Commentary: Improving access to cardiac rehabilitation (Heart: Road for health) for Aboriginal and Torres Strait Islander peoples in rural and remote areas of North Queensland.

AIMS: To focus on the needs, challenges and opportunities to improve access to cardiac rehabilitation (CR) (Heart: Road to health [HRH]) for Aboriginal and Torres Strait Islander peoples in rural and remote (R&R) areas of North Queensland. CONTEXT: It is known that there is insufficient access to HRH for Aboriginal and Torres Strait Islander peoples in R&R areas of NQ, who have the highest rates of heart disease and socioeconomic disadvantage mainly due to poor social determinants of health. However, at least in part due to the impact of colonialism and predominantly western medicalised approach to health care, few gains have been made. APPROACH: This commentary draws on recent research and literature and reflects on cultural issues that impact on improving access to an HRH for Aboriginal and Torres Strait Islander peoples in R&R areas. The underutilisation of the skills of Aboriginal and Torres Strait Islander Health Workers (ATSIHW) and a lack of a defined process to ensure access to culturally responsive HRH are discussed. Finally, a way forward is proposed that includes the development of policies, pathways and guidelines to ensure that appropriate support is available in the client's home community. CONCLUSION: It is proposed that culturally responsive, accessible and effective HRH is achievable through the reorientation of current health systems that include a continuous client-centred pathway from hospital to home. In this model, ATSIHW will take a lead or partnership role in which their clinical, cultural brokerage and health promotion skills are fully utilised.

Cardiac rehabilitation in rural and remote areas of North Queensland: How well are we doing?

OBJECTIVE: To address access to cardiac rehabilitation (CR) for people in R&R areas, this research aimed to investigate: (1) post discharge systems and support for people returning home from hospital following treatment for heart disease (HD). (2) propose changes to improve access to CR in R&R areas of NQ. SETTING: Four focus communities in R&R areas of NQ. PARTICIPANTS: Focus communities' health staff (resident/visiting) (57), community leaders (10) and community residents (44), discharged from hospital in past 5 years following treatment for heart disease (purposeful sampling). DESIGN: A qualitative descriptive case study, with data collection via semi-structured interviews. Inductive/deductive thematic analysis was used to identify primary and secondary themes. Health service audit of selected communities. RESULTS: Health services in the focus communities included multipurpose health services, and primary health care centres staffed by resident and visiting staff that included nurses, Aboriginal and Torres Strait Islander Health Workers, medical officers, and allied health professionals. Post-discharge health care for people with HD was predominantly clinical. Barriers to CR included low referrals to community-based health professions by discharging hospitals; poorly defined referral pathways; lack of guidelines; inadequate understanding of holistic, multidisciplinary CR by health staff, community participants and leaders; limited centre-based CR services; lack of awareness, or acceptance of telephone support services. CONCLUSION: To address barriers identified for CR in R&R areas, health care systems' revision, including development of referral pathways to local health professionals, CR guidelines and in-service education, is required to developing a model of care that focuses on self-management and education: Heart: Road to Health.

Multiple systemic venous air emboli after fatal basilar skull fracture.

•This case is significant for extensive systemic vascular air emboli in the right ventricle (visually estimated at 30 ml), pulmonary artery, inferior vena cava, hepatic veins, and iliac vein, which is a rare and novel consequence of fatal basal skull fracture.•Collections of air in the right ventricle and left external iliac vein were visible on imaging prior to contrast administration, making an iatrogenic etiology unlikely.

Importance of cardiac rehabilitation in rural and remote areas of Australia.

OBJECTIVE: To assess implementation of in-patient cardiac rehabilitation (Phase-1-cardiac rehabilitation), impact on people in rural and remote areas of Australia and potential methods for addressing identified weaknesses. DESIGN: Exploratory case study methodology using qualitative and quantitative methods. Qualitative data collection via semi-structured interviews, using thematic analysis, augmented by quantitative data collection via a medical record audit. SETTING: Four regional hospitals (2 Queensland Health and 2 private) providing tertiary health care. PARTICIPANTS: (a) Hospital in-patients with heart disease ≥18 years. (b) Staff responsible for their care. OUTCOME MEASURES: Implementation of Phase-1-cardiac rehabilitation in tertiary hosptials in North Queensland and the impact on in-patients discharge planning and post discharge care. Recommentations and implications for practice are proposed to address deficits. RESULTS: Phase-1-cardiac rehabilitation implementation rates, in-patient understanding and multidisciplinary team involvement were low. The highest rates of Phase-1-cardiac rehabilitation were for in-patients with a length of stay three days or more  in cardiac units with cardiac educators. Rates were lower in cardiac units with no cardiac educators, and lowest for in-patients in all areas of all hospitals with length of stay of two days or less days. Low Phase-1-cardiac rehabilitation implementation rates resulted in poor in-patient understanding about their disease, treatment and post-discharge care. Further, medical discharge summaries rarely mentioned cardiac rehabilitation/secondary prevention or risk factor management resulting in a lack of information for health care providers on cardiac rehabilitation and holistic health care. CONCLUSION: Implementation of Phase-1-cardiac rehabilitation in regional hospitals in this study fell short of recommended best practice, resulting in patients' poor preparation for discharge, and insufficient information on holistic care for health care providers in rural and remote areas. These factors potentially impact on holistic care for people returning home following treatment for heart disease.

Heart disease, hospitalisation and referral: Coaching to Achieving Cardiovascular Health through cardiac rehabilitation in Queensland.

