Childhood fish oil supplementation modifies associations between traffic related air pollution and allergic sensitisation.

BACKGROUND: Studies of potential adverse effects of traffic related air pollution (TRAP) on allergic disease have had mixed findings. Nutritional studies to examine whether fish oil supplementation may protect against development of allergic disease through their anti-inflammatory actions have also had mixed findings. Extremely few studies to date have considered whether air pollution and dietary factors such as fish oil intake may interact, which was the rationale for this study. METHODS: We conducted a secondary analysis of the Childhood Asthma Prevention Study (CAPS) birth cohort, where children were randomised to fish oil supplementation or placebo from early life to age 5 years. We examined interactions between supplementation and TRAP (using weighted road density at place of residence as our measure of traffic related air pollution exposure) with allergic disease and lung function outcomes at age 5 and 8 years. RESULTS: Outcome information was available on approximately 400 children (~ 70% of the original birth cohort). Statistically significant interactions between fish oil supplementation and TRAP were seen for house dust mite (HDM), inhalant and all-allergen skin prick tests (SPTs) and for HDM-specific interleukin-5 response at age 5. Adjusting for relevant confounders, relative risks (RRs) for positive HDM SPT were RR 1.74 (95% CI 1.22-2.48) per 100 m local road or 33.3 m of motorway within 50 m of the home for those randomised to the control group and 1.03 (0.76-1.41) for those randomised to receive the fish oil supplement. The risk differential was highest in an analysis restricted to those who did not change address between ages 5 and 8 years. In this sub-group, supplementation also protected against the effect of traffic exposure on pre-bronchodilator FEV1/FVC ratio. CONCLUSIONS: Results suggest that fish oil supplementation may protect against pro-allergic sensitisation effects of TRAP exposure. Strengths of this analysis are that supplementation was randomised and independent of TRAP exposure, however, findings need to be confirmed in a larger experimental study with the interaction investigated as a primary hypothesis, potentially also exploring epigenetic mechanisms. More generally, studies of adverse health effects of air pollution may benefit from considering potential effect modification by diet and other factors. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry. www.anzctr.org.au Registration: ACTRN12605000042640 , Date: 26th July 2005. Retrospectively registered, trial commenced prior to registry availability.

The experiences of patients and carers living with multimorbid, non-communicable diseases

BACKGROUND: Non-communicable diseases (NCDs) are increasing in prevalence and straining health systems globally. This creates a so-called 'burden of disease', which can be traced in terms of fiscal health system matters and in terms of quality of life and lived experiences of people with NCDs. The United Nations has called for a global agenda to manage NCDs and reduce their burden. OBJECTIVE: The purpose of this article is to summarise key findings from the Serious and Continuing Illness Policy and Practice Study concerning patients’ and carers’ experiences of multimorbid NCDs in Australia. We focus on the relevance of findings for policy and general practitioners in Australia. DISCUSSION: We suggest that a complex multimorbidity policy is needed to contextualise and guide single-illness NCD policies. Our research suggests that specialist NCD nurses and allied health professionals could have important roles in improving care coordination between general practices and community health centres.

Distrusting doctors' evidence: a qualitative study of disability income support policy makers.

Objective The aim of the present study was to describe how policy makers (bureaucrats and politicians) in Australia and Ontario (Canada) perceive evidence provided by doctors to substantiate applications for disability income support (DIS) by their patients with mental illnesses. Because many mental illnesses (e.g. depression) lack diagnostic tests, their existence and effects are more difficult to demonstrate than most somatic illnesses. Methods Semi-structured interviews were conducted with 45 informants, all influential in the design of the assessment of DIS programs. The informants were subcategorised into advocates, legal representatives, doctors (general practitioners (GPs) and specialists (e.g. psychiatrists)), policy insiders and researchers. Informants were found through snowball sampling. Following the principles of grounded theory, data collection and analysis occurred in tandem. Results Informants expressed some scepticism about doctors' evidence. Informants perceived that doctors could, due to lack of diagnostic certainty, 'write these things [evidence] however [they] want to'. Psychiatrists, perceived as having more time and skills, were considered as providing more trustworthy evidence than GPs. Conclusion Doctors, providing evidence to support applications, play an important role in determining disability. However, policy makers perceive doctors' evidence about mental illnesses as less trustworthy than evidence about somatic illnesses. This affects decisions by government adjudicators. What is known about the topic? Doctors (GPs and psychiatrists) are often asked to provide evidence to substantiate a DIS application for those with mental illnesses. We know little about the perception of this evidence by the policy makers who consider these applications. What does this paper add? Policy makers distrust doctors' evidence in relation to mental illnesses. This is partly because many mental illnesses lack diagnostic proof, in contrast with evidence for somatic conditions, where the disability is often visible and proven through diagnostic tests. Furthermore, GPs' evidence is considered less trustworthy than that of psychiatrists. What are the implications for practitioners? Although doctors' evidence is often required, the utility of their evidence is limited by policy makers' perceptions.

