Development and outcomes of a primary care-based sleep assessment service in Canterbury, New Zealand.

Prior to 2007, increasing demand for sleep services, plus inability to adequately triage severity, led to long delays in sleep assessment and accessing continuous positive airway pressure. We established a community sleep assessment service carried out by trained general practices using a standardised tool and overnight oximetry. All cases were discussed at a multi-disciplinary meeting, with four outcomes: severe obstructive sleep apnoea treated with continuous positive airway pressure; investigation with more complex studies; sleep physician appointment; no or non-severe sleep disorder for general practitioner management. Assessment numbers increased steadily (~400 in 2007 vs. 1400 in 2015). Median time from referral to assessment and multi-disciplinary meeting was 28 and 48 days, respectively. After the first multi-disciplinary meeting, 23% of cases were assessed as having severe obstructive sleep apnoea. More complex studies (mostly flow based) were required in 49% of patients, identifying severe obstructive sleep apnoea in a further 13%. Thirty-seven percent of patients had obstructive sleep apnoea severe enough to qualify for funded treatment. Forty-eight percent of patients received a definitive answer from the first multi-disciplinary meeting. Median time from referral to continuous positive airway pressure for 'at risk' patients with severe obstructive sleep apnoea, e.g., commercial drivers, was 49 days, while patients with severe obstructive sleep apnoea but not 'at risk' waited 261 days for continuous positive airway pressure. Ten percent of patients required polysomnography, and 4% saw a sleep specialist. In conclusion, establishment of a community sleep assessment service and sleep multi-disciplinary meeting led to significantly more assessments, with short waiting times for treatment, especially in high-risk patients with severe obstructive sleep apnoea. Most patients can be assessed without more complex studies or face-to-face review by a sleep specialist. SLEEP DISORDERS: MORE ASSESSMENTS, SHORTER WAITS WITH COMMUNITY SLEEP SERVICE: A community-based service for common sleep disorders can provide rapid and easily accessed sleep assessment and treatment. A team led by Michael Hlavac and Michael Epton from Christchurch Hospital describe the creation of a sleep assessment service within the Canterbury district of New Zealand, in which initial assessments are conducted throughout the community by general practice teams under guidance and advice from sleep specialists at the region's largest hospital. Before the service, there were around 300 sleep assessments per year in all of Canterbury, a region with a population of around 510,000. Now, that number has more than tripled, with shorter waiting times for treatment, especially for people with severe sleep apnoea. The authors conclude that most patients can be assessed for a suspected sleep disorder without needing to visit a hospital's sleep unit.

Sex-based differences in lifting technique under increasing load conditions: A principal component analysis.

The objective of the present study was to determine if there is a sex-based difference in lifting technique across increasing-load conditions. Eleven male and 14 female participants (n = 25) with no previous history of low back disorder participated in the study. Participants completed freestyle, symmetric lifts of a box with handles from the floor to a table positioned at 50% of their height for five trials under three load conditions (10%, 20%, and 30% of their individual maximum isometric back strength). Joint kinematic data for the ankle, knee, hip, and lumbar and thoracic spine were collected using a two-camera Optotrak motion capture system. Joint angles were calculated using a three-dimensional Euler rotation sequence. Principal component analysis (PCA) and single component reconstruction were applied to assess differences in lifting technique across the entire waveforms. Thirty-two PCs were retained from the five joints and three axes in accordance with the 90% trace criterion. Repeated-measures ANOVA with a mixed design revealed no significant effect of sex for any of the PCs. This is contrary to previous research that used discrete points on the lifting curve to analyze sex-based differences, but agrees with more recent research using more complex analysis techniques. There was a significant effect of load on lifting technique for five PCs of the lower limb (PC1 of ankle flexion, knee flexion, and knee adduction, as well as PC2 and PC3 of hip flexion) (p < 0.005). However, there was no significant effect of load on the thoracic and lumbar spine. It was concluded that when load is standardized to individual back strength characteristics, males and females adopted a similar lifting technique. In addition, as load increased male and female participants changed their lifting technique in a similar manner.

