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BACKGROUND: This review was carried out to synthesize the evidence of the effectiveness of community health worker (CHW) navigation in primary care chronic disease management. METHODS: We searched the English language literature between January 1990 and March 2020 in Medline, Embase, Emcare, PubMed, Psych Info, CINAHL, Scopus, and Medline Epub ahead of print. Data extraction, quality rating, and assessment of the reporting of interventions were performed by two reviewers independently and the findings were synthesized narratively. RESULTS: Twenty-nine articles met the inclusion criteria. All but two were carried out in the USA and half were randomized controlled trials. Six of the 29 studies were of strong methodological quality while 12 were moderate and 11 weak. Overall, CHW navigation interventions were effective in increasing adherence to cancer screening and improving use of primary care for chronic disease management. There was insufficient evidence that they improved clinical outcomes or risk factors and reduced use of secondary or tertiary care or that they were cost-effective. However, criteria for recruitment, duration, and mode of training and supervision arrangements varied greatly between studies. DISCUSSION: CHW navigation interventions improved aspects of chronic disease management. However, there is insufficient evidence of the impact on patient experience, clinical outcomes, or cost-effectiveness of the interventions. Future research should focus on standardizing organizational components of the CHW navigation interventions and evaluating their cost-effectiveness. PROTOCOL REGISTRATION: The review protocol was published in PROSPERO (CRD42020153921). SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-06667-y.

Background The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management program was introduced to Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The program supports General Practitioners (GP)s claiming for up to one general practice management plan (GPMP) and one team care arrangement (TCA) every year and the patient claiming for up to five private allied health visits. We describe the profile of participants who claimed for GPMPs and/or TCAs in Central and Eastern Sydney (CES) and explore if GPMPs and/or TCAs are associated with fewer emergency hospitalisations (EH)s or potentially preventable hospitalisations (PPH)s over the following 5 years. Methods This research used the CES Primary and Community Health Cohort/Linkage Resource (CES-P&CH) based on the 45 and Up Study to identify a community-dwelling population in the CES region. There were 30,645 participants recruited within the CES area at baseline. The CES-P&CH includes 45 and Up Study questionnaire data linked to MBS data for the period 2006–2014. It also includes data from the Admitted Patient Data Collection, Emergency Department Data Collection and Deaths Registry linked by the NSW Centre for Health Record Linkage. Results Within a two-year health service utilisation baseline period 22% (5771) of CES participants had at least one claim for a GPMP and/or TCA. Having at least one claim for a GPMP and/or TCA was closely related to the socio-demographic and health needs of participants with higher EHs and PPHs in the 5 years that followed. However, after controlling for confounding factors such as socio-demographic need, health risk, health status and health care utilization no significant difference was found between having claimed for a GPMP and/or TCA during the two-year health service utilisation baseline period and EHs or PPHs in the subsequent 5 years. Conclusions The use of GPMPs and/or TCAs in the CES area appears well-targeted towards those with chronic and complex care needs. There was no evidence to suggest that the use of GPMPs and /or TCAs has prevented hospitalisations in the CES region.

Paediatric neurology syndromes are a broad and complex group of conditions with a large spectrum of clinical phenotypes. Joubert syndrome is a genetically heterogeneous neurological ciliopathy syndrome with molar tooth sign as the neuroimaging hallmark. We reviewed the clinical, radiological and genetic data for several families with a clinical diagnosis of Joubert syndrome but negative genetic analysis. We detected biallelic pathogenic variants in LAMA1, including novel alleles, in each of the four cases we report, thereby establishing a firm diagnosis of Poretti–Boltshauser syndrome. Analysis of brain MRI revealed cerebellar dysplasia and cerebellar cysts, associated with Poretti–Boltshauser syndrome and the absence of typical molar tooth signs. Using large UK patient cohorts, the relative prevalence of Joubert syndrome as a cause of intellectual disability was 0.2% and of Poretti–Boltshauser syndrome was 0.02%. We conclude that children with congenital brain disorders that mimic Joubert syndrome may have a delayed diagnosis due to poor recognition of key features on brain imaging and the lack of inclusion of LAMA1 on molecular genetic gene panels. We advocate the inclusion of LAMA1 genetic analysis on all intellectual disability and Joubert syndrome gene panels and promote a wider awareness of the clinical and radiological features of these syndromes.

Background Pre-existing comorbidities can compromise recovery post-stroke. However, the association between comorbidity burden and patient-rated perceived impact has not been systematically investigated. To date, only observer-rated outcome measures of function, disability, and dependence have been used, despite the complexity of the impact of stroke on an individual. Aim Our aim was to explore the association between comorbidity burden and patient-rated perceived impact and overall recovery, within the first-year post-stroke, after adjusting for stroke severity, age, and sex. Methods The sample comprised 177 stroke survivors from 18 hospitals throughout Australia and New Zealand. Comorbidity burden was calculated using the Charlson Comorbidity Index. Perceived impact and recovery were measured by the Stroke Impact Scale index and Stroke Impact Scale overall recovery scale. Quantile regression models were applied to investigate the association between comorbidity burden and perceived impact and recovery. Results Significant negative associations between the Charlson Comorbidity Index and the Stroke Impact Scale index were found at three months. At the .25 quantile, a one-point increase on the Charlson Comorbidity Index was associated with 6.80-points decrease on the Stroke Impact Scale index (95%CI: −11.26, −2.34; p = .003). At the median and .75 quantile, a one-point increase on the Charlson Comorbidity Index was associated, respectively, with 3.58-points decrease (95%CI: −5.62, −1.54; p = .001) and 1.76-points decrease (95%CI: −2.80, −0.73; p = .001) on the Stroke Impact Scale index. At 12 months, at the .25 and .75 quantiles, a one-point increase on the Charlson Comorbidity Index was associated, respectively, with 6.47-points decrease (95%CI: −11.05, −1.89; p = .006) and 1.26-points decrease (95%CI: −2.11, −0.42; p = .004) on the Stroke Impact Scale index. For the Stroke Impact Scale overall recovery measure, significant negative associations were found only at the median at three months and at the .75 quantile at 12 months. Conclusion Comorbidity burden is independently associated with patient-rated perceived impact within the first-year post-stroke. The addition of patient-rated impact measures in personalized rehabilitation may enhance the use of conventional observer-rated outcome measures.

