Etest ECVs/ECOFFs for Detection of Resistance in Prevalent and Three Nonprevalent Candida spp. to Triazoles and Amphotericin B and Aspergillus spp. to Caspofungin: Further Assessment of Modal Variability.

Susceptibility testing is an important tool in the clinical setting; its utility is based on the availability of categorical endpoints, breakpoints (BPs), or epidemiological cutoff values (ECVs/ECOFFs). CLSI and EUCAST have developed antifungal susceptibility testing, BPs, and ECVs for some fungal species. Although the concentration gradient strip bioMérieux Etest is useful for routine testing in the clinical laboratory, ECVs are not available for all agent/species; the lack of clinical data precludes development of BPs. We reevaluated and consolidated Etest data points from three previous studies and included new data. We defined ECOFFinder Etest ECVs for three sets of species-agent combinations: fluconazole, posaconazole, and voriconazole and 9 Candida spp.; amphotericin B and 3 nonprevalent Candida spp.; and caspofungin and 4 Aspergillus spp. The total of Etest MICs from 23 laboratories (Europe, the Americas, and South Africa) included (antifungal agent dependent): 17,242 Candida albicans, 244 C. dubliniensis, 5,129 C. glabrata species complex (SC), 275 C. guilliermondii (Meyerozyma guilliermondii), 1,133 C. krusei (Pichia kudriavzevii), 933 C. kefyr (Kluyveromyces marxianus), 519 C. lusitaniae (Clavispora lusitaniae), 2,947 C. parapsilosis SC, 2,214 C. tropicalis, 3,212 Aspergillus fumigatus, 232 A. flavus, 181 A. niger, and 267 A. terreus SC isolates. Triazole MICs for 66 confirmed non-wild-type (non-WT) Candida isolates were available (ERG11 point mutations). Distributions fulfilling CLSI ECV criteria were pooled, and ECOFFinder Etest ECVs were established for triazoles (9 Candida spp.), amphotericin B (3 less-prevalent Candida spp.), and caspofungin (4 Aspergillus spp.). Etest fluconazole ECVs could be good detectors of Candida non-WT isolates (59/61 non-WT, 4 of 6 species).

Tear lipid layer thickness and ocular comfort with a novel device in dry eye patients with and without Sjögren's syndrome.

BACKGROUND: To measure changes in tear-film lipid-layer thickness (LLT) and symptoms in patients with dry eye symptoms with and without Sjögren's syndrome after using a novel device. The device is designed to promote release of meibomian sebum into the tear film by delivering latent heat to the eyelids. STUDY DESIGN: Two prospective, controlled, randomised, observer-masked, single-intervention studies. METHODS: Two independent studies were conducted in a major university hospital in the South West of England. The first study involved 24 patients with dry eye symptoms without Sjögren's [the PDE study] and the second study involved 31 patients with dry eye symptoms and Sjögren's syndrome (the SS study). The PDE study was randomised into two groups. Group I (12 patients) underwent 10 min of treatment with the activated device and Group II (12 patients) had no treatment. The SS study was similarly randomised into Group I (17 patients) and Group II (14 patients). The LLT and subjective alterations in ocular comfort of each subject were assessed prior and immediately after 5 and 30 min subsequent to the 10-min period. In the SS study, a further assessment was carried out at 60 min. RESULTS: In the PDE study, treated patients exhibited a bilateral increase of LLT at 5 min (right eyes, 1.2 levels, p<0.0005; left eyes, 1.0 levels, p<0.0005, Mann-Whitney) and at 30 min (right eyes, 0.7 levels, p<0.005; left eyes, 0.6 levels, p<0.005). Mean symptom scores improved in the treated group compared with the control group at 5 min (treatment group, +2.0; control group, +0.2; p<0.05) and 30 min (treatment group, +2.8; control group, +0.4; p<0.015). In the SS study, treated patients exhibited a bilateral increase of LLT, 5 min (right eyes, 0.5 levels, p<0.009; left eyes, 0.5 levels, p<0.005, Monte Carlo 2-tailed), 30 min (right eyes, 0.5 levels, p<0.007; left eyes 0.5 levels, p<0.002) and 60 min (right eyes, 0.3 levels, p<0.1; left eyes, 0.3 levels, p<0.05). There was no change in any of the control patients in any of the assessments. With regard to symptom scores, the mean change at 5 min measured +0.8 in the treatment group and remained relatively unchanged at +0.1 in the control group (p<0.1). At 30 min, this change measured +1.3 in the treatment group and +0.1 in the control group (p<0.03) and at 60 min, the change measured +1.5 in the treatment group and remained at +0.1 in the control group (p<0.02). CONCLUSION: Meibomian therapy with this novel device increases LLT and ocular comfort in patients with dry eye symptoms with and without Sjögren's syndrome.

