Clinicians' attitudes toward standardized assessment and diagnosis within child and adolescent psychiatry.

BACKGROUND: There is a strong call for clinically useful standardized assessment tools in everyday child and adolescent psychiatric practice. The attitudes of clinicians have been raised as a key-facilitating factor when implementing new methods. An explorative study was conducted aimed to investigate the clinicians' attitudes regarding standardized assessments and usefulness of diagnoses in treatment planning. METHODS: 411 mental health service personnel working with outpatient and inpatient assessment and treatment within the specialist child and adolescent mental health services, Stockholm County Council were asked to participate in the study, of which 345 (84%) agreed answer a questionnaire. The questionnaire included questions regarding Attitudes toward Standardized Assessment and Utility of Diagnosis. Descriptive analyses were performed and four subscales were compared with information from a similar study in US using the same instruments. The demographic and professional characteristics (age, working years, gender, education, profession, management position, involvement in assessment, level of service) in terms of prediction of attitudes were studied by univariate and multivariate linear regressions. RESULTS: Overall, the clinicians had quite positive attitudes and were more positive compared to a similar study conducted in the US earlier. There were differences in attitudes due to several characteristics but the only characteristic predicting all subscales was type of profession (counselor, nurse, psychiatrist, psychologist, other), with counselors being less positive than other groups. CONCLUSION: The overall positive attitudes toward standard assessment are of importance in the development of evidence-based practice and our study implies that clinicians in general value and are willing to use standardized assessment. Nevertheless, there are specific issues such as adequate training and available translated assessment instrument that need to be addressed. When implementing new methods in practice, there are general as well as specific resistances that need to be overcome. Studies in different cultural settings are of importance to further extend the knowledge of what is general and what is specific barriers.

Patient Experiences of Life Years After Severe Civilian Lower Extremity Trauma With Vascular Injury.

OBJECTIVE: Severe lower limb trauma with arterial injury is often devastating for the individual. Many studies describe how to manage these injuries when they occur. Short-term functional outcome is quite well described, but the patients are often young, and their suffering is physical, mental, and social from a lifelong perspective. The aim of this study was to report patient experiences of their lives several years after their accidents, and to explore mechanisms of how to improve management. METHOD: The Swedvasc registry was searched for participants from 1987 to 2011, living in the region of Uppsala, Sweden. Some amputated participants were added from the Walking Rehabilitation Center. There were five reconstructed patients with an intact limb, and three with amputations. In depth interviews were conducted and systematically analyzed, using A Giorgi's descriptive phenomenological method. RESULTS: Eight patients participated, five with reconstructed and three with amputated limbs. Life affecting functional impairments were described by all patients. The patients undergoing amputation had received more structured follow up and support through the Walking Rehabilitation Center. The satisfaction with the cosmetic result was poorer than expected. All patients had developed strategies of how to cope with their impairments and stated they now lived "normal lives." CONCLUSIONS: Despite substantial physical, psychological, and cosmetic impairments years after severe lower limb trauma, the participants described life as "normal" and mainly satisfactory. Transition to the new situation could have been facilitated by more frequent and continuous follow up after discharge from hospital, in particular among the non-amputated patients who tend to be lost to follow up. Findings also indicate that family members have to be acknowledged, strengthened, and supported.

Control charts as an early-warning system for workplace health outcomes.

INTRODUCTION: Statistical process control (SPC) charts have not been widely used to monitor workplace health and work environments. This research and effort to develop a more accurate and easy to use management control system for employee health is important from a humanistic, societal and economic standpoint, as well as complying with laws that regulate work environments. OBJECTIVE: The purpose of the study is to design and discuss control charts as an early warning system for workplace health outcomes to promote workplace health management. Another purpose is to discuss relevant factors in the concept of the out-of-control action plan (OCAP) as a response when a chart warns that the workplace process may be malfunctioning. PARTICIPANTS: Two Swedish organizations were selected as case study organizations: a department at a university and an elderly care operation in a municipality. METHODS: This study was explorative and should be seen as a starting point in learning how to use control charts for workplace health management. Self-assessed general health and new sick-cases per employee were selected as indicators for the control charts. RESULTS: An integrated early warning system with Cumulative Sums- and Shewhart-charts are presented to show a possible method as to how an early warning system can be structured through the use of statistical control charts. CONCLUSIONS: The conclusion of this study is that control charts, along with well-designed implementation, make up a powerful and useable managerial early-warning system which promotes workplace health and helps to prevent sickness absence.

