Prospective Trial of CPAP in Community-Dwelling Adults with Down Syndrome and Obstructive Sleep Apnea Syndrome

Adults with Down syndrome (DS) are predisposed to obstructive sleep apnoea (OSA), but the effectiveness and acceptability of continuous positive airway pressure treatment (CPAP) in this group has rarely been formally assessed. This study was designed as a pilot randomised, parallel controlled trial for one month, continuing as an uncontrolled cohort study whereby the control group also received the intervention. Symptomatic, community-dwelling DS individuals exhibiting ≥10 apnoeas/hypopneas per hour in bed on a Type 3 home sleep study were invited to participate in this study, with follow-up at 1, 3, 6, and 12 months from baseline. Measurements of sleepiness, behaviour, cognitive function and general health were undertaken; the primary outcome was a change in the pictorial Epworth Sleepiness Scale (pESS) score. Twenty-eight participants (19 male) were enrolled: age 28 ± 9 year; body mass index 31.5 ± 7.9 kg/m2; 39.6 ± 32.2 apnoeas/hypopneas per hour in bed; pESS 11 ± 6/24. The pilot randomised controlled trial at one month demonstrated no change between the groups. At 12 months, participant (p = 0.001) pESS and Disruptive (p 0.0001), Anxiety/Antisocial (p = 0.024), and Depressive (p = 0.008) behaviour scores were reduced compared to baseline. Improvement was noted in verbal (p = 0.001) and nonverbal intelligence scores (p = 0.011). General health scores also improved (p = 0.02). At the end of the trial, 19 participants continued on treatment. Use of CPAP in adults with DS and OSA led to a number of significant, sustained improvements in sleepiness and behavioural/emotional outcomes at 12 months

Does personality play a role in continuous positive airway pressure compliance?

Key points Continuous positive airway pressure (CPAP) adherence is low among individuals with obstructive sleep apnoea. Type D personality and high scores on the depression and hypochondriasis scales on the Minnesota Multiphasic Personality Inventory (MMPI) have been identified as factors contributing to non-compliance with CPAP. Further research into personality type may assist in understanding why some people adhere to CPAP, while others fail. Obstructive sleep apnoea (OSA) is a condition characterised by repetitive, intermittent partial or complete collapse/obstruction of the upper airway during sleep. Continuous positive airway pressure (CPAP) is highly efficacious in treating OSA but its effectiveness is limited due to suboptimal acceptance and adherence rates, with as many as 50% of OSA patients discontinuing CPAP treatment within the first year. Until recently, research has focused on examining mechanistic and demographic factors that could explain nonadherence (e.g. age, sex, race and education level) with limited applicability in a prospective or clinical manner. More recent research has focused on personality factors or types of patients with OSA who comply and do not comply with CPAP adherence in an attempt to enhance the accuracy of predicting treatment compliance. Type D personality has been found to be prevalent in one third of patients with OSA. The presence of Type D personality increases noncompliance and poor treatment outcomes due to negative affectivity, social inhibition, unhealthy lifestyle, and a reluctance to consult and/or follow medical advice. Conversely, individuals who are more likely to adhere to CPAP treatment tend to have a high internal locus of control and high self-efficacy, self-refer for treatment, and have active coping skills. By assessing personality and coping skills, the clinician may gain insight into the likelihood of a patient’s adherence to treatment. If the patient displays potential risk factors for CPAP noncompliance, the clinician can offer the patient education, refer them to a support group, engage in behavioural/motivational therapy and undertake regular follow-up visits or phone calls incorporating troubleshooting to increase CPAP adherence, especially in individuals with Type D personality

Genome sequence of an Australian kangaroo, Macropus eugenii, provides insight into the evolution of mammalian reproduction and development.

BACKGROUND: We present the genome sequence of the tammar wallaby, Macropus eugenii, which is a member of the kangaroo family and the first representative of the iconic hopping mammals that symbolize Australia to be sequenced. The tammar has many unusual biological characteristics, including the longest period of embryonic diapause of any mammal, extremely synchronized seasonal breeding and prolonged and sophisticated lactation within a well-defined pouch. Like other marsupials, it gives birth to highly altricial young, and has a small number of very large chromosomes, making it a valuable model for genomics, reproduction and development. RESULTS: The genome has been sequenced to 2 × coverage using Sanger sequencing, enhanced with additional next generation sequencing and the integration of extensive physical and linkage maps to build the genome assembly. We also sequenced the tammar transcriptome across many tissues and developmental time points. Our analyses of these data shed light on mammalian reproduction, development and genome evolution: there is innovation in reproductive and lactational genes, rapid evolution of germ cell genes, and incomplete, locus-specific X inactivation. We also observe novel retrotransposons and a highly rearranged major histocompatibility complex, with many class I genes located outside the complex. Novel microRNAs in the tammar HOX clusters uncover new potential mammalian HOX regulatory elements. CONCLUSIONS: Analyses of these resources enhance our understanding of marsupial gene evolution, identify marsupial-specific conserved non-coding elements and critical genes across a range of biological systems, including reproduction, development and immunity, and provide new insight into marsupial and mammalian biology and genome evolution

Strategies to improve control of sexually transmissible infections in remote Australian Aboriginal communities: a stepped-wedge, cluster-randomised trial

BACKGROUND: Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates. METHODS: In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16–34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis . We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044. FINDINGS: Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16–34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84–1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15–1·65; p=0·0006). INTERPRETATION: Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities.James Ward, Rebecca J Guy, Alice R Rumbold, Skye McGregor, Handan Wand, Hamish McManus, Amalie Dyda, Linda Garton, Belinda Hengel, Bronwyn J Silver, Debbie Taylor-Thomson, Janet Knox, Basil Donovan, Matthew Law, Lisa Maher, Christopher K Fairley, Steven Skov, Nathan Ryder, Elizabeth Moore, Jacqueline Mein, Carole Reeve, Donna Ah Chee, John Boffa and John M Kaldo

