Home versus hospital-based cardiac rehabilitation: A systematic review

Comprehensive cardiac rehabilitation has positive effects on many cardiac risk factors (physical activity, smoking status, cholesterol, anxiety and depression) and can lead to improvements in mortality, morbidity and quality of life. Most formal cardiac rehabilitation in the UK is offered within a hospital or centre setting, although this may not always be convenient or accessible for many cardiac patients, especially those in remote areas. The proportion of eligible patients who successfully complete a cardiac rehabilitation program remains low. There are many reasons for this but geographical isolation and transport issues are important. This systematic review examines the current evidence for home- versus hospital-based cardiac rehabilitation. Home-based cardiac rehabilitation offers greater accessibility to cardiac rehabilitation and has the potential to increase uptake. While there have been fewer studies of home-based cardiac rehabilitation, the available data suggest that it has comparable results to hospital-based programs. Many of these studies are small and heterogeneous in terms of interventions but home-based cardiac rehabilitation appears both safe and effective. Available evidence suggests that it results in longer lasting maintenance of physical activity levels compared with hospital-based rehabilitation and is equally effective in improving cardiac risk factors. Furthermore, it has the potential to be a more cost-effective intervention for patients who cannot easily access their local centre or hospital. Currently home-based cardiac rehabilitation is not offered routinely to all patients but it appears to have the potential to increase uptake in patients who are unable, or less likely, to attend more traditional hospital-based cardiac rehabilitation programs

Repeatable antibiotic prescriptions: an assessment of patient attitudes, knowledge and advice from healthcare professionals

Background Previous Australian research has identified that general practice software systems appear to be associated with an increase in repeatable antibiotic prescriptions. Such prescriptions potentially facilitate the use of antibiotics without medical consultation and may be inconsistent with attempts to promote prudent use of antimicrobials. Aims We sought to assess knowledge and attitudes to antibiotics amongst patients presenting with a repeatable prescription; and the provision of supporting advice from healthcare professionals regarding use of these repeats. Method Six community pharmacies across Tasmania invited patients presenting with a repeatable antibiotic prescription to participate in the study. Participants were asked to complete a questionnaire and return this to the research team in a pre-paid envelope. Results Fifty-seven of 244 surveys were returned to the research team, representing a response rate of 23%. Regarding provision of advice on use of the repeat, 14 (25%) of respondents stated that they were given no advice by the prescriber and 19 (30%) no advice from the pharmacist. Five (9%) were given no advice from either prescriber or pharmacist. One-third of respondents indicated that they would keep the repeat for future use and around three-quarters perceived no major safety concerns with antibiotics. Conclusion Further research is needed, however this small study suggests that provision of information to patients regarding appropriate use of repeatable antibiotic prescriptions is sub-optimal. This coupled with existing patient knowledge and attitudes may contribute to inappropriate use of antibiotics

The Effect of Pulmonary Artery Catheter Use on Costs and Long-Term Outcomes of Acute Lung Injury

Background: The pulmonary artery catheter (PAC) remains widely used in acute lung injury (ALI) despite known complications and little evidence of improved short-term mortality. Concurrent with NHLBI ARDS Clinical Trials Network Fluid and Catheters Treatment Trial (FACTT), we conducted a prospectively-defined comparison of healthcare costs and long-term outcomes for care with a PAC vs. central venous catheter (CVC). We explored if use of the PAC in ALI is justified by a beneficial cost-effectiveness profile. Methods: We obtained detailed bills for the initial hospitalization. We interviewed survivors using the Health Utilities Index Mark 2 questionnaire at 2, 6, 9 and 12 m to determine quality of life (QOL) and post-discharge resource use. Outcomes beyond 12 m were estimated from federal databases. Incremental costs and outcomes were generated using MonteCarlo simulation. Results: Of 1001 subjects enrolled in FACTT, 774 (86%) were eligible for long-term follow-up and 655 (85%) consented. Hospital costs were similar for the PAC and CVC groups ($96.8k vs.$89.2k, p = 0.38). Post-discharge to 12 m costs were higher for PAC subjects ($61.1k vs. 45.4k, p = 0.03). One-year mortality and QOL among survivors were similar in PAC and CVC groups (mortality: 35.6$14.4k and mean loss of 0.3 quality-adjusted life years (QALYs)) and a 94.2% probability of being higher than the $100k/QALY willingness-to-pay threshold. Conclusion: PAC use increased costs with no patient benefit and thus appears unjustified for routine use in ALI. Trial Registration: www.clinicaltrials.gov NCT00234767. © 2011 Clermont et al

Strengthening impact assessment: a call for integration and focus

We suggest that the impact assessment community has lost its way based on our observation that impact assessment is under attack because of a perceived lack of efficiency. Specifically, we contend that the proliferation of different impact assessment types creates separate silos of expertise and feeds arguments for not only a lack of efficiency but also a lack of effectiveness of the process through excessive specialisation and a lack of interdisciplinary practice. We propose that the solution is a return to the basics of impact assessment with a call for increased integration around the goal of sustainable development and focus through better scoping. We rehearse and rebut counter arguments covering silo-based expertise, advocacy, democracy, sustainability understanding and communication. We call on the impact assessment community to rise to the challenge of increasing integration and focus, and to engage in the debate about the means of strengthening impact assessment

