Narrowband ultraviolet B treatment for psoriasis is highly economical and causes significant savings in cost for topical treatments.

BACKGROUND: Narrowband ultraviolet B (NB-UVB) treatment for psoriasis is considered expensive. However, existing data are based on estimates and do not consider indirect cost savings. OBJECTIVES: To define the actual costs of NB-UVB incurred by the service provider, as well as treatment-associated cost savings. METHODS: We performed data linkage of (i) comprehensive treatment records and (ii) prescribing data for all NB-UVB treatment episodes spanning 6 years in a population of 420 000. We minimized data fluctuation by compiling data from four independent treatment sites, and using drug prescriptions unrelated to psoriasis as a negative control. RESULTS: National Health Service Tayside spent an average of £257 per NB-UVB treatment course (mean 257 ± 63, range 150-286, across four independent treatment sites), contrasting sharply with the estimate of £1882 used by the U.K. National Institute for Health and Care Excellence. The cost of topical treatments averaged £128 per patient in the 12 months prior to NB-UVB, accounting for 42% of the overall drug costs incurred by these patients. This was reduced by 40% to £53 per patient over the 12-month period following NB-UVB treatment, while psoriasis-unrelated drug prescription remained unchanged, suggesting disease-specific effects of NB-UVB. The data were not due to site-specific factors, as confirmed by highly similar results observed between treatment sites operated by distinct staff. Finally, we detail all staff hours directly and indirectly involved in treatment, allowing direct translation of cost into other healthcare systems. CONCLUSIONS: NB-UVB is a low-cost treatment; cost figures currently used in health technology appraisals are an overestimate based on the data presented here. Creating or extending access to NB-UVB is likely to offer additional savings by delaying or avoiding costly third-line treatments for many patients.

Routine use of PICO dressings may reduce overall groin wound complication rates following peripheral vascular surgery.

BACKGROUND: Approximately 19% of morbidity in peripheral vascular surgery is attributable to wound complications, which can result in delayed healing, and also arterial or graft infection leading to limb loss and even mortality in extreme cases. AIM: To determine whether groin wound complications were reduced following the routine introduction of PICO negative pressure wound therapy dressings in patients who underwent peripheral vascular surgery. METHODS: Patients who underwent peripheral vascular surgery from 2011 to 2016 were identified and divided into PICO and non-PICO groups. Patient, procedure and wound characteristics were tabulated and analysed. Patients were followed-up for at least six weeks postoperatively. Wound complication rates, infection confirmed by microbiology, and requirement for re-admission due to wound complications were noted. Basic cost analysis was performed. FINDINGS: In total, 151 patients were analysed (N = 73 PICO, N = 78 non-PICO). No difference in age (P = 0.862), body mass index (P = 0.673), diabetes (P = 0.339), pre-operative albumin (P = 0.196), use of drain (P = 0.343) and history of meticillin-resistant Staphylococcus aureus (P = 0.281) was observed between groups. The PICO group contained more smokers than the non-PICO group (45% vs 29%, P = 0.034). Wound complications were seen in 8% (N = 6) of the PICO group and 19% (N = 15) of the non-PICO group (P = 0.042). No significant difference in infection was found between the two groups (3% vs 6%, P = 0.249), but fewer seromas were observed when PICO dressings were used (1.4% vs 7.7%, P = 0.069). Haematoma (2.7% vs 3.8%, P = 0.531) and dehiscence rates (1.4% vs 1.3%, P = 0.735) were similar between the two groups. CONCLUSIONS: Routine use of PICO dressings is associated with a reduction in wound complication rates following peripheral vascular surgery, and is cost-effective.

Help-Seeking Behavior in Survivors of Intimate Partner Violence: Toward an Integrated Behavioral Model of Individual Factors.