OBJECTIVES: To describe rates of hospitalisation and Coaching on Achieving Cardiovascular Health referral, for Queensland's adults with heart and related disease, and comparisons between Aboriginal and Torres Strait Islander and non-Indigenous peoples in northern Queensland. DESIGN: Descriptive retrospective epidemiological study of Queensland Health Patient Admission Data Collection for adults with heart and related disease, and Coaching on Achieving Cardiovascular Health referral data. Relative risk and age standardisation were calculated for Aboriginal and Torres Strait Islander and non-Indigenous peoples. PARTICIPANTS: Queensland's adults ≥20 years, hospitalised with heart and related disease (1 January 2012-31 December 2016). SETTING: Queensland, Australia. MAIN OUTCOME MEASURES: Queensland Health Hospital and Health Services' hospitalisation and Coaching on Achieving Cardiovascular Health referral rates for heart and related disease. RESULTS: Queensland's Aboriginal and Torres Strait Islander peoples have a higher hospitalisation rate for heart and related disease, with higher rates for northern Queensland. Queensland's overall Coaching on Achieving Cardiovascular Health referral rates were low, but higher for Aboriginal and Torres Strait Islander peoples. Deficiencies in documentation of Aboriginal and Torres Strait Islander people's status affected results in some areas. CONCLUSION: Queensland's Aboriginal and Torres Strait Islander peoples were more likely to be admitted to hospital for heart and related disease and referred to Coaching on Achieving Cardiovascular Health than non-Indigenous peoples. However, hospitalisation and Coaching on Achieving Cardiovascular Health referral rates are unlikely to reflect the needs of Aboriginal and Torres Strait Islander peoples especially in rural and very remote areas given their higher mortality and morbidity rates and fewer services.

Cardiac rehabilitation services for people in rural and remote areas: an integrative literature review.

INTRODUCTION: Morbidity and mortality from heart disease continues to be high in Australia with cardiac rehabilitation (CR) recognised as best practice for people with heart disease. CR is known to reduce mortality, reoccurrence of heart disease, hospital readmissions and costs, and to improve quality of life. Australian Aboriginal and Torres Strait Islanders (Australian First Peoples or Indigenous peoples) have a greater need for CR due to their higher burden of disease. However, CR referral, access and attendance remain low for all people who live in rural and remote areas. The aim of this integrative review was to identify barriers, enablers and pathways to CR for adults living independently in rural and remote areas of high-income countries, including Australia. METHODS: Studies were identified through five online data bases, plus reference lists of the selected studies. The studies focused on barriers and enablers of CR for adults in rural and remote areas of Australia and other high-income countries, in English peer-reviewed journals (2007-2016). A mix of qualitative, quantitative and mixed method studies were reviewed through a modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), followed by a critical review and thematic analysis. RESULTS: Sixteen studies were selected: seven qualitative, four quantitative and five mixed method. Five themes that influence CR attendance were identified: referral, health services pathways and planning; cultural and geographic factors necessitating alternative and flexible programs; professional roles and influence; knowing, valuing, and psychosocial factors; and financial costs - personal and health services. Factors identified that impact on referral and access to CR were hospital inpatient education programs on heart disease and risk factors; discharge processes including CR eligibility criteria and referral to ensure continuum and transition of care; need for improved accessibility of services, both geographically and through alternative programs, including home based with IT and/or telephone support. Also, the need to ensure that health professionals understand, value and support CR; the impact of mental health, coping with change and competing priorities; costs including travel, medications and health professional consultations; as well as low levels of involvement of Australian First Peoples in their own care and poor cultural understanding by non-Australian First Peoples staff all negatively impact on CR access and attendance. CONCLUSION: This study found weak systems with low referral rates and poor access to CR in rural and remote areas. Underlying factors include lack of health professional and public support, often based on poor perception of benefits of CR, compounded by scarce and inflexible services. Low levels of involvement of Australian First Peoples, as well as a lack of cultural understanding by non-Australian First Peoples staff, is evident. Overall, the findings demonstrate the need for improved models of referral and access, greater flexibility of programs and professional roles, with management support. Further, increased education and involvement of Australian First Peoples, including Indigenous health workers taking a lead in their own people's care, supported by improved education and greater cultural awareness of non-Australian First Peoples staff, is required.

HIV Risk Behavior Among Female Substance Abusers.

HIV is an increasingly critical and costly health problem for American women. Substance use plays a major role in HIV infection in women. There are several plausible explanations for the association between substance use and HIV risk behavior. Pregnant substance abusers are a population deserving of special attention given the prevalence of risk behavior in this population and the added risk of perinatal transmission of HIV. Current guidelines for the screening and treatment of HIV among pregnant women and their infants are delineated. Substance abuse treatment has a limited impact on HIV risk behavior in female substance abusers. Similarly, traditional knowledge- and skill-based HIV risk reduction interventions have modest efficacy in this population. Hence, there is a need to develop new interventions that directly target sex- and drug-related HIV risk behavior among female substance abusers. Recent work suggests that the incorporation of motivational interviewing components into traditional HIV risk reduction interventions may be a promising new direction for the field.

Ictal hiccup during absence seizure in a child.

Absence seizures are one of the features of idiopathic generalised epilepsy (IGE) and occur as component of many different syndromes. They are commonly associated with various clinical features such as mild clonic components, change in postural tone, automatisms and autonomic phenomena. Childhood absence epilepsy (CAE) is the prototype IGE with typical absence seizures. We report a child who had prominent ictal hiccups during an absence seizure, and discuss the possible mechanisms. [Published with video sequences].