Cost-effectiveness of primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes: results from the Collaborative Atorvastatin Diabetes Study (CARDS).

AIMS/HYPOTHESIS: We estimated the cost-effectiveness of atorvastatin treatment in the primary prevention of cardiovascular disease in patients with type 2 diabetes using data from the Collaborative Atorvastatin Diabetes Study (CARDS). SUBJECTS AND METHODS: A total of 2,838 patients, who were aged 40 to 75 years and had type 2 diabetes without a documented history of cardiovascular disease and without elevated LDL-cholesterol, were recruited from 32 centres in the UK and Ireland and randomly allocated to atorvastatin 10 mg daily (n = 1,428) or placebo (n = 1,410). These subjects were followed-up for a median period of 3.9 years. Direct treatment costs and effectiveness were analysed to provide estimates of cost per endpoint-free year over the trial period for alternative definitions of endpoint, and of cost per life-year gained and cost per quality-adjusted life-year (QALY) gained over a patient's lifetime. RESULTS: Over the trial period, the incremental cost-effectiveness ratio (ICER) was estimated to be 7,608 pounds per year free of any CARDS primary endpoint; the ICER was calculated to be 4,896 pounds per year free of any cardiovascular endpoint and 4,120 pounds per year free of any study endpoint. Over lifetime, the incremental cost per life-year gained was 5,107 pounds and the cost per QALY was 6,471 pounds (costs and benefits both discounted at 3.5%). CONCLUSIONS/INTERPRETATION: Primary prevention of cardiovascular disease with atorvastatin is a cost-effective intervention in patients with type 2 diabetes, with the ICER for this intervention falling within the current acceptance threshold ( 20,000 pounds per QALY) specified by the National Institute for Health and Clinical Excellence (NICE).

Perceived organizational support and perceived external prestige: predicting organizational attachment for university faculty, staff, and administrators.

The present article introduces a social-exchange model of organizational attachment incorporating both direct exchange and indirect exchange. Participants were 325 university employees. The present results indicated that perceived organizational support (POS) and perceived external prestige (PEP) both contribute to organizational attachment. Further, the results showed that the extent to which POS and PEP are related to organizational attachment is moderated by occupational proxies of cosmopolitan-local role orientation. POS was more strongly related to the affective commitment and withdrawal cognitions of staff and administrators than to those of faculty. PEP was more strongly related to affective commitment and withdrawal cognitions of university faculty than to those of university staff and administrators. The authors discussed the need to incorporate relational variables such as PEP into other social-exchange frameworks.

Use of community health needs assessment for regional planning in country South Australia.

This study examined the impact of community health needs assessments used in country South Australian health service planning between 1995 and 1999. Data were collected from regional health planning officers during a Search Conference and a series of Delphi rounds. The needs assessments were found to vary from regionally to locally driven approaches. Locally driven approaches ensured local involvement but the process was slower and required more effort from the planner. It was also felt that locally driven approaches could exacerbate tension between a community's imperatives and the regional focus of regional decision-makers. In the overall regional budgets, the reallocation of health service funds according to the needs assessment findings was only small because of difficulties in refocusing from traditional clinical services in the short term. In contrast, the impact on health service thinking about population health issues was thought to have been more significant, for example, in the development of regional women's health plans. The use of community health needs assessments was useful, but for greater impact these should not now be so 'broad-brushed', but be more focused on feasible changes that health services could support. Other priority-setting techniques, such as marginal analysis, should also be used to determine where maximum health gains can be obtained.

A closer look at the relationship between justice perceptions and union participation.

In this study, a series of nested models was tested to assess the extent to which the relationship between process-related justice and union participation is mediated by perceived union support and union commitment. Members of a steelworkers' local (N = 615) participated in the study. Fit indices most strongly supported a fully mediated model. Unlike previous research, process-related justice was operationalized as 2 distinct variables: procedural and interactional justice. Interactional justice was found to have a substantially stronger relationship with support perceptions than procedural justice. Results also indicated union support accounted for a greater amount of unique variance in union commitment than perceived union instrumentality. The results are discussed in relation to trust theory and the generalization of organization science across different types of organizations.