This study examined individual behavioral predictors of help-seeking using the frameworks of the Andersen model and the theory of planned behavior in a sample of help-seeking female survivors of intimate partner violence (IPV). In-person interviews were conducted with 372 women (Mage = 34.41 years, 66% African American). Results indicated that variables suggested by the Andersen model, including age, depression, psychological aggression, and posttraumatic stress-related arousal symptoms, were significant predictors of help-seeking. Variables suggested by the theory of planned behavior, including perceived helpfulness of resource and perceived controllability of the violence, were also significantly related to help-seeking. However, a combined model including variables from both theoretical approaches accounted for the most variance in help-seeking behavior. Overall, results suggest that these models are useful conceptualizations of help-seeking in an IPV population and that it is important to consider personal characteristics, need-based variables, and cognitive factors in outreach efforts.

Patients Accessing Ambulatory Care for HIV-infection: Epidemiology and Prevalence Assessment.

This study describes the demographics and treatment status of HIV-infected adults accessing ambulatory care in the Republic of Ireland and estimates diagnosed HIV prevalence rates. 3254 HIV-infected adults attended 1 of the 6 specialist HIV centres in the 12- month period 1st July 2009 to 30th June 2010. 2023/3254 (62%) were male, 1761/3133 (56%) Irish and 1048/3133 (34%) African. 1924/3098 (62%) resided in the Dublin area. The mean age was 39.8 years (SD 9.3); probable route of acquisition was available for 2898/3254 (89%); heterosexual acquisition accounted for 1442 (50%), MSM 777 (27%) and IDU 598 (21%). 2574/3202 (80%) were on highly active antiretroviral therapy (HAART). Of these 87% had HIV-RNA levels < 50cpm and 94% < 500cpm. The HIV diagnosed prevalence rate is estimated at 1.09/1000 nationally and at 2.25/1000 in the Dublin area for 15-59 year olds.

A study of service provision in psychocutaneous medicine.

BACKGROUND: Psychocutaneous medicine concerns the recognition and treatment of psychological distress and psychiatric morbidity associated with dermatological diseases. A study in 2004 examining resources in the UK highlighted a number of deficiencies, and recommended that psychodermatology services be available, at least regionally, in the UK. Although there is now increased recognition of psychodermatology, this study of the availability of these services shows that provision has deteriorated since 2004. AIM: To study the service provision of psychocutaneous medicine in the UK. METHODS: Consultants in dermatology units across the UK were asked to take part in an online survey, accessible via an emailed link. This consisted of 10 questions concerning availability of psychodermatology services and psychological support for patients within their local trusts, both in adult and in child and adolescent medicine. Basic percentages were used to analyse quantitative data and content analysis for qualitative data. RESULTS: From 154 surveys, 127 responses were returned. The data indicated that despite frequently encountering patients who required psychological and psychiatric input, a large majority of UK dermatologists have inadequate access to appropriate support in their department. Importantly, this included the child and adolescent medicine and skin cancer departments, despite there being clear objectives for these services to be routinely available. CONCLUSIONS: A lack of resources in psychocutaneous medicine was highlighted in 2004, and the situation has not improved, or is, if anything, worse. Essential access to psychiatric and psychological support for patients is not currently available in most dermatology departments across the country.

Nonequilibrium fluctuation-dissipation inequality and nonequilibrium uncertainty principle.

The fluctuation-dissipation relation is usually formulated for a system interacting with a heat bath at finite temperature, and often in the context of linear response theory, where only small deviations from the mean are considered. We show that for an open quantum system interacting with a nonequilibrium environment, where temperature is no longer a valid notion, a fluctuation-dissipation inequality exists. Instead of being proportional, quantum fluctuations are bounded below by quantum dissipation, whereas classically the fluctuations vanish at zero temperature. The lower bound of this inequality is exactly satisfied by (zero-temperature) quantum noise and is in accord with the Heisenberg uncertainty principle, in both its microscopic origins and its influence upon systems. Moreover, it is shown that there is a coupling-dependent nonequilibrium fluctuation-dissipation relation that determines the nonequilibrium uncertainty relation of linear systems in the weak-damping limit.

Accuracy of perturbative master equations.

We consider open quantum systems with dynamics described by master equations that have perturbative expansions in the system-environment interaction. We show that, contrary to intuition, full-time solutions of order-2n accuracy require an order-(2n+2) master equation. We give two examples of such inaccuracies in the solutions to an order-2n master equation: order-2n inaccuracies in the steady state of the system and order-2n positivity violations. We show how these arise in a specific example for which exact solutions are available. This result has a wide-ranging impact on the validity of coupling (or friction) sensitive results derived from second-order convolutionless, Nakajima-Zwanzig, Redfield, and Born-Markov master equations.