Disability income support design and mental illnesses: a review of Australia and Ontario.

AIM: Mental illnesses have many distinctive features that make determining eligibility for disability income support challenging - for example, their fluctuating nature, invisibility and lack of diagnostic clarity. How do policy makers deal with these features when designing disability income support? More specifically, how do mental illnesses come to be considered eligible disabilities, what tools are used to assess mental illnesses for eligibility, what challenges exist in this process, and what approaches are used to address these challenges? We aimed to determine what evidence is available to policy makers in Australia and Ontario, Canada, to answer these questions. METHODS: Ten electronic databases and grey literature in both jurisdictions were searched using key words, including disability income support, disability pension, mental illness, mental disability, addiction, depression and schizophrenia, for articles published between 1991 and June 2013. This yielded 1341 articles, of which 20 met the inclusion criteria and were critically appraised. RESULTS: Limited evidence is available on disability income support design and mental illnesses in the Australian and Ontarian settings. Most of the evidence is from the grey literature and draws on case law. Many documents reviewed argued that current policy in Australia and Ontario is frequently based on negative assumptions about mental illnesses rather than evidence (either peer reviewed or in the grey literature). Problems relating to mental illnesses largely relate to interpretation of the definition of mental illness rather than the definition itself. CONCLUSIONS: The review confirmed that mental illnesses present many challenges when designing disability income support and that academic as well as grey literature, especially case law, provides insight into these challenges. More research is needed to address these challenges, and more evidence could lead to policies for those with mental illnesses that are well informed and do not reinforce societal prejudices.

Screening, Education, and Rehabilitation Services for Hearing Loss Provided to Clients with Low Vision: Measured and Perceived Value Among Participants of the Vision-Hearing Project.

OBJECTIVES: Combined vision and hearing impairment, termed dual sensory impairment (DSI), is associated with poorer health outcomes compared with a single sensory loss alone. Separate systems of care exist for visual and hearing impairment which potentially limit the effectiveness of managing DSI. To address this, a Hearing Screening Education Model (HSEM) was offered to older adults attending a low-vision clinic in Australia within this pilot study. The present study aimed to evaluate the benefits of seeking help on hearing handicap, self-perceived health, and use of community services among those identified with unmet hearing needs after participation in the HSEM. DESIGN: Of 210 older adults (>55 years of age) who completed the HSEM and were referred for follow-up, 169 returned for a follow-up interview at least 12 months later. Of these, 68 (40.2%) sought help, and the majority were seen by a hearing healthcare provider (89.7%). Changes in hearing handicap, quality of life, and reliance on community services between the baseline and 12-month follow-up were compared between those who sought help and those who did not. In addition, the perceived value of the HSEM was assessed. RESULTS: Results showed that there was no significant difference in hearing handicap between those who sought help (mean change -1.02 SD = 7.97, p = 0.3) and those who did not (mean change 0.94 SD = 7.68, p = 0.3), p = 0.18. The mental component of the SF-36 worsened significantly between baseline and follow-up measures across the whole group (mean change -2.49 SD = 9.98, p = 0.002). This was largely driven by those not seeking help, rather than those seeking help, but was not significantly different between the two groups. Those who sought help showed a significant reduction in the use of community services compared with those who did not. Further, all participants positively viewed the HSEM's underlying principle of greater integration between vision and hearing services. CONCLUSIONS: These findings suggest a need to further develop and evaluate integrated models of healthcare for older adults with DSI. It also highlights the importance of using broader measures of benefit, other than use of hearing aids to evaluate outcomes of hearing healthcare programs.

Exploring interhospital transfers and partnerships in the hospital sector in New South Wales, Australia.

