Medicine (Northwest Academic Centre) - Research Publications
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ItemFeasibility and impact of a post-discharge geriatric evaluation and management service for patients from residential care: the Residential Care Intervention Program in the Elderly (RECIPE)(BMC, 2014-04-16)BACKGROUND: Geriatric evaluation and management has become standard care for community dwelling older adults following an acute admission to hospital. It is unclear whether this approach is beneficial for the frailest older adults living in permanent residential care. This study was undertaken to evaluate (1) the feasibility and consumer satisfaction with a geriatrician-led supported discharge service for older adults living in residential care facilities (RCF) and (2) its impact on the uptake of Advanced Care Planning (ACP) and acute health care service utilisation. METHODS: In 2002-4 a randomised controlled trial was conducted in Melbourne, Australia comparing the geriatrician-led outreach service to usual care for RCF residents. Patients were recruited during their acute hospital stay and followed up at the RCF for six months. The intervention group received a post-discharge home visit within 96 hours, at which a comprehensive geriatric assessment was performed and a care plan developed. Participants and their families were also offered further meetings to discuss ACPs and document Advanced Directives (AD). Additional reviews were made available for assessment and management of intercurrent illness within the RCF. Consumer satisfaction was surveyed using a postal questionnaire. RESULTS: The study included 116 participants (57 intervention and 59 controls) with comparable baseline characteristics. The service was well received by consumers demonstrated by higher satisfaction with care in the intervention group compared to controls (95% versus 58%, p = 0.006).AD were completed by 67% of participants/proxy decision makers in the intervention group compared to 13% of RCF residents prior to service commencement. At six months there was a significant reduction in outpatient visits (intervention 21 (37%) versus controls 45 (76%), (p < 0.001), but no difference in readmissions rates (39% intervention versus 34% control, p = 0.6). There was a trend towards reduced hospital bed-day utilisation (intervention 271 versus controls 372 days). CONCLUSION: It is feasible to provide a supported discharge service that includes geriatrician assessment and care planning within a RCF. By expanding the service there is the potential for acute health care cost savings by decreasing the demand for outpatient consultation and further reducing acute care bed-days.
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ItemRelationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions(BMC, 2015-05-29)BACKGROUND: There is increased interest in developing multidisciplinary ambulatory care models of service delivery to manage patients with complex chronic diseases. These programs are expensive and given limited resources it is important that care is targeted effectively. One potential screening strategy is to identify individuals who report the greatest decrement in health related quality of life (HRQoL) and thus greater need. The aim of this study was to explore the relationship between HRQoL, comorbid conditions and acute health care utilisation. METHODS: A prospective, longitudinal cohort design was used to evaluate the impact of HRQoL on acute care utilisation rates over three-years of follow-up. Participants were enrolled in chronic disease management programs run by a metropolitan health service in Australia. Baseline data was collected from 2007-2009 and follow-up data until 2012. Administrative data was used to classify patients' primary reasons for enrolment, number of comorbidities (Charlson Score) and presentations to acute care. At enrolment, HRQoL was measured using the Assessment of Quality of Life (AQoL) instrument, for analysis AQoL scores were dichotomised at two standard deviations below the population norm. RESULTS: There were 1999 participants (54 % male) with a mean age of 63 years (range 18-101), enrolled in the study. Participants' primary health conditions at enrolment were: diabetes 915 (46 %), chronic respiratory disease 463 (23 %), cardiac disease 260 (13 %), peripheral vascular disease, and 181 (9 %) and aged care 180 (9 %). At 1-year multivariate logistic regression models demonstrated that AQOL utility score was not predictive of acute care presentations after adjusting for comorbidities. Over 3-years an AQoL utility score in the lowest quartile was predictive of both ED presentation (OR 1.58, 95 % CI, 1.16-2.13, p = 0.003) and admissions (OR 1.67, 95 % CI.1.21 to 2.30, p = 0.002) after adjusting for differences in age and comorbidities. CONCLUSION: This study found that both HRQoL and comorbidities were predictive of subsequent acute care attendance over 3-years of follow-up. At 1-year, comorbidities was a better predictor of acute care representation than HRQoL. To maximise benefits, programs should initially focus on medical disease management, but subsequently switch to strategies that enhance health independence and raise HRQoL.
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ItemInvestigating the predictive ability of gait speed and quadriceps strength for incident falls in community-dwelling older women at high risk of fracture(ELSEVIER IRELAND LTD, 2014)Gait speed is a recommended geriatric assessment of physical performance, but may not be regularly examined in clinical settings. We aimed to investigate whether quadriceps strength tests demonstrate similar predictive ability for incident falls as gait speed in older women. We investigated 135 female volunteers aged mean±SD 76.7±5.0 years (range 70-92) at high risk of fracture. Participants completed gait speed assessments using the GAITRite Electronic Walkway System, and quadriceps strength assessments using a hand-held dynamometer (HHD). Participants reported incident falls monthly for 3.7±1.2 years. N=99 (73%) participants fell 355 times during the follow-up period (mean fall rate 83 per 100 person years). We observed a reduced odds ratio for multiple falls (0.83, 95% CI 0.70-0.98) and a reduced hazard ratio for time to first fall (0.90, 95% CI 0.83-0.98), according to quadriceps strength. There was also a significantly shorter time to first fall for those with low quadriceps strength (<7.0 kg; lowest tertile) compared with those with normal quadriceps strength (estimated means [95% CI] 1.54 [1.02, 2.06] vs. 2.23 [1.82, 2.64] years; P=0.019), but not for those with low (<1.0 m/s) vs. normal gait speed (P=0.15). Quadriceps strength is a significant predictor of incident falls over three years amongst community-dwelling older women at high risk of fracture. Quadriceps strength tests may be an acceptable alternative to gait speed for geriatric assessments of falls risk.