Objectives General practitioner (GP) follow-up after a hospital admission is an important indicator of integrated care. We examined the characteristics of patients who saw a GP within 2 weeks of hospital discharge in the Central and Eastern Sydney (CES) region, Australia, and the relationship between GP follow-up and subsequent hospitalisation. Methods This data linkage study used a cohort of 10 240 people from the 45 and Up Study who resided in CES and experienced an overnight hospitalisation in the 5 years following recruitment (2007–14). Characteristics of participants who saw a GP within 2 weeks of discharge were compared with those who did not using generalised linear models. Time to subsequent hospitalisation was compared for the two groups using Cox proportional hazards regression models stratified by prior frequency of GP use. Results Within 2 weeks of discharge, 64.3% participants saw a GP. Seeing a GP within 2 weeks of discharge was associated with lower rates of rehospitalisation for infrequent GP users (i.e.

ObjectivesTo review effective models of community health worker (CHW) involvement in preventive care for disadvantaged culturally and linguistically diverse (CALD) patients in primary healthcare (PHC) that may be applicable to the Australian context.DesignSystematic scoping review.Data sourcesThe studies were gathered through searching Medline, EMBASE, EMCARE, PsycINFO, CINAHL and online portals of relevant organisations.Eligibility criteriaAll selected studies were original research studies which essentially evaluated preventive intervention undertake by CHWs in PHC. The intervened population were adults with or without diagnosed chronic health disease, culturally and linguistically diverse, or vulnerable due to geographic, economic and/or cultural characteristics that impede or compromise their access to healthcare.Data extraction and synthesisData extraction was undertaken systematically in an excel spreadsheet while the findings were synthesised in a narrative manner. The quality appraisal of the selected studies was performed using effective public health practice project quality assessment tool.ResultsA total of 1066 articles were identified during the initial search of six bibliographic databases. After screening the title, abstract and full text, 37 articles met the selection and methodological criteria and underwent data extraction. A high-quality evidence-base supporting the positive impact of CHWs supporting patients’ access to healthcare and influencing positive behaviour change was found. Positive impacts of CHW interventions included improvements in clinical disease indicators, screening rates and behavioural change. Education-focused interventions were more effective in improving patient behaviour, whereas navigation interventions were most effective in improving access to services. Implementation was enhanced by cultural and linguistic congruence and specific training of CHWs in the intervention but reduced by short duration interventions, dropouts and poor adherence of patients.ConclusionThe evidence generated from this systematic scoping review demonstrates the contribution of CHWs to improving access to preventive care for patients from CALD and disadvantaged backgrounds by providing both education and navigational interventions. More research is needed on CHW training and the incorporation of CHWs into primary health care (PHC) teams.

© 2018 The Author(s). Background: In Australia there is commitment to developing interventions that will 'Close the Gap' between the health and welfare of Indigenous and non-Indigenous Australians and recognition that early childhood interventions offer the greatest potential for long term change. Nurse led sustained home visiting programs are considered an effective way to deliver a health and parenting service, however there is little international or Australian evidence that demonstrates the effectiveness of these programs for Aboriginal infants. This protocol describes the Bulundidi Gudaga Study, a quasi-experimental design, comparing three cohorts of families from the Macarthur region in south western Sydney to explore the effectiveness of the Maternal Early Childhood Sustained Home-visiting (MECSH) program for Aboriginal families. Methods: Mothers were recruited when booking into the local hospital for perinatal care and families are followed up until child is age 4 years. Participants are from three distinct cohorts: Aboriginal MECSH intervention cohort (Group A), Non-Aboriginal MECSH intervention cohort (Group B) and Aboriginal non-intervention cohort (Group C). Eligible mothers were those identified as at risk during the Safe Start assessment conducted by antenatal clinic midwives. Mothers in Group A were eligible if they were pregnant with an Aboriginal infant. Mothers in Group B were eligible if they were pregnant with a non-Aboriginal infant. Mothers in Group C are part of the Gudaga descriptive cohort study and were recruited between October 2005 and May 2007. The difference in duration of breastfeeding, child body mass index, and child development outcomes at 18 months and 4 years of age will be measured as primary outcomes. We will also evaluate the intervention effect on secondary measures including: child dental health; the way the program is received; patterns of child health and illness; patterns of maternal health, health knowledge and behaviours; family and environmental conditions; and service usage for mothers and families. Discussion: Involving local Aboriginal research and intervention staff and investing in established relationships between the research team and the local Aboriginal community is enabling this study to generate evidence regarding the effectiveness of interventions that are feasible to implement and sustainable in the context of Aboriginal communities and local service systems. Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12616001721493 Registered 14 Dec 2016. Retrospectively registered.

Objective: Describe a group of patients who presented with thyrotoxicosis and were also found to have adrenal insufficiency. Methods: Patient cases were collected over the past year at University of North Carolina at Chapel Hill. Their clinical, laboratory, exam, and imaging findings are presented along with a review of the literature. Results: Four patients presented to the emergency room with thyrotoxicosis and were diagnosed with concomitant adrenal insufficiency; three of the four were found to have adrenal crisis at presentation. Patient 1 was diagnosed with recurrent Graves thyrotoxicosis, then was subsequently diagnosed with secondary adrenal insufficiency due to lymphocytic hypophysitis. Patients 2 through 4 were given a new diagnosis of Graves thyrotoxicosis, then were subsequently found to also have primary adrenal insufficiency. Conclusion: It is important to recognize the possibility of adrenal insufficiency in patients with autoimmune hyperthyroidism who have an atypical presentation. Thyrotoxicosis can trigger adrenal crisis in patients with concomitant adrenal insufficiency; thus, any delay in diagnosis is potentially life threatening.

