Health service utilization and related costs attributable to diabetes.

AIMS: To estimate the health service use and direct healthcare costs attributable to diabetes using best available data and methods. METHODS: A nationally representative sample of adults aged ≥50 years was analysed (n=8107). Health service use in the previous 12 months included the number of general practitioner visits, outpatient department visits, hospital admissions, and accident and emergency department attendances. Multivariable negative binomial regression was used to estimate the associations between diabetes and frequency of visits. Average marginal effects were applied to unit costs for each health service and extrapolated to the total population, calculating the incremental costs associated with diabetes. RESULTS: The prevalence of diabetes was 8.0% (95% CI: 7.4, 8.6). In fully adjusted models, diabetes was associated with additional health service use. Compared to those without diabetes, people with diabetes have, on average, 1.49 (95% CI: 1.10, 1.88) additional general practitioner visits annually. Diabetes was associated with an 87% increase in outpatient visits, a 52% increase in hospital admissions and a 33% increase in accident and emergency department attendances (P<0.001). The incremental cost of this additional service use, nationally, is an estimated €88,894,421 annually, with hospital admissions accounting for 67% of these costs. CONCLUSION: Using robust methods, we identified substantially increased service use attributable to diabetes across the health system. Our findings highlight the urgent need to invest in the prevention and management of diabetes.

Identifying the needs for competency-based education in Europe: a needs assessment of cardiologists across 52 countries.

Objective: This international needs assessment was mandated by the European Society of Cardiology (ESC) to obtain an in-depth understanding of the current gaps and challenges of European cardiology professionals, with the aim to provide evidence for the development of needs-driven educational and professional development activities. Methods: This ethics-approved needs assessment was conducted among cardiologists from all sub-specialties across 56 countries of Europe and the Mediterranean basin. A mixed-methods research approach was used, combining qualitative in-depth interviews and focus groups with a quantitative survey. Results: Seventy-four (74) cardiologists participated in the qualitative phase and 866 completed the survey. Respondents represented 52 of the 56 targeted countries. Three themes were identified: 1) Challenges in the clinical decision-making process, 2) Challenges in establishing the patient-physician relationship, and 3) Sub-optimal team communication and collaboration. Specific gaps and causalities related to each challenge were found. Although most of the gaps were common across countries and sub-specialties, some significant differences were noted. Conclusion: The findings of this needs assessment indicate gaps and challenges in clinical practice across countries and across sub-specialities. Taking cardiology as an example, this study identifies clear areas of focus, especially around issues of collaboration and communication, for targeted competency-based education in Europe.

The 'Toolbox' of strategies for managing Haemonchus contortus in goats: What's in and what's out.

A dynamic and innovative approach to managing the blood-consuming nematode Haemonchus contortus in goats is critical to crack dependence on veterinary anthelmintics. H. contortus management strategies have been the subject of intense research for decades, and must be selected to create a tailored, individualized program for goat farms. Through the selection and combination of strategies from the Toolbox, an effective management program for H. contortus can be designed according to the unique conditions of each particular farm. This Toolbox investigates strategies including vaccines, bioactive forages, pasture/grazing management, behavioural management, natural immunity, FAMACHA, Refugia and strategic drenching, mineral/vitamin supplementation, copper Oxide Wire Particles (COWPs), breeding and selection/selecting resistant and resilient individuals, biological control and anthelmintic drugs. Barbervax(®), the ground-breaking Haemonchus vaccine developed and currently commercially available on a pilot scale for sheep, is prime for trialling in goats and would be an invaluable inclusion to this Toolbox. The specialised behaviours of goats, specifically their preferences to browse a variety of plants and accompanying physiological adaptations to the consumption of secondary compounds contained in browse, have long been unappreciated and thus overlooked as a valuable, sustainable strategy for Haemonchus management. These strategies are discussed in this review as to their value for inclusion into the 'Toolbox' currently, and the future implications of ongoing research for goat producers. Combining and manipulating strategies such as browsing behaviour, pasture management, bioactive forages and identifying and treating individual animals for haemonchosis, in addition to continuous evaluation of strategy effectiveness, is conducted using a model farm scenario. Selecting strategies from the Toolbox, with regard to their current availability, feasibility, economical cost and potential ease of implementation depending on the systems of production and their complementary nature, is the future of managing H. contortus in farmed goats internationally and maintaining the remaining efficacy of veterinary anthelmintics.

