An assessment of introducers used for airway management.

Different introducers are available to assist with tracheal intubation. Subtle differences in the design of introducers can have a marked effect on safety and performance. The Difficult Airway Society's Airway Device Evaluation Project Team proposal states that devices should only be purchased for which there is at least a case-control study on patients assessing airway devices. However, resources are not currently available to carry out a case-control study on all introducers available on the market. This study comprised a laboratory and manikin-based investigation to identify introducers that could be suitable for clinical investigation. We included six different introducers in laboratory-based assessments (design characteristics) and manikin-based assessments involving the participation of 30 anaesthetists. Each anaesthetist attempted placement in the manikin's trachea with each of the six introducers in a random order. Outcomes included first-time insertion success rate; insertion success rate; number of attempts; time to placement; and distance placed. Each anaesthetist also completed a questionnaire. First-time insertion success rate depended significantly on the introducer used (p = 0.0016) and varied from 47% (Armstrong and P3) to 77% (Intersurgical and Frova). Median time to placement (including oesophageal placement) varied from 10 s (Eschmann and Frova) to 20 s (P3) (p = 0.0025). Median time to successful placement in the trachea varied from 9 s (Frova) to 22 s (Armstrong) (p = 0.037). We found that the Armstrong and P3 devices were not as acceptable as other introducers and, without significant improvements to their design and characteristics, the use of these devices in studies on patients is questionable. The study protocol is suitable for differentiating between different introducers and could be used as a basis for assessing other types of devices.

Low-coverage sequencing cost-effectively detects known and novel variation in underrepresented populations.

Genetic studies in underrepresented populations identify disproportionate numbers of novel associations. However, most genetic studies use genotyping arrays and sequenced reference panels that best capture variation most common in European ancestry populations. To compare data generation strategies best suited for underrepresented populations, we sequenced the whole genomes of 91 individuals to high coverage as part of the Neuropsychiatric Genetics of African Population-Psychosis (NeuroGAP-Psychosis) study with participants from Ethiopia, Kenya, South Africa, and Uganda. We used a downsampling approach to evaluate the quality of two cost-effective data generation strategies, GWAS arrays versus low-coverage sequencing, by calculating the concordance of imputed variants from these technologies with those from deep whole-genome sequencing data. We show that low-coverage sequencing at a depth of ≥4× captures variants of all frequencies more accurately than all commonly used GWAS arrays investigated and at a comparable cost. Lower depths of sequencing (0.5-1×) performed comparably to commonly used low-density GWAS arrays. Low-coverage sequencing is also sensitive to novel variation; 4× sequencing detects 45% of singletons and 95% of common variants identified in high-coverage African whole genomes. Low-coverage sequencing approaches surmount the problems induced by the ascertainment of common genotyping arrays, effectively identify novel variation particularly in underrepresented populations, and present opportunities to enhance variant discovery at a cost similar to traditional approaches.

Primary surgical management of anterior pelvic organ prolapse: a systematic review, network meta-analysis and cost-effectiveness analysis.

BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP. METHODS: We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective. MAIN RESULTS: We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values. CONCLUSIONS: Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty. TWEETABLE ABSTRACT: New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.

Bypassing proximal health care facilities for acute care: a survey of patients in a Ghanaian Accident and Emergency Centre.

OBJECTIVE: To characterise the population that presents to the Accident and Emergency Centre (AEC) at Komfo Anokye Teaching Hospital (KATH) and to identify risk factors associated with bypassing proximal care facilities. METHODS: A structured questionnaire was verbally administered to patients presenting to the AEC over 2 weeks. The questionnaire focused on the use of health care resources and characteristics of current illness or injury. Measures recorded include demographics, socioeconomic status, chief complaint, transportation and mobility, reasons for choosing KATH and health care service utilisation and cost. RESULTS: The total rate of bypassing proximal care was 33.9%. On multivariate analysis, factors positively associated with bypassing included age older than 38 years (OR: 2.18, P 0.04) and prior visits to facility (OR 2.88, P 0.01). Bypassers were less likely to be insured (OR 0.31, P 0.01), to be seeking care due to injury (OR 0.42, P 0.03) and to have previously sought care for the problem (OR 0.10, P < 0.001). CONCLUSIONS: Patients who bypass facilities near them to seek care at an urban AEC in Ghana do so for a combination of reasons including familiarity with the facility, chief complaint and insurance status. Understanding bypassing behaviour is important for guiding health care utilisation policy decisions and streamlining cost-effective, appropriate access to care for all patients.