Rationale/objective The COVID-19 pandemic has brought far-reaching consequences on individual and societal levels. Social distancing and physical hygiene constitute effective public health measures to limit the spread of the virus. This study investigated age and gender demographics, in tandem with national levels of human development, as crucial factors influencing self-reported compliance with COVID-19-related public health measures. Methods The present study leveraged a large multi-national sample that ranged across the adult lifespan (18–100 years) and comprised 45,772 women and men from 66 countries/territories. Data were collected in Spring (2020) during the earlier phase of the COVID-19 pandemic. Self-reports of compliance with two public health measures (spatial distancing and physical hygiene) were assessed via online survey. Human Development Index (HDI), developed by the United Nations Development Program, was used as a proxy of a country's achievement in key dimensions of human development. Results Older age, female gender, and lower HDI were independently associated with greater self-reported compliance. A significant three-way interaction further revealed that self-reported compliance was lowest in young males from well-developed countries, while highest among females across all ages from less-developed countries. Conclusion The study offers an integration of individual-level and country-level demographic predictors of self-reported compliance and allows for robust testing in a large multi-national adult lifespan sample for enhanced generalizability. The results highlight the potential of data-driven, tailored (i.e., towards specific demographics, countries) health campaigns and public policies in the fight against a global pandemic.

Type 2 Diabetes (T2DM) is emerging as a major global health issue. T2DM can adversely affect cognition and increase dementia risk. This systematic review aimed to examine the functional brain changes that may underlie cognitive dysfunction in adults with T2DM. Studies were restricted to those which used functional magnetic resonance imaging (fMRI). Nineteen independent studies were identified, mostly comprised of middle aged or older adults. Resting-state studies demonstrated that compared to controls, connectivity of the Default Mode Network (DMN) was reduced and the majority of task-based studies identified reduced activation in T2DM patients in regions relevant to task performance. Abnormalities of low frequency spontaneous brain activity were observed, particularly in visual regions. As most studies demonstrated that alterations in fMRI were related to poorer neuropsychological task performance, these results indicate that functional brain abnormalities in T2DM have consequences for cognition.

The present study investigates whether self-esteem and entitlement moderate the relation between jealousy (cognitive, emotional, behavioral) and the Dark Triad (narcissism, Machiavellianism, psychopathy). To test this question, 453 participants (311 females, 140 males, 2 unidentified) between the ages of 17 to 81 years (M = 33.19, SD = 10.32) completed the Multidimensional Jealousy Scale, the Short-D3, the Psychological Entitlement Scale, and the Rosenberg Self-Esteem Scale. The interaction of self-esteem and Machiavellianism has an effect on cognitive jealousy and emotional jealousy, and the interaction of selfesteem and narcissism has an effect on behavioral jealousy. The interaction of entitlement and narcissism has an effect on emotional jealousy and behavioral jealousy, and the interaction of entitlement and psychopathy has an effect on cognitive jealousy. These findings identify dimensions of the Dark Triad and other personality traits that influence the propensity to experience different types of jealousy.

Introduction: In Australia there has been a sharp increase in the proportion of older people who live alone. Living alone increases the risk of being socially isolated or experiencing loneliness. Older people who are lonely have an increased risk of dying sooner and are more likely to experience a decline in their mobility [1]. Understanding if and how social isolation/loneliness impacts on managing health conditions and use of health services is important in providing quality care and preventing premature mortality. Living alone is not necessarily a predictor of social isolation/loneliness, rather lack of time spent with family or friend may be a better indicator. More supportive social relationships are related to a decreased mortality risk [2]. Research has been undertaken on the determinants of isolation/loneliness (individual, social, community and environment), however less emphasis has occurred on the medical determinants and how these might be mitigated. Using our existing data linkage resource, the Central and Eastern Sydney Primary and Community Health Cohort/Resource (CES-P&CH), which includes questionnaire data, primary care records, prescribing information, hospital records, emergency department records, cancer registry, and vital statistics on over 30,000 participants in CES aged 45 years and over we explored patterns of service use in people who are socially isolated. Methods: A record linkage study using 45 and Up Study questionnaire data, MBS claims, hospitalisations and deaths was undertaken. Social isolation was defined using a combination of baseline questionnaire data on living arrangements, family and friend support, and health issues that impacted on work/daily activities. Participant characteristics and health conditions at baseline (2006-2009) and health service use (including GP presentations, care plan use, and number and frequency of hospitalisations over the next 10 years) were compared for those who were defined as socially isolated versus those who were not using multivariate/time series models. Results and Discussion: At baseline 20% of participant lived alone; 30.8% had no partner; 18.5% had no children; 44.3% were not working; 4.9% regularly need help with daily tasks; 12.0% had severe physical limitations; 8.8% did not have support from family or friends; 9.6% were urinary incontinent, and 11.3% had depression or anxiety. These participants were included in the socially isolated group for the analysis if they had multiple risks. This paper will discuss the different algorithms that were developed to describe social isolation. This paper will also provide the results from the multivariate/time series models and how this information is being/can be used to better understand and provide person-centred quality care in CES. Limitations and suggestions for future research: Because the research study used an existing record linkage resource we were limited to the items that were included in the questionnaire to define social isolations. This research study would benefit from sensitivity testing of the resultant social isolation algorithm. References: 1- Perissinotto CM, Stijacic CI, Covinsky KE. Loneliness in older persons: a predictor of functional decline and death. Arch Intern Med 2012;172(14):1078-83. 2- Holt-Lunstad J, Smith TB, Layton JB. Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 2010;7(7): e1000316. doi:10.1371/journal.pmed.1000316

Background Recently arrived culturally and linguistically diverse migrant mothers in Western Industrialised Nations are less likely to access health care and are more likely to report negative healthcare experiences than more established migrant or non-migrant populations. This is particularly an issue in Australia where nearly half of all Australians were born overseas or have at least one parent born overseas. Methods A systematic scoping review was conducted to identify a) the main enablers and barriers to accessing appropriate health care for migrant families with a new baby/young child who speak a language other than English, and b) the effectiveness of interventions that have been tested to improve access to appropriate health care for this group. Three academic databases (CINAHL, Medline and ProQuest) were searched, with additional publications identified through expert knowledge and networks. Data was extracted and analysed according to the Access framework, which conceptualises access to health care as being generated by the interaction of dimensions of accessibility of services (supply side) and abilities of potential users (demand side). Results A total of 1964 records were screened for eligibility, with nine of these included in the review. Seven studies only described barriers and enablers to health care access, one study reported on an evaluation of an intervention and one study described the barriers and enablers and the evaluation of an intervention. This review identified that the most significant barriers occurred on the supply side, within the ‘appropriateness’ domain. Overall, the most frequently cited barrier was a lack of cultural sensitivity/understanding of different cultural practices (five studies). The most significant enablers also occurred on the supply side, but within the ‘acceptability’ domain. The most frequently cited enabler was cultural sensitivity and understanding. Conclusions There is a dearth of evaluated interventions in the peer reviewed literature to improve appropriate access to postnatal care for migrant families who speak a language other than English. The literature focuses on identifying barriers and enablers to access to healthcare for this population group. Interventions which aim to address barriers within the ‘appropriateness’ dimension may have the greatest impact on access.