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ItemHigh Incidence of Low Catheter-Tissue Contact Force at the Cavotricuspid Isthmus During Catheter Ablation of Atrial Flutter: Implications for Achieving Isthmus Block(WILEY, 2015-08)INTRODUCTION: Recurrent atrial flutter following cavotricuspid isthmus (CTI) ablation remains a significant problem. The prevalence of low contact force (CF) during CTI ablation using standard tools is unknown. Our aim was to characterize the prevalence of low CF applications when experienced operators performed CTI ablation using "traditional" markers of contact blinded to CF measurements. METHODS AND RESULTS: Average CF (grams, g) and force-time integral (FTI) was analyzed in 458 lesions in 17 patients undergoing CTI ablation. The isthmus was divided into the annular, mid and caval segments for region-specific analysis. Despite "good" contact using traditional markers, there was significant variability in CF within each isthmus segment (e.g., annular CTI 1-57 g). A high proportion of lesions had a CF <10 g (40%). Lowest CF was the annular (median 9 g), followed by the mid (12 g) and the caval CTI (18 g, P < 0.001). Sites of acute CTI re-connection had a lower average CF and FTI than nonreconnected sites (P < 0.05). Each 1 g increase in CF was associated with a 16% reduction in risk of recovered CTI conduction (95% confidence interval: 4-27%, P = 0.01). CONCLUSION: Use of surrogate markers of "good contact" during ablation by experienced operators in the absence of real-time CF sensing resulted in nearly half of all lesions being delivered with low CF with marked region-specific variability in CF. Low CF was implicated in longer time to achieve conduction block and increased risk of acute reconnection. These findings underscore the importance of real-time CF measurements for optimizing ablation of typical atrial flutter.
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ItemThromboembolic stroke associated with thoracic outlet syndrome(ELSEVIER SCI LTD, 2014-05)Thoracic outlet syndrome occurs due to compression of the neurovascular structures as they exit the thorax. Subclavian arterial compression is usually due to a cervical rib, and is rarely associated with thromboembolic stroke. The mechanism of cerebral embolisation associated with the thoracic outlet syndrome is poorly understood, but may be due to retrograde propagation of thrombus or transient retrograde flow within the subclavian artery exacerbated by arm abduction. We report an illustrative patient and review the clinical features, imaging findings and management of stroke associated with thoracic outlet syndrome.
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ItemA Retrospective Analysis of the Relationship between Ethnicity, Body Mass Index, and the Diagnosis of Gestational Diabetes in Women Attending an Australian Antenatal Clinic(HINDAWI LTD, 2015)Purpose. To estimate the prevalence of gestational diabetes mellitus (GDM) in a multiethnic population, assess the association between country of birth (COB) and GDM, and assess whether the association varies by body mass index (BMI). Methods. A retrospective study of 5260 pregnant women attending Sunshine Hospital, Australia, between 1st July 2012 and 30th June 2013. We fitted logistic regression models to assess the association between COB and GDM. An interaction between BMI and COB was assessed by likelihood ratio test. Results. In the 4610 included in our analysis, most common were women born in Australia or New Zealand (ANZ, 1932, 41.9%) and in Southeast Asia (922, 20%). GDM was diagnosed in 606 (13.2%) women. After adjusting for confounders, women from East Asia were most likely to develop GDM (37, 24.0%) and 5-fold more likely than women from ANZ (OR = 4.77, 95% CI: 3.12, 7.31, p < 0.001). Women from other Asian countries had a 3-fold increased risk of GDM compared to women from ANZ. There was no evidence of an interaction by BMI (p = 0.24). Conclusions. Women born in Asia have higher risk of GDM compared to women born in ANZ. These data provide support for including COB in GDM management policies.