Cost and affordability of healthy food in rural South Australia.

INTRODUCTION: As in many other countries, Australian consumers have recently had to accommodate increases in costs of basic food, and during the financial year 2007-2008 overall food prices rose by nearly 4%. Food costs are mediating factors in food choice, especially for low-income groups, where food security is often tenuous. There are reports that rural populations may have higher levels of food insecurity, although the evidence is often contradictory. METHODS: To assess cost and affordability of food in rural areas this study used the Healthy Food Basket (HFB) methodology, which has been applied in a number of settings. The HFBs were costed at supermarkets and stores in different locations with different degrees of rurality. RESULTS: Compared with metropolitan areas, healthy food is more expensive in rural areas; costs are even higher in more remote areas. The overall affordability of HFB in rural areas was not significantly different from metro areas. The main difference concerned low socio-economic status (SES) groups, where the proportion of household income spent on the HFB was three times that of higher SES groups. CONCLUSIONS: The unaffordability of healthy food, or 'food stress' in low SES groups is a concern, especially when this group carries the greatest burden of diet-related disease. Findings suggest that there is a need to consider both rurality and SES when developing policy responses to decrease the cost and increase the affordability of healthy foods in rural and remote areas.

Ethnicity and social deprivation independently influence metabolic control in children with type 1 diabetes.

AIMS/HYPOTHESIS: This study was performed to evaluate the influence of ethnicity and socioeconomic status (SES) on metabolic control in a population-based cohort of children with type 1 diabetes mellitus, and to evaluate whether any relationship between ethnicity and HbA(1c) is mediated by SES. METHODS: We performed a retrospective review of all patients under age 16 years with type 1 diabetes (n = 555) from 1995 to 2005 in the greater Auckland region, New Zealand. Diabetes care variables and HbA(1c) values were collected prospectively, during clinic visits. RESULTS: The mean population HbA(1c) was 8.3 +/- 1.3%. Maori and Pacific patients had poorer metabolic control than their European counterparts (9.1% and 9.3% vs 8.1%, p < 0.001) and higher rates of moderate to severe hypoglycaemia (31.1 and 24.8 vs 14.9 events/100 patient-years, p = 0.03). In multiple linear regression analysis, both ethnicity and SES were independently associated with HbA(1c) (p < 0.001). Other factors associated with higher HbA(1c) level were longer duration of diabetes, higher insulin dose, lower BMI z score and less frequent blood glucose monitoring (p < 0.001). CONCLUSIONS/INTERPRETATION: Both ethnicity and SES independently influenced metabolic control in a large, unselected population of children with type 1 diabetes. Irrespective of SES, Maori and Pacific youth with type 1 diabetes were at greater risk of both moderate to severe hypoglycaemia and long-term complications associated with poor metabolic control.

The Charlson comorbidity score: a superior comorbidity assessment tool for the prostate cancer multidisciplinary meeting.

