The Muscle-Gut-Brain Axis and Psychiatric Illness.

The microbiota-gut-brain axis (MGBA) has been the subject of much research over the past decade, offering an exciting new paradigm for the treatment of psychiatric disorders. In this review, the MGBA is extended to include skeletal muscle and the potential role of an expanded "muscle-gut-brain axis" (MuGBA) in conditions such as anxiety and depression is discussed. There is evidence, from both preclinical and human studies, of bidirectional links between the gut microbiome and skeletal muscle function and structure. The therapeutic role of exercise in reducing depressive and anxiety symptoms is widely recognised, and the potential role of the gut microbiota-skeletal muscle link is discussed within this context. Potential pathways of communication involved in the MuGBA including the tryptophan-kynurenine pathway, intestinal permeability, immune modulation, and bacterial metabolites such as short-chain-fatty-acids are explored.

Minding metabolism: targeted interventions to improve cardio-metabolic monitoring across early and chronic psychosis.

BACKGROUND: Antipsychotics (APs) increase weight, metabolic syndrome, diabetes and cardiovascular disease. Guidelines recommend cardio-metabolic monitoring at initial assessment, at 3 months and then annually in people prescribed APs. AIM: To determine the rates of cardio-metabolic monitoring in AP treated early and chronic psychosis and to assess the impact of targeted improvement strategies. METHODS: Medical records were reviewed in two cohorts of first-episode psychosis (FEP) patients before and after the implementation of a physical health parameter checklist and electronic laboratory order set. In a separate group of patients with chronic psychotic disorders, adherence to annual monitoring was assessed before and 3 months after an awareness-raising educational intervention. RESULTS: In FEP, fasting glucose (39% vs 67%, p=0.05), HbA1c (0% vs 24%, p=0.005) and prolactin (18% vs 67%, p=0.001) monitoring improved. There were no significant differences in weight (67% vs 67%, p=1.0), BMI (3% vs 10%, p=0.54), waist circumference (3% vs 0%, p=1.0), fasting lipids (61% vs 76% p=0.22) or ECG monitoring (67% vs 67%, p=1.0). Blood pressure (BP) (88% vs 57%, p=0.04) and heart rate (91% vs 65%, p=0.03) monitoring dis-improved. Diet (0%) and exercise (<15%) assessment was poor. In chronic psychotic disorders, BP monitoring improved (20% vs 41.4%, p=0.05), whereas weight (17.0% vs 34.1%, p=0.12), BMI (9.7% vs 12.1%, p=1.0), fasting glucose (17% vs 24.3%, p=0.58) and fasting lipids remained unchanged (17% vs 24.3%, p=0.58). CONCLUSIONS: Targeted improvement strategies resulted in a significant improvement in a limited number of parameters in early and chronic psychotic disorders. Overall, monitoring remained suboptimal.

Scale-up of the Stepping On fall prevention program amongst older adults in NSW: Program reach and fall-related health service use.

ISSUE ADDRESSED: We describe the reach of the scale-up of Stepping On, a fall prevention program targeting community-dwellers aged ≥65 years in NSW, along with fall-related ambulance service use and fall-related hospitalisations after scale-up. METHODS: Data on program provision were received from Local Health Districts. Routinely collected fall-related ambulance usage and hospital admissions in NSW residents aged ≥65 years between 2009 and 2015 were compared within Statistical Local Areas prior to and following the implementation of Stepping On using multilevel models. RESULTS: Between 2009 and 2014 the program was delivered in 1077 sites to 10 096 older adults. Rates of fall-related ambulance use and hospital admissions per 100-person-years were 1-2 in people aged 66-74, 4-5 in people aged 75-84 and 12-13 in people aged ≥85. These rates increased over time (P < .001). The interaction between time and program delivery was not significant for fall-related ambulance use or hospital admissions. The time-related increase in fall-related ambulance usage in people aged 75-84 years may have been moderated by the Stepping On program (rate ratio 0.97, 95% CI 0.93-1.00, P = .045). CONCLUSIONS: There was no indication of a reduced rate of fall-related ambulance use or hospital admissions across the entire sample. Ambulance call-outs for falls in people aged 75-84 years may have reduced following program participation. SO WHAT?: Program scale-ups need to reach a large proportion of the target population with a focus on those groups contributing most to fall-related health service utilisation. Linking individual participants' health data as part of large-scale evaluations may provide better insights into program outcomes.

Trends in fall-related ambulance use and hospitalisation among older adults in NSW, 2006-2013: a retrospective, population-based study.

Objective and importance of study: To describe characteristics and temporal trends of fall-related ambulance service use and hospital admission in older adults in New South Wales (NSW), Australia. Such information will facilitate a more targeted approach to planning and delivery of health services to prevent falls and their adverse sequelae in different groups of older adults. STUDY TYPE: Retrospective population-based descriptive study. METHODS: Fall-related ambulance use and hospital admissions for all falls and injurious falls in NSW residents aged ≥65 years between 2006 and 2013 were obtained from two discrete sources of routinely collected data. Rates of use are presented descriptively. RESULTS: There were 314 041 occasions of fall-related ambulance use by older adults and 331 311 fall-related hospitalisations, of which 69% (n = 227 753) were for injurious falls. Fractures accounted for 57% of injurious hospitalisations. Slips and trips were the most common mechanism of falls requiring hospitalisation (52%). Residents of aged care facilities had a greater proportion of fall injury hospitalisations compared with people living in the community (85% and 65%, respectively). CONCLUSIONS: Rates of fall-related ambulance use and hospitalisation were similar and continued to increase over time. Increased effort is needed to prevent falls and associated injury among older people in NSW, particularly among people living in aged care facilities. Ongoing monitoring of rates and the characteristics of people who fall are needed to determine the long-term impact of fall prevention interventions.