Two strategies for phosphorus removal from reject water of municipal wastewater treatment plant using alum sludge.

In view of the well recognized need of reject water treatment in MWWTP (municipal wastewater treatment plant), this paper outlines two strategies for P removal from reject water using alum sludge, which is produced as by-product in drinking water treatment plant when aluminium sulphate is used for flocculating raw waters. One strategy is the use of the alum sludge in liquid form for co-conditioning and dewatering with the anaerobically digested activated sludge in MWWTP. The other strategy involves the use of the dewatered alum sludge cakes in a fixed bed for P immobilization from the reject water that refers to the mixture of the supernatant of the sludge thickening process and the supernatant of the anaerobically digested sludge. Experimental trials have demonstrated that the alum sludge can efficiently reduce P level in reject water. The co-conditioning strategy could reduce P from 597-675 mg P/L to 0.14-3.20 mg P/L in the supernatant of the sewage sludge while the organic polymer dosage for the conditioning of the mixed sludges would also be significantly reduced. The second strategy of reject water filtration with alum sludge bed has shown a good performance of P reduction. The alum sludge has P-adsorption capacity of 31 mg-P/g-sludge, which was tested under filtration velocity of 1.0 m/h. The two strategies highlight the beneficial utilization of alum sludge in wastewater treatment process in MWWTP, thus converting the alum sludge as a useful material, rather than a waste for landfill.

Utilization of FAST (Focused Assessment with Sonography for Trauma) in 1999: results of a survey of North American trauma centers.

Although much has been written about FAST (Focused Assessment with Sonography for Trauma) in the last decade little is known about its present clinical utilization. The purpose of this study was to evaluate and characterize the contemporary utilization of FAST at trauma centers in the United States and Canada. In 1999 trauma directors or their delegates at Level I regional trauma centers in the United States and Canada were surveyed either by fax or phone regarding the present utilization and the future of FAST at their center. The overall survey response rate was 91 per cent with 96 of 105 centers completing the survey. Of the 96 centers surveyed 78 were in the United States and 18 were in Canada. Of the 78 U.S. centers surveyed 62 (79%) routinely use FAST, and it is done by surgeons in 39 per cent, surgeons and emergency departments in 21 per cent, emergency departments in 5 per cent, and radiologists in 35 per cent. Most centers (79%) thought that it sped up their workups, and 89 per cent said it was an advance in patient care. FAST is used in penetrating injury at 58 per cent of centers, and some centers use FAST to assess organ injury. The utilization of diagnostic peritoneal lavage and CT has markedly decreased at many centers. Almost all respondents thought that FAST should be a component of surgery resident training. The utilization of FAST is significantly less in Canada than in the United States (P < 0.05). Our conclusions are the following. FAST has become routinely used at the majority of the U.S. centers surveyed. FAST is performed by clinicians at 65 per cent of the trauma centers surveyed. The utilization of CT and diagnostic peritoneal lavage has changed. Many centers have broadened the scope of FAST to include the assessment of organ, pediatric, and penetrating injury.

Rapid diagnosis of chronic myeloid leukaemia by linking PCR to capillary gel electrophoresis.

The move to the use of molecular diagnostics in medicine has gathered momentum in the last few years and new methodologies are being sought to reduce the labour component and hence the cost of these molecular diagnostics. A method is described which links PCR to capillary electrophoresis and this allows both a rapid and quantitative diagnosis. In the example provided, the diagnosis of chronic myeloid leukaemia, the method describes improvements in cost per test, greater sensitivity over traditional methods and an estimate of the level of product. The latter points are important in those disorders for which bone marrow transplantation is used as a curative regime in providing earlier detection of relapse.