Clinical assessment of near-infrared spectroscopy for noninvasive diabetes screening.

BACKGROUND: Current diabetes screening techniques comprise the fasting plasma glucose (FPG) and oral glucose tolerance tests. Both tests demand patient compliance, and neither test has ideal performance. Near-infrared (NIR) spectroscopy is a noninvasive means of interrogating characteristics of a sample and is evaluated as a novel screening method for type 2 diabetes. METHODS: One hundred fifty-four patients with and without type 2 diabetes were recruited. Their forearm skin was measured with the NIR spectroscopic system, and a capillary blood glucose measurement was also taken. Sixty-six patients returned for a second visit at a later date. A multivariate model, generated from a separate training study, was employed to produce a quantitative risk marker of disease for each NIR spectrum. Sensitivity and specificity (the probabilities that the NIR method will correctly identify a subject as having diabetes or as not having diabetes, respectively) were calculated. As the NIR method produces a continuous rather than categorical classification, various thresholds were evaluated to give several sensitivity and specificity pairs. Test reproducibility was also determined. RESULTS: At a false-positive rate of 70%, the NIR test had a sensitivity of 77.7%, which is comparable to the 77.3% sensitivity for the FPG test as reported for the Third National Health and Nutrition Examination Survey (NHANES III) study. The reproducibility of the NIR test was also similar to the FPG test (inter-day agreement rates of 84.2% and 79.2%, respectively). CONCLUSIONS: A noninvasive NIR spectroscopic measurement of the volar forearm was shown to have comparable performance characteristics with the FPG test. The source of the spectroscopic signal is still uncertain and is the subject of ongoing research.

Risk factors for nosocomial pneumonia. Focus on prophylaxis.

Despite an increased understanding of the pathogenesis of NP and advances in diagnosis and treatment, the risk, cost, morbidity, and mortality of NP remain unacceptably high. This article has identified strategic areas for primary and secondary prophylaxis that are simple and cost-effective. Realizing that the pathogenesis of NP requires bacterial colonization and the subsequent entry of these bacteria into the lower respiratory tree helps highlight the role of cross-infection and the importance of standard infection control procedures. Similarly the role of sedation and devices as risk factors can be reduced by minimizing the duration and intensity of sedation and length of exposure to invasive devices. Additional low-cost interventions that have been shown to be effective in preventing NP are the positioning of patients in a semirecumbent position and the appropriate use of enteral feeding, antibiotics, and selected medical devices. Prophylaxis of NP and VAP is carried out best by a multidisciplinary management team comprised of physicians (critical care, pulmonary medicine, infectious diseases, and primary care), critical care and infection control nurses, and respiratory therapists, even though this approach may result in decreased professional autonomy and freedom. This group should review the current guidelines, pathways, and standards for short-term and long-term prophylaxis of NP and VAP, then integrate them into and monitor their use for routine patient care. The risk factors and prophylaxis strategies for NP discussed in this article apply primarily to patients in acute care facilities, but also are relevant to alternative health care settings as well as the care of ill patients in ambulatory settings. The routine use of effective team policies for prophylaxis needs to be monitored by the Joint Commission for the Accreditation of Health Care or other agencies. Research to delineate the most effective and feasible strategies for prophylaxis NP has been compromised by insufficient funding and lack of adequate, randomized multicenter studies to enable generalizability of results. Effective strategies for prophylaxis have not been disseminated widely or implemented in hospitals. Successful short-term and long-term strategies for prophylaxis must be evaluated and implemented by a team of physicians, nurses, and respiratory therapists. More than 100 years ago, Sir William Osler warned health care providers, "Remember how much you don't know." The authors would add that clinicians have acquired significant knowledge about risk factors and prophylaxis of NP in the 1980s and 1990s, but prophylaxis as a theory rather than an action. If the tree has not been planted, the time is now.

Does prior administration of enoxaparin influence the effects of levobupivacaine on blood clotting? Assessment using the Thrombelastograph.

