Profiling the risk factors associated with falls in older people with diabetes receiving at-home nursing care: Retrospective analysis of an Australian aged care provider database.

Falls among older people with diabetes mellitus (DM) are a major health concern. Preventive measures can be implemented to reduce the likelihood of falls. The aim of this study was to determine the factors most strongly associated with falls in older people living with DM who receive at-home care support services. This will inform home-visiting nurses to prioritise falls prevention strategies in the care of clients who are at high risk of falls. A retrospective analysis of routinely collected data from a large not-for-profit community aged care service provider was undertaken. The sample comprised adults aged ≥65 years residing in Victoria, Australia, with a recorded diagnosis of DM, and who received at least one episode of care by the aged care provider during July 1, 2014 and June 30, 2015. Self-reported data on falls in previous 6 months was obtained via the Comprehensive Health Assessment Tool (CHAT). Selection of factors associated with falls was guided by the Falls Risk for Older People in the Community (FROP-Com) assessment tool. For the study population, data for these factors were obtained from clients' self-reported CHAT data, and from International Classification of Disease codes obtained from medical records. Descriptive statistics were used to identify the demographic and clinical profile; logistic regression was used to assess the strength of association between various factors and the occurrence of a fall. Data were obtained for 1,574 older adults; overall prevalence of falls was 30.6% (n = 482). Significant factors displaying the highest odds of falling were gait issues (OR: 2.11, p = 0.002); needing help to walk (OR: 1.91, p = <0.001); and cognitive dysfunction (OR: 1.55, p = 0.001). Interpreted with caution, several factors contribute to an increased odds of falling in older people with DM. Home-visiting nurses are uniquely placed to introduce preventive interventions to reduce the likelihood of debilitating falls in this population.

Community-Dwelling Older Women: The Association Between Living Alone and Use of a Home Nursing Service.

OBJECTIVE: To investigate the use of home nursing by community-dwelling older women to determine the nature of services required by those living alone. DESIGN: A retrospective cohort study using routinely collected data. SETTING AND PARTICIPANTS: Women aged 55 years and older living in metropolitan Melbourne who received an episode of nursing care from a large community home-based nursing service provider between January 1, 2006 and December 31, 2015. METHODS: Descriptive and inferential statistical analyses were used to examine the relationship between client- and service-related factors and use of community nursing services. The primary outcome of interest was the hours of service received in a care episode. RESULTS: A total of 134,396 episodes of care were analyzed, in which 51,606 (38.4%) episodes involved a woman who lived alone. The median hours of care per episode to women who lived alone was almost 70% more than that for women who lived with others. Multivariable regression identified factors influencing the amount of service use: living alone status, cognitive health status, and number of required home nursing activities. After adjusting for confounding and interactions, living alone was associated with at least 13% more hours of care than is provided to those not living alone. Compared with women who lived with others, women living alone required almost double the amount of assistance with medication management and were 30% more likely to experience a deterioration in their condition or be discharged from home nursing care into an acute hospital. From 2006 to 2015, for all women there was a trend toward fewer hours of nursing service provided per episode. CONCLUSIONS AND IMPLICATIONS: Community-dwelling older women who live alone have greater service needs and higher rates of discharge to hospital. This knowledge will help guide provision of services and strategies to prevent clinical deterioration for this population.

Trajectories of home nursing use for older women in Melbourne, Australia: 2006-2015.

OBJECTIVE: To profile changes in older women accessing home nursing between 2006 and 2015, focussing on living circumstances. METHODS: Data pertaining to Australian women aged 55+ who accessed a home nursing service between 2006 and 2015 were analysed, stratified by living status. Comparisons were made between the years 2006 and 2015; rates and relative rates of use per 1000 clients were calculated. RESULTS: Fewer women lived alone in 2015 compared with 2006. Women were older, less likely to be born in Australia, speak English at home, had more diagnoses and higher average Charlson Comorbidity Index scores in 2015. Relative rates of service use for older women living with others increased slightly over the 10 years, while decreasing by 13% for those living alone. CONCLUSION: Women using home nursing services are older than previously, more medically complex, more likely to be born from countries other than Australia and speak a preferred language other than English.

Emergency demand, repeat and frequent presentations by older patients in metropolitan Melbourne: A retrospective cohort study using routinely collected hospital data.