Percutaneous dilational tracheostomy: report of 356 cases.

OBJECTIVE: To evaluate the procedure time, complications, and percutaneous dilational tracheostomy (PDT) charges. DESIGN: Operative data were prospectively collected for 356 PDTs including the initial series of 141 PDTs reported in 1994. Short- and long-term complications were retrospectively identified by review of medical records and patient telephone interviews. MATERIALS AND METHODS: PDT was performed using the "Ciaglia" method of serial dilation over a Seldinger guidewire. Discharged patients (n = 258) were followed for a mean (+/-SD) of 10 +/- 7 months. MEASUREMENTS AND MAIN RESULTS: The mean procedure time was 15 +/- 8 minutes; operative mortality rate, 0.3% (1/356); overall complication rate, 19% (69/356); long-term symptomatic tracheal stenosis rate, 3.7% (8/214). The mean total patient charge for bedside PDT was $1,370; for open tracheostomy in the operating room, $2,675. CONCLUSIONS: Surgeons can rapidly perform PDT at the bedside with a lower risk of complications than open tracheostomy and at a significantly reduced patient charge.

Audit of antibiotic usage in medium-sized general hospital over an 11-year period. The impact of antibiotic policies.

The objective of the present study was to evaluate trends in antibiotic expenditure over an 11-year period (1982-1992) in a 370-bed district general hospital in Northern Ireland and to examine the impact of two separate antibiotic policies on antibiotic usage. A further objective was to examine the attitudes of prescribers to the second policy. Drug utilization review was used to collect information on antibiotic expenditure and usage before and after introduction of separate antibiotic policies in 1985 (not intensively monitored) and 1989 (intensively monitored). A main questionnaire was used to determine the attitudes of prescribers. The first policy (1985) showed no benefits with regard to the number of antibiotic entities stocked (45 before, 45 after), number of dosage units issued (9.3% increase) or expenditure (33.3% increase). The 1989 policy led to significant reductions in the number of antibiotic entities stocked (28.9%), number of antibiotics issued (11.9%) and expenditure (6.1%). Expenditure began to spiral upwards when active monitoring of the second policy was suspended. The majority of prescribers (87.2%) who responded to the questionnaire (56.5% response rate) felt that the 1989 policy made a positive contribution to antibiotic usage in the hospital.

Improvement of coronary morphology and blood flow after stenting. Assessment by intravascular ultrasound and intracoronary Doppler.

Intravascular ultrasound (IVUS) and intracoronary Doppler (ICD) were performed in eight patients (54.3 +/- 6.5 years, 6 male) immediately after PTCA and after stenting. ICD was also performed before PTCA. After PTCA, IVUS has demonstrated intimal rupture in all patients. After stenting, IVUS revealed wall wrapping of the intimal flap with a free lumen in all patients. The lumen diameter was 2.42 +/- 0.55 mm after PTCA and was 2.74 +/- 0.49 mm after stenting (p < 0.001). The cross-sectional area increased from 4.70 +/- 1.99 mm2 post-PTCA to 6.40 +/- 2.15 mm2 post-stent (p < 0.005). Coronary flow velocity reserve, calculated by the ratio of mean flow velocity at rest and after intracoronary papaverine administration, increased from 2.05 +/- 1.01 to 2.99 +/- 1.14 after PTCA (p = 0.015); and increased to 4.51 +/- 1.33 after stenting (p < 0.001). The morphological data derived from IVUS correlated with the functional information obtained with ICD. In addition to its established role in bail out situations, stent implantation may be considered when a suboptimal morphological and functional result has been demonstrated.

Open access echocardiography in management of heart failure in the community.