Immigrants and equitable health-care delivery in rural areas.

In response to settlement patterns in Australia, most immigrant specialist services and programs have been developed in metropolitan locations and large provincial cities. However, immigrants have also settled in smaller numbers in country locations. It is of concern, therefore, to consider how responsive and equitable health-care services can be delivered in country regions when immigrants do not reach the critical mass that would warrant the development of specialist services. This paper draws on a consultation conducted in South Australia to propose a way forward in linking country health services with local immigrant communities and immigrant specialist services in cities.

Prevalence and management of hypertension in type 1 diabetes mellitus in Europe: the EURODIAB IDDM Complications Study.

AIM: To examine the prevalence of hypertension and the rates of hypertension awareness by investigating treatment and control among respondents to the EURODIAB IDDM Complications Study, and to explore the variation in hypertension management by age, sex and end-organ damage. METHODS: A cross-sectional study, examining 3250 randomly selected Type 1 diabetic patients from 31 diabetes clinics in 16 European countries between 1989 and 1990. Mean age was 32.7 years (SD= 10.0) and mean duration of diabetes mellitus (DM) was 14.7 years (SD=9.3). Subjects were asked about a history of high blood pressure (BP) and current prescribed medications were recorded by the subject's physician. Hypertension was defined as having a systolic BP > or = 140 mmHg or diastolic BP > or = 90 mmHg or current use of antihypertensives. Control was defined as a BP < 130/85 mmHg. RESULTS: Twenty-four per cent of subjects had hypertension, among whom fewer than one-half (48.5%) were aware of a previous diagnosis and a similar proportion (42.2%) were on treatment. Only 11.3% of those with hypertension were both treated and controlled. The majority (81%) of those receiving drug therapy for hypertension were on a single drug, most commonly an angiotensin-converting enzyme inhibitor (47%). CONCLUSION: These data show the extent of undermanagement of hypertension in Type 1 DM across Europe prior to the publication of the St. Vincent Declaration and provide a useful baseline against which future improvements in the management of hypertension can be monitored.

Vietnamese women and Pap smears: issues in promotion.

OBJECTIVE: Australian data indicate that Vietnamese-born women in Australia have a significantly higher incidence of cervical cancer than other Australian women. This study explored self-reported factors associated with Vietnamese-born women's participation in cervical screening. METHOD: A structured 60-item questionnaire was used to conduct an interview survey with 199 Vietnamese-born women over the age of 18 years and resident in Adelaide. RESULTS: Eighty-seven per cent (87%) of the women had heard of a Pap smear and 75% had had a test at some time. Reported participation increased with age, education level, marriage and length of stay in Australia. The family doctor was the most important source of information about Pap smears and the majority of the women reported they would have a smear if recommended by their doctor. Friends and family were the second information source about cervix screening. CONCLUSIONS AND IMPLICATIONS: These findings have clear implications for practice. Strategies to promote preventive health messages to this group of women should involve general practitioners and peer networks.

Establishing a new university department of rural health: the first 2 years of the South Australian Centre for Rural and Remote Health.

This study aimed to describe the establishment of a new University Department of Rural Health (UDRH) in South Australia and to report early achievements. In May 1997, the UDRH was established, key staff were recruited, infrastructure was developed and in April 1998 a Joint University Committee on Rural and Remote Health was formed. By mid-1999, 14 full-time equivalent staff were employed in Whyalla and Adelaide. Early achievements include: review of undergraduate rural placements; increased rural clinical placements by 1000 student-weeks; partnership with the Dental School resulting in training opportunities and falling public waiting lists; multidisciplinary teaching practices in four rural sites; priority public health projects established; competitive research grants won; and a capital grant to strengthen Aboriginal health services infrastructure secured. These early achievements demonstrate UDRH potential to have a real impact on health worker education, service delivery, and public health status in rural and remote areas. This strong foundation must now be built on.

Are we providing for ethnic diversity in accident & emergency (A&E) departments?