OBJECTIVE: To describe patterns for potentially avoidable general practice (PAGP)-type and non-PAGP-type ED presentations by older patients during 2008 and 2012. METHODS: Retrospective analysis of ED presentations by patients ≥70 years for 2008 and 2012. Metropolitan Melbourne public hospital data were obtained from the Victorian Emergency Minimum Dataset. Outcomes were characteristics of PAGP-type and non-PAGP-type presentations as defined by the Australian Institute of Health and Welfare; numbers and rates per 1000 population ≥70 years of repeat (×2-3/year) and frequent (≥ ×4/year) PAGP-type and non-PAGP-type presentations. RESULTS: The older metropolitan Melbourne population increased by 10.3% between 2008 and 2012, whereas the number of ED presentations increased by 12.7%. The volume of PAGP-type presentations decreased by 2.6%, with declining rates per 1000 population ≥70 years of repeat (7.2-6.2) and frequent (0.7-0.4) presentation. In contrast, the volume of non-PAGP-type presentations grew by 15.4%, with increasing repeat (57.6-60.7) and frequent (13.1-14.2) presentation rates per 1000 population ≥70 years. The majority (39%) of non-PAGP-type presentations by frequent ED attenders were due to cardiovascular or respiratory problems. CONCLUSION: The rate of repeat and frequent PAGP-type presentations by older people decreased in 2012 compared with 2008, suggesting that initiatives implemented to reduce avoidable presentations may have had an effect. However, an increase in the rate of frequent non-PAGP-type presentations, predominately for acute exacerbation of cardiovascular and respiratory conditions, has important implications for planning future healthcare delivery; hence, the importance of initiatives such as the Health Care Home.

Emergency department utilisation by older people in metropolitan Melbourne, 2008-12: findings from the Reducing Older Patient's Avoidable Presentations for Emergency Care Treatment (REDIRECT) study.

Objective Older patients are over-represented in emergency departments (ED), with many presenting for conditions that could potentially be managed in general practice. The aims of the present study were to examine the characteristics of ED presentations by older patients and to identify patient factors contributing to potentially avoidable general practitioner (PAGP)-type presentations. Methods A retrospective analysis was performed of routinely collected data comprising ED presentations by patients aged ≥70 years at public hospitals across metropolitan Melbourne from January 2008 to December 2012. Presentations were classified according to the National Healthcare Agreement definition for PAGP-type presentations. Presentations were characterised according to patient demographic and clinical factors and were compared across PAGP-type and non-PAGP-type groups. Results There were 744519 presentations to the ED by older people, of which 103471 (13.9%) were classified as PAGP-type presentations. The volume of such presentations declined over the study period from 20893 (14.9%) in 2008 to 20346 (12.8%) in 2012. External injuries were the most common diagnoses (13761; 13.3%) associated with PAGP-type presentations. Sixty-one per cent of PAGP-type presentations did not involve either an investigation or a procedure. Patients were referred back to a medical officer (including a general practitioner (GP)) in 58.7% of cases. Conclusion Older people made a significant number of PAGP-type presentations to the ED during the period 2008-12. A low rate of referral back to the primary care setting implies a potential lost opportunity to redirect older patients from ED services back to their GPs for ongoing care. What is known about the topic? Older patients are increasingly attending EDs, with a proportion attending for problems that could potentially be managed in the general practice setting (termed PAGP-type presentations). What does this paper add? This study found that PAGP-type presentations, although declining, remain an important component of ED demand. Patients presented for a wide array of conditions and during periods that may indicate difficulty accessing a GP. What are the implications for practitioners? Strategies to redirect PAGP-type presentations to the GP setting are required at both the primary and acute care levels. These include increasing out-of-hours GP services, better triaging and appointment management in GP clinics and improved communication between ED clinicians and patients' GPs. Although some strategies have been implemented, further examination is required to assess their ongoing effectiveness.

After-hours medical deputising services: patterns of use by older people.

