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Biomedical subjects

R F Heller

Publications and source records attributed to R F Heller.

At least 37 records · Page 2Linked to original sources
PubMed2001

Quality of life: an index for identifying high-risk cardiac patients.

A sample of 945 cardiac patients admitted under emergency conditions completed a quality of life questionnaire 4 months post-discharge. Half (471) were randomly allocated to a group used to develop a logistic regression model to predict mortality and cardiovascular morbidity 8 months later. Age 65-85 years, ever having heart failure, experiencing another cardiovascular event since discharge, and low global quality of life (QOL) score were found to be predictive of these outcomes; an interaction between QOL and heart failure was also found. The model was used to formulate a risk index which was validated in the remaining 474 patients. The index defines four levels of increasing risk of adverse outcomes, with rates in the development and validation groups, respectively, of: low risk 4% and 9%; moderate risk 13% and 15%; high risk 31% and 33%; very high risk 52% and 40%. Scores in the emotional, physical and social QOL domains were also found to be predictive of adverse outcomes, suggesting that interventions in any of these areas may prove beneficial. The index may be useful for follow-up evaluation of cardiac patients.

Adult↗
PubMed2001

Trends in the hospital management of unstable angina.

STUDY OBJECTIVE: To examine the hospital management of unstable angina (UAP) in 1996 and 1998, according to patient demographic variables and disease severity. DESIGN: Medical record review. SETTING: 37 hospitals across New South Wales, Australia, representative of the secondary and tertiary care hospitals in the State. PARTICIPANTS: All patients (or a random sample of patients) with UAP admitted to these hospitals during five months in 1996 and six months in 1998 (1872 and 1368 patients respectively). MAIN RESULTS: In the two years between 1996 and 1998, there was an increase in the use of beta blockers and a corresponding decrease in the use of calcium channel blockers, as well as a decrease in the use of intravenous nitrates. Those aged 75 or more were roughly half as likely as those aged less than 65 to be prescribed heparin, aspirin and heparin, beta blockers, intravenous nitrates, and only one third as likely to be offered coronary angiography in hospital. They were one and a half times as likely to be prescribed calcium channel blockers compared with the youngest age group. A similar pattern was seen for gender, where men were more likely than women to be given aspirin, aspirin and heparin, and coronary angiography, and less likely to be given calcium channel blockers. Those with a past history were less likely, and those with more severe disease were more likely than others to be given most interventions. CONCLUSIONS: In view of the low use of evidence-based management of UAP among women and the elderly, it would seem appropriate for disease management guidelines to target these groups.

Adrenergic beta-Antagonists↗
PubMed2001

Knowledge of stroke risk factors, warning symptoms, and treatment among an Australian urban population.

BACKGROUND AND PURPOSE: Reduction in the risk of stroke and increase in the speed of hospital presentation after the onset of stroke both depend on the level of knowledge of stroke in the general population. The aim of the present study was to assess baseline knowledge regarding stroke risk factors, symptoms, treatment, and information resources. METHODS: A community-based telephone interview survey was conducted in the Newcastle urban area in Australia. A total of 1278 potential participants between the ages of 18 to 80 were selected at random from an electronic telephone directory. A trained telephone interviewer conducted a telephone survey using the Computer-Assisted Telephone Interviewing (CATI) program. RESULTS: A total of 822 participants completed the telephone interview. Six hundred three participants (73.4%) correctly identified the brain as the affected organ in stroke. The most common risk factors for stroke identified by respondents were smoking (identified by 324 [39.4%]) and stress (identified by 277 [33.7%]). The most common warning sign of stroke described by respondents was "blurred and double vision or loss of vision in an eye," listed by 198 (24.1%). A total of 626 (76.2%) respondents correctly listed >/=1 established stroke risk factor, but only 409 (49.8%) respondents correctly listed >/=1 warning sign. CONCLUSIONS: The level of knowledge in the community of established stroke risk factors, warning signs, and treatment as indicated by this survey suggests that a community-based education program to increase public knowledge of stroke may contribute to reducing the risk of stroke and to increasing the speed of hospital presentation after the onset of stroke.

Adolescent↗
PubMed2000

Death and readmission in the year after hospital admission with cardiovascular disease: the Hunter Area Heart and Stroke Register.