Objective The aim of the present study was to explore characteristics of interhospital transfers (IHT) and sharing of care among hospitals in New South Wales (NSW), Australia. Methods Data were extracted from patient-level linked hospital administrative datasets for separations from all NSW acute care hospitals from 1 July 2013 to 30 June 2015. Patient discharge and arrival information was used to identify IHTs. Characteristics of patients and related hospitals were then analysed. Results Transfer-in patients accounted for 3.9% of all NSW admitted patients and, overall, 7.3% of NSW admissions were associated with transfers (IHT rate). Patients with injuries and circulatory system diseases had the highest IHT rate, accounting for one-third of all IHTs. Patients were more often transferred to larger than smaller hospitals (61% vs 29%). Compared with private hospitals, public hospitals had a higher IHT rate (8.4% vs 5.1%) and a greater proportion of transfer-out IHTs (52% vs 28%). Larger public hospitals had lower IHT rates (3-8%) compared with smaller public hospitals (13-26%). Larger public hospitals received and retransferred higher proportions of IHT patients (52-58% and 11% respectively) than their smaller counterparts (26-30% and 2-3% respectively). Less than one-quarter of IHTs were between the public and private sectors or between government health regions. The number of interacting hospitals and their interactions varied across hospital peer groups. Conclusion NSW IHTs were often to hospitals with greater speciality services. The patterns of interhospital interactions could be affected by organisational and regional preferences. What is known about the topic? IHTs aim to provide efficient and effective care. Nonetheless, information on transfers and the sharing of care among hospitals in an Australian setting is lacking. Studies of transfers and hospital partnership patterns will inform efforts to improve patient-centred transfers and hospital accountability in terms of end outcomes for patients. What does this paper add? Transfer-in patients accounted for 3.9% of all NSW admissions; they were often (61%) transferred to hospitals with greater speciality services. The number of IHTs and sharing of care among hospitals varied across hospital peer groups, and could have been affected by organisational and regional preferences. What are the implications for practitioners? The findings of the present study suggest that different patterns of IHTs may not only have resulted from clinical priorities, but that organisational and regional preferences are also likely to be influential factors. Patient-centred IHTs and the development of guidelines need to be pursued to enhance the care and functionality of healthcare. Patient sharing should be acknowledged in hospital and regional performance profiling.

And Why So Great a "No?": The Donor and Academic Communities' Failure to Confront Global Chronic Disease.

Chronic diseases are the dominant issues for global public health in terms of mortality, morbidity, and cost, and they have been identified as such for >40 years. Despite their predominance, however, these diseases-cardiovascular disease (CVD), diabetes, cancer, pulmonary disease, mental health, and dementia-attract little attention in the public health curriculum and even less from the funding community. We explore the rationales that have perpetuated this inability or unwillingness to match need with effort. We examine 3 concepts that impede changing this relationship: 1) the traditional contextual view of public health that emerged, to be sure with great success, in the post-World War II era; 2) the failure of public health to transition to economic development as the goal of health assistance; and 3) the unwillingness of public health to confront social, political, and economic policies as the foci of upstream drivers of the public's health. We conclude with a discussion of the need for public health to expand its horizon and tear down the walls of the silos that inhibit the emergence of relevant global public health.

Telomere length in early childhood: Early life risk factors and association with carotid intima-media thickness in later childhood.

BACKGROUND: Reduced telomere length is a measure of biological aging that is predictive of cardiac events in adults, and has been mechanistically implicated in the onset and progression of atherosclerosis. We sought to describe the early life factors associated with leukocyte telomere length in early childhood, and to determine whether telomere length measured during early childhood is associated with arterial wall thickening later in childhood. DESIGN: A longitudinal birth cohort recruited antenatally in Sydney from 1997 to 1999. METHODS: Leukocyte telomere length was measured in 331 children at age 3.6 years (SD 1.0); of whom 268 children without diabetes had carotid intima-media thickness assessed by ultrasound at age 8 years. RESULTS: Male sex, younger paternal age and higher maternal body mass index were associated with shorter telomere length in early childhood, which in turn was associated with greater carotid intima-media thickness at age 8 years (standardised ß = -0.159, P = 0.01). There was a graded association across quartiles of telomere length (Ptrend = 0.001) with the highest odds of elevated intima-media thickness (>75th percentile) being in children with the shortest telomeres (odds ratio 4.00 (95% confidence interval 1.58 to 10.14) relative to those with the longest telomeres, P = 0.003). This association remained after adjustment for early life risk factors (Ptrend = 0.001). CONCLUSIONS: Reduced telomere length in early childhood is independently associated with arterial wall thickness in later childhood, suggesting that reduced telomere length during early childhood may be a marker of vascular disease risk.

Carotid extramedial thickness is associated with local arterial stiffness in children.