The development of a community-based spirometry service in the Canterbury region of New Zealand: observations on new service delivery.

In 2008, as part of the changes to develop integrated health care services in the Canterbury region of New Zealand, the local health board in collaboration with general practitioners, respiratory specialists and scientists introduced a programme for general practices to provide laboratory-quality spirometry in the community. The service adhered to the 2005 ATS/ERS international spirometry standards. The spirometry service was provided by trained practice nurses and community respiratory nurses, and was monitored and quality assured by certified respiratory scientists in the Respiratory Physiology Laboratory, Christchurch Hospital and CISO (Canterbury Initiative Services Organisation). These two organisations were responsible for organising training seminars and refresher courses on spirometry technique and interpretation of results. A total of 10 practices have now become approved spirometry providers, with the number of tests carried out in the primary care setting increasing gradually. Consistently high-quality spirometry tests have been obtained and are now presented on a centrally available results database for all hospital and community clinicians to review. Although the service has proved to be more convenient for patients, the tests have not been delivered as quickly as those carried out by the Respiratory Physiology Laboratory. However, the time scales for testing achieved by the community service is considered suitable for investigation of chronic disease. The success of the service has been dependent on several key factors including hospital and clinical support and a centralised quality assurance programme, a comprehensive training schedule and online clinical guidance and close integration between primary and secondary care clinicians.

Self-management plans in the primary care of patients with chronic obstructive pulmonary disease.

OBJECTIVE AND BACKGROUND: The role of COPD self-management plans in improving health outcomes remains unclear. The objective of this study was to assess whether self-management plans administered in primary care have beneficial effects on quality of life, self-care behaviour and health outcomes in the long term for patients with COPD. MATERIAL, PATIENTS AND METHODS: The study was a prospective, unblinded, randomized controlled trial of usual care vs. usual care plus structured education on the use of a written self-management plan and patient-initiated short courses of antibiotics and oral corticosteroids. The study was conducted in general practice, in Christchurch, New Zealand. Participants were 159 patients with COPD randomized by general practice site into control or intervention groups. The primary outcome measure was change in St. George's Respiratory Questionnaire. Secondary variables were frequency of hospital and primary-care attendance, frequency of use of courses of antibiotics and oral corticosteroids over 12 months, and change in Hospital Anxiety and Depression Scale. Self-management knowledge was assessed using a structured interview, the COPD Self-Management Interview. RESULTS: Self-management plans and structured education were associated with higher levels of self-management knowledge at 12 months, but had no effect on change in St. George's Respiratory Questionnaire, health utilization, mental health or self-reported outcomes of patients with COPD managed in general practice. CONCLUSIONS: Self-management knowledge was higher in the intervention group but there was no difference in quality of life or health outcomes due to self-management plans.

Home management of mild to moderately severe community-acquired pneumonia: a randomised controlled trial.

OBJECTIVE: To determine whether community management of mild to moderate community-acquired pneumonia (CAP) is as effective and acceptable as standard hospital management of CAP. DESIGN: Randomised controlled trial. SETTING: Christchurch, New Zealand, primary and secondary care. PARTICIPANTS: 55 patients presenting or referred to the emergency department at Christchurch Hospital with mild to moderately severe pneumonia, assessed using a validated pneumonia severity assessment score, from July 2002 to October 2003. INTERVENTIONS: Hospital treatment as usual or comprehensive care in the home delivered by primary care teams. MAIN OUTCOME MEASURES: Primary: days to discharge, days on intravenous (IV) antibiotics, patient-rated symptom scores. Secondary: health status measured using level of functioning at 2 and 6 weeks, patient satisfaction. RESULTS: The median number of days to discharge was higher in the home care group (4 days; range, 1-14) than in the hospital groups (2 days; range, 0-10; P = 0.004). There was no difference in the number of days on IV antibiotics or on subsequent oral antibiotics. Patient-rated symptom scores at 2 and 6 weeks, median change in symptom severity from baseline to 6 weeks, and general functioning at 2 and 6 weeks did not differ between the groups. Patients in both groups were satisfied with their treatment, with a clear preference for community treatment (P < 0.001). CONCLUSIONS: Mild to moderately severe CAP can be managed effectively in the community by primary care teams. This model of comprehensive care at home can be implemented by primary care teams with suitable funding structures.