The low molecular weight heparin, enoxaparin (by inhibition of factors Xa and IIa) and amide local anaesthetics (by altering platelet function) exert anti-clotting effects. Although these agents are often used in combination during the perioperative period, their potential interactive effect on clotting has not been defined. Blood from 10 ASA I-II patients who received enoxaparin 0.5 mg kg(-1) s.c. was studied using a Thrombelastograph (TEG) either alone or in combination with levobupivacaine (2.5 mg ml(-1) or 2.5 microg ml(-1)) or saline (50% dilution). In blood from patients who had received enoxaparin 0.5 mg kg(-1) s.c. 12 h previously, levobupivacaine 2.5 mg ml(-1) (but not 2.5 microg ml(-1)) produced significant changes in TEG clotting parameters (mean (SD) 15.7 (4.8) mm, 29.6 (25.6) mm, 34.4 (14.6) mm, 34.3 (12.2) degrees compared with control values of 6.1 (1.3) mm, 2.5 (0.5) mm, 63.5 (6.4) mm and 74.1 (2.9) degrees for r, K, MA, and alpha angle respectively).

Commentary: quality of alcohol, drug, and mental health services for American Indian children and adolescents.

American Indian children and adolescents suffer from a high prevalence of alcohol, drug, and mental (ADM) disorders. Unfortunately, the systems of services for these children and youth have never been able to address adequately their mental health needs. Thus, the revolutionary changes now taking place within these service systems, in particular the marked increase in the direct provision of services by Indian tribes and organizations, provides a unique opportunity to address these historical shortcomings. In this paper, we describe our existing knowledge concerning the quality of ADM services for American Indian children and adolescents and their critical sociodemographic, sociocultural, and epidemiologic contexts. We then consider the implications of these studies for improving the quality of care as well as its measurement and monitoring.

The Trust experience: eight years on.

In 1992 the author described her experience of working in a newly formed acute NHS Trust hospital. One of the key messages of the paper concerned the pace of radical changes experienced. Eight years on, the process of change has accelerated still further, and healthcare professionals working in the NHS face newer and tougher challenges with regard to funding, recognition and survival. This paper describes the author's personal view of developments so far.

An interprovincial external quality assessment of the ability of Canadian laboratories to detect the vancomycin and penicillin resistance of Enterococcus faecium D366.

OBJECTIVE: To evaluate the ability of Canadian laboratories to identify enterococci and detect low-level resistance to penicillin, ampicillin and vancomycin in five provinces and two territories by two external quality assessment schemes. METHODS: Enterococcus faecium, strain D366, with minimum inhibitory concentrations for vancomycin and penicillin of 32 and 16 mg/L respectively, was distributed during a routine proficiency survey. Laboratories were required to culture and identify the isolate and to test antimicrobial susceptibility. Participants were assessed against consensus reference values. RESULTS: Three hundred and sixty-four hospital, commercial and public-health laboratories participated, using their established procedures for patient samples. The isolate was identified to the species level by 222 (61%) laboratories and to the genus level by a further 98 participants. Forty-four failed to meet the expected standard. Vancomycin resistance was detected by 94%. Those reporting a falsely susceptible result used disk diffusion testing. Penicillin resistance was noted by 250 of 258 laboratories reporting on this agent. An incorrect ampicillin-susceptible finding was reported by 62 of 147 laboratories using automated microdilution or agar dilution methods. CONCLUSIONS: Most laboratories identified the isolate to an appropriate level. Detection of low-level vancomycin and penicillin resistance was achieved by the majority. Ampicillin resistance was less readily detected.

Early detection of prostate cancer. Part II: Estimating the risks, benefits, and costs. American College of Physicians.