Aim:To describe the characteristics of people in Central and Eastern Sydney (CES), NSW, who had a General Practice Management Plan (GPMP) and claimed for at least one private allied health service item; and to examine if allied health service use results in less hospitalisations over a five-year period.Background:The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management programme was introduced to the Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The programme supports general practitioners claiming up to one GPMP and one Team Care Arrangement every year, and the patient additionally claiming for up to five private allied health services visits.Methods:A prospective longitudinal study was conducted. The sample consisted of 5771 participants in CES who had a GPMP within a two-year health service utilisation baseline period (2007–2009). The analysis used the 45 and Up Study questionnaire data linked to the MBS, hospitalisation, death and emergency department data for the period 2006–2014.Findings:Of the eligible participants, 43% (2460) had at least one allied health service item claim in the subsequent 12 months. Allied health services were reported as physiotherapy, podiatry and other allied health services. The highest rates of allied health service use were among participants aged 85 years and over (49%). After controlling for confounding factors, a significant difference was found between having claimed for five or more physiotherapy services and emergency admissions (HR: 0.83; 95% CI: 0.72–0.95) and potentially preventable hospitalisations (HR: 0.79; 95% CI: 0.64–0.96) in the subsequent five years. Use of allied health service items was well targeted towards those with chronic and complex care needs, and use of physiotherapy services was associated with less avoidable hospitalisations.

The current study extended previous literature that had investigated the attractiveness of the Dark Triad (DT) personality to youthful women (Carter, Campbell, & Muncer, 2014), by comparing responses between two age groups. Participants (N = 1001 females) consisted of undergraduate students and women sampled from various North American communities. Participants read descriptions of male personalities and rated their attractiveness. Descriptions of male characters were designed to portray a combination of high scores on the Dark Triad traits (Machiavellianism, narcissism, and sub-clinical psychopathy), and results were compared to ratings on a low-scoring DT personality. Results were generally supportive of the hypotheses, such that younger women were more attracted to the Dark Triad traits than were older women; older women also rated the low-scoring DT personality as significantly more attractive than did younger women. However, inconsistent with previous literature, younger women rated the low-scoring DT personality as significantly more favorable than the high-scoring DT personality. Further, the participants' level of fertility did not significantly influence attractiveness ratings. The current study's findings may deepen understanding of the ways in which mating strategies change with age, as well as the qualities that women desire in a mate, in order to improve mating success.

OBJECTIVES: To assess potential inequitable impacts of a proposed Teen Triple P Positive Parenting Program (Teen PPP) in Manitoba to achieve equity of access and outcomes for families of diverse backgrounds; recommend (if required) alternative actions to promote greater equity of access and outcomes for families participating in Teen PPP; and evaluate the influence of recommendations on implementation of the proposed program. INTERVENTION: An equity-focused health impact assessment (EfHIA) of the proposed Teen PPP was conducted, using a standard EfHIA framework. Methods used to assess potential Teen PPP impacts included: a literature review, key informant interviews and 14 community consultations. Evidence was analyzed, summarized and presented to the project Steering Committee (SC), along with draft recommendations for ensuring that equity is considered in Teen PPP planning and rollout. OUTCOMES: The SC prioritized 12 possible inequitable impacts of Teen PPP with potential to prevent certain parents/caregivers either from accessing the proposed program or benefitting adequately from the program, causing them to drop out prematurely. Recommendations for avoiding these impacts were finalized by the SC and presented to provincial government officials responsible for the proposed program. Follow-up interviews with these individuals indicated that the recommendations were well received and raised equity-related issues that will be considered in future program planning decisions. CONCLUSION: EfHIA is a proven planning tool for ensuring that health equity is considered in all policies, which is one of the necessary conditions for reducing inequities and closing the health equity gap throughout Canada within a generation.

The goal of the present investigation was to assess whether the Dark Triad traits (Machiavellianism, narcissism, psychopathy) add significantly to the prediction of misconduct and the propensity to engage in high-stakes deception. Self-report scores were collected (n = 464) via the Short-D3 assessing the Dark Triad traits, the Comprehensive Misconduct Inventory measuring misconduct, and the Propensity to Lie Questionnaire investigating lying tendencies. Significant correlations were observed between nearly all variables, but in a multiple regression only psychopathy added significantly to the prediction of the misconduct factors. Further, only Machiavellianism was a significant predictor of high-stakes deception over and above the other predictors in the model.

Florence Levy,1 Andrew Pipingas,2 Elizabeth V Harris,2 Maree Farrow,3 Richard B Silberstein2 1School of Psychiatry, University of New South Wales and Head, Child and Family East, Prince of Wales Hospital, Sydney, NSW, Australia; 2Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, Victoria, Australia; 3Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania, Australia Objective: To compare the use of the Continuous Performance Task (CPT) reaction time variability (intraindividual variability or standard deviation of reaction time), as a measure of vigilance in attention-deficit hyperactivity disorder (ADHD), and stimulant medication response, utilizing a simple CPT X-task vs an A-X-task. Method: Comparative analyses of two separate X-task vs A-X-task data sets, and subgroup analyses of performance on and off medication were conducted. Results: The CPT X-task reaction time variability had a direct relationship to ADHD clinician severity ratings, unlike the CPT A-X-task. Variability in X-task performance was reduced by medication compared with the children’s unmedicated performance, but this effect did not reach significance. When the coefficient of variation was applied, severity measures and medication response were significant for the X-task, but not for the A-X-task. Conclusion: The CPT-X-task is a useful clinical screening test for ADHD and medication response. In particular, reaction time variability is related to default mode interference. The A-X-task is less useful in this regard. Keywords: ADHD, continuous performance task, reaction time variability, stimulant medication