OBJECTIVES: To compare outcomes one year after hospital admission for patients initially discharged with a diagnosis of acute myocardial infarction (AMI), other ischaemic heart disease (other IHD), congestive heart failure (CHF) or stroke. DESIGN: Cohort study. SETTING: Hunter Area Heart and Stroke Register, which registers all patients admitted with heart disease or stroke to any of the 22 hospitals in the Hunter Area Health Service in New South Wales. PATIENTS: 4981 patients with AMI, other IHD, CHF or stroke admitted to hospital as an emergency between 1 July 1995 and 30 June 1997 and followed for at least one year. MAIN OUTCOME MEASURES: Death from any cause or emergency hospital readmission for cardiovascular disease. RESULTS: In-hospital mortality varied from 1% of those with other IHD to 22% of those with stroke. Almost a third of all patients discharged alive (and 38% of those aged 70 or more) had died or been readmitted within one year. This varied from 22% of those with stroke to 49% of those with CHF. The causes of death and readmission were from a spectrum of cardiovascular disease, regardless of the cause of the original hospital admission. CONCLUSIONS: Data from this population register show the poor outcome, especially with increasing age, among patients admitted to hospital with cardiovascular disease. This should alert us to determine whether optimal secondary prevention strategies are being adopted among such patients.

Aged↗
PubMed2000

Stated and actual management of acute myocardial infarction among different specialties.

OBJECTIVES: To examine the variation in stated management of acute myocardial infarction (AMI) among clinicians of different specialties, and to compare stated with actual practice. DESIGN: Mail survey using a hypothetical case history, and review of medical records. SETTING: 47 public hospitals in New South Wales. SUBJECTS: 224 cardiologists, general/other physicians and general practitioners (GPs) who manage patients with AMI; 390 patients admitted for AMI between February and June 1996. OUTCOME MEASURES: Stated and actual use of treatments and investigations for AMI. RESULTS: Stated use of aspirin, thrombolysis and beta-blockers (95%-100%, 95%-100% and 80%-86%, respectively) was high in all three specialties. Cardiologists were significantly more likely than GPs to state use of heparin (87% v 57%; P < 0.001), ACE inhibitors (84% v 49%; P < 0.001) and echocardiography or gated pool heart scan (79% v 26%; P < 0.001). Stated use of nitrates by cardiologists was significantly lower compared with the other specialties (29% v 50% and 44%; P = 0.027). Actual use of aspirin was high (> 80%) in all specialties. Actual use of thrombolysis was similar to stated use after adjusting for factors such as time to hospital arrival and ST-segment elevation. There were substantial differences between stated and actual use. CONCLUSIONS: There were differences in practice patterns between and among clinicians of different specialties in NSW, consistent with findings from other countries. The high stated and actual use of aspirin and thrombolysis is encouraging.

Adult↗
PubMed2000

Where do developing World clinicians obtain evidence for practice: a case study on pneumonia.

There are few data on the practice of evidence based medicine in the developing world, nor on the actual sources of evidence that clinicians use in practice. To test the hypothesis that there was variation between and within developing countries in the proposed management of a patient with hospital acquired pneumonia, and that part of the variation can be explained by the sources of evidence used. Questionnaire responses to hypothetical case history. Investigators from 6 centres within the International Clinical Epidemiology Network (INCLEN) in China, Thailand, India, Egypt, and Kenya. Doctors chosen to represent primary and secondary hospital practice in the regions of the study centres. Investigations and initial treatments which would be ordered for a hypothetical 60-year-old woman who develops pneumonia 5 days after hospital admission, whether local data on antibiotic sensitivities are available and where information would be obtained to guide management. Chest x-ray and sputum gram stain/culture were consistently the most commonly ordered investigations, there being much greater variation in the initial treatment choices with either penicillin, a third-generation cephalosporin or aminoglycoside being the most popular choice. Textbooks were the commonest form of information source, and access to a library, textbooks and journals were statistically significantly associated with appropriate choice of investigations, but not treatment. Access to local antibiotic sensitivities was associated with appropriate initial treatment choice. Improving access to information in the literature and to local data may increase the practice of evidence-based medicine in the developing world.

Cross Infection↗
PubMed2000

Differences in cardiac procedures among patients in metropolitan and non-metropolitan hospitals in New South Wales after acute myocardial infarction and angina.