Monte Carlo study of the dependence of the KAP-meter calibration coefficient on beam aperture, x-ray tube voltage and reference plane.

The Monte Carlo method was used to study the dependence of the calibration coefficient on the tube voltage, beam aperture and reference plane in simplified over-couch geometries modelling VacuTec's type 70157 KAP-meter both with and without an additional filter. The MCNP5 code was used to calculate (i) energy imparted to air cavities of the KAP-meter and (ii) spatial distribution of air collision kerma at entrance and exit planes of the KAP-meter and at a plane close to the patient. From these data, the air kerma area product and calibration coefficient were calculated and their dependence on the tube voltage and beam aperture was analysed. It was found that the variation of the calibration coefficient as a function of tube voltage was up to 40% when the additional filter was used. The additional filter placed closely in front of the KAP-meter decreased the calibration coefficient for the patient plane by about 10% compared to the ideal additional filter. The effect of the beam aperture was small at the patient plane and negligible for the exit plane.

A 4D approach to the analysis of functional brain images: application to FMRI data.

This paper presents a new approach to functional magnetic resonance imaging (FMRI) data analysis. The main difference lies in the view of what comprises an observation. Here we treat the data from one scanning session (comprising t volumes, say) as one observation. This is contrary to the conventional way of looking at the data where each session is treated as t different observations. Thus instead of viewing the v voxels comprising the 3D volume of the brain as the variables, we suggest the usage of the vt hypervoxels comprising the 4D volume of the brain-over-session as the variables. A linear model is fitted to the 4D volumes originating from different sessions. Parameter estimation and hypothesis testing in this model can be performed with standard techniques. The hypothesis testing generates 4D statistical images (SIs) to which any relevant test statistic can be applied. In this paper we describe two test statistics, one voxel based and one cluster based, that can be used to test a range of hypotheses. There are several benefits in treating the data from each session as one observation, two of which are: (i) the temporal characteristics of the signal can be investigated without an explicit model for the blood oxygenation level dependent (BOLD) contrast response function, and (ii) the observations (sessions) can be assumed to be independent and hence inference on the 4D SI can be made by nonparametric or Monte Carlo methods. The suggested 4D approach is applied to FMRI data and is shown to accurately detect the expected signal.

[Clostridium difficile-associated diarrhea--a growing problem in geriatric care]. / Clostridium difficile-associerad diarré--ett växande problem inom geriatriken.

From 1994 to 1998 the incidence of Clostridium difficile-associated diarrhoea (CDAD) in the Department of Geriatric Medicine, Huddinge University Hospital increased from 0.5% to 2.2% of all admissions. Corresponding figures for the whole hospital were 0.3% and 0.6%, respectively. The increase in CDAD at the Department of Geriatric Medicine was parallel with a more than doubled consumption of antibiotics. All geriatric patients with CDAD had been treated with antibiotics before onset of diarrhoea. Out of the antibiotic prescriptions 48% were a cephalosporin (mainly cefuroxim). In a matched reference group of geriatric patients 51% had been treated with antibiotics during the hospital stay. The patients with CDAD spent 27 +/- 14 days in hospital as compared to 13 +/- 9 days (P < 0.05) in the reference population.

What is the most effective way to reduce incidence of amputation in the diabetic foot?

Approximately 40-60% of all amputations of the lower extremity are performed in patients with diabetes. More than 85% of these amputations are precipitated by a foot ulcer deteriorating to deep infection or gangrene. The prevalence of diabetic foot ulcers has been estimated to be 3-8%. The complexity of these ulcers necessitates a multifactorial approach in which aggressive management of infection and ischemia is of major importance. For the same reason, a process-oriented approach in the evaluation of prevention and management of the diabetic foot is essential. Healing rates of foot ulcers are unknown with the exception of specialised centres where it is between 80-90%. The negative consequences of diabetic foot ulcers on quality of life include not only morbidity but also disability and premature mortality. Costs for healing ulcers are high and even higher for ulcers resulting in amputation, due to prolonged hospitalisation, rehabilitation, and need for home care and social service for disabled patients. Therefore, one of the most important steps to reduce cost in the management of the diabetic foot is to avoid amputations. A cost-effective management should not only be focused on the short-term cost until healing but also on the long-term cost, since foot ulcer and especially amputation are related to increased re-ulceration rate and lifelong disability. A multidisciplinary approach including preventive strategy, patient and staff education, and multifactorial treatment of foot ulcers has been reported to reduce the amputation rate by more than 50%.