The effects of post-translational processing on dystroglycan synthesis and trafficking.

Dystroglycan is a component of the dystrophin glycoprotein complex that is cleaved into two polypeptides by an unidentified protease. To determine the role of post-translational processing on dystroglycan synthesis and trafficking we expressed the dystroglycan precursor and mutants thereof in a heterologous system. A point mutant in the processing site, S655A, prevented proteolytic cleavage but had no effect upon the surface localisation of dystroglycan. Mutation of two N-linked glycosylation sites that flank the cleavage site inhibited proteolytic processing of the precursor. Furthermore, chemical inhibition of N- and O-linked glycosylation interfered with the processing of the precursor and reduced the levels of dystroglycan at the cell surface. Dystroglycan processing was also inhibited by the proteasome inhibitor lactacystin. N-linked glycosylation is a prerequisite for efficient proteolytic processing and cleavage and glycosylation are dispensable for cell surface targeting of dystroglycan.

Antibiotic resistance in uncomplicated urinary tract infection: problems with interpreting cumulative resistance rates from local community laboratories.

AIMS: To determine the resistance rates and patterns in bacteria causing uncomplicated urinary tract infections (UTIs) presenting to general practitioners (GPs) in Christchurch. METHODS: 82 randomly selected GPs in Christchurch participated in the study. Midstream urine (MSU) samples were prospectively collected for standard microbiological analysis on all women between the ages of 16 and 50 years presenting with symptoms of dysuria and frequency and who had positive dipstick testing to either (or both) nitrites or leucocytes. MSUs were submitted for bacterial colony counts and resistance testing of isolates present in adequate numbers. RESULTS: 374 specimens were collected. 299 filled the inclusion criteria, of which 94 fulfilled criteria for significant infection. Trimethoprim resistance was found in 8, (8.5%) (95%CI 2.8,14.2) overall with a resistance rate for Escberichia coli (E. coli) to trimethoprim of 11.5%. This compared with cumulative resistance rates from local community laboratories for E. coli to trimethoprim of 19%. For a woman in this age group presenting with symptoms of UTI we estimated that her probability of having a trimethoprim resistant organism was 2.7%. CONCLUSION: Trimethoprim remains a reasonable first line treatment for uncomplicated UTI in Christchurch. Actual resistance rates are significantly less than those derived from routine pooled laboratory specimens, and when used in an intention to treat calculation to inform empiric prescribing, become even less significant. While collection of these routine data is essential to provide early warning of emergent resistance, a truly representative rate should be determined to inform prescribing decisions if resistance appears to be increasing.

A comparison of visual- and response-generated cues in a spatial DMTS task for rats.

In an attempt to clarify the nature of the memory cues used in a spatial, working memory task, rats were tested in a two-choice water maze. Each trial consisted of an information run, which forced the rat to the correct choice compartment, a retention period, and a test run. A response-associated cue condition, in which the relevant cue was the direction of the turn in the information run, was compared to a visual cue condition in which the animal had to remember whether the escape platform had been in the light or dark compartment. Of the subjects supplied with either visual or response-associated cues, the subjects allowed to employ response-associated cues did better, but the best performance occurred when both cues were available. When rats trained with both cues present were forced to choose between cues, they stopped using either and reverted to making a preferred right or left turn. The results support the idea that rats can form integrated, relational-cue memories which, in some circumstances, prove a hindrance to performance.

Influence of two levels of concurrent infection with Ostertagia circumcincta and Trichostrongylus vitrinus on the growth performance of lambs.

Groups of seven lambs were infected on five days each week for 11 weeks with either 1000 or 2000 Trichostrongylus vitrinus larvae alone or concurrently with 1500 or 2500 Ostertagia circumcincta larvae and their growth performance compared to that of worm-free controls. The cumulative liveweight gain of the infected groups was significantly lower than that of the controls but the gain of the concurrently infected lambs did not differ significantly from the respective T vitrinus group. There were no significant differences in the numbers of T vitrinus or O circumcincta recovered from the single and concurrently infected groups, although there was a tendency for lower mean T vitrinus burdens at the higher level of ostertagia/trichostrongylus infection. The distribution of T vitrinus along the small intestine was similar in single and concurrently infected lambs. The reason for the lack of a marked additive effect on growth rate with concurrent infection is discussed in relation to changes in the concentration of two plasma constituents and lesions in the gastrointestinal tract.