An observational cohort study examined the difference in use of cardiac procedures during and after hospital admission for acute chest pain in 47 metropolitan or non-metropolitan hospitals across New South Wales (NSW). There were 3836 patients, represented by 4151 admissions to hospital after acute myocardial infarction (AMI), unstable angina or other angina. Follow up at 22 months was completed on 1695 patients. Patients admitted to metropolitan hospitals had higher rates of most cardiac procedures while in-patients than did patients in non-metropolitan hospitals. Odds ratios (95% confidence intervals) for the use of exercise stress tests, echocardiograms, nuclear studies and coronary angiography were 3.30 (1.38, 7.90), 9.34 (4.07, 21.44), 4.87 (2.08, 11.39) and 68.64 (17.29, 272.49), respectively, for patients with AMI and 1.93 (0.91, 4.12), 5.60 (1.60, 19.57), 3.51 (1.48, 8.33) and 38.57 (9.36, 158.94), respectively, for patients with unstable angina. Rates were similar between hospital types during the 22 months after discharge. The appropriateness of this large variation in resource use between metropolitan and non-metropolitan hospitals requires examination.

Adult↗
PubMed2000

Postgraduate courses in quality improvement: achievements and future directions.

Since 1996, the Centre for Clinical Epidemiology and Biostatistics at the University of Newcastle has offered courses in Quality Improvement in Health Care. The courses are offered at Graduate Certificate, Graduate Diploma and Masters levels, principally by distance learning. They offer training in research methods as well as the concepts and application of quality improvement. Feedback from students, many of whom are quality coordinators in Australian health care facilities, has been positive. Enrolments are taken mid-year as well as at the beginning of the academic year.

Australia↗
PubMed2000

Mortality after acute myocardial infarction is lower in metropolitan regions than in non-metropolitan regions.

STUDY OBJECTIVES: To compare in-hospital mortality for acute myocardial infarction (AMI) between metropolitan and non-metropolitan hospitals after adjustment for patients' severity; to examine the role of the use of effective cardiac medications in the possible mortality difference between these types of hospital. DESIGN: Retrospective cohort study. SETTING: 47 acute public hospitals in metropolitan and non-metropolitan areas of New South Wales, Australia, taking part in the Acute Cardiac Care Project based on medical record review. PATIENTS: 1665 patients with principal discharge diagnosis of AMI from February to June 1996. MAIN RESULTS: There was no difference in crude mortality rate (assessed as seven day mortality) between metropolitan and non-metropolitan hospitals (11.0% compared with 10.7% respectively, p=0.893). After adjustment for severity in a logistic regression model, the odds of death in non-metropolitan hospitals was significantly higher than in metropolitan hospitals (odds ratio = 1. 90; 95% CI 1.21, 3.23). The addition of the use of effective cardiac medications to the model resulted in the difference between hospital type becoming non-significant (odds ratio=1.09; 95% CI 0.57, 2.07). CONCLUSIONS: In-hospital mortality in non-metropolitan hospitals was higher than that in metropolitan hospitals, after adjustment for patients' severity. This might partly be explained by the difference in use of effective cardiac medications between hospital type.

Acute Disease↗
PubMed2000

Influence of admission body temperature on stroke mortality.

BACKGROUND AND PURPOSE: The influence of body temperature on stroke outcome remains uncertain. The aim of this study was to investigate the prognostic role of admission body temperature on short-term and long-term mortality in a retrospective cohort study of patients with acute stroke. METHODS: A retrospective cohort of 509 patients with acute stroke, admitted to a tertiary hospital between July 1, 1995, and June 30, 1997, was studied. The relationship between admission body temperature and mortality both in-hospital and at 1-year mortality was evaluated. Body temperature on admission was classified as hypothermia (</=36.5 degrees C), normothermia (>36.5 degrees C and </=37.5 degrees C), and hyperthermia (>37.5 degrees C). Logistic regression and proportional hazards function analysis were performed after adjustment for clinical predictors of stroke outcome. RESULTS: In ischemic stoke, mortality was lower among patients with hypothermia and higher among patients with hyperthermia. The odds ratio for in-hospital mortality in hypothermic versus normothermic patients was 0.1 (95% CI, 0.02 to 0.5). The relative risk for 1-year mortality of hyperthermic versus normothermic patients was 3.4 (95% CI, 1.6 to 7.3). A similar but nonsignificant trend for in-hospital mortality was seen among patients with hemorrhagic stroke. CONCLUSIONS: An association between admission body temperature and stroke mortality was noted independent of clinical variables of stroke severity. Hyperthermia was associated with an increase in 1-year mortality. Hypothermia was associated with a reduction in in-hospital mortality.