Introduction : Addressing the burden of chronic disease and reducing the cost of health care has provoked interest in better integrating health care. Aim: To explore the uptake of measures of integrated care among a cohort of participants in the 45 and Up Study and to examine the factors that are associated with uptake and the impact on hospitalisation. Theory/Methods : Eligible subjects were identified from the NSW 45 and Up longitudinal population health study who resided in a specific catchment area. Their baseline data were linked to the NSW Admitted Patient Data Collection, NSW Registry of Births Deaths and Marriages, and Australian Department of Human Services Medicare data. The final linked data collection comprised 26,429 participants. Measures of integrated care included: a) Preparation of a general practice management plan (GPMP) and/or implementation of team care arrangements (TCA); b) Review of GPMP/TCA; c) Continuity of primary care provider; d) Medicare claims for health assessments, allied health or nursing care. Hospitalisation was defined as any hospitalisation in the 12 months following recruitment. The study factors included demographic characteristics, socioeconomic status, lifestyle and health and wellbeing. Results : A claim for preparation of a GPMP/TCA arrangement was noted for 16% and a review of GPMP/TCA by 6% of subjects. Older age, number of health conditions, physical impairment, psychological distress and frailty were associated with increased likelihood of preparation or review claims. A third of participants had continuity of care. Continuity increased with age, being born overseas and physical limitation and psychological distress or frailty. Seven percent of subjects had claims for nursing and allied health and these were more frequent in females, older participants, and those who reported more health conditions, physical limitation, psychological distress or frailty. One quarter of participants had one or more hospitalisations in the 12 months following recruitment. Claims for the integration measures were associated with an increased risk of hospitalisation. Discussions, conclusion and learnings : There are positive benefits from implementing integrated measures in primary care for older patients with chronic health conditions. There are opportunities to enhance the implementation of these among at risk hospitalised patients to ensure that they are referred back to general practice following an admission. Limitations : The 45 and Up cohort is not designed as a cross-sectional study, nor can it provide prevalence estimates. The limitation of current linked data collections based on administrative data collections is the lack of clinical indicators. This preliminary work had the capacity to investigate only 12 months of follow-up. The facility to include ongoing linkage will enable follow up of at least 10 years of data. Suggestions for future research : Further research is needed to explore associations between general practice care and hospitalisation and to examine the factors that are associated with care planning and multidisciplinary care following hospitalisation.

The bone marrow niche is a dynamic and complex microenvironment that can both regulate, and be regulated by the bone matrix. Within the bone marrow (BM), mesenchymal stromal cell (MSC) precursors reside in a multi-potent state and retain the capacity to differentiate down osteoblastic, adipogenic, or chondrogenic lineages in response to numerous biochemical cues. These signals can be altered in various pathological states including, but not limited to, osteoporotic-induced fracture, systemic adiposity, and the presence of bone-homing cancers. Herein we provide evidence that signals from the bone matrix (osteocytes) determine marrow adiposity by regulating adipogenesis in the bone marrow. Specifically, we found that physiologically relevant levels of Sclerostin (SOST), which is a Wnt-inhibitory molecule secreted from bone matrix-embedded osteocytes, can induce adipogenesis in 3T3-L1 cells, mouse ear- and BM-derived MSCs, and human BM-derived MSCs. We demonstrate that the mechanism of SOST induction of adipogenesis is through inhibition of Wnt signaling in pre-adipocytes. We also demonstrate that a decrease of sclerostin in vivo, via both genetic and pharmaceutical methods, significantly decreases bone marrow adipose tissue (BMAT) formation. Overall, this work demonstrates a direct role for SOST in regulating fate determination of BM-adipocyte progenitors. This provides a novel mechanism for which BMAT is governed by the local bone microenvironment, which may prove relevant in the pathogenesis of certain diseases involving marrow adipose. Importantly, with anti-sclerostin therapy at the forefront of osteoporosis treatment and a greater recognition of the role of BMAT in disease, these data are likely to have important clinical implications.

There have been few incidence studies of vascular parkinsonism (VP), progressive supranuclear palsy (PSP), and parkinsonian-type multiple system atrophy (MSA-P). We measured the age-, gender- and socioeconomic-specific incidence rates for these conditions in north-east Scotland.Incident non drug-induced parkinsonian patients were identified prospectively over three years by several overlapping methods from a baseline primary care population of 311,357. Parkinsonism was diagnosed if patients had two or more cardinal motor signs. Patients had yearly follow-up to improve diagnostic accuracy. Incidence rates using the diagnosis by established research criteria at latest follow-up were calculated for each condition by age, gender, and socioeconomic status.Of 377 patients identified at baseline with possible or probable parkinsonism, 363 were confirmed as incident patients after median follow-up of 26 months (mean age 74.8 years, SD 9.8; 61% men). The crude annual incidence was 3.2 per 100,000 (95% confidence interval (CI) 2.2-4.3) for VP, 1.7 per 100,000 (95% CI 1.0-2.4) for PSP, and 1.4 per 100,000 (95% CI 0.8-2.1) for MSA-P. VP and MSA-P were more common in men (age-adjusted male to female ratios 2.58 (95% CI 1.65-3.83) and 8.65 (95% CI 4.73-14.5) respectively). Incidence did not vary with socioeconomic status.This is the first community-based, prospective study to report the incidence of vascular parkinsonism and the third to report the incidence of PSP and MSA-P. Further follow-up and comparison with similar studies in different populations will yield valuable prognostic and aetiological information on these conditions.