INTRODUCTION: Multidisciplinary team (MDT) meetings use precise prognostic factors to select treatment options for patients with prostate cancer. Comorbidity is judged subjectively. Recent publications favour the Charlson comorbidity score (CS) for the use in the management of prostate cancer. We assess the feasibility of using the CS by our MDT in planning the treatment of patients with prostate cancer. PATIENTS AND METHODS: Patients from the histopathology database aged less than 75 years and with a diagnosis of localized prostate cancer between 1993 and 1995 were included in a notes audit. A second group consisted of patients recommended for curative treatment for localized prostate cancer by the local MDT in 2004. Data on comorbidity, prostatic malignancy and survival up to 10 years was collected. The prognostic accuracy of the CS was assessed for those patients offered radical treatment between 1993 and 1995. RESULTS: Of 1043 patients initially assessed, 37 patients with localized prostate cancer were identified. Using Cox regression, we found the CS to be a statistically significant predictor of survival, following radical treatment for localized prostate cancer (P=0.005). Current practice in 2004 (56 patients) shows a mean (range) Charlson probability of 10-year survival for radical prostatectomy of 0.823 (0.592-0.923) and for radical radiotherapy of 0.653 (0.07-0.936). CONCLUSIONS: Our results support the findings of recent research. We also found the CS easy to calculate and therefore feasible to use in our MDT setting. We propose the introduction of the Charlson score by prostate cancer MDTs to assess age and comorbidity.

Establishing the National Chlamydia Screening Programme in England: results from the first full year of screening.

BACKGROUND: The phased implementation of the National Chlamydia Screening Programme (NCSP) began in September 2002. The NCSP offers opportunistic screening for chlamydia to women and men under 25 years of age attending clinical and non-clinical screening venues using non-invasive urine or vulvo-vaginal swab samples tested via nucleic acid amplification. This review describes the implementation of the NCSP, reports positivity rates for the first year, and explores risk factors for genital chlamydial infection. METHODS: Cross sectional study of the first year's screening data from the NCSP. A standardised core dataset for each screening test was collected from 302 screening venues, excluding genitourinary medicine (GUM) clinics, across 10 phase 1 programme areas. We estimated chlamydia positivity by demographic and behavioural characteristics, and investigated factors associated with infection through univariate and multivariate analyses. RESULTS: Chlamydia positivity among people under 25 years of age screened in non-GUM settings was 10.1% (1538/15 241) in women and 13.3% (156/1172) in men. Risk factors varied by sex: for women-age 16-19, non-white ethnicity, and sexual behaviours were associated with infection; for men-only age 20-24 and non-white ethnicity were associated with infection. DISCUSSION: In the first phase of the NCSP, 16 413 opportunistic screens among young adults under 25 years of age were performed at non-GUM settings and testing volume increased over time. Rates of disease were similar to those found during the English screening pilot and were comparable to the first year of widespread screening in Sweden and the United States. The screening programme in England will continue to expand as further phases are included, with national coverage anticipated by 2008.

Predictors of social support and caregiver outcomes.

PURPOSE: This study identified predictors of caregiver's burden, satisfaction, depression, and social support. Little has been done to identify predictors of social support for caregivers at risk for negative outcomes. DESIGN: Correlational descriptive study. METHODS: A subset of interview data from a larger intervention study was utilized. Independent variables were caregiver/care-recipient characteristics and social support. Dependent variables included caregiver burden, satisfaction, depression, anxiety, and hostility. RESULTS: Eighty-one caregiver/care-recipient dyads from the community participated in this study. Caregivers were women with a mean age of 67.53 years (range 39-86). Difficulty arranging assistance from confidante or friends correlated significantly and positively with caregiver burden (r = .38; p <.001) and depression (r = .34; p = .002), and negatively with satisfaction (r = -.28; p = .013). FINDINGS/IMPLICATIONS: Arranging assistance is more important than frequency of social network contact with respect to burden and depression. The findings indicate a need for further investigation and the consideration of interventions for at risk caregivers.

Maximum cold-induced food consumption in mice selected for high locomotor activity: implications for the evolution of endotherm energy budgets.