OBJECTIVES: Experimental evidence suggests that structural changes to the arterial adventitia may be a key vascular determinant of early arterial stiffening, although this has not been directly studied. Accordingly, we hypothesized that in young children, in whom this relationship would not be altered by atheroma, carotid extramedial thickness (EMT), a measure that incorporates the thickness of the arterial adventitia, perivascular tissues and the internal jugular venous wall, would be associated with localized arterial stiffness of the same arterial region. METHODS: We studied 248 healthy prepubescent children (aged 8 years). Carotid diameter and carotid EMT were measured by high-resolution ultrasound. Carotid blood pressure was derived from brachial blood pressure and carotid tonometry. Three measures of localized arterial stiffness (ß stiffness index, distensibility coefficient and incremental modulus of elasticity) were calculated for the common carotid artery. Results were adjusted for heart rate and DBP, two important hemodynamic determinants of arterial stiffness. RESULTS: Carotid EMT was associated with all three measures of arterial stiffness (ß stiffness index: standardized ß = 0.121, P = 0.03; distensibility coefficient: standardized ß = -0.121, P = 0.05; incremental modulus of elasticity: standardized ß = 0.140, P = 0.02). These associations remained significant after adjustment for potential confounders such as sex, height, waist circumference, BMI and body surface area. CONCLUSION: Carotid EMT is associated with the stiffness of the same arterial segment in children, suggesting that the arterial adventitia may be involved in early changes in arterial stiffness during childhood.

The lack of a non-communicable disease curriculum threatens the relevance of global public health education.

BACKGROUND: Non-communicable diseases (NCDs) such as cardiovascular diseases (CVDs), cancer, lung disease and diabetes are major public health challenges for emerging economies. However, Masters of Public Health (MPH) curricula in the USA do not provide germane coursework. METHODS: To assess the availability of global NCD courses in MPH curricula, we searched the websites of the 50 schools accredited by the Council on Education for Public Health as of 1 July 2013. Our questionnaire queried availability of a global or international health department or track, availability of an NCD track, and the presence of courses on NCD, NCD risk factors, CVD or global NCDs as well as global health infrastructure. RESULTS: All schools had online course coursework available. Thirty-one schools (62%) offered a global/international health track or certificate; 38 (76%) offered an NCD course but only 4 (8%) offered a global NCD course. Of the schools with a global health program, none required an NCD course but all offered courses on global health economics or infrastructure. CONCLUSION: For public health schools to be aligned with global realities and to retain a leadership role, curricular initiatives that highlight the NCD epidemic and its societal complexities will need new emphasis.

Efficacy of a home-based educational strategy involving community health volunteers in improving self-care in patients with chronic heart failure in western Iran: A randomized controlled trial.

BACKGROUND: This study aimed to evaluate the effectiveness of a home-based educational strategy using community health volunteers (CHVs) in improving self-care of patients with chronic heart failure (CHF) in comparison with an educational strategy using formal health professionals (FHPs) at hospital, and also with a control group receiving usual care in western Iran. METHODS AND RESULTS: A three-arm controlled trial randomly allocated 231 patients with CHF into a control group and two intervention groups undertaking two different educational approaches - a face-to-face education program by CHVs at the patients' homes and a formal education program using paid FHPs at hospital. Data obtained through interviewing patients before and two months after interventions were analyzed. Self-care components significantly increased after the intervention in both interventional groups compared to the control group (p<0.001). Differences between the two strategies were not significant, except for self-care confidence being greater in the groups exposed to the health professionals (p=0.004). The mean and standard deviation (SD) of the changes in self-maintenance, self-management and self- confidence score (each with a maximum score of 100) for the CHVs group were 26.2±12.7, 29.4±11 9.5±17; for the health professional group were 29.5±12, 31.3±12, 18.1±17; and for the control group were 2.7±9, 10.2±10, -0.30±11 respectively. CONCLUSION: The home-based face-to-face education by CHVs improved self-care maintenance and self-care management in patients with CHF as effectively as the education provided by health professionals in a formal health education program, and much better than the usual care.

Self-care and Its Predictors in Patients With Chronic Heart Failure in Western Iran.

BACKGROUND: Chronic heart failure (CHF) is an increasing and costly health problem worldwide. Effective self-care behaviors reduce the cost and improve CHF outcomes. Interventions targeting improvement of self-care need to identify the baseline status of patients and factors associated with self-care to tailor the programs to patients' needs. AIM: The aim of this study was to describe self-care and its predictors in patients with CHF in western Iran. METHODS: In a cross-sectional study, 255 patients with CHF in Kermanshah were recruited and 231 (mean [SD] age, 66 [13] years; 51.5% women) completed the interviews. Self-care maintenance, self-care management, and self-care confidence were evaluated using a Persian heart failure self-care index. Each of these 3 measures had a total possible score of 100, with 22 indicators. RESULTS: The mean (SD) self-care scores were low: maintenance, 33.8 (10.7); management, 32.2 (12.0); and confidence, 43.6 (15.6). Self-care maintenance was significantly and positively associated with education, disease duration, and living conditions. Self-care management was significantly and positively associated with education and number of hospital admissions. However, the parameter estimates in all those relationships were small. CONCLUSION: Self-care in patients with CHF in Iran needs major improvement, and many determinants of self-care identified by other studies were not consistently associated with poor self-care scores in Iran. Further research considering a wide range of factors associated with self-care (eg, socioeconomic and health system-related factors) and application of culturally relevant interventional strategies is recommended.