OBJECTIVE: To assess the value of an open access echocardiography service. DESIGN: Study of new open access service for general practitioners, who were invited to refer patients taking diuretics for suspected heart failure, untreated patients with symptoms of possible heart failure, and asymptomatic patients with risk factors for left ventricular systolic dysfunction. SETTING: Regional cardiology centre. SUBJECTS: 259 consecutive patients. MAIN OUTCOME MEASURES: Presence or absence of left ventricular systolic dysfunction and consequent changes in clinical management. RESULTS: 119 treated patients, 99 untreated patients, and nine asymptomatic patients were referred over five months. 32 were considered to be inappropriately referred. Among the treated patients, 31 had impaired left ventricular systolic function and five had valvular disease; angiotensin converting enzyme inhibitors were recommended for 34 of these patients. In addition, 53 were thought not to need diuretics. Eight untreated patients had impaired systolic function and six valvular disease. CONCLUSIONS: The service was well used by general practitioners and led to advice to change management in more than two thirds of patients.

Aorta and aortic valve morphologies predisposing to aortic dissection. An in vivo assessment with transoesophageal echocardiography.

Predisposing factors for aortic dissection are well known from necropsy series. To evaluate the frequency of aortic and aortic valve disease in aortic dissection in vivo, 139 patients with acute aortic dissection (96 men, 43 women, mean age 60.5 +/- 15.7 years) were studied by transoesophageal echocardiography (TEE) using 3.5 and 5.0 MHz transducers. Left ventricular hypertrophy by TEE, defined as an end-diastolic wall thickness of the left ventricular septal wall over 1.5 cm, was found in 42 (67.7%) of 62 patients with type I, in 10 (58.8%) of 17 patients with type II and in 46 (76.7%) of 60 patients with type III dissection. The mean value for the aortic root diameter was 3.2 +/- 1.3 cm.m-2 in type I dissection and 2.8 +/- 0.9 cm.m-2(ns) in type II dissection. In the patient group with type III dissection this diameter was significantly smaller (1.8 +/- 0.9 cm.m-2; P < 0.001). Thickening of aortic valve leaflets was demonstrated in six (9.7%) of 62 patients with aortic dissection type I (two of them with mild aortic stenosis), in two (11.8%) of 17 patients with aortic dissection type II and in 15 (25.0%) of 60 patients with aortic dissection type III. A bicuspid aortic valve was diagnosed in five (6.3%) of 79 patients with aortic dissection types I and II and in one (1.7%) of 60 patients with type III dissection. By colour coded Doppler echocardiography, aortic regurgitation was found in 46 (74.2%) of 62 patients with type I, 13 (76.5%) of 17 patients with type II and 23 (38.3%) of 60 patients with type III dissection.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of spontaneous coronary artery dissection by intravascular ultrasound in a patient with unstable angina.

We describe a case of spontaneous coronary artery dissection that gave rise to post infarction unstable angina. An ambiguous angiographic appearance was shown by intracoronary ultrasound to arise from an extensive coronary dissection. The dissection membrane separating true and false lumina and features to suggest sluggish flow and early thrombosis in the false lumen were observed. No increase in lumen calibre was evident on ultrasound after PTCA (probably a consequence of the relatively large ultrasound catheter blank), but coronary flow reserve measured with intracoronary Doppler did improve and the patient remained stable and free of angina following the procedure.

Comparison of intravascular ultrasound and angiography in the assessment of myocardial bridging.

