Evidence to service gap: cardiac rehabilitation and secondary prevention in rural and remote Western Australia.

BACKGROUND: Cardiovascular disease (CVD), a leading cause of morbidity and mortality, has similar incidence in metropolitan and rural areas but poorer cardiovascular outcomes for residents living in rural and remote Australia. Cardiac Rehabilitation (CR) is an evidence-based intervention that helps reduce subsequent cardiovascular events and rehospitalisation. Unfortunately CR attendance rates are as low as 10-30% with rural/remote populations under-represented. This in-depth assessment investigated the provision of CR and secondary prevention services in Western Australia (WA) with a focus on rural and remote populations. METHODS: CR and Aboriginal Community Controlled Health Services were identified through the Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Structured interviews with CR coordinators included questions specific to program delivery, content, referral and attendance. RESULTS: Of the 38 CR services identified, 23 (61%) were located in rural (n = 11, 29%) and remote (n = 12, 32%) regions. Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) found 77% of rural/remote services were hospital-based, with no service providing a comprehensive home-based or alternative method of program delivery. The majority of rural (60%) and remote (80%) services provided CR through chronic condition exercise programs compared with 17% of metropolitan services; only 27% of rural/remote programs provided education classes. Rural/remote coordinators were overwhelmingly physiotherapists, and only 50% of rural and 33% of remote programs had face-to-face access to multidisciplinary support. Patient referral and attendance rates differed greatly across WA and referrals to rural/remote services generally numbered less than 5 per month. Program evaluation was reported by 33% of rural/remote coordinators. CONCLUSION: Geography, population density and service availability limits patient access to CR services in rural/remote WA. Current inadequacies in delivering comprehensive centre-based CR in rural/remote settings impedes management of cardiovascular risk and opportunities for event reduction. Health pathways that ensure referral and continuity of care are needed, with emerging technology-based CR support to supplement centre-based CR services requiring assessment. Implementing systematic data collection across services to establish benchmarks and enable service monitoring and evaluation is needed.

Cardiac Rehabilitation for Aboriginal and Torres Strait Islander people in Western Australia.

BACKGROUND: Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in Australia. Australian Aboriginal and Torres Strait Islander (Indigenous) people have higher levels of CVD compared with non-Indigenous people. Cardiac Rehabilitation (CR) is an evidence-based intervention that can assist with reducing subsequent cardiovascular events and rehospitalisation. Unfortunately, attendance rates at traditional CR programs, both globally and in Australia, are estimated to be as low as 10-30 % and Indigenous people are known to be particularly under-represented. An in-depth assessment was undertaken to investigate the provision of CR and secondary preveniton services in Western Australia (WA) with a focus on rural, remote and Indigenous populations. This paper reports on the findings for Indigenous people. METHODS: Cardiac rehabilitation and Aboriginal Medical Services (n = 38) were identified for interview through the Heart Foundation Directory of Western Australian Cardiac Rehabilitation and Secondary Prevention Services 2012. Semi-structured interviews with CR coordinators were conducted and included questions specific to Indigenous people. RESULTS: Interviews with coordinators from 34 CR services (10 rural, 12 remote, 12 metropolitan) were conducted. Identification of Indigenous status was reported by 65 % of coordinators; referral and attendance rates of Indigenous patients differed greatly across WA. Efforts to meet the cultural needs of Indigenous patients varied and included case management (32 %), specific educational materials (35 %), use of a buddy or mentoring system (27 %), and access to an Aboriginal Health Worker (71 %). Staff cultural awareness training was available for 97 % and CR guidelines were utilised by 77 % of services. CONCLUSION: The under-representation of Indigenous Australians participating in CR, as reported in the literature and more specifically in this study, mandates a concerted effort to improve services to better meet the needs of Indigenous patients with CVD as part of closing the gap in life expectancy. Improving access to culturally appropriate CR and secondary prevention in WA must be an important component of this effort given the high rates of premature cardiovascular disease affecting Indigenous people. Our findings also highlight the importance of good systematic data collection across services. Health pathways that ensure continuity of care and alternative methods of CR delivery with dedicated resources are needed.

Getting on with life: accepting the permanency of an implantable cardioverter defibrillator.

