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STUDY OBJECTIVES: To compare the use of sleep diagnostic tests, the risks, and cofactors, and outcomes of the care of Indigenous and non-indigenous Australian adults in regional and remote Australia in whom sleep related breathing disorders have been diagnosed. METHODS: A retrospective cohort study of 200 adults; 100 Aboriginal and Torres Strait Islander and 100 non-indigenous adults with a confirmed sleep related breathing disorder diagnosed prior to September 2011 at Alice Springs Hospital and Cairns Hospital, Australia. RESULTS: Results showed overall Indigenous Australians were 1.8 times more likely to have a positive diagnostic sleep study performed compared with non-indigenous patients, 1.6 times less likely in central Australia and 3.4 times more likely in far north Queensland. All regional and remote residents accessed diagnostic sleep studies at a rate less than Australia overall (31/100,000/y (95% confidence interval, 21-44) compared with 575/100,000/y). CONCLUSION: The barriers to diagnosis and ongoing care are likely to relate to remote residence, lower health self-efficacy, the complex nature of the treatment tool, and environmental factors such as electricity and sleeping area. Indigeneity, remote residence, environmental factors, and low awareness of sleep health are likely to affect service accessibility and rate of use and capacity to enhance patient and family education and support following a diagnosis. A greater understanding of enablers and barriers to care and evaluation of interventions to address these are required. COMMENTARY: A commentary on this article appears in this issue on page 1255.

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BACKGROUND: Pulmonary rehabilitation (PR) is recommended in the management of people with chronic obstructive pulmonary disease (COPD), but referral to this service is low. AIMS: To identify barriers to, and facilitators for, referral to PR programmes from the perspective of Australian general practitioners. METHODS: Semi-structured interviews were conducted with general practitioners involved in the care of people with COPD. Interview questions were informed by a validated behavioural framework and asked about participants' experience of referring people with COPD for PR, and barriers to, or facilitators of, this behaviour. Interviews were audiotaped, transcribed verbatim, and analysed using content analysis. RESULTS: Twelve general practitioners participated in this study, 10 of whom had never referred a patient to a PR programme. Four major categories relating to barriers to referral were identified: low knowledge of PR for COPD; low knowledge of how to refer; actual or anticipated access difficulties for patients; and questioning the need to do more to promote exercise behaviour change. Awareness of benefit was the only current facilitator. Three major categories of potential facilitators were identified: making PR part of standard COPD care through financial incentive; improving information flow with regard to referrals and services; and informing patients and public. CONCLUSIONS: Significant barriers to referral exist, but opportunities to change the organisation of practice and information management were identified. Behaviour change strategies which directly target these barriers and incorporate facilitators should make up the key components of interventions to improve referral to PR by general practitioners who care for people with COPD.

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BACKGROUND AND OBJECTIVE: Pulmonary rehabilitation (PR) is recommended in the management of people with chronic obstructive pulmonary disease (COPD), but implementation appears to be low. The aim of this study was to determine the frequency of referral to, and attendance at, PR programmes in a sample of patients with COPD. METHODS: A cross-sectional study of patients admitted to a tertiary hospital in South Australia, with a primary diagnosis of COPD between March and November 2011 was conducted. Data were collected from medical records and patient interview. RESULTS: From 235 admissions with preliminary coding as COPD, 88 patients had COPD as the primary reason for admission and were potentially eligible for rehabilitation. While 57% had been referred to rehabilitation during their disease course, only 18% had attended and completed at least half the programme. Seven patients had attended in the previous 2 years. Mean percentage predicted forced expiratory volume in 1 s was 42% at the time of referral. During the index admission, discussion of rehabilitation resulting in a referral occurred in 14 cases (16%). No demographic or disease characteristics were associated with referral/no referral; being reviewed by a COPD nurse coordinator during admission increased the likelihood of referral (odds ratio = 18.7, 95% confidence interval: 3.8-91.4). CONCLUSIONS: PR had been implemented in a small proportion of patients admitted to hospital with an exacerbation of COPD due to gaps in both referral to and subsequent attendance at a programme. Strategies to improve referral to and participation in PR are required.