Effect of concurrent infection with Ostertagia circumcincta and Trichostrongylus vitrinus on the performance of lambs.

The interaction between Ostertagia circumcincta and Trichostrongylus vitrinus was investigated in lambs continuously infected over 12 weeks. Four groups of seven lambs were given either zero, 1000 T vitrinus larvae per day, 2500 O circumcincta larvae per day or infected concurrently. Overall liveweight gain was reduced by 17, 20 and 30 per cent in T vitrinus, O circumcincta and concurrent infection, respectively. T vitrinus infection significantly lowered serum phosphorus concentrations by week 4. In the concurrent infection the decline in phosphorus concentration was more gradual and only differed significantly from the controls during the final four weeks of the trial. There were no significant differences between the total numbers of T vitrinus or O circumcincta recovered from single or combined infections. The lack of an additive effect on performance may be due to a delayed establishment of T vitrinus in the presence of O circumcincta.

Effect of Ostertagia ostertagi on lamb performance and cross resistance to O circumcincta.

Fifteen worm-free lambs (two-and-a-half to three months or four to four-and-a-half months old) were infected with 3500 or 4000 Ostertagia ostertagi larvae on five days each week for six weeks, and their performance compared to that of controls. Eleven lambs were killed after eight weeks and four were challenged with O circumcincta to determine whether any cross resistance had developed. A feature of the O ostertagi infection was the considerable variation in response. Overall liveweight gain was lowered by 24 per cent in the two-and-a-half to three-month-old infected lambs, mainly due to reductions of 27 to 40 per cent in four of the seven lambs. There was no consistent effect in the older lambs. The worm populations consisted mainly of early fourth stage larvae and developing worms, but a small percentage reached sexual maturity and these produced a low faecal egg count (1 to 63 eggs per gram). Numerous intraluminal refractive crystals were present in the gut of both adult worms and developing stages, possibly reflecting degenerative changes. Hypertrophy of the abomasal mucosa with patchy loss of differentiation was a feature of the infection, and in four lambs serum pepsinogen concentrations were elevated. Exposure to O ostertagi did confer some protection against challenge with O circumcincta in that worm counts were reduced to about 60 per cent of those in controls, although no increase was observed in the numbers of arrested larvae. The successful passage of O ostertagi through young lambs could be important in mixed or alternate grazing systems by providing a reservoir of infection for the alternate host.

Effect of experimental Ostertagia circumcincta infection on the performance of grazing lambs.

Groups of 10 three-and-a-half-month-old Suffolkcross lambs were infected daily, five times a week, for 12 weeks with either zero, 500, 1500, 3000 or 5000 larvae of Ostertagia circumcincta and grazed together on a series of 'clean' paddocks. All the lambs were moved at seven to 10 day intervals to a fresh paddock to prevent autoinfection and were killed after 14 weeks. Another group was killed at the outset as a control for carcase analysis. Mean O circumcincta populations were 34 (grazing control) and 1224, 473, 1092 and 4331 for the groups receiving 500, 1500, 3000 and 5000 larvae per day respectively. The percentage of fourth stage larvae increased with increasing larval intake. Extensive abomasal damage with mucosal hypertrophy and depletion of parietal cells occurred in the lambs receiving 3000 and 5000 O circumcincta larvae per day. Intakes of 1500 larvae per day and above depressed growth rate by 24 to 37 per cent, reduced the deposition of protein in the carcase by 34 to 52 per cent and lowered calcium/phosphorus deposition by 23 to 48 per cent. Plasma pepsinogen concentrations were consistently elevated in lambs receiving 3000 or 5000 larvae per day and may be a useful aid to recognising abomasal damage sufficient to affect productivity.