Cost analysis of ambulatory blood pressure monitoring in initiating antihypertensive drug treatment in Australian general practice

The document attached has been archived with permission from the editor of the Medical Journal of Australia. An external link to the publisher’s copy is included.Objective: To compare the cost of ambulatory blood pressure monitoring (ABPM) with the putative savings made through treatment avoided by identification and non-treatment of those with "white coat" hypertension. Design: A cost analysis based on a model of four alternative strategies (no ABPM, yearly, two-yearly, or three-yearly monitoring) over a seven-year period applied to a case series from Australian general practice. Participants: 62 patients newly diagnosed by their GPs as having hypertension and requiring drug treatment. Main outcome measures: The proportion of patients shown to not need treatment. The discounted costs to the Pharmaceutical Benefits Scheme, Medical Benefits Scheme and patients. Results: 16 of 62 patients (26%; 95% CI, 15%–37%) were normotensive on ABPM and did not require treatment. All monitoring strategies are more expensive in the first year, but the initial costs are offset by year 3 and the monitoring strategies are cost saving thereafter. Sensitivity analysis shows that this result holds across a range of costs of pharmacotherapy and proportion of patients with white coat hypertension. Conclusion: The additional costs of 24-hour ABPM in the first year are offset by savings associated with patients with white coat hypertension who would otherwise have been treated.Ben Ewald and Brita Pekarsk

Health risks from indoor gas appliances

Background Cooking and heating with gas is common in Australian homes and is a risk factor for several important health problems; however, there is little awareness of these risks among doctors or the public. Gas stove use is estimated to cause 12% of childhood asthma in Australia. Objective The aim of this article is to help general practitioners identify when gas combustion products such as nitrogen dioxide might be contributing to asthma in children and adults and to alert them to the risks of carbon monoxide (CO) poisoning, which can be hard to diagnose. Discussion There are excellent alternatives to the use of gas in domestic appliances and some simple behavioural changes that can reduce exposure in situations where appliances cannot yet be removed. CO poisoning can be insidious. Mild exposure can cause headache, nausea, vomiting, dizziness, malaise and confusion, so it can be mistaken for common conditions such as influenza or gastroenteritis. The COMA mnemonic is clinically useful. Increased awareness of these issues can provide patients with safer and healthier living environments

Internal structure of the San Jacinto fault zone at Blackburn Saddle from seismic data of a linear array

Local and teleseismic earthquake waveforms recorded by a 180-m-long linear array (BB) with seven seismometers crossing the Clark fault of the San Jacinto fault zone northwest of Anza are used to image a deep bimaterial interface and core damage structure of the fault. Delay times of P waves across the array indicate an increase in slowness from the southwest most (BB01) to the northeast most (BB07) station. Automatic algorithms combined with visual inspection and additional analyses are used to identify local events generating fault zone head and trapped waves. The observed fault zone head waves imply that the Clark fault in the area is a sharp bimaterial interface, with lower seismic velocity on the southwest side. The moveout between the head and direct P arrivals for events within ∼40 km epicentral distance indicates an average velocity contrast across the fault over that section and the top 20 km of 3.2 per cent. A constant moveout for events beyond ∼40 km to the southeast is due to off-fault locations of these events or because the imaged deep bimaterial interface is discontinuous or ends at that distance. The lack of head waves from events beyond ∼20 km to the northwest is associated with structural complexity near the Hemet stepover. Events located in a broad region generate fault zone trapped waves at stations BB04–BB07. Waveform inversions indicate that the most likely parameters of the trapping structure are width of ∼200 m, S velocity reduction of 30–40 per cent with respect to the bounding blocks, Q value of 10–20 and depth of ∼3.5 km. The trapping structure and zone with largest slowness are on the northeast side of the fault. The observed sense of velocity contrast and asymmetric damage across the fault suggest preferred rupture direction of earthquakes to the northwest. This inference is consistent with results of other geological and seismological studies

Association between Participation in Outpatient Cardiac Rehabilitation and Self-Reported Receipt of Lifestyle Advice from a Healthcare Provider: Results of a Population-Based Cross-Sectional Survey

We test the hypothesis that the odds of self-reported receipt of lifestyle advice from a health care provider will be lower among outpatient cardiac rehabilitation (OCR) nonattendees and nonreferred patients compared to OCR attendees. Logistic regression was used to analyse cross-sectional data provided by 65% (4971/7678) of patients aged 20 to 84 years discharged from public hospitals with a diagnosis indicating eligibility for OCR between 2002 and 2007. Among respondents, 71% (3518) and 55% (2724) recalled advice regarding physical activity and diet, respectively, while 88% (592/674) of smokers recalled quit advice. OCR attendance was low: 36% (1764) of respondents reported attending OCR, 11% (552) did not attend following referral, and 45% (2217) did not recall being invited. The odds of recalling advice regarding physical activity and diet were significantly lower among OCR nonattendees compared to attendees (OR 0.34, 95% CI 0.21, 0.56 and OR 0.33, 95% CI 0.25, 0.44, resp.) and among nonreferred respondents compared to OCR attendees (OR 0.10, 95% CI 0.07, 0.15 and OR 0.17, 95% CI 0.14, 0.22, resp.). Patients hospitalised for coronary heart disease should be referred to OCR or a suitable alternative to improve recall of lifestyle advice that will reduce the risk of further coronary events