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BACKGROUND: Clinical care components for people with COPD are recommended in guidelines if high-level evidence exists. However, there are gaps in their implementation, and factors which act as barriers or facilitators to their uptake are not well described. The aim of this pilot study was to explore implementation of key high-evidence COPD guideline recommendations in patients admitted to hospital with a disease exacerbation, to inform the development of a larger observational study. METHODS: This study recruited consecutive COPD patients admitted to a tertiary hospital. Patient demographic, disease and admission characteristics were recorded. Information about implementation of target guideline recommendations (smoking cessation, pulmonary rehabilitation referral, influenza vaccination, medication use and long-term oxygen use if hypoxaemic) was gained from medical records and patient interviews. Interviews with hospital-based doctors examined their perspectives on recommendation implementation. RESULTS: Fifteen patients (aged 76(9) years, FEV1%pred 58(15), mean(SD)) and nine doctors participated. Referral to pulmonary rehabilitation (5/15 patients) was underutilised by comparison with other high-evidence recommendations. Low awareness of pulmonary rehabilitation was a key barrier for patients and doctors. Other barriers for patients were access difficulties, low perceived health benefits, and co-morbidities. Doctors reported they tended to refer patients with severe disease and frequent hospital attendance, a finding supported by the quantitative data. CONCLUSIONS: This study provides justification for a larger observational study to test the hypothesis that pulmonary rehabilitation referral is low in suitable COPD patients, and closer investigation of the reasons for this evidence-practice gap.

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BACKGROUND: There is a known association between obstructive sleep apnea (OSA) and atrial fibrillation (AF); however, how OSA affects the atrial myocardium is not well described. OBJECTIVE: To determine whether patients with OSA have an abnormal atrial substrate. METHODS: Forty patients undergoing ablation of paroxysmal AF and in sinus rhythm (20 with OSA [apnea-hypopnea index ≥ 15] and 20 reference patients with no OSA [apnea-hypopnea index < 15] by polysomnography) were studied. Multipolar catheters were positioned at the lateral right atrium (RA), coronary sinus, crista terminalis, and RA septum to determine the effective refractory period at 5 sites, conduction time along linear catheters at the RA and the coronary sinus, conduction at the crista terminalis, and sinus node function (corrected sinus node recovery time). Biatrial electroanatomic maps were created to determine the voltage, conduction, and distribution of complex electrograms (duration ≥ 50 ms). RESULTS: The groups had no differences in the prevalence of established risk factors for AF. Patients with OSA had the following compared with those without OSA: no difference in effective refractory period (P = .9), prolonged conduction times along the coronary sinus and RA (P = .02), greater number (P = .003) and duration (P = .03) of complex electrograms along the crista terminalis, longer P-wave duration (P = .01), longer corrected sinus node recovery time (P = .02), lower atrial voltage (RA, P <.001; left atrium, P <.001), slower atrial conduction velocity (RA, P = .001; left atrium, P = .02), and more widespread complex electrograms in both atria (RA, P = .02; left atrium, P = .01). CONCLUSION: OSA is associated with significant atrial remodeling characterized by atrial enlargement, reduction in voltage, site-specific and widespread conduction abnormalities, and longer sinus node recovery. These features may in part explain the association between OSA and AF.