OBJECTIVES: To examine how older people use an after-hours medical deputising service that arranges home visits by locum general practitioners; to identify differences in how people who live in the community and those who live in residential aged care facilities (RACFs) use this service. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of routinely collected administrative data from the Melbourne Medical Deputising Service (MMDS) for the 5-year period, 1 January 2008 - 31 December 2012. Data for older people (≥ 70 years old) residing in greater Melbourne and surrounding areas were analysed. MAIN OUTCOME MEASURES: Numbers and rates of MMDS bookings for acute after-hours care, stratified according to living arrangements (RACF v community-dwelling residents). RESULTS: Of the 357 112 bookings logged for older patients during 2008-2012, 81% were for RACF patients, a disproportionate use of the service compared with that by older people dwelling in the community. Most MMDS bookings resulted in a locum GP visiting the patient. During 2008-2012, the booking rate for RACFs increased from 121 to 168 per 1000 people aged 70 years or more, a 39% increase; the booking rate for people not living in RACFs increased from 33 to 40 per 1000 people aged 70 years or more, a 21% increase. CONCLUSIONS: After-hours locum GPs booked through the MMDS mainly attended patients living in RACFs during 2008-2012. Further research is required to determine the reasons for differences in the use of locum services by older people living in RACFs and in the community.

Cryptosporidium p30, a galactose/N-acetylgalactosamine-specific lectin, mediates infection in vitro.

Cryptosporidium sp. cause human and animal diarrheal disease worldwide. The molecular mechanisms underlying Cryptosporidium attachment to, and invasion of, host cells are poorly understood. Previously, we described a surface-associated Gal/GalNAc-specific lectin activity in sporozoites of Cryptosporidium parvum. Here we describe p30, a 30-kDa Gal/GalNAc-specific lectin isolated from C. parvum and Cryptosporidium hominis sporozoites by Gal-affinity chromatography. p30 is encoded by a single copy gene containing a 906-bp open reading frame, the deduced amino acid sequence of which predicts a 302-amino acid, 31.8-kDa protein with a 22-amino acid N-terminal signal sequence. The p30 gene is expressed at 24-72 h after infection of intestinal epithelial cells. Antisera to recombinant p30 expressed in Escherichia coli react with an approximately 30-kDa protein in C. parvum and C. hominis. p30 is localized to the apical region of sporozoites and is predominantly intracellular in both sporozoites and intracellular stages of the parasite. p30 associates with gp900 and gp40, Gal/GalNAc-containing mucin-like glycoproteins that are also implicated in mediating infection. Native and recombinant p30 bind to Caco-2A cells in a dose-dependent, saturable, and Gal-inhibitable manner. Recombinant p30 inhibits C. parvum attachment to and infection of Caco-2A cells, whereas antisera to the recombinant protein also inhibit infection. Taken together, these findings suggest that p30 mediates C. parvum infection in vitro and raise the possibility that this protein may serve as a target for intervention.

Homologues of insecticidal toxin complex genes in Yersinia enterocolitica biotype 1A and their contribution to virulence.

Yersinia enterocolitica is an enteric pathogen that consists of six biotypes: 1A, 1B, 2, 3, 4, and 5. Strains of the latter five biotypes can carry a virulence plasmid, known as pYV, and several well-characterized chromosomally encoded virulence determinants. Y. enterocolitica strains of biotype 1A lack the virulence-associated markers of pYV-bearing strains and were once considered to be avirulent. There is growing epidemiological, clinical, and experimental evidence, however, to suggest that some biotype 1A strains are virulent and can cause gastrointestinal disease. To identify potential virulence genes of pathogenic strains of Y. enterocolitica biotype 1A, we used genomic subtractive hybridization to determine genetic differences between two biotype 1A strains: an environmental isolate, Y. enterocolitica IP2222, and a clinical isolate, Y. enterocolitica T83. Among the Y. enterocolitica T83-specific genes we identified were three, tcbA, tcaC, and tccC, that showed homology to the insecticidal toxin complex (TC) genes first discovered in Photorhabdus luminescens. The Y. enterocolitica T83 TC gene homologues were expressed by Y. enterocolitica T83 and were significantly more prevalent among clinical biotype 1A strains than other Yersinia isolates. Inactivation of the TC genes in Y. enterocolitica T83 resulted in mutants which were attenuated in the ability to colonize the gastrointestinal tracts of perorally infected mice. These results indicate that products of the TC gene complex contribute to the virulence of some strains of Y. enterocolitica biotype 1A, possibly by facilitating their persistence in vivo.