Quantification of NSW Ambulance Record Linkages with Multiple External Datasets.

This study has two aims: 1) to describe linkage rates between ambulance data and external datasets for "episodes of care" and "patient only" linkages in New South Wales (NSW), Australia; and 2) to detect and report any systematic issues with linkage that relate to patients, and operational or clinical variables that may introduce bias in subsequent studies if not adequately addressed. During 2010-11, the Centre for Health Record Linkage (CHeReL) in NSW, linked the records for patients attended by NSW Ambulance paramedics for the period July 2006 to June 2009, with four external datasets: Emergency Department Data Collection; Admitted Patient Data Collection; NSW Registry of Births, Deaths and Marriages death registration data; and the Australian Bureau of Statistics mortality data. This study reports linkage rates in terms of those "expected" to link and those who were "not expected" to link with external databases within 24 hours of paramedic attendance. Following thorough data preparation processes, 2,041,728 NSW Ambulance care episodes for 1,116,509 patients fulfilled the inclusion criteria. The overall episode-specific hospital linkage rate was 97.2%. Where a patient was not transported to hospital following paramedic care, 8.6% of these episodes resulted in an emergency department attendance within 24 hours. For all care episodes, 5.2% linked to a death record at some time within the 3-year period, with 2.4% of all death episodes occurring within 7 days of a paramedic encounter. For NSW Ambulance episodes of care that were expected to link to an external dataset but did not, nonlinkage to hospital admission records tended to decrease with age. For all other variables, issues relating to rates of linkage and nonlinkage were more indiscriminate. This quantification of the limitations of this large linked dataset will underpin the interpretation and results of ensuing studies that will inform future clinical and operational policies and practices at NSW Ambulance.

Level of agreement between prehospital and emergency department vital signs in trauma patients.

OBJECTIVES: Describe the level of agreement between prehospital (emergency medical service [EMS]) and ED vital signs in a group of trauma patients transported to an inner city Major Trauma Centre. We also sought to determine factors associated with differences in recorded vital sign measurements. METHODS: All adult patients meeting trauma triage criteria and transported directly from scene of injury by New South Wales Ambulance to our institution were included. The primary outcome was the difference in vital signs: heart rate (HR), systolic blood pressure (SBP), respiratory rate (RR) and Glasgow Coma Scale (GCS), between ED and EMS recorded measurements. Agreement was assessed using intraclass correlation coefficients and enhanced Bland-Altman plots. Multivariable linear regression models were used to determine factors associated with vital sign differences. RESULTS: The 1181 trauma patients met inclusion criteria. Intraclass correlation coefficients were as follows: GCS 0.74 (95% confidence interval [CI], 0.37, 1.12); HR 0.41 (95% CI, 0.30, 0.53); SBP 0.37 (95% CI, 0.27, 0.46); and RR 0.29 (95% CI, 0.06, 0.51). Bland-Altman derived 95% limits of agreement lay outside a priori limits of clinical agreement for SBP and RR and were within limits of clinical agreement for GCS and HR. SBP and HR differences were associated with prehospital airway and fluid intervention. CONCLUSIONS: Agreement was demonstrated between EMS and ED GCS scores but not RR and SBP recordings. Discrepancies appeared to reflect physiological changes in response to EMS initiated interventions. Trauma triage algorithms and risk models might need to take these measurement differences, and factors associated with them, into account.

Do smoke-free environment policies reduce smoking on hospital grounds? Evaluation of a smoke-free health service policy at two Sydney hospitals.

OBJECTIVE: To evaluate the compliance of hospital staff, inpatients and visitors with Sydney South West Area Health Service's Smoke-free Environment Policy. METHODS: Six sites were observed at two Sydney hospitals 2 weeks before implementation of the policy and at 2 weeks, 6 months, 12 months, 18 months and 2 years after implementation. RESULTS: There was an overall significant 36% (P≤0.05) reduction in observed smoking incidents on hospital grounds 2 years after implementation. Two years after implementation, observed smoking incidents reduced by 44% (P≤0.05) in staff, 37% (P≤0.05) in visitors and remained unchanged among inpatients. CONCLUSIONS AND IMPLICATIONS: The Smoke-free Environment Policy was effective in reducing visitors and staff observed smoking on hospital grounds, but had little effect on inpatients' smoking. Identifying strategies to effectively manage nicotine addiction and promote cessation amongst hospital inpatients remains a key priority.

Pregnant smokers are receptive to smoking cessation advice and use of nicotine replacement therapy.

Pregnant women who identified themselves as smokers were surveyed to ascertain their attitudes towards and likelihood of using nicotine replacement therapy (NRT) if it were to be provided free of charge at antenatal clinics. Smokers were asked to participate in a brief anonymous survey to identify current levels of smoking, nicotine dependence, attitudes towards cessation, use of cessation aids and whether they would use free NRT if it were provided with support at antenatal clinics. The majority of women were supportive of NRT being offered to pregnant smokers (87%), and 64% reported they would be very likely to use NRT if it were offered free from the antenatal clinic. These results provide strong support for a comprehensive cessation strategy implemented in antenatal clinics.