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BACKGROUND: Clinical guidelines for management of patients with chronic obstructive pulmonary disease (COPD) include recommendations based on high levels of evidence, but gaps exist in their implementation. The aim of this study was to examine the perspectives of medical practitioners regarding implementation of six high-evidence recommendations for the management of people with COPD. METHODS: Semi-structured interviews were conducted with medical practitioners involved with care of COPD patients in hospital and general practice. Interviews sought medical practitioners' experience regarding implementation of smoking cessation, influenza vaccination, pulmonary rehabilitation, guideline-based medications, long-term oxygen therapy for hypoxemia and plan and advice for future exacerbations. Interviews were audiotaped, transcribed verbatim and analyzed using content analysis. RESULTS: Nine hospital-based medical practitioners and seven general practitioners participated. Four major categories were identified which impacted on implementation of the target recommendations in the care of patients with COPD: (1) role clarity of the medical practitioner; (2) persuasive communication with the patient; (3) complexity of behavioral change required; (4) awareness and support available at multiple levels. For some recommendations, strength in all four categories provided significant enablers supporting implementation. However, with regard to pulmonary rehabilitation and plans and advice for future exacerbations, all identified categories that presented barriers to implementation. CONCLUSION: This study of medical practitioner perspectives has indicated areas where significant barriers to the implementation of key evidence-based recommendations in COPD management persist. Developing strategies to target the identified categories provides an opportunity to achieve greater implementation of those high-evidence recommendations in the care of people with COPD.

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Cardiac and respiratory rhythms reveal transient phases of phase-locking which were proposed to be an important aspect of cardiorespiratory interaction. The aim of this study was to quantify cardio-respiratory phase-locking in obstructive sleep apnea (OSA). We investigated overnight polysomnography data of 248 subjects with suspected OSA. Cardiorespiratory phase-coupling was computed from the R-R intervals of body surface ECG and respiratory rate, calculated from abdominal and thoracic sensors, using Hilbert transform. A significant reduction in phase-coupling was observed in patients with severe OSA compared to patients with no or mild OSA. Cardiorespiratory phase-coupling was also associated with sleep stages and was significantly reduced during rapid-eye-movement (REM) sleep compared to slow-wave (SW) sleep. There was, however, no effect of age and BMI on phase coupling. Our study suggests that the assessment of cardiorespiratory phase coupling may be used as an ECG based screening tool for determining the severity of OSA.

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BACKGROUND AND OBJECTIVES: Alexithymia is a personality trait associated with difficulty identifying and verbalizing feelings. It has been associated with poorly controlled asthma and near-fatal asthma. The primary objectives were to (1) determine the prevalence of alexithymia in a group of moderate to severe asthmatics who attended an Outpatient Clinic; and (2) investigate the relationship between alexithymia and asthma control, management, and communication. METHODS: Twenty-five moderate to severe asthma patients were recruited from the Royal Adelaide Hospital Outpatient Respiratory Clinic. Participants were either mailed the questionnaire pack or completed it after a clinic appointment. Existing validated questionnaires were used to collect data. The primary outcome measures were alexithymia, asthma control, adherence to medication; patient satisfaction with communication with health care providers and health-related quality of life. Data were analyzed using Pearson correlations, linear regression and analysis of variance (ANOVA) in SPSS. A p value

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The increased morbidity and mortality resulting from respiratory failure in patients with neuromuscular disorders and/or kyphoscoliosis can be reversed with non-invasive ventilation. Spontaneous mode bilevel pressure ventilation is preferred to other modes of ventilation, due to relative ease of use, but may not be suitable for all patients. We report a 27-year old woman with Multi-minicore disease whose respiratory failure was refractory to spontaneous mode bilevel pressure ventilation. When we altered settings and provided mandatory inspiratory rise time and respiratory rate, it augmented her respiratory efforts and improved ventilation. Our case report describes the benefit of individualising non-invasive ventilation in the management of respiratory failure due to neuromuscular weakness and kyphoscoliosis.