PURPOSE: To evaluate the potential benefits, harms, and economic consequences of digital rectal examination and measurement of prostate-specific antigen (PSA) for the early detection of prostate cancer. DATA SOURCES: Relevant studies were identified from a MEDLINE search (1966 to 1995), reviews, bibliographies of retrieved articles, author files, and abstracts. STUDY SELECTION: Probabilities for individual clinical outcomes were derived from various sources, including the largest screening study of community volunteers to data, analyses of Medicare claims, and recently published meta-analyses of the outcomes of alternative treatment strategies. Cost estimates were based on the 1992 Medicare fee schedule. DATA EXTRACTION: A cost-effectiveness model for one-time digital rectal examination and PSA measurement was constructed to examine the possible outcomes. RESULTS: If a favorable set of assumptions is used, one-time digital rectal examination and PSA measurement may increase average life expectancy by approximately 2 weeks at a reasonable marginal cost for men who are between 50 and 69 years of age. Considerable iatrogenic illness would occur. If less favorable assumptions are used, the estimated net benefit would decrease and cost-effectiveness ratios would dramatically increase. Even if favorable assumptions are used, the model suggests that screening adds only a few days to the average life expectancy of men who are older than 69 years of age. If the assumptions are less favorable, older men are harmed. CONCLUSIONS: The model suggests that screening may be reasonable in younger men if optimistic assumptions consistent with existing observational data are made. The lack of direct evidence showing a net benefit of screening for prostate cancer seems to mandate more clinician-patient discussion for this procedure than for many other routine tests.

The Diabetes Care Support Service for general practitioners in Auckland.

AIMS: Diabetic complications can often be prevented by timely detection and intervention. Optimising diabetes care requires effective monitoring of risk factors at both practice and district level. We describe a novel method which combines district monitoring of diabetes with enhanced diabetes care by individual general practitioners. METHODS: All general practitioners in south and west Auckland (n = 291) were invited to join the Diabetes Care Support Service (DCSS). This involved the identification of all diabetic patients within the practice and the completion of an audit from with key measures of diabetes and its care. RESULTS: Audit was completed for 217 (75%) of general practitioners and 4611 diabetic patients: 39% of general practitioners completed their own audit. The proportion of completed patient assessments ranged between 35% (foot pulses) and 89% (blood pressure). The process was found to be helpful by 88% of general practitioners (who commented). CONCLUSION: The DCSS is a seamless, service-orientated approach to the delivery of diabetes care by primary and secondary services and is likely to improve care district-wide and identify the need for further interventions. Subsequent audit passes will allow the demonstration and monitoring of any changes that occur, as well as the demonstration of its feasibility and acceptability on an ongoing basis.

Ethnic differences in diabetes care in a multiethnic community in New Zealand.

Residents of two districts of South Auckland, New Zealand with a high proportion of Maori and Pacific Islands people were visited door to door to ascertain the prevalence of known diabetes and its tissue damage. The household survey canvassed 55,518 residents in 12,770 (91%) of 14,002 residences. Diabetes interviews were available for 176,214 (82%) Europeans, 286,336 (85%) Maori and 495,585 (85%) Pacific Islands diabetic patients. Europeans were older than Maori and Pacific Islands patients currently and at diagnosis. When compared with Europeans, Maori and Pacific Islands patients had a higher chance of having had their diabetes diagnosed in pregnancy, were least likely to be receiving antihypertensive or insulin therapy, were more likely to be blind, and were more likely to have received retinal photocoagulation. There were no ethnic differences in either the proportion of those receiving no ongoing care or in the proportion seen at least once by the diabetes services. Maori people were most likely to be current smokers, were most likely to have defaulted from the diabetic diet and to be dissatisfied with the diabetes service. Pacific Islands people were least likely to have neuropathic symptoms in their feet or to report a known myocardial infarction. Significant ethnic differences in diabetes and its care exist in South Auckland.

Quality improvement of diagnostic microbiology through a peer-group proficiency assessment program. A 20-year experience in Ontario. The Microbiology Committee.