Definitions and outcome measures for mucous membrane pemphigoid: Recommendations of an international panel of experts

Mucous membrane pemphigoid encompasses a group of autoimmune bullous diseases with a similar phenotype characterized by subepithelial blisters, erosions, and scarring of mucous membranes, skin, or both. Although knowledge about autoimmune bullous disease is increasing, there is often a lack of clear definitions of disease, outcome measures, and therapeutic end points. With clearer definitions and outcome measures, it is possible to directly compare the results and data from various studies using meta-analyses. This consensus statement provides accurate and reproducible definitions for disease extent, activity, outcome measures, end points, and therapeutic response for mucous membrane pemphigoid and proposes a disease extent score, the Mucous Membrane Pemphigoid Disease Area Index

What about the event? How do tourism leveraging strategies affect small-scale events?

This study draws on contingency theory to investigate whether tourism leveraging strategies designed for mega-events are applicable to small-scale events. In-depth interviews conducted with eight event managers of small-scale events revealed that the managers perceived grant funding offered to promote tourism leveraging to be a diversion from the core purpose of staging the event. Restrictions on grant funding directed the event managers' focus to increasing the number of tourists and their length of stay and their spending in the destination. While event managers acknowledged that engaging in tourism leveraging expanded the event's target markets and increased the size of the event, they believed that tourism operators were the key beneficiaries of the leveraging. Mutual benefits between event and tourism organisations occurred when the funding partner(s) and the event collaborated. A grounded theory model was developed to show the impact of tourism leveraging strategies on small-scale events. The findings are consistent with the tenets of contingency theory, which suggest that managerial solutions are not automatically scalable

The utility of relationships in the creation and maintenance of an event portfolio

Purpose: Event portfolios promote synergies among events and stakeholders within a destination in order to maximise resources. The purpose of this paper is to examine the role of relationships in the creation and maintenance of an event portfolio using the four stages of Parvatiyar and Sheth’s (2000) process model of relationship marketing: formation, management and governance, performance evaluation, and evolution. Design/methodology/approach: Nine semi-structured interviews were conducted with tourism and government stakeholders involved in the creation and maintenance of an event portfolio within a single destination. Findings: The destination outlined clear strategic goals through an event strategy. An Events Board was established to bring together key stakeholders from tourism, events, and government to oversee the development of an event portfolio. The Events Board gave advice to relevant tourism and government stakeholders on which events they should provide funding. Developing relationships was not a stated objective, but the Events Board realised the importance of relationships to create and maintain the destination’s event portfolio. Long-term funding contracts were used as a mechanism to establish relationships and were an impetus for interaction. Relationships were also maintained through dedicated staff who managed the relationships between the destination stakeholders and the events. Practical implications: Understanding factors that contribute to the successful creation and maintenance of event portfolios can inform destination stakeholders who are responsible for generating tourism through events. Originality/value: Limited research has examined the creation and maintenance of event portfolios. This study provides insight into the central importance of relationships in creating and maintaining an event portfolio

Developing leveraging strategies for pre-Games training for mega-events in non-host cities

Purpose: The purpose of this paper is to explore how non-host cities strategically plan to leverage pre-Games training for the 2018 Gold Coast Commonwealth Games to maximize benefits to the city. Design/methodology/approach: Eight semi-structured interviews were conducted with key tourism and government stakeholders involved in developing leveraging strategies for pre-Games training in a non-host city. Interviews were conducted a little over 18 months before the 2018 Gold Coast Commonwealth Games. Findings: A model of the strategic planning of leveraging pre-Games training is presented. Pre-Games training was positioned as a leverageable resource. The non-host city was well positioned to host pre-Games training given its existing sport focus and facilities and its proximity to the host city and its similar climate. Opportunities, objectives, means, and considerations were constantly developed. The city strategically targeted teams to maximize the use of the training facilities and make the most of the value of well-known athletes, while being cautious of overcrowding. The teams had to be secured before strategies were devised to achieve other opportunities and objectives. Short-term benefits included generating tourism through visiting teams and entourages and integrating visiting teams into the local community through education and sport programming. Long-term benefits included building the destination’s capacity and reputation as a place for elite training camps and tourism. Practical implications: Understanding how to develop strategies to leverage pre-Games training can inform those responsible for developing and implementing pre-Games training strategies and lead to maximizing the benefits to a city or region. Originality/value: Limited research has examined the strategic planning process used to develop tactics to leverage mega-events. This study provides insight into the strategic planning process of non-host cities to increase short- and long-term benefits by leveraging pre-Games training

It was never ours: Formalised event hosting rights and leverage

The awarding of event rights is an integral element of large-scale event hosting. While formalised regulations often act as a coordination mechanism to ensure events are implemented in accordance with strict parameters, how the formalised regulations of event rights owners influence the ability of host cities to leverage and benefit from events is unclear. Through 19 in-depth interviews, this study investigates how formalised regulations of the International Cricket Council (ICC) influenced how two host nations, Barbados and Jamaica, leveraged the 2007 ICC Cricket World Cup. Results revealed that the formalised environment limited the benefits to host countries, but leveraging was still possible. Some stakeholders pushed back against the restrictions to secure targeted benefits from the event. Significantly, these benefits continue to contribute to local economies 10 years after the event. A grounded theory model demonstrates how formalised regulations influence host destinations’ efforts to leverage benefits from an event