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The National Notifiable Disease Surveillance System received 1,201 tuberculosis (TB) notifications in 2006, of which 1,142 were new cases and 59 were relapses. The incidence of TB in Australia was 5.8 cases per 100,000 population in 2006 up from 5.3 per 100,000 in 2005, but still below 6 per 100,000 as it has been since 1985. Eighty-five per cent of TB notifications in 2006 were in people born outside Australia. The incidence in people born overseas and Indigenous Australians were 20.7 and 6.6 cases per 100,000 population, respectively. By contrast, the incidence of TB in the non-Indigenous Australian-born population was 0.9 cases per 100,000 population. Household or other close contact was reported as the most common risk factor for TB infection. The number of cases of TB reported in health care workers increased in 2006; these were mostly in health care workers born in TB-endemic countries and there were no reports of TB transmission in Australian health care settings. Outcome data of the 2005 TB cohort indicates that treatment success was attained in more than 95% of cases. Progress towards TB elimination in Australia will rely on continued TB awareness, maintenance of high standards of TB diagnostic and control practices, and promoting regional and global TB control activities.

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The National Notifiable Disease Surveillance System received 1,072 tuberculosis (TB) notifications in 2005, of which 1,022 were new cases and 50 were relapses. The incidence of TB in Australia was 5.3 cases per 100,000 population in 2005 and has remained at a stable rate since 1985. The high-incidence groups remain people born overseas and Indigenous Australians at 20.6 and 5.9 cases per 100,000 population, respectively. By contrast, the incidence of TB in the non-Indigenous Australian-born population was 0.8 cases per 100,000 population. Rates in the Australian-born, both Indigenous and non-Indigenous have been declining since 1991, while rates in the overseas-born have been increasing. TB control in Australia relies on pre-migration screening and provision of free and effective treatment.

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Obstructive sleep apnoea (OSA) is an independent risk factor for hypertension, which is a major cause of stroke. The prevalence and associations of OSA in a cohort of stroke patients were studied. The safety and tolerability of early treatment with nasal continuous airways pressure (nCPAP) was also assessed. Consecutive subjects admitted with acute stroke were assessed clinically, radiologically and with scales assessing prior OSA risk, dysphagia and disability. Sleep studies were performed within the first few days of admission using a portable diagnostic system. Twenty-nine of 55 (53%) subjects had evidence of OSA, using an apnoea-hypopnoea index (AHI) of 10 or greater. The AHI was significantly associated with an index of prior OSA symptoms, but not with history of hypertension, degree of dysphagia, or type and severity of stroke. Use of a portable diagnostic system for detecting OSA in the acute stroke setting was well tolerated. OSA is common after acute stroke and exceeds rates seen in control populations of similar age (53% vs. 11%). Early treatment with nCPAP was effective and well tolerated.

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The National Notifiable Disease Surveillance System received 1,076 tuberculosis (TB) notifications in 2004, of which 1,043 were new cases and 33 were relapses. The incidence of TB in Australia has remained at a stable rate since 1985 and was 5.4 cases per 100,000 population in 2004. The high-incidence groups remain people born overseas and Indigenous Australians at 21.7 and 8.1 cases per 100,000 population, respectively. By contrast, the incidence of TB in the non-Indigenous Australian-born population was 1.0 cases per 100,000 population. Comparison of the 2004 TB notification data against the performance indicators set by National Tuberculosis Advisory Committee highlights that enhanced TB control measures should be considered among these high-risk groups.

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In 2001, there were 997 cases of tuberculosis (TB) reported to the National Notifiable Diseases Surveillance System, of which, 967 were new cases of TB and 30 cases were relapses. The incidence rate of TB in Australia in 2001 was 5.1 cases per 100,000 population. The highest incidence of TB was reported in people born overseas (19.3 cases per 100,000 population), followed by Indigenous Australians (9.8 cases per 100,000 population). In contrast, the incidence rate of TB in the non-Indigenous Australian-born population was 1.0 cases per 100,000 population. This pattern of TB incidence rates amongst the sub-populations of Australia has been observed for over 10 years. Eighty-six per cent of TB cases completed treatment in 2001. Treatment was unsuccessful in 7 cases and only 22 cases defaulted. The National Tuberculosis Advisory Committee has published a National Strategic Plan with performance indicators to ensure that this enviable record of TB control is maintained and improved.

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