OBJECTIVES: The aim of the study was to find what data on ethnicity are collected in North Thames Accident & Emergency (A&E) departments. Also to investigate how the data are used, what staff recruitment and training policies were in place, and to discover whether written material in different languages and interpreters were available. METHODS: This was a qualitative study using semi-structured questionnaires. A range of staff working in A&E departments in North Thames (that had a primary care initiative in place) were interviewed. RESULTS: Ethnic origin was recorded in all units but not on every patient. Only one unit had actively recruited staff from an ethnic minority. None of the units had formal training in place for staff to gain an appreciation of issues facing patients from ethnic minorities. Interpreters and written material in appropriate languages were available in all units. CONCLUSIONS: Whilst the needs of patients from ethnic minorities were recognised in all of the units there appeared to be scope for further research and development. There is a need for providers to undertake comprehensive studies on the utilisation and health needs of ethnic minorities attending both primary care and A&E services. Only with this information can more appropriate services be provided.

Multicultural health care: reconciling universalism and particularism.

One of the issues of concern in multicultural health care is the degree to which one universal (or mainstream) service can meet the needs of all groups and the extent to which specialist (or ethno-specific) services are required to meet the needs of particular groups. In order to advance debate on this issue, multiculturalism is examined against concepts of identity, equality, bureaucracy and participation. While the appeal of universal healthcare services is that they appear to deliver equal health care to all, they in fact systematically advantage those whose values most closely fit with the dominant social norms. Although ethnic-specific services may overcome this problem, in that they enable 'tailor-made' care, it is unlikely that they would be able to meet all of the health needs of all people from ethnic minorities, especially in locations where numbers are low. Ethnic minority participation in the processes of the health system is proposed as a way for the universal health system to reconcile the need to treat people equally (universalism), but in accordance with their unique and different needs (particularism).

New drugs, new vaccines, new diseases. An interview with Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases (NIAID).

PIP: This document presents an interview with Dr. Anthony Fauci on the development of a new generation of vaccines to prevent and possibly eradicate a legion of deadly diseases ranging from tuberculosis to AIDS. Infections that have caused major devastations in the world today include tuberculosis, malaria, schistosomiasis, filariasis, pneumococcal pneumonia, influenza, AIDS, and Ebola. Agencies should be making sure that the basic research base in microbiology, immunology, antimicrobials, and vaccinology is at the very highest level. The integration of research efforts between countries depends on collaboration between the investigators of home countries with foreign investigators. Among new developments in vaccinology are an acellular pertussis vaccine for pertussis/whooping cough (an extremely contagious disease that causes death), DNA immunization (a new technique applicable to all types of diseases), and transgenic plants for immunization against hepatitis, pertussis, and polio. As of now, AIDS in Western countries has declined, while in Africa and Asia its spread has accelerated. Combination therapy for AIDS has had a profound impact on the level of the virus in the body; however, the treatment is still vague. The good news with regard to AIDS is that education is having an impact; this is exemplified by the situation in Thailand, where the government together with nongovernmental organizations and the military has begun a crash education campaign regarding prostitutes and the use of condoms. Progress is being made in the search for better vaccine candidates. AIDS-like epidemics involving new diseases are bound to emerge at some future point, though, given the long-term historical trend.^ieng

The radial artery as a bypass graft.

The radial artery is being reintroduced into clinical practice to increase the number of arterial grafts for patients undergoing coronary artery bypass surgery. The radial artery is readily available from one or both forearms and removal is safe in patients who have a normal collateral circulation to the hand. Harvesting the radial artery with the adjacent veins using a minimal touch technique and vasodilators will prevent vasospasm and possibly early occlusion. A concern is that subclinical atheroma is present in many patients. The radial artery can be used as a single graft, anastomosed in a "Y" fashion with the internal mammary artery, or used as a sequential graft. The early mortality and complications are low. There are potential cost savings because the need for an incision in the leg is avoided, so that patients may be discharged early. The early results of radial artery grafting are encouraging. Further follow-up is required to determine the late patency and effects on survival of using the radial artery graft.

The relationship between socioeconomic status and diabetes control and complications in the EURODIAB IDDM Complications Study.