OBJECTIVE: To evaluate the microbiology laboratory performance in Ontario over a 20-year period of participation in a quality assessment program and to assess the impact of quality improvement strategies. DESIGN: Longitudinal review of isolation, identification, and antimicrobial susceptibility testing of bacteria from lyophilized, simulated patient samples. SETTING: Ontario medical laboratories, licensed by the Ministry of Health, have been subjected to mandatory testing by the Laboratory Proficiency Testing Program of the Ontario Medical Association since 1974. Survey reports, information bulletins, correspondence, on-site consultations, educational assistance tutorials, and teleconference education are used as quality improvement strategies. PARTICIPANTS AND INTERVENTIONS: Laboratories were subjected annually to 20 external quality assessment challenges. Performance was assessed against consensus reference values. Single survey and cumulative profiles were reviewed by a peer-group panel for acceptable or unacceptable performance. Specific interventions are used to improve collective and individual laboratory performance. RESULTS: The number of microbiology laboratories declined from 335 in 1974 to 190 in 1994. Twenty-one percent failed expected performance standards on initial review. One hundred forty-two on-site consultations and 61 educational assistance tutorials have been provided. Twenty-five laboratories were declared nonproficient. Since 1989, 50% of the laboratories have scored at or above 80% for isolation and identification, but 25% have scored at or below 50% on susceptibility testing, and 10% or fewer have scored at or above 80%. Poor susceptibility testing performance is due to inappropriate agent selection, not testing errors. CONCLUSIONS: The emphasis of the Laboratory Proficiency Testing Program is on quality improvement, not punishment. Performance has improved, but poor performers have the same characteristics as in 1974. Identification to species is common owing to the use of commercial systems. Automated susceptibility testing has increased to 45% of participants.

An assessment of the utilization of diagnostic parasitology laboratory services in Ontario.

OBJECTIVE: Diagnostic parasitology services in Ontario were assessed to determine whether the reduction in the number of provider laboratories from 209 to 70 over the period 1977 to 1994 has affected the availability and quality of service. DESIGN: A questionnaire on parasitology practice was distributed to all laboratories. Responses were validated against data from the requisitions, work cards and reports submitted by licensed parasitology laboratories in a pattern-of-practice survey. SETTING AND PARTICIPANTS: Laboratories in Ontario are licensed by the provincial Ministry of Health and subjected to mandatory proficiency testing. Laboratories not licensed in parasitology may receive specimens for referral to another facility for processing. MAIN OUTCOME MEASURES: Assessment included receipt of fecal specimens for parasitology, on-site testing, the limitation of testing, work referred elsewhere for primary investigation or confirmation, laboratory to which work was referred, and the turnaround time for both on-site and referred work. RESULTS: Ninety-eight per cent of 338 laboratories returned the questionnaire. Three hundred and six received specimens for parasitology. Sixty-four performed the testing. Of the remainder, 235 referred to 40 laboratories. Approximately 31,000 specimens were processed monthly, with 78% examined within private laboratories and 62% having a turnaround time of at least three days. The yield of positive findings was 3% or more of patients. CONCLUSIONS: The presence of fecal parasites has been reliably determined and the genus, species and stage of the organism correctly identified. Utilization must be improved through understanding of the factors increasing the pretest likelihood of a positive finding.

Diversity of urine bacteriology practice in Ontario: An external quality assessment.

OBJECTIVE: Assessment of urine bacteriology practice in Ontario regarding appropriateness of quantification and the accuracy and Système International d'Unités (SI) conformity in the reporting of results. DESIGN AND SETTING: A simulated urine specimen with Escherichia coli at a target of 100×10 colony forming units (CFU)/L was submitted to licensed Ontario bacteriology laboratories. Data on the isolation and quantification of the pathogen were required within a stipulated time. Reference values were determined by consensus agreement of the findings of seven designated laboratories. PARTICIPANTS: The challenge was administered to 182 Ontario laboratories licensed to perform urine bacteriological assessment. There was no stratification by type or complexity of facility. MAIN OUTCOMES: Samples were processed by routine procedures. Date and time of receipt of the sample, date tested, bacterial count, associated quantification units and the method used were the data required. A copy of the report using the laboratory's normal reporting format to user-physicians was requested. RESULTS: The organism was isolated and correctly identified by 179 laboratories. Only 58% of laboratories reported a count of 100×10(3) CFU/L or more, with 42% reporting a count of between 10 and 100×10(3) CFU/L. The majority used a standard 0.001 mL loop method. Only 87 participants reported using the correct notation of SI units, although a further 65 reported as CFU/L. CONCLUSION: The variety of reporting formats is of concern. Processing and reporting should be standardized. Laboratories should provide an explanatory note or interpretation when nomenclature or format of a report is changed.