Coordinated care versus standard care in hospital admissions of people with chronic illness: a randomised controlled trial.

OBJECTIVE: To determine whether Care Navigation (CN), a nurse-led hospital-based coordinated care intervention, reduced the use of hospital services and improved quality of life for patients with chronic illness. DESIGN: Randomised controlled trial; participants were allocated to CN or standard care. PARTICIPANTS AND SETTING: Patients with chronic illness presenting to the emergency department of Nepean Hospital, Sydney, New South Wales. High-risk status for an unplanned admission was defined as i) three or more unplanned hospital admissions in 12 months for patients aged ≥ 70 or at least one admission for cardiac or respiratory disease in patients aged 16-69 years; or ii) judged by a CN nurse to be high risk and likely to benefit. MAIN OUTCOME MEASURES: Numbers of re-presentations or readmissions, quality of life, time to re-presentation, readmission or death, length of stay, and access to hospital and community health services. RESULTS: 500 participants were randomised between May 2010 and February 2011; 359 by previous unplanned admission and 141 by clinical impression. The CN group received more community health services (rate ratio, 1.94; 95% CI, 1.35-2.81; P < 0.001) than participants receiving standard care; however, this did not result in statistically significant differences in number of re-presentations (rate ratio, 0.83; 95% CI, 0.68-1.01; P = 0.07), number of readmissions (rate ratio, 0.85; 95% CI, 0.70-1.04; P = 0.11), quality of life at 24 months (mean difference, 0; 95% CI, - 0.10 to 0.09, P = 0.93), or other measures. CONCLUSIONS: CN did not improve quality of life or reduce unplanned hospital presentations or admissions despite community health services almost doubling. Future service development should explore potential benefits of linking navigated intrahospital care to ongoing, proactive care planning and delivery in the community. TRIAL REGISTRATION: ACTRN12609000554268.

The effectiveness of perindopril vs. lisinopril on reducing the incidence of diabetes and renal diseases: A cohort study of 20,252 patients.

BACKGROUND: Lisinopril and perindopril are two commonly used first-line antihypertensive agents. Few studies compared their effectiveness in reducing the incidence of renal diseases and diabetes. METHODS: Adult patients who received new prescriptions of lisinopril or perindopril from 2001 to 2005 in all public hospitals and clinics in Hong Kong were included, and followed up for at least 2 years. Patients prescribed the angiotensin converting enzyme inhibitors (ACEIs) for <1 month were excluded. The incidence of admissions due to renal diseases and diabetes was evaluated. We used Cox proportional hazard regression models to assess hospital admissions as the outcome measures, adjusting for age, sex, socioeconomic status, service types, and the proportion of days covered as a measure of medication adherence. The regression models were constructed with propensity score matching to minimize indication biases. RESULTS: 20,252 eligible patients with an average age of 64.5 years (SD 15.0) were included. The admission rates 24 months within the date of index prescription due to renal diseases were 3.1% (lisinopril) and 2.3% (perindopril); and 9.6% (lisinopril) and 7.2% (perindopril) for diabetes. Except for admissions due to diabetes at 6 months, lisinopril users were significantly more likely to be admitted due to renal diseases (adjusted hazard ratios: 1.304 to 1.378) and diabetes (1.146 to 1.231) than perindopril users at all time points. CONCLUSIONS: Patients prescribed different ACEIs might have a different incidence of hospital admissions. Future studies should be conducted to evaluate the comparative effectiveness of different ACEIs on various patient-centered outcomes by head-to-head randomized controlled trials.

Identifying the Barriers and Opportunities for Enhanced Coherence between Agriculture and Public Health Policies: Improving the Fat Supply in India.

The national Government of India has published draft regulation proposing a 5% upper limit of trans fat in partially hydrogenated vegetable oils (PHVOs). Global recommendations are to replace PHVOs with unsaturated fat but it is not known whether this will be feasible in India. We systematically identified policy options to address the three major underlying agricultural sector issues that influence reformulation with healthier oils: the low productivity of domestically produced oilseeds leading to a reliance on palm oil imports, supply chain wastage, and the low availability of oils high in unsaturated fats. Strengthening domestic supply chains in India will be necessary to maximize health gains associated with product reformulation.