We studied house mice (Mus domesticus) that had been artificially selected for high activity to test the hypothesis that a high capacity for energy assimilation in cold-exposed endotherms could evolve as a correlated response to selection for increased locomotor activity. After 10 generations of selection for increased voluntary wheel-running, mice from four selected lines ran 75 % more wheel revolutions per day than did mice from four random-bred, control lines. The maximum cold-induced rates of food consumption (C(max); mean 10.6 g day(-1)) and energy assimilation (A(max); mean 141 kJ day(-1)) were not significantly higher in the selected than in the control mice. However, in cold-exposure trials, mice from the selected lines maintained body mass better than did mice from the control lines. C(max) and A(max) were positively correlated with the amount of wheel-running activity measured before cold-exposure and also with the rates of food consumption measured when the mice had access to running wheels. In females at least, the correlation was significant not only among individuals but also among adjusted means of the replicate lines, which suggests the presence of a positive genetic correlation between the traits. Thus, despite the lack of a significant difference between the selected and control lines in maximum rate of food consumption, the remaining results conform to the hypothesis that a selection for increased locomotor activity could be a factor behind the evolution of the ability to sustain activity and maintain energy balance during prolonged cold-exposure, as occurred during the evolution of mammalian and avian endothermy.

Applying your corporate compliance skills to the HIPAA security standard.

Compliance programs are an increasingly hot topic among healthcare providers. These programs establish policies and procedures covering billing, referrals, gifts, confidentiality of patient records, and many other areas. The purpose is to help providers prevent and detect violations of the law. These programs are voluntary, but are also simply good business practice. Any compliance program should now incorporate the Health Insurance Portability and Accountability Act (HIPAA) security standard. Several sets of guidelines for development of compliance programs have been issued by the federal government, and each is directed toward a different type of healthcare provider. These guidelines share certain key features with the HIPAA security standard. This article examines the common areas between compliance programs and the HIPAA security standard to help you to do two very important things: (1) Leverage your resources by combining compliance with the security standard with other legal and regulatory compliance efforts, and (2) apply the lessons learned in developing your corporate compliance program to developing strategies for compliance with the HIPAA security standard.

Energy cost of wheel running in house mice: implications for coadaptation of locomotion and energy budgets.

Laboratory house mice (Mus domesticus) that had experienced 10 generations of artificial selection for high levels of voluntary wheel running ran about 70% more total revolutions per day than did mice from random-bred control lines. The difference resulted primarily from increased average velocities rather than from increased time spent running. Within all eight lines (four selected, four control), females ran more than males. Average daily running distances ranged from 4.4 km in control males to 11.6 km in selected females. Whole-animal food consumption was statistically indistinguishable in the selected and control lines. However, mice from selected lines averaged approximately 10% smaller in body mass, and mass-adjusted food consumption was 4% higher in selected lines than in controls. The incremental cost of locomotion (grams food/revolution), computed as the partial regression slope of food consumption on revolutions run per day, did not differ between selected and control mice. On a 24-h basis, the total incremental cost of running (covering a distance) amounted to only 4.4% of food consumption in the control lines and 7.5% in the selected ones. However, the daily incremental cost of time active is higher (15.4% and 13.1% of total food consumption in selected and control lines, respectively). If wheel running in the selected lines continues to increase mainly by increases in velocity, then constraints related to energy acquisition are unlikely to be an important factor limiting further selective gain. More generally, our results suggest that, in small mammals, a substantial evolutionary increase in daily movement distances can be achieved by increasing running speed, without remarkable increases in total energy expenditure.

The provision of psychosexual services by genitourinary medicine physicians in the United Kingdom.

A postal questionnaire survey, enquiring about the provision of psychosexual services, was sent to each GUM clinic in the UK. Of the 246 questionnaires distributed, replies were received from 166 directors responsible for 171 (69.5%) clinics. Of the 140 (84%) who supported the provision of a sexual dysfunction service, 59 (42%) currently provided such a service. Doctors and psychologists were the health care professionals most commonly involved in sexual dysfunction services for patients who were referred both internally and from external sources such as general practice and diabetic clinics. Patients with a variety of dysfunctions were being treated with a broad range of therapies, a reflection probably of the multidisciplinary nature of the team providing the service. However, it appears that junior doctors are not being trained in this field at present.