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ItemLeft ventricular torsional dynamics post exercise for LV diastolic function assessment(BMC, 2014-02-15)AIMS: 2D speckle tracking echocardiography allows for assessment of left ventricular (LV) torsional deformation as a composite function of the radial, longitudinal and circumferential fibres. We test the hypothesis that post-exercise LV torsional dynamics are more sensitive markers for myocardial dysfunction than resting measures, and better predictors for exercise capacity compared to post-exercise LV diastolic filling pressure (E/e'). METHODS: We studied 88 patients referred for stress echocardiogram. Treadmill exercise was performed using Bruce protocol, and echo images were acquired using GE Vivid 7. LV rotational dynamics were analysed by speckle tracking method using the GE ECHOPAC software. Tertiles were defined according to exercise capacity measured by the achieved metabolic equivalents (METS) adjusted for age and gender. Comparison was made between LV torsional dynamics and E/e' to correlate with METS to predict exercise capacity. RESULTS: Mean age of the study population was 58 years, 48% females. Patients with systolic dysfunction or evidence of ischaemia were excluded from the analysis. No significant correlation was found between METS and LV torsion measures at rest. There was statistically significant correlation between METS and post-exercise LV torsion (r=0.34, p=0.001), twist velocity increase (r=0.27, p=0.01), and incremental change in torsion (r=0.22, p<0.05). In addition, a correlation was also shown between post-exercise E/e' and METS (r=-0.33, p=0.002). CONCLUSION: Post-exercise LV torsional dynamics correlate with exercise capacity and may be a useful tool for assessing LV myocardial function in subjects with normal LVEF.
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ItemClinical Utility of Exercise Training in Heart Failure with Reduced and Preserved Ejection Fraction(SAGE PUBLICATIONS LTD, 2015)Reduced exercise tolerance is an independent predictor of hospital readmission and mortality in patients with heart failure (HF). Exercise training for HF patients is well established as an adjunct therapy, and there is sufficient evidence to support the favorable role of exercise training programs for HF patients over and above the optimal medical therapy. Some of the documented benefits include improved functional capacity, quality of life (QoL), fatigue, and dyspnea. Major trials to assess exercise training in HF have, however, focused on heart failure with reduced ejection fraction (HFREF). At least half of the patients presenting with HF have heart failure with preserved ejection fraction (HFPEF) and experience similar symptoms of exercise intolerance, dyspnea, and early fatigue, and similar mortality risk and rehospitalization rates. The role of exercise training in the management of HFPEF remains less clear. This article provides a brief overview of pathophysiology of reduced exercise tolerance in HFREF and heart failure with preserved ejection fraction (HFPEF), and summarizes the evidence and mechanisms by which exercise training can improve symptoms and HF. Clinical and practical aspects of exercise training prescription are also discussed.
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ItemMuscle strength and areal bone mineral density at the hip in women: a cross-sectional study(BIOMED CENTRAL LTD, 2015-05-24)BACKGROUND: Muscle strengthening exercises are promoted for building and maintaining a healthy skeleton. We aimed to investigate the relationship between muscle strength and areal bone mineral density (BMD) at the hip in women aged 26-97 years. METHODS: This cross-sectional study utilises data from 863 women assessed for the Geelong Osteoporosis Study. Measures of hip flexor and abductor strength were made using a hand-held dynamometer (Nicholas Manual Muscle Tester). The maximal measure from three trials on each leg was used for analyses. BMD was measured at the hip using dual energy x-ray absorptiometry (DXA; Lunar DPX-L). Total lean mass, body fat mass and appendicular lean mass were determined from whole body DXA scans. Linear regression techniques were used with muscle strength as the independent variable and BMD as the dependent variable. Models were adjusted for age and indices of body composition. RESULTS: Measures of age-adjusted hip flexor strength and hip abductor strength were positively associated with total hip BMD. For each standard deviation (SD) increase in hip flexor strength, the increase in mean total hip BMD (SD) was 10.4 % (p = 0.009). A similar pattern was observed for hip abductor strength, with an increase in mean total hip BMD of 22.8 % (p = 0.025). All associations between hip muscle strength and total hip BMD were independent of height, but were nullified after adjusting for appendicular lean mass or total lean mass. CONCLUSIONS: There was a positive association observed between muscle strength and BMD at the hip. However, this association was explained by measures of lean mass.
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ItemAssociations between socioeconomic status and primary total knee joint replacements performed for osteoarthritis across Australia 2003-10: data from the Australian Orthopaedic Association National Joint Replacement Registry(BMC, 2014-10-28)BACKGROUND: Relatively little is known about the social distribution of total knee joint replacement (TKR) uptake in Australia. We examine associations between socioeconomic status (SES) and TKR performed for diagnosed osteoarthritis 2003-10 for all Australian males and females aged ≥ 30 yr. METHODS: Data of primary TKR (n=213,018, 57.4% female) were ascertained from a comprehensive national joint replacement registry. Residential addresses were matched to Australian Census data to identify area-level social disadvantage, and categorised into deciles. Estimated TKR rates were calculated. Poisson regression was used to model the relative risk (RR) of age-adjusted TKR per 1,000py, stratified by sex and SES. RESULTS: A negative relationship was observed between TKR rates and SES deciles. Females had a greater rate of TKR than males. Surgery utilisation was greatest for all adults aged 70-79 yr. In that age group differences in estimated TKR per 1,000py between deciles were greater for 2010 than 2003 (females: 2010 RR 4.32 and 2003 RR 3.67; males: 2010 RR 2.04 and 2003 RR 1.78). CONCLUSIONS: Identifying factors associated with TKR utilisation and SES may enhance resource planning and promote surgery utilisation for end-stage osteoarthritis.