The first reported treatment of Nager syndrome associated hearing loss with bone-anchored hearing aids: case report.

OBJECTIVE: To report the first case of treatment of Nager syndrome associated conductive hearing loss with bone-anchored hearing aids, in a three-year-old boy. METHOD: Clinical case report and current literature review regarding the use of bone-anchored hearing aids in the treatment of conductive hearing loss in children. RESULTS: A three year eight month old boy with Nager syndrome was successfully treated for conductive hearing loss using bilateral bone-anchored hearing aids. CONCLUSION: This is the first case report of the use of bone-anchored hearing aids to treat Nager syndrome associated conductive hearing loss. Treatment was safe and successful in this case.

Cardiovascular risk management and its impact in Australian general practice patients with type 2 diabetes in urban and rural areas.

OBJECTIVE: To investigate the cardiovascular disease (CVD) risk management and its impact on Australian general practice patients with type 2 diabetes in urban and rural areas between 2000 and 2002, and to compare trends over time and differences between urban and rural areas. DESIGN AND METHODS: Population-based repeated cross-sectional study. 6305 patient records from 2000 to 2002 were extracted from registers of diabetes type 2 patients held by 16 Divisions of General Practice (250 practices) across Australia. Multivariate logistic regression comparing urban and rural patients at differing time-periods and comparing trend changes was conducted using multilevel analysis. RESULTS: Prescribing of antihypertensive and lipid-lowering medications was infrequent but increased in both urban and rural areas from 2000 to 2002 (p<0.05), while attendance at other allied health professionals did not. While the proportion of patients meeting targets for high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol increased in both areas over time, only in urban areas were there improvements in total cholesterol and blood pressure over time. The proportion of patients meeting targets for HDL-C, triglycerides and smoking cessation were higher in urban areas than in rural areas by 2002. CONCLUSIONS: Despite a number of national initiatives to improve general practice care and specifically support better care in rural areas, cardiovascular risk management and its impact in Australian general practice patients with type 2 diabetes was still suboptimal during the study period especially among patients from rural areas. Greater effort will be required to reduce the disparity in risk factor prevention for CVD between urban and rural people with type 2 diabetes in Australia.

Diabetes information management systems. General practitioner and population reach.

AIM: To assess the extent to which Australian divisions of general practice are facilitating structured management of diabetes. METHOD: The study was conducted over a 12 month period (1998/1999) and involved two postal surveys of Australia's 123 divisions. RESULTS: In both surveys 53% of divisions were implementing a diabetes program, the main components being continuing education of general practitioners (GPs), establishment of information systems, use of guidelines and shared care. In the 30 divisions operating a program for more than 12 months there was a significant increase in the proportion of GPs registering patients (p = 0.03) and the population who were registered with diabetes (p < 0.001). In 43% of divisions, GP reach was greater than 50%. Population reach of more than 50% was achieved by only 17% of divisions. The larger the division, the lower the GP participation rate (p = 0.001) and the lower the population reach (p < 0.001). CONCLUSION: Strategies to facilitate adequate reach of programs in divisions with large populations warrant consideration. This may include the formation of subgroups and support for practices and divisions to implement structured evidence based care systems for the management of chronic diseases in general practice.

A randomised trial of an intervention to develop health promoting schools in Australia: the south western Sydney study.

OBJECTIVE: This paper describes the evaluation of a health promoting schools intervention carried out in the south western region of Sydney, Australia. The evaluation sought to assess the project's impact on structures to support the health promoting school concept and changes in health-related policies and practices within 22 local schools. METHODS: A randomised controlled study was employed. Intervention schools were offered seminars and training in the health promoting schools concept, encouraged to use a resource kit to help them establish their school as health promoting and invited to participate in a support network. Pre- and post measures of awareness, school structures and policies and practices to support the development of a health promoting school were taken and intervention and control schools compared. RESULTS: There was an increased level of awareness of the health promoting school concept among intervention schools. However, there were no significant changes in health-related policies and practices at the school level, among both intervention and control schools. CONCLUSIONS: A longer time frame and more structured support are required to influence school structures to support the development of a health promoting school. IMPLICATIONS: To facilitate organisational change in schools, health promoting school interventions need to provide structured support for schools and recognise that change takes time. A committee to initiate action, a plan to guide work and school support are likely to facilitate the adoption of the health promoting schools approach. Further work to refine the measurement of school-based action and its outcome and the development of indicators for a health promoting school is needed.

Where's the common ground? A survey of hospitals, community health centres and divisions of general practice in Australia.

BACKGROUND: Divisions of general practice are key structures for integration between general practice and other health services in Australia. AIM: To compare the views of divisions of general practice toward integration of care with those of hospitals and community health services. METHOD: Representative national samples of public hospitals and community health centres (CHCs) and a census of divisions of general practice (DGP) were surveyed on their current collaborations and links as well as barriers to and factors that enhance integration between general practitioners and other health services. RESULTS: There is wide agreement on the need for greater integration. Personal links (via letter, phone and face to face) were thought to be useful. However, general practice liaison officers were seen as especially useful. All organizations rated different accountabilities and responsibilities as a highly significant barrier. Resources, structures for collaboration and high level organisational support were rated as being more useful in enabling greater integration. CONCLUSION: Formalizing collaboration will require changes to funding and accountability. However there is also a need for cultural change to support greater integration of patient care between general practice and both hospitals and community health services.

Integration between GPs and hospitals: lessons from a division-hospital program.