Introduction: It is anticipated that by 2030 the number of older people and people living with long term conditions will have significantly increased. At the same time, it is expected that there will be a shift to providing more health care in the community. Browning et al [1] using a prospective 16-year longitudinal study of 1000 older Australians described three ageing groups (i) ageing well (30%); initially ageing well then deteriorating (50%); consistently ageing poorly (20%). Understanding the predictors of services use in older people is important in planning and providing quality care. Predictors of general practice service use from a small community-based studies have included: lower age, fewer medical conditions, restful sleep, good nutrition, decreased stress, being a non-smoker and good social support [2]. Using our existing data linkage resource, the Central and Eastern Sydney Primary and Community Health Cohort/Resource (CES-P&CH), which includes questionnaire data, primary care records, prescribing information, hospital records, emergency department records, cancer registry, and vital statistics on over 30,000 participants in CES aged 45 years and over (over 250,000 in NSW for comparison) we identified the predictors of service use (including general practice, pharmaceuticals, emergency departments, hospitalisations) amongst people aged over 75 years. Methods: A record linkage study using 45 and Up Study questionnaire data, MBS claims, PBS claims, Emergency Department visits, hospitalisations and deaths was undertaken. Participant characteristics at baseline (2006-2009) included demographics, health behaviours, social capital, functional status, and health conditions. Service characteristics included type of service, length of stay, location. Predictive models were developed to examine the participant/service characteristics with higher/lower service use over time. Results and Discussion: We identified 6,067 participants who were aged over 75 years in CES at baseline. Of these 59.0% had seen a GP 8 times or more in 2008, 19.6% had seen a specialist 8 times or more, 26.7% had attended an ED at least once, and 44.2% had been hospitalised at least once. In 2014 rates of GP use, specialist use and hospital admissions remained the same however ED visits had increased by 5%. This paper will discuss the different predictive models that were developed to describe service use. This paper will also provide the results from the predictive models and how this information is being/can be used to better plan and provide quality care for older people in CES. Limitations and suggestions for future research: Because the research study used an existing record linkage resource we were limited to the participant and service characteristics that were available. This research study would benefit from the inclusion on non-admitted data such as outpatient, community services and aged care services. References: 1- Browning C, Enticott J, Thomas S and Kendig H. 2017. Trajectories of ageing well among older Australians: a 16-year longitudinal study. Ageing and Society. 2017; 1-22. 2 -Korten AE, Jacomb PA, Jiao Z, Christensen H, Jorm AF, Henderson AS, Rodgers B. Predictors of GP service use: a community survey of an elderly Australian sample. Aust N Z J Public Health. 1998; 22: 609-615.

The number of older people living with chronic health conditions is increasing in Australia. The Chronic Disease Management (CDM) items program was introduced to the Medicare Benefits Schedule (MBS) to encourage a more structured approach to managing patients with chronic conditions. Initial uptake was slow and recent research has suggested that uptake is decreasing. This paper examines: person MBS CDM claims in NSW between 2006 and 2014 — using baseline survey data (2006–09) from the Sax Institute’s 45 and Up Study linked to MBS and Death Registry data (2006–14) — and MBS CDM claims per 100000 population — using billing data sourced from the Medicare Australia Statistics website — to systematically examine any changes in uptake using a time-series analysis. After age adjustment, claims for initial plans increased from 11.3% in 2006 to 22.4% in 2014. Increases were also seen for allied health service claims (from 4.1% in 2006 to 20.8% in 2014) and for plan reviews (from 5.9% in 2006 to 16.0% in 2014). These increases were consistent with the MBS summary claims data. There is evidence that these plans are appropriately targeting those in most need; however, there is limited evidence of their effect. Claims for plan reviews, although increasing, are suboptimal and may indicate poor continuity of care.

Objective: To describe the use and reporting of Health Impact Assessment (HIA) in Australia and New Zealand between 2005 and 2009. Methods: We identified 115 HIAs undertaken in Australia and New Zealand between 2005 and 2009. We reviewed 55 HIAs meeting the study's inclusion criteria to identify characteristics and appraise the quality of the reports. Results: Of the 55 HIAs, 31 were undertaken in Australia and 24 in New Zealand. The HIAs were undertaken on plans (31), projects (12), programs (6) and policies (6). Compared to Australia, a higher proportion of New Zealand HIAs were on policies and plans and were rapid assessments done voluntarily to support decision-making. In both countries, most HIAs were on land use planning proposals. Overall, 65% of HIA reports were judged to be adequate. Conclusion: This study is the first attempt to empirically investigate the nature of the broad range of HIAs done in Australia and New Zealand and has highlighted the emergence of HIA as a growing area of public health practice. It identifies areas where current practice could be improved and provides a baseline against which future HIA developments can be assessed. Implications: There is evidence that HIA is becoming a part of public health practice in Australia and New Zealand across a wide range of policies, plans and projects. The assessment of quality of reports allows the development of practical suggestions on ways current practice may be improved. The growth of HIA will depend on ongoing organisation and workforce development in both countries.

Limb girdle muscular dystrophy type 2L or anoctaminopathy is a condition mainly characterized by adult onset proximal lower limb muscular weakness and raised CK values, due to recessive ANO5 gene mutations. An exon 5 founder mutation (c.191dupA) has been identified in most of the British and German LGMD2L patients so far reported. We aimed to further investigate the prevalence and spectrum of ANO5 gene mutations and related clinical phenotypes, by screening 205 undiagnosed patients referred to our molecular service with a clinical suspicion of anoctaminopathy. A total of 42 unrelated patients had two ANO5 mutations (21%), whereas 14 carried a single change. We identified 34 pathogenic changes, 15 of which are novel. The c.191dupA mutation represents 61% of mutated alleles and appears to be less prevalent in non-Northern European populations. Retrospective clinical analysis corroborates the prevalently proximal lower limb phenotype, the male predominance and absence of major cardiac or respiratory involvement. Identification of cases with isolated hyperCKaemia and very late symptomatic male and female subjects confirms the extension of the phenotypic spectrum of the disease. Anoctaminopathy appears to be one of the most common adult muscular dystrophies in Northern Europe, with a prevalence of about 20%-25% in unselected undiagnosed cases. © 2013 WILEY PERIODICALS, INC.

Background and objectives Treatment with mepolizumab, a humanized monoclonal antibody to interleukin-5, reduces the rate of asthma exacerbations and the requirement for systemic glucocorticoids while maintaining asthma control. Treatment decisions are guided by predictors of response, including blood eosinophil thresholds in patients with frequent exacerbations despite intensive anti-inflammatory and controller treatment. Identification of additional predictors of response could aid treatment decisions. We investigated genetic associations that may predict response to mepolizumab-treatment. Methods In this post hoc analysis of DREAM and MENSA, association of genetic markers was tested in patients with severe asthma treated with mepolizumab who provided consent for pharmacogenetic research. Association was tested in a tiered approach with alpha spend differing for candidate genetic markers selected for prior history of association with relevant traits or pathways and in a genome-wide analyses (p Results No genetic marker was significantly associated with the primary endpoint, clinically significant exacerbation rate. One genetic marker was associated with time to first clinically significant exacerbation, but this association was driven by the DREAM data and was not supported in additional sensitivity analyses by treatment regimen/dose. Conclusion No genetic effect on mepolizumab-treatment response was identified in this population on intensive asthma treatment, with history of frequent exacerbations and pre-selected for airway eosinophilia.