Increasing numbers of people with cardiovascular disease are requiring the insertion of Implantable Cardioverter Defibrillators (ICDs). Although these devices are an effective life-saving treatment, psychological distress sometimes accompanies their insertion. A qualitative approach was used to explore the experiences, concerns and needs of recipients of the device in Western Australia. Twenty-two tape-recorded interviews were carried out and transcribed verbatim. This paper focuses on the physical and psychological adjustments following the insertion of the device. A central theme of 'getting on with it' used to cope with the permanency of the device was identified. This was an approach to life in which the presence of the device was accepted and then put aside while life was continued and optimized. This study provides directions for the identification of persons who might be experiencing difficulties adjusting, or who are taking extended amounts of time to accept the permanency of the device.

Rapid purification of EGFP, EYFP, and ECFP with high yield and purity.

Most current high throughput purification procedures for the green fluorescent protein (GFP) suffer from poor yields and low purity. An improved purification procedure that delivers highly pure protein (>95% homogeneity) in high yields (>70% of the initial fluorescent protein content) has been developed. The purification procedure requires only two steps: the cell lysate is heated to 60 degrees C for 4 min in ammonium sulfate and triethylamine, followed by hydrophobic interaction chromatography using isopropanol during the elution phase. The resulting pure product exhibits the same fluorescence profile as the crude sample. This procedure has been demonstrated on three commercial variants of GFP from Aequorea victoria, enhanced green, enhanced yellow, and enhanced cyan fluorescent protein (Becton-Dickinson). The yield and purity of material are superior to other recently described methods.

Reasons for attending and not attending a support group for recipients of implantable cardioverter defibrillators and their carers.

There is evidence to suggest that people who have an implantable cardioverter defibrillator and their caregivers experience psychological distress. This qualitative descriptive study explored the experiences, concerns and needs of recipients of implantable cardioverter defibrillators and their caregivers who attended or did not attend a support group organized by a public hospital located in Perth, Western Australia, Australia. Eleven recipients of implantable cardioverter defibrillators and their caregivers participated in this study. Among those who attended the support group, four major themes were identified: providing information, connecting with others, helping others and attendance. Explanations for non-attendance included difficulties attending because of the location, not wanting to be reminded about the implantable cardioverter defibrillator, and a perception, among younger recipients, that the support group was comprised of mainly older recipients with whom they had little in common.

Sucrose transport across the vacuolar membrane of Ananas comosus.

This paper originates from a presentation at the IIIrd International Congress on Crassulacean Acid Metabolism, Cape Tribulation, Queensland, Australia, August 2001. In Ananas comosus L. (Merr.) (pineapple), a widely cultivated bromeliad that exhibits crassulacean acid metabolism (CAM), much of the carbohydrate synthesized during the daytime appears to accumulate as soluble sugars in the vacuole. To investigate the mechanism of sugar transport into the vacuole, microsomal extracts were prepared from deacidifying leaves harvested during Phase III of the CAM cycle. The vesicle preparations exhibited features expected for a fraction highly enriched in vacuolar membranes (tonoplast), i.e. the ATPase activity of 16 ±2nkat mg-1 protein was inhibited 96% by 50 mm KNO3, an inhibitor of vacuolar ATPases, and was only 7% inhibited by 100µm NaN3 plus 100µm Na3VO4, inhibitors of mitochondrial and plasma membrane ATPases, respectively. Further, the microsomal ATPase activity showed a pH optimum between 7.0 and 8.0, typical of a vacuolar ATPase. When presented with Mg-ATP, vesicles established H+ gradients that could be maintained for at least 25 min. The vesicles were able to take up [14C]sucrose from an external medium. Sucrose uptake exhibited saturable kinetics with an apparent Km of 50 m sucrose and apparent Vmax of 171 ± 5 pkat mg-1 protein. Sucrose uptake was not dependent upon, nor stimulated by, Mg-ATP, suggesting that the mechanism of sucrose transport into the vacuole in A. comosus does not involve H+-coupled cotransport. However, the initial rates of sucrose uptake from the external medium were stimulated when vesicles were preloaded with sucrose. This trans-stimulation is consistent with characteristics expected for a sucrose uniporter capable of operating in an exchange mode. It is proposed that the accumulation of glucose and fructose in leaf vacuoles of Ananas during the light period involves at least two steps - transport of sucrose into the vacuole by a mechanism exhibiting characteristics of a sucrose uniporter, followed by cleavage of sucrose by a vacuolar acid invertase to form glucose and fructose.