Aged↗
PubMed2000

Improving stroke outcome: the benefits of increasing availability of technology.

INTRODUCTION: A decision analysis was performed to explore the potential benefits of interventions to improve the outcome of patients admitted to hospital with a stroke, in the context of the technology available in different parts of the world. METHODS: The outcome of death or dependency was used with a six-month end-point. RESULTS: Four settings were identified that would depend on the resources available. The proportion of stroke patients who were dead or dependent at six months was 61.5% with no intervention at all. Setting 4, with the only intervention being the delayed introduction of aspirin, produced a 0.5% absolute improvement in outcome (death or dependency), and the addition of an organized stroke unit (Setting 3) produced the largest incremental improvement, of 2.7%. Extra interventions associated with non-urgent computed tomography and thus the ability to avoid anticoagulation or aspirin for those with a haemorrhagic stroke (Setting 2), and immediate computed tomography scanning to allow the use of thrombolytics in non-haemorrhagic stroke (Setting 1), produced only small incremental benefits of 0.4% in each case. DISCUSSION: To reduce the burden of illness due to stroke, efforts at primary prevention are essential and likely to have a greater impact than even the best interventions after the event. In the absence of good primary prevention, whatever is possible must be done to reduce the sequelae of stroke. This analysis provides a rational basis for beginning the development of clinical guidelines applicable to the economic setting of the patient.

Decision Support Techniques↗
PubMed1999

Variation in stated management of acute myocardial infarction in five countries.

We examined the variation in stated practice in the management of acute myocardial infarction (AMI) among doctors in Australia, Brazil, Chile, India and Thailand. Hospitals were identified as primary, secondary or tertiary by investigators from around their own region. All doctors within each hospital who would be expected to treat patients with AMI were asked to indicate which investigations and treatments they would offer to a patient with an AMI who develops angina on Day 3 after admission. The numbers of hospitals ranged from 5 to 26 per country, and doctor response rates varied from 70 to 100%. Within-country variation was large, and statistically significant variations were seen between countries in the use of most interventions. The large variation both between and within a range of countries across the economic spectrum suggests a widespread need for agreement about what constitutes appropriate management after AMI.

Australia↗
PubMed1999

The cross cultural context of obesity: an INCLEN multicentre collaborative study.

Associations between obesity and cardiovascular disease have been documented in the Developed World and have been linked with levels of 'development' in Developing World countries. This study aimed to explore the sociocultural influences on attitudes towards obesity, physical activity and dietary change using a four level conceptual framework (from personal to societal influences). Focus group discussions were conducted in: India, Indonesia, Cameroon, Egypt and Australia. The results of these discussions were analysed to reveal emergent themes. The interpretation of the qualitative data emphasised the need to incorporate influences beyond the individual in efforts to reverse or prevent obesity related disease.

Adult↗
PubMed1999

Asthma and chronic obstructive airway diseases are associated with osteoporosis and fractures: a literature review.

The objective was to assess the association between asthma and/or chronic obstructive airway diseases (COAD), and osteoporosis, and appraise treatments of osteoporosis in these patients. MEDLINE and Excerpta Medica were searched for original research with control groups which tested the above association. One cohort and nine cross-section studies of bone density in patients with asthma and/or COAD were retrieved. These demonstrated clinically important bone density reductions of up to 29% in subjects, dependent upon daily oral corticosteroids, by a variety of measurement techniques, at various bone sites. Bone density reduction has also been less consistently reported in the absence of oral corticosteroids, suggesting that other factors including high-dose inhaled corticosteroids may have a role. Fracture studies. Three studies in oral corticosteroid-dependent asthmatics demonstrated a vertebral fracture prevalence up to 56%, and annual vertebral fracture incidence of up to 42%. The strength of the available evidence is limited, but suggests that patients with asthma and/or COAD are at increased risk of osteoporosis. The evidence of the association between osteoporosis and inhaled corticosteroids is much more limited than for oral corticosteroids. Bisphosphonates are promising agents to maintain and/or promote bone mass in this patient group.

Administration, Inhalation↗