Association between Participation in Outpatient Cardiac Rehabilitation and Self-Reported Receipt of Lifestyle Advice from a Healthcare Provider: Results of a Population-Based Cross-Sectional Survey

We test the hypothesis that the odds of self-reported receipt of lifestyle advice from a health care provider will be lower among outpatient cardiac rehabilitation (OCR) nonattendees and nonreferred patients compared to OCR attendees. Logistic regression was used to analyse cross-sectional data provided by 65% (4971/7678) of patients aged 20 to 84 years discharged from public hospitals with a diagnosis indicating eligibility for OCR between 2002 and 2007. Among respondents, 71% (3518) and 55% (2724) recalled advice regarding physical activity and diet, respectively, while 88% (592/674) of smokers recalled quit advice. OCR attendance was low: 36% (1764) of respondents reported attending OCR, 11% (552) did not attend following referral, and 45% (2217) did not recall being invited. The odds of recalling advice regarding physical activity and diet were significantly lower among OCR nonattendees compared to attendees (OR 0.34, 95% CI 0.21, 0.56 and OR 0.33, 95% CI 0.25, 0.44, resp.) and among nonreferred respondents compared to OCR attendees (OR 0.10, 95% CI 0.07, 0.15 and OR 0.17, 95% CI 0.14, 0.22, resp.). Patients hospitalised for coronary heart disease should be referred to OCR or a suitable alternative to improve recall of lifestyle advice that will reduce the risk of further coronary events

Internal structure of the San Jacinto fault zone at Blackburn Saddle from seismic data of a linear array

Local and teleseismic earthquake waveforms recorded by a 180-m-long linear array (BB) with seven seismometers crossing the Clark fault of the San Jacinto fault zone northwest of Anza are used to image a deep bimaterial interface and core damage structure of the fault. Delay times of P waves across the array indicate an increase in slowness from the southwest most (BB01) to the northeast most (BB07) station. Automatic algorithms combined with visual inspection and additional analyses are used to identify local events generating fault zone head and trapped waves. The observed fault zone head waves imply that the Clark fault in the area is a sharp bimaterial interface, with lower seismic velocity on the southwest side. The moveout between the head and direct P arrivals for events within ∼40 km epicentral distance indicates an average velocity contrast across the fault over that section and the top 20 km of 3.2 per cent. A constant moveout for events beyond ∼40 km to the southeast is due to off-fault locations of these events or because the imaged deep bimaterial interface is discontinuous or ends at that distance. The lack of head waves from events beyond ∼20 km to the northwest is associated with structural complexity near the Hemet stepover. Events located in a broad region generate fault zone trapped waves at stations BB04–BB07. Waveform inversions indicate that the most likely parameters of the trapping structure are width of ∼200 m, S velocity reduction of 30–40 per cent with respect to the bounding blocks, Q value of 10–20 and depth of ∼3.5 km. The trapping structure and zone with largest slowness are on the northeast side of the fault. The observed sense of velocity contrast and asymmetric damage across the fault suggest preferred rupture direction of earthquakes to the northwest. This inference is consistent with results of other geological and seismological studies

Association between participation in outpatient cardiac rehabilitation and self-reported receipt of lifestyle advice from a healthcare provider: results of a population-based cross-sectional survey

We test the hypothesis that the odds of self-reported receipt of lifestyle advice from a health care provider will be lower among outpatient cardiac rehabilitation (OCR) nonattendees and nonreferred patients compared to OCR attendees. Logistic regression was used to analyse cross-sectional data provided by 65% (4971/7678) of patients aged 20 to 84 years discharged from public hospitals with a diagnosis indicating eligibility for OCR between 2002 and 2007. Among respondents, 71% (3518) and 55% (2724) recalled advice regarding physical activity and diet, respectively, while 88% (592/674) of smokers recalled quit advice. OCR attendance was low: 36% (1764) of respondents reported attending OCR, 11% (552) did not attend following referral, and 45% (2217) did not recall being invited. The odds of recalling advice regarding physical activity and diet were significantly lower among OCR nonattendees compared to attendees (OR 0.34, 95% CI 0.21, 0.56 and OR 0.33, 95% CI 0.25, 0.44, resp.) and among nonreferred respondents compared to OCR attendees (OR 0.10, 95% CI 0.07, 0.15 and OR 0.17, 95% CI 0.14, 0.22, resp.). Patients hospitalised for coronary heart disease should be referred to OCR or a suitable alternative to improve recall of lifestyle advice that will reduce the risk of further coronary events

