain major variations between different centres. The training of general physicians, geriatricians, and neurologists in stroke medicine must be seen as a priority.

Stroke rehabilitation services in New Zealand.

AIMS: To obtain an overall picture of the organisation of stroke rehabilitation services throughout New Zealand and to see if this is consistent with recommendations in evidence-based guidelines. METHODS: A questionnaire was sent to all hospitals in New Zealand. This included questions about access to organised stroke rehabilitation, guidelines for the management of common problems after stroke, and the use of audit. RESULTS: All 48 hospitals surveyed responded, with 37 providing inpatient stroke rehabilitation services. Only one hospital (serving 9% of the population) provided a dedicated, inpatient stroke rehabilitation facility. In the other 36 hospitals, stroke rehabilitation was performed in assessment, treatment and rehabilitation units (25 hospitals, 84%) or general medical wards (8 hospitals, 7%). Only 57% of the population had access to hospitals with a nominated lead clinician for stroke rehabilitation services. Thirty per cent were served by hospitals without a multidisciplinary therapy team expert in stroke care. Guidelines for the management of common problems following stroke were used in most hospitals. Only 8 hospitals (28%) had audited their stroke rehabilitation services. CONCLUSIONS: The organisation and type of rehabilitation services available for people with stroke are not consistent with best practice or accepted guidelines. The development of an organised approach to stroke rehabilitation services in New Zealand must be seen as a priority.

Changes in stroke care at Auckland Hospital between 1996 and 2001.

AIMS: In 1996, we performed a descriptive audit of stroke care in Auckland Hospital. Since then, a mobile stroke team has been established. We have repeated the 1996 audit to assess changes in stroke management. METHODS: From 1 June to 30 September 2001, information was prospectively recorded for all patients with stroke. RESULTS: There were 177 strokes in 175 patients (92 men, mean age 70.9, standard deviation [SD] 14.9 years). Ninety-seven percent of patients had cerebral imaging (median 4.5 hours; interquartile range [IQR] 2.7-11.6). Acute aspirin was given to 78% of patients in 2001 and 40% in 1996 (p <0.001). Twenty-four percent of patients were kept 'nil by mouth' for at least 24 hours (46% in 1996, p <0.001). At discharge, 73% of patients were taking antiplatelet or anticoagulant therapy (61% in 1996, p <0.001). Only 50% of the patients with elevated discharge blood pressures were taking antihypertensives. There had been a reduction in the mean length of hospital stay to 16 days (21 days in 1996) but no significant change in mortality (14% compared with 17% in 1996). CONCLUSION: A stroke service may increase the attention to the 'processes' of stroke care and use of therapies, which are shown to be of benefit in randomised controlled trials.