BACKGROUND: In autopsy, myocardial bridging is a common finding. With coronary angiography, a systolic compression, mainly of the left anterior descending coronary artery, is observed in 1% to 3% of the patients. Controversy exists concerning the functional importance of this finding. To obtain a functional insight into the myocardial bridging, intravascular ultrasound and intracoronary Doppler were performed. METHODS AND RESULTS: Intracoronary ultrasound and Doppler were performed in 14 patients with angiographic evidence of systolic vessel compression ("milking effect") in the left anterior descending coronary artery. The 4.8F, 20-MHz ultrasound catheter could not be advanced through the entire myocardial bridge segment in 6 of the 14 patients studied because the lumen was < 1.6 mm. In these patients, only the proximal parts of the bridge segment were scanned. The changes in cross-sectional shape during the cardiac cycle were determined for both the normal proximal segment and the bridge segment by use of a semiautomatic computer program. Intracoronary Doppler (20 MHz) was performed in 7 patients with a 3F catheter. A highly characteristic systolic eccentric or concentric compression with delayed relaxation in diastole of the myocardial bridging segment was clearly visualized in all patients. The cross-sectional lumen area variation was 40 +/- 25% in the bridging segments and 9 +/- 7% in the normal segments (P < .01). No atherosclerotic lesions were detected in the bridge or the distal segment in the 8 patients in whom the IVUS catheter was successfully advanced through the entire myocardial bridge. However, atherosclerotic plaques were found in the segments proximal to the bridge in 12 of 14 patients (86%). The resting mean flow velocity was 6.4 +/- 1.2 cm/s; the maximal mean flow velocity after intracoronary administration of 10 mg papaverine was 14.1 +/- 3.4 cm/s. The coronary flow velocity reserve was 2.2 +/- 0.7. A highly characteristic pattern showing a prominent peak in coronary velocity in early diastole was observed in 86% of patients, and this pattern was enhanced after injection of intracoronary papaverine. CONCLUSION: Intravascular ultrasound demonstrated a characteristic systolic compression of the bridge segments. The delayed compression release may explain the characteristic sharp early diastolic peak in coronary flow velocity found with intracoronary Doppler in vessels with myocardial bridging. Reduced coronary flow reserve may be related to this phenomenon, possibly explaining signs of ischemia detected in some of the patients, but may alternatively be a result of the presence of atherosclerosis in the segment proximal to the bridge in these patients.

Closed versus open endotracheal suctioning: costs and physiologic consequences.

OBJECTIVE: To examine the physiologic consequences and costs associated with two methods of endotracheal suctioning: closed vs. open. DESIGN: A prospective, randomized, controlled study. SETTING: An eight-bed trauma intensive care unit (ICU) in a 460-bed level I trauma center. PATIENTS: The study included 35 trauma/general surgery patients (16 in the open suction group, 19 in the closed suction group) who were treated with a total of 276 suctioning procedures (127 open, 149 closed). MEASUREMENTS AND MAIN RESULTS: Physiologic data collected after hyperoxygenation, immediately after suctioning, and 30 secs after suctioning, were compared with baseline values. Open endotracheal suctioning resulted in significant increases in mean arterial pressure throughout the suctioning procedure. Both methods resulted in increased mean heart rates. However, 30 secs after the procedure, the open-suction method was associated with a significantly higher mean heart rate than was the closed method. Closed suctioning was associated with significantly fewer dysrhythmias. Arterial oxygen saturation and systemic venous oxygen saturation decreased with open suctioning. In contrast, arterial oxygen saturation and systemic venous oxygen saturation increased with the closed suction method. There was no difference between the two methods in the occurrence of nosocomial pneumonia. Open endotracheal suctioning cost $1.88 more per patient per day and required more nursing time. CONCLUSIONS: The closed suction method resulted in significantly fewer physiologic disturbances. Closed suctioning appears to be an effective and cost-efficient method of endotracheal suctioning that is associated with fewer suction-induced complications.

Blunt trauma to the abdomen.

There is general agreement that physical examination alone is inadequate for abdominal evaluation in the multiply injured blunt trauma patient; but controversy exists regarding the preferred method of detecting intraabdominal injuries requiring celiotomy. Both peritoneal lavage and the newer computed tomography imaging techniques have advantages and disadvantages. Direct comparisons of the two techniques have not determined a preferred method. When used as complementary rather than competitive studies, diagnostic peritoneal lavage and computed tomography imaging provide more information than either test alone.