[The diabetic foot. Optimal prevention and treatment can halve the risk of amputation]. / Diabetikers fotproblem. Rätt prevention och behandling kan halvera risken för amputation.

Almost half of all lower leg amputations are performed in patients with diabetes. In over 70 per cent of these cases, amputation is precipitated by progression of foot ulceration to deep gangrenous infection. Most foot ulcers are preceded by trauma, usually due to ill-fitting shoes, and are precipitated by sensory motor neuropathy with varying degrees of peripheral vascular disease. The Swedish Medical Research Council and the Swedish Institute for Health Services Development arranged a conference on diabetic foot problems in April 1998, the purpose of which was to arrive at a consensus regarding the prevention and management of diabetic foot. It was concluded that a satisfactory multidisciplinary approach should include regular control of feet and footwear, preventive foot care (education, footwear, chiropody), continuous follow-up of high-risk feet, and early recognition of revascularisation. Continuous registration of amputation, irrespective of type, cause and site, might substantially reduce the amputation rate among diabetics. Were such an approach to reduce the incidence of diabetes-related amputation by 50 per cent, annual costs for the management of diabetic foot in Sweden would be reduce by SEK 400 million (the value of improved quality of life not taken into consideration).

Interrater variability and validity in subjective nutritional assessment of elderly patients.

The subjective Global Assessment technique was evaluated with regard to its reliability and validity in a Swedish elderly population. Ninety patients, 70 years of age or older, and newly admitted to the geriatric clinic, participated in the study. The nutritional state was assessed subjectively by two independent observers using the Subjective Global Assessment form, and objectively, using a combination of anthropometry and serum-protein analysis. The subjectively assessed malnutrition rate was about 20% higher than that assessed objectively. The agreement level between the two observers was 77.8%, Kappa 0.56 (< 0.001), and the levels between the subjective and objective assessments were 57.8% (Kappa = 0.17) and 73.3% (Kappa = 0.46), respectively. The experienced observer identified 85.2% of those who were defined as malnourished using the objective criteria and the less experienced observer, 66.6%. Furthermore, a regression analysis indicated weight index as the main significant objective factor influencing the subjective assessment. The subjective technique could be regarded as reliable from a clinical and preventive perspective since the agreement between the two rates was just under 80%. It seems also to be valid since the subnormalities in the selected criteria showed a similar pattern. The necessity of being well trained in order to manage nutritional status assessment, for both clinical and research purposes, is obvious.

Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting.

The purpose of this study was to analyze long-term costs for foot ulcers in diabetic patients. Patients were treated and followed prospectively by a foot care team. A retrospective economic analysis was performed of costs for 274 patients during 3 years from healing of an initial foot ulcer, with or without amputation. Costs were estimated for inpatient care, outpatient care, home care, and social service. The cost calculations include costs due to complications and disability related to the initial ulcer, costs related to recurrence of ulcer, and costs for prevention of new ulcers. Expected total present value cost per patient during 3 years of observation was $26,700 (U.S. dollars) for primary healed patients with critical ischemia and $16,100 for primary healed patients without critical ischemia. For patients who healed with an amputation, the corresponding costs were $43,100 after a minor amputation and $63,100 after a major amputation. When estimating the costs for diabetic foot ulcers, it is not sufficient to calculate short-term costs. Long-term costs are high, mainly due to the need for increased home care and social service, but also due to costs for recurrent ulcers and new amputations.

Cross-sectional assessment and subgroup comparison of functional disability in patients with rheumatoid arthritis in a Swedish health-care district.

A cross-sectional study was undertaken on 222 patients with rheumatoid arthritis (RA) within a Swedish health-care district. An exploratory analysis of functional status, according to a Swedish version of the Health Assessment Questionnaire (HAQ), was carried out in order to explore the extent and pattern of functional disability in an unselected group of individuals with RA. The mean score of functional disability according to HAQ increased with more clinical manifest disease. There were no significant differences between the mean score in men and women. Most functional disability was related to hand-grip function and the ability to take care of personal hygiene. Increased functional disability was significantly associated with increasing age and disease duration. There was no significant relation between functional status and housing condition and educational level. A strong correlation was found between pain and functional disability. Multiple regression analysis was performed and predictive functional scores were tabulated based upon sex, age at onset and duration of RA disease.

Topical treatment