The aim of the study reported here was to evaluate current initiatives in GP-hospital integration and highlight areas where further research, development and evaluation are required. Seven pre-existing GP-hospital programs were selected and given supplementary funding to allow for more effective evaluation. These local evaluations were then incorporated into a national program on GP-hospital collaboration. We found that the seven projects made substantial progress towards their goals, and in the process highlighted important aspects of successful collaboration. The collective evaluation of DHIP identified expected benefits of collaboration for patients (improved access to services, reduced anxiety, and fewer post discharge complications), for GPs (increased involvement in acute care and in hospital decision making), and for service organisations (stronger working relationships, increased capacity, and greater efficiency). Barriers to service integration were also identified, including the different cultures of Divisions and hospitals, their lack of internal coherence and the Commonwealth-state divide. The evaluation showed that much has been achieved in building the relationships and the capacity needed for GP-hospital collaboration, and that effective models exist. The current challenge is to extend successful models across health areas and make effective collaboration part of the normal system of care. Substantial progress towards integrated care relies on a shift from a focus on systems within general practice or hospital environments to a patient centred approach. This will require general practice, hospitals, community services and consumer organisations to form long term partnerships and move beyond their currently disjointed view of acute and community care. The development of practical indicators for integrated care will support the process and facilitate shared learning across Commonwealth and state divides.

The DNA translocation and ATPase activities of restriction-deficient mutants of Eco KI.

Eco KI, a type I restriction enzyme, specifies DNA methyltransferase, ATPase, endonuclease and DNA translocation activities. One subunit (HsdR) of the oligomeric enzyme contributes to those activities essential for restriction. These activities involve ATP-dependent DNA translocation and DNA cleavage. Mutations that change amino acids within recognisable motifs in HsdR impair restriction. We have used an in vivo assay to monitor the effect of these mutations on DNA translocation. The assay follows the Eco KI-dependent entry of phage T7 DNA from the phage particle into the host cell. Earlier experiments have shown that mutations within the seven motifs characteristic of the DEAD-box family of proteins that comprise known or putative helicases severely impair the ATPase activity of purified enzymes. We find that the mutations abolish DNA translocation in vivo. This provides evidence that these motifs are relevant to the coupling of ATP hydrolysis to DNA translocation. Mutations that identify an endonuclease motif similar to that found at the active site of type II restriction enzymes and other nucleases have been shown to abolish DNA nicking activity. When conservative changes are made at these residues, the enzymes lack nuclease activity but retain the ability to hydrolyse ATP and to translocate DNA at wild-type levels. It has been speculated that nicking may be necessary to resolve the topological problems associated with DNA translocation by type I restriction and modification systems. Our experiments show that loss of the nicking activity associated with the endonuclease motif of Eco KI has no effect on ATPase activity in vitro or DNA translocation of the T7 genome in vivo.

Shared care through divisions of general practice: moving forward.

Divisions of general practice have established a wide variety of structured programs to support shared care over the past six years. Differences in the adoption and continuation of these programs appear to be related to a number of factors, including local opportunities and external funding and demands on divisions, relationships and the capacity of the divisions and their health service partners.

On the structure and operation of type I DNA restriction enzymes.

Type I DNA restriction enzymes are large, molecular machines possessing DNA methyltransferase, ATPase, DNA translocase and endonuclease activities. The ATPase, DNA translocase and endonuclease activities are specified by the restriction (R) subunit of the enzyme. We demonstrate that the R subunit of the Eco KI type I restriction enzyme comprises several different functional domains. An N-terminal domain contains an amino acid motif identical with that forming the catalytic site in simple restriction endonucleases, and changes within this motif lead to a loss of nuclease activity and abolish the restriction reaction. The central part of the R subunit contains amino acid sequences characteristic of DNA helicases. We demonstrate, using limited proteolysis of this subunit, that the helicase motifs are contained in two domains. Secondary structure prediction of these domains suggests a structure that is the same as the catalytic domains of DNA helicases of known structure. The C-terminal region of the R subunit can be removed by elastase treatment leaving a large fragment, stable in the presence of ATP, which can no longer bind to the other subunits of Eco KI suggesting that this domain is required for protein assembly. Considering these results and previous models of the methyltransferase part of these enzymes, a structural and operational model of a type I DNA restriction enzyme is presented.

EcoKI with an amino acid substitution in any one of seven DEAD-box motifs has impaired ATPase and endonuclease activities.

For type I restriction systems, recently determined nucleotide sequences predict conserved amino acids in the subunit that is essential for restriction but not modification (HsdR). The conserved sequences emphasize motifs characteristic of the DEAD-box family of proteins which comprises putative helicases, and they identify a new candidate for motif IV. We provide evidence based on an analysis of Eco KI which supports both the relevance of DEAD-box motifs to the mechanism of restriction and the new definition of motif IV. Amino acid substitutions within the newly identified motif IV and those in six other previously identified DEAD-box motifs, but not in the original motif IV, confer restriction-deficient phenotypes. We have examined the relevance of the DEAD-box motifs to the restriction pathway by determining the steps permitted in vitro by the defective enzymes resulting from amino acid substitutions in each of the seven motifs. Eco KI purified from the seven restriction-deficient mutants binds to an unmethylated target sequence and, in the presence of AdoMet, responds to ATP by undergoing the conformational change essential for the pathway of events leading to DNA cleavage. The seven enzymes have little or no ATPase activity and no endonuclease activity, but they retain the ability to nick unmodified DNA, though at reduced rates. Nicking of a DNA strand could therefore be an essential early step in the restriction pathway, facilitating the ATP-dependent translocation of DNA, particularly if this involves DNA helicase activity.