Data on patient access to, and use of, primary and secondary care services are a potential tool for population health and health service planning, and for researchers. The Sax Institute’s 45 and Up Study was established to support research about healthy ageing. This paper considers how data from the 45 and Up Study could be useful to Local Health Districts and the Primary Health Networks in New South Wales to support their work, particularly in evaluating integration of primary and secondary health services. Preliminary exploration of these data identified more than 31 000 participants in the 45 and Up Study living in central and eastern Sydney who were included in some demonstration projects. The value of these data to the region included access to a population-based sample of residents, and capacity to link to health data held within different jurisdictions and local data sources. The resultant data collection can address questions of interest to planners working in primary and secondary care, such as integration and coordination of services, including transition of care. These are key performance goals for both sectors.

Background and aims Central blood pressure rises with age, which increases cardiovascular risk. There is some evidence that nutritional supplements may be useful to reduce central blood pressures in older people, but no studies have investigated the effects of multivitamin supplements for this purpose. This randomized, double-blind, placebo-controlled study investigated the effects of 16-weeks supplementation with gender-specific multivitamin and herbal supplements. Method Participants were healthy individuals, free from heart disease, and included 160 females aged ≥50 and 79 males aged 50–65 years. Analyses of co-variance, correcting for baseline cardiovascular assessments, were used to determine the effects of supplementation on central cardiovascular measures including augmentation index, augmentation pressure and pulse pressure. Significance was set at p = 0.016. Results No effects of multivitamin supplementation were observed in either males or females (respectively) for central augmentation index (p = 0.841; p = 0.296), central augmentation pressure (p = 0.794; p = 0.442), and central pulse pressure (p = 0.078; p = 0.304). Similarly, there was no treatment effect observed for brachial systolic, diastolic or pulse pressures. Conclusion Four months multivitamin supplementation does not appear to exert any benefit to measures of central blood pressure in healthy older people.

Aim To describe factors people consider important in deciding whether or not to donate their brain for research after death. Background Brain tissue retrieved at post-mortem is needed to further research into neurological conditions such as Parkinson's disease. Previous research has focussed mainly on attitudes to organ donation for transplantation. Design Data were gathered and analysed using a qualitative approach based on grounded theory. Methods Nineteen people who had made a decision about brain donation, five people with Parkinson's and 14 unaffected individuals, were identified through theoretical sampling. Interviews conducted between September 2007–January 2008 were analysed to identify themes representing the concerns of participants, when making a decision. Findings The three main themes identified were views and beliefs about post-mortem, the importance of family and the things people do not talk about. Although participants were more familiar with the concept of organ donation for transplantation, unanimous support was expressed for brain donation for research. However, beliefs about death and post-mortem, influence of family and the difficulty in talking and thinking about things to do with death all posed barriers to consent when actually asked to make a decision. For some, however, being asked had acted as a catalyst, transforming previously held positive attitudes into a decision to consent. Conclusion Guidelines for asking developed from these findings highlight the importance of discussing the issue to raise awareness in potential donors, involving family members, and giving accurate and appropriate information to inform, reassure and to dispel misconceptions.

Objective Nutritional and vitamin status may be related to cognitive function and decline in older adults. The aim of this study was to investigate the effects of nutritional supplementation on cognition in older men. Method The current study was an 8-week, placebo-controlled, double-blind investigation into the effects of a multivitamin, mineral and herbal supplement (Swisse Men's Ultivite®, Swisse Vitamins Pty Ltd, Melbourne, Australia) on cognitive performance in older men. Participants were 51 male individuals aged between 50 and 74 years, with a sedentary lifestyle. Cognitive performance was assessed at baseline and post-treatment using a computerised battery of cognitive tasks, enabling the measurement of a range of attentional and memory processes. Blood measures of vitamin B, folate and homocysteine were collected prior to and after supplementation. Results The results of this study revealed that contextual recognition memory performance was significantly improved following multivitamin supplementation (p < 0.05). Performance on other cognitive tasks did not change. Levels of vitamin B and folate were significantly increased with a concomitant decrease in homocysteine, indicating that relatively short-term supplementation with a multivitamin can benefit these risk factors for cognitive decline. Conclusion Findings from this study indicate that daily multivitamin supplementation may improve episodic memory in older men at risk of cognitive decline. Copyright © 2012 John Wiley & Sons, Ltd.

This paper reflects on the challenges and strategies used to conduct a sustained nurse home visiting randomised trial within the universal child and family health service system in Australia. The Maternal Early Childhood Sustained Home-visiting (MECSH) programme is a complex multilevel intervention acting in parallel at the individual and organisational levels, addressing change in individuals and families, as well as the structural and social factors that affect the individuals, particularly families’ access to support and services. MECSH is targeted towards 20–25% of the population who are at risk of poorer maternal and child health and development outcomes. Establishing the intervention within the service system and conducting the research trial simultaneously presented many challenges. The researchers encountered both technical and ethical problems. The role of researchers as disinterested, objective scientists was constantly challenged. We argue that the MECSH trial was a hybrid research model, testing both efficacy and effectiveness, in a participatory framework. Hybrid research can help to generate evidence of the effectiveness of multilevel interventions in more timely ways, but requires greater investment in the time and resources to conduct the research. We see that such investment would pay dividends in the simultaneous development, testing and embedding of effective interventions for families and sustainable capacity for services.