Stereotactic breast biopsy is accurate, minimally invasive, and cost effective.

BACKGROUND: We reviewed our experience with stereotactic core needle breast biopsy (SCNBB) for accuracy, complication rate, and staging profile of malignancies diagnosed. METHODS: Since March 1993, 530 stereotactic biopsies were performed. Of these, 25 cases underwent stereotactic core needle biopsy with subsequent wire-guided biopsy. RESULTS: In 25 patients with stereotactic and open biopsy, there was an accuracy for SCNBB of 96%. The number of biopsies rose from 100 to 250 biopsies annually, with an equivalent pre-test positive predictive value for mammography (17% to 19% historical versus 20% with SCNBB). The total number of de novo cancer diagnoses have increased from a mean of 57 to a mean of 71 annually. The percentage of tumors in situ, stage I or stage II, has increased from 60% to 69%. CONCLUSIONS: Stereotactic core needle biopsy combines a high accuracy with a low complication rate. Its aggressive application for tissue diagnosis in suspicious nonpalpable mammographic lesions has increased the proportion of early (in situ and T1 or T2) tumors discovered, and increased the total number of breast cancers diagnosed.

Nursing staff back injuries: prevalence and cost in long term care facilities.

This report describes the period prevalence and cost of back injuries to nursing staff of long term care facilities in comparison to nurses employed industry wide and to other occupations industry wide. The period prevalence of back injuries to nursing staff in long term care facilities was highest for nurse aides, followed by LPNs and then RNs. Nurses (combined) had a period prevalence of back injuries nearly 1.5 times higher than all employees of long term care facilities and 6 times higher than all occupations combined industry wide. Within long term care facilities, nurses sustaining back injuries were younger and had been employed for a shorter period of time than the average for all nurses employed in long term care facilities. Back injuries accounted for more than half of the indemnity and medical costs for all injuries incurred in nursing homes and industry wide. The findings highlight the need for better prevention and rehabilitation

Cost-effectiveness of cervical cytologic examination during pregnancy.

BACKGROUND: We undertook a study to determine the cost-effectiveness of performing routine cervical cytologic examination during pregnancy. METHODS: The costs generated by doing routine prenatal cervical cytologic examination were calculated based on chart review in a family practice setting. A consecutive sample of 523 patients giving birth during 1990 was used. Analysis was done on 423 of those patients with prenatal Papanicolaou smear results recorded. Cost savings from detection of curable disease and utility of the test in terms of well-years saved were calculated from published statistics using a single-step Markov process to model the population at risk. RESULTS: For patients of all ages using a discount rate of 5 percent, the cost generated by prenatal cervical cytologic examination was $146,400 per well-year of life saved. Age stratification showed cost per well-year to range from $321,600 for patients aged 15 to 19 years to $48,800 for those aged 35 to 39 years. CONCLUSIONS: Routine prenatal cervical cytologic examination is significantly less cost-effective than the most commonly done medical procedures. If medical funding is limited, elimination of this test should be considered for women with normal findings on cervical cytologic examinations within the previous 2 to 3 years.

Reduction of psychiatric inpatient stay for older adults by intensive case management.

An intensive case management program was offered for a 5-month period to all older persons admitted to a county inpatient unit. A quasiexperimental design was used for program evaluation with comparison to a preintervention baseline period and to younger adults on the inpatient unit during both baseline and intervention periods. Length of stay was reduced from 27 days during baseline to 12 days during intervention. For the younger patient group, length of stay changed from 11 to 12 days. Contrary to expectation, older patients were the young-old, mostly first admissions, and with mostly functional rather than organic diagnoses. This reduction in length of stay would save about $6,750 per geriatric admission.