OBJECTIVE: To determine whether there are socioeconomic differences in diabetes control and complications in people with IDDM. RESEARCH DESIGN AND METHODS: We conducted a prevalence survey of 1,217 men and 1,170 women with IDDM age 25-60 years from European clinics. Age at completion of education defined socioeconomic status: < or = 14 years defined those with primary education; 15-18 years, as secondary education; and > 19 years, as college education. Glycemic control, lipids, diet, retinopathy, neuropathy, and heart disease were assessed centrally. RESULTS: People with a primary education were older and had diabetes for longer than those with a college education. The mean percentage of HbA1c was worst in the primary-educated men (6.6 vs. 6.1%, P = 0.0007 for trend) and women (6.5 vs. 6.0%, P = 0.0007). Total cholesterol level was higher in primary-educated than in college-educated men (5.6 vs 5.3 mmol/l, P = 0.002), as was triglyceride level (1.23 vs. 1.02 mmol/l, P = 0.0001). College-educated people were the least likely to be current smokers (P < 0.0001), and were most likely to partake in vigorous exercise (P < 0.001). Surprisingly, There was little difference in the prevalence of heart disease by educational status in men, while it was highest in the least educated women, but proliferative retinopathy was more common in primary- than in college-educated men (16 vs 10%, P = 0.04) as was macroalbuminuria (15 vs 9%, P = 0.03). Glycemic control could not fully account for these differences. CONCLUSIONS: Healthy lifestyles are more prevalent in better educated men and women with IDDM, but these are not reflected in heart disease prevalence in men. The lower prevalence of severe microvascular complications in better educated men, unaccounted for by better glycemic control, requires further investigation.

An outcome study of patient-controlled morphine analgesia, with or without ketorolac, following radical retropubic prostatectomy.

PURPOSE: We compared the effects of postoperative pain control strategies on recovery after radical retropubic prostatectomy. MATERIALS AND METHODS: The results in 22 consecutive patients who underwent radical retropubic prostatectomy between 1993 and 1994 were evaluated. Pain control was achieved using morphine patient-controlled analgesia in 11 patients or nonsteroidal anti-inflammatory ketorolac in 11. Outcome measures were compared between the 2 groups. RESULTS: The interval to return of bowel function, length of hospitalization and total hospital costs were significantly decreased in the ketorolac treated patients. CONCLUSIONS: Pain control with ketorolac affords excellent analgesia while allowing for earlier recovery of bowel function, shorter hospitalization and lower overall costs in patients undergoing radical retropubic prostatectomy.

Challenging old notions of professionalism: how can nurses work with paraprofessional ethnic health workers?

Despite a recognition that health care systems in western countries need to become more responsive to their culturally diverse populations, health professionals have been slow to change their dominant monocultural work practices. Paraprofessional ethnic health workers have been employed in Australia to increase the access of non-English-speaking background communities to health services; however, they have generally not been able to form effective teamwork relationships with health professionals. Research into the use of ethnic health workers is explored to propose changes in the way that professional nurses practise alongside these workers. Concepts within professionalism and within a primary health care approach are considered against a framework of cultural differences between nurses and non-English-speaking background clients. It is unrealistic that nurses should expect to attain the cultural knowledge required to provide total care to all their clients in a diverse society, without a partnership with cultural intermediaries. Such an expectation is likely to produce lists of cultural traits that stereotype ethnic clients, rather than lead to an understanding of each client's individual needs. More effective teamwork between professional nurses and paraprofessional ethnic health workers is proposed so that together they can ensure health care is delivered in ways that are flexible and responsive to cultural differences.

Ethnic health workers in primary health care.

Ethnic health workers were employed to increase the access of communities of non-English-speaking background to health services, but their role has remained unclear in a national health system that has been criticised for being slow to respond to the needs of these communities. Interviews and a questionnaire were used to survey a convenience sample of 40 South Australian ethnic health workers, how they should perform their roles and their ability to fulfil them. Interviews with 11 staff from the New South Wales Ethnic Health Worker Program then provided a broader perspective to the South Australian findings. High-priority roles were to provide help to solve immediate health problems. Roles included providing access as well as services. There were pressures on ethnic health workers to become service providers: clients from non-English-speaking backgrounds expected assistance with a wide range of problems, and mainstream staff lacked competence in meeting these needs. Ethnic health workers' involvement in needs assessment and health agency change was limited by these pressures, by ethnic health workers' separation from the work of mainstream staff and because systematic planning of services to non-English-speaking communities was lacking. The appropriate role for an ethnic health worker is as an access provider, with a greater emphasis on needs assessment and agency change. Agencies need to develop culturally appropriate service plans and training so that ethnic health workers and mainstream staff are better able to work together.