Background Treatment with long-acting β 2 -agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) for chronic obstructive pulmonary disease (COPD) is standard, but response varies. We investigated genetic association with treatment response to umeclidinium (UMEC, a LAMA), vilanterol (VI, a LABA), and combination therapy. Methods Data from 17 clinical trials (N = 6075) in patients with COPD receiving once-daily UMEC/VI (125/25mcg or 62.5/25mcg), UMEC (125 or 62.5mcg), VI (25mcg) or placebo were used. Genetic association with change from baseline in trough forced expiratory volume in 1 s (FEV 1 ) ∼24 h post-dosing was assessed for: (i) 3 β 2 -adrenoceptor ( ADRB2 ) gene variants; (ii) 298 single-nucleotide polymorphisms (SNPs) with prior evidence of associations; (iii) human leukocyte antigen (HLA) alleles and (iv) genome-wide association study (GWAS) SNPs. Other endpoints were (i) reversibility at screening; and at baseline: (ii) FEV 1 ; (iii) forced vital capacity (FVC), and (iv) FEV 1 /FVC ratio. Using linear regression, the inverse normal transformed residuals were pooled together, first across treatment group, then across studies for each monotherapy, then combination therapy and finally for every treated patient. Results Of 6075 patients, 1849 received UMEC/VI, 1390 received UMEC, 1795 received VI, and 1041 received placebo. None of the ADRB2 variants, HLA alleles or GWAS variants tested were associated with treatment response or baseline endpoints. Four SNPs in FAM13A (rs7671167, rs2869967, rs1964516, rs1903003) were significantly associated with baseline FEV 1 /FVC ratio (p −5 ) after adjusting for multiple testing. Conclusions No genetic association was found with treatment response to UMEC or VI when administered as monotherapies or in combination.

Cowden syndrome (CS) is an autosomal dominant genodermatosis associated with characteristic mucocutaneous findings of facial trichilemmomas, palmoplantar keratoses, sclerotic fibromas, and oral papillomas. Mucocutaneous neuromas have also been reported in association with CS. We describe a patient with CS whose sole cutaneous finding was palisaded encapsulated neuromas (PENs) with a plexiform growth pattern in an acral location. Along with previous reports, this case suggests that acral plexiform PENs may be an early, highly specific finding in CS and highlights the importance of screening these patients for PTEN mutation.

Objective There is a demonstrated association between poor mood and deficiency in several micronutrients. Multivitamin supplements contain a wide range of nutrients, suggesting that they may be effective in improving mood; however, few studies have investigated this potential in randomized, controlled trials. This study investigates the effects of a multivitamin, mineral, and herbal supplement on mood and stress in a group of healthy, older male volunteers. Methods In this randomized, double-blind, placebo-controlled trial, fifty men, aged 50-69years, supplemented for a period of 8weeks with a multivitamin formulation that contained vitamins (at levels above recommended daily intakes), minerals, antioxidants, and herbal extracts, or a placebo. They completed a series of mood and stress questionnaires at baseline and post-supplementation. Results Compared with placebo, there was a significant reduction in the overall score on a depression anxiety and stress scale and an improvement in alertness and general daily functioning in the multivitamin group. Conclusions Supplementation with a multivitamin, mineral and herbal formulation may be useful in improving alertness and reducing negative mood symptoms and may also improve feelings of general day-to-day well-being.

Background To describe an organizing framework, Population Impact Analysis, for applying the findings of systematic reviews of public health literature to estimating the impact on a local population, with the aim of implementing evidence-based decision-making. Methods A framework using population impact measures to demonstrate how resource allocation decisions may be influenced by using evidence-based medicine and local data. An example of influenza vaccination in the over 65s in Trafford to reduce hospital admissions for chronic obstructive pulmonary disease (COPD) is used. Results The number of COPD admissions due to non-vaccination of the over 65 in Trafford was 16.4 (95 confidence interval: 13.5; 19.5) and if vaccination rates were taken up to 90, 11.5 (95 confidence interval: 9.3; 13.8) admissions could have been prevented. A total of 705 (95 confidence interval: 611; 861) people would have to be vaccinated against influenza to prevent one hospital admission. Conclusions Population Impact Analysis can help the 'implementation' aspect of evidence for population health. It has been developed to support public health policy makers at both local and national/international levels in their role of commissioning services. © 2012 The Author.

Objective To investigate the impact of a long-term nurse home visiting programme, embedded within a universal child health system, on the health, development and well-being of the child, mother and family. Design Randomised controlled trial. Setting/participants 208 (111 intervention, 97 comparison) eligible at-risk mothers living in a socioeconomically disadvantaged area in Sydney, booking into the local public hospital for confinement. Intervention A sustained and structured nurse home visiting antenatal and postnatal parenting education and support programme. Control Usual universal care. Main outcome measures The quality of the home environment for child development (12–24 months), parent–child interaction and child mental, psychomotor and behavioural development at 18 months. Results Mothers receiving the intervention were more emotionally and verbally responsive (HOME observation) during the first 2 years of their child9s life than comparison group mothers (mean difference 0.5; 95% CI 0.1 to 0.9). Duration of breastfeeding was longer for intervention mothers than comparison mothers (mean difference 7.9 weeks; 95% CI 2.9 to 12.9). There was no significant difference in parent–child interaction between the intervention and comparison groups. There were no significant overall group differences in child mental, psychomotor or behavioural development. Mothers assessed antenatally as having psychosocial distress benefitted from the intervention across a number of areas. Conclusion This sustained nurse home visiting programme showed trends to enhanced outcomes in many, but not all, areas. Specifically, it resulted in clinically enhanced outcomes in breastfeeding duration and, for some subgroups of mothers, women9s experience of motherhood and children9s mental development. Trial registration number ACTRN12608000473369.

Objective: This paper describes the establishment of the Gudaga Study, an Aboriginal birth cohort in south-west Sydney, and our approach to follow-up of participants. The Study describes the health, development, and services use of Aboriginal infants and their mothers. The research team works closely with the local Aboriginal community to implement the research. Methods: All mothers in the maternity ward of an urban hospital were surveyed to identify mothers with an Aboriginal infant. These and some additional mothers identified through other networks were recruited to the study. Results: The number of mothers were surveyed was 2,108. Mothers of Aboriginal infants were younger (25.3 years compared to 28.4 years, p

Pregnancy causes marked hemodynamic changes that may have a “legacy effect” beyond the gestational period. Whether parity is associated with long term cardiac remodeling and electrocardiogram (ECG) changes warrants further investigation. Using the Dallas Heart Study, a multiethnic population