Clinical Study Association between Participation in Outpatient Cardiac Rehabilitation and Self-Reported Receipt of Lifestyle Advice from a Healthcare Provider: Results of a Population-Based Cross-Sectional Survey

We test the hypothesis that the odds of self-reported receipt of lifestyle advice from a health care provider will be lower among outpatient cardiac rehabilitation (OCR) nonattendees and nonreferred patients compared to OCR attendees. Logistic regression was used to analyse cross-sectional data provided by 65% (4971/7678) of patients aged 20 to 84 years discharged from public hospitals with a diagnosis indicating eligibility for OCR between 2002 and 2007. Among respondents, 71% (3518) and 55% (2724) recalled advice regarding physical activity and diet, respectively, while 88% (592/674) of smokers recalled quit advice. OCR attendance was low: 36% (1764) of respondents reported attending OCR, 11% (552) did not attend following referral, and 45% (2217) did not recall being invited. The odds of recalling advice regarding physical activity and diet were significantly lower among OCR nonattendees compared to attendees (OR 0.34, 95% CI 0.21, 0.56 and OR 0.33, 95% CI 0.25, 0.44, resp.) and among nonreferred respondents compared to OCR attendees (OR 0.10, 95% CI 0.07, 0.15 and OR 0.17, 95% CI 0.14, 0.22, resp.). Patients hospitalised for coronary heart disease should be referred to OCR or a suitable alternative to improve recall of lifestyle advice that will reduce the risk of further coronary events

How many steps/day are enough? For older adults and special populations

Older adults and special populations (living with disability and/or chronic illness that may limit mobility and/or physical endurance) can benefit from practicing a more physically active lifestyle, typically by increasing ambulatory activity. Step counting devices (accelerometers and pedometers) offer an opportunity to monitor daily ambulatory activity; however, an appropriate translation of public health guidelines in terms of steps/day is unknown. Therefore this review was conducted to translate public health recommendations in terms of steps/day. Normative data indicates that 1) healthy older adults average 2,000-9,000 steps/day, and 2) special populations average 1,200-8,800 steps/day. Pedometer-based interventions in older adults and special populations elicit a weighted increase of approximately 775 steps/day (or an effect size of 0.26) and 2,215 steps/day (or an effect size of 0.67), respectively. There is no evidence to inform a moderate intensity cadence (i.e., steps/minute) in older adults at this time. However, using the adult cadence of 100 steps/minute to demark the lower end of an absolutely-defined moderate intensity (i.e., 3 METs), and multiplying this by 30 minutes produces a reasonable heuristic (i.e., guiding) value of 3,000 steps. However, this cadence may be unattainable in some frail/diseased populations. Regardless, to truly translate public health guidelines, these steps should be taken over and above activities performed in the course of daily living, be of at least moderate intensity accumulated in minimally 10 minute bouts, and add up to at least 150 minutes over the week. Considering a daily background of 5,000 steps/day (which may actually be too high for some older adults and/or special populations), a computed translation approximates 8,000 steps on days that include a target of achieving 30 minutes of moderate-to-vigorous physical activity (MVPA), and approximately 7,100 steps/day if averaged over a week. Measured directly and including these background activities, the evidence suggests that 30 minutes of daily MVPA accumulated in addition to habitual daily activities in healthy older adults is equivalent to taking approximately 7,000-10,000 steps/day. Those living with disability and/or chronic illness (that limits mobility and or/physical endurance) display lower levels of background daily activity, and this will affect whole-day estimates of recommended physical activity

The evolution of transmission mode

This article reviews research on the evolutionary mechanisms leading to different transmission modes. Such modes are often under genetic control of the host or the pathogen, and often in conflict with each other via trade-offs. Transmission modes may vary among pathogen strains and among host populations. Evolutionary changes in transmission mode have been inferred through experimental and phylogenetic studies, including changes in transmission associated with host-shifts and with evolution of the unusually complex life cycles of many parasites. Understanding the forces that determine the evolution of particular transmission modes presents a fascinating medley of problems for which there is a lack of good data and often a lack of conceptual understanding or appropriate methodologies. Our best information comes from studies that have been focused on the vertical vs. horizontal transmission dichotomy. With other kinds of transitions, theoretical approaches combining epidemiology and population genetics are providing guidelines for determining when and how rapidly new transmission modes may evolve, but these are still in need of empirical investigation and application to particular cases. Obtaining such knowledge is a matter of urgency in relation to extant disease threats