Reef state and performance as indicators of cumulative impacts on coral reefs

Coral bleaching, cyclones, outbreaks of crown-of-thorns seastar, and reduced water quality (WQ) threaten the health and resilience of coral reefs. The cumulative impacts from multiple acute and chronic stressors on “reef State” (i.e., total coral cover) and “reef Performance” (i.e., the deviation from expected rate of total coral cover increase) have rarely been assessed simultaneously, despite their management relevance. We evaluated the dynamics of coral cover (total and per morphological groups) in the Central and Southern Great Barrier Reef over 25 years, and identified and compared the main environmental drivers of State and Performance at the reef level (i.e. based on total coral cover) and per coral group. Using a combination of 25 environmental metrics that consider both the frequency and magnitude of impacts and their lagged effects, we find that the stressors that correlate with State differed from those correlating with Performance. Importantly, we demonstrate that WQ metrics better predict Performance than State. Further, inter-annual dynamics in WQ (here available for a subset of the data) improved the explanatory power of WQ metrics on Performance over long-term WQ averages. The lagged effects of cumulative acute stressors, and to a lesser extent poor water quality, correlated negatively with the Performance of some but not all coral groups. Tabular Acropora and branching non-Acropora were the most affected by water quality demonstrating that group-specific approaches aid in the interpretation of monitoring data and can be crucial for the detection of the impact of chronic pressures. We highlight the complexity of coral reef dynamics and the need of evaluating Performance metrics in order to prioritise local management interventions

The impact of nurse/physician collaboration on patient length of stay

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75064/1/j.1365-2834.2008.00926.x.pd

Neurologists’ experiences of participating in the CODES study—A multicentre randomised controlled trial comparing cognitive behavioural therapy vs standardised medical care for dissociative seizures

Purpose We investigated neurologists’ experience of participating in the large CODES trial involving around 900 adults with dissociative seizures which subsequently evaluated the effectiveness of tailored cognitive behavioural therapy (CBT) plus standardised medical care versus standardised medical care alone in 368 patients with dissociative seizures. Method We asked all neurologists referring patients with dissociative seizures to the CODES study to complete a 43-item online survey. This examined neurologists’ (i) demographics, (ii) knowledge of dissociative seizures before and after their involvement in the CODES trial, (iii) clinical practice before, during and since their involvement, and (iv) their experience of the CODES trial. Results Forty-three (51%) neurologists completed the questionnaire. Only about half of neurologists could make referrals to psychological intervention specific for dissociative seizures before and after the trial. One-third of doctors reported having changed their referral practice following their involvement. The majority (>69%) agreed that patient satisfaction with different aspects of the trial was very high, and 83.7% thought that it was easy to recruit patients for the study. Over 90% agreed they would like the treatment pathway to continue. Respondents found different elements of the trial useful, in particular, the patient factsheet booklet (98%), diagnosis communication advice (93%) and the CBT package (93%). Conclusions Neurologists participating in CODES generally found it easy to recruit patients and perceived patient satisfaction as very high. However, 46.5% of neurologists could not offer psychotherapy once the trial had finished, suggesting that problems with lack of access to psychological treatment for dissociative seizures persist

Counterintuitive active directional swimming behaviour by Atlantic salmon during seaward migration in the coastal zone

Acknowledgements We thank the Cromarty Firth District Salmon Fishery Board for logistical support and three anonymous referees who improved an earlier draft of this paper. Funding for this work came from Scottish & Southern Energy Renewables. We are grateful for the skills and expertise of Bill Ruck at Moray First Marine along with the crews of Marine Scotland Science vessels who were integral to the successful deployment and recovery of equipment. Some receivers were also made available from the Ocean Tracking Network (OTN) The data underlying this article will be shared on reasonable request to the corresponding author.Peer reviewedPublisher PD

Updating and validating quality prescribing indicators for use in Australian general practice

© 2019 La Trobe University. This study aims to update and validate quality prescribing indicators (QPIs) for Australian general practice. The study comprised two phases: (1) developing preliminary potential QPIs based on the 2006 National Prescribing Service (NPS) MedicineWise indicators, published literature, international indicators and guidelines, and through qualitative focus group discussions; and (2) validating the proposed QPIs through a two-round online survey using the Delphi technique. The Delphi panel included four GPs, four pharmacists and two clinical pharmacologists. The Delphi panel rated the potential QPIs for their validity, importance and feasibility using a 1-10 Likert scale. In round one, all proposed QPIs presented as 'prescribing rules' achieved high scores regarding validity, importance and feasibility No rule was eliminated and three new rules were introduced. Rules were reworded into 'prescribing indicators' for round two, which resulted in 35 indicators being accepted and two indicators being eliminated. The final QPIs also include seven drug-drug interactions, which received high scores in round one. In conclusion, 42 QPIs were nominated for use in Australian general practice, based on their validity, importance and feasibility. If implemented, these QPIs have the potential to assist in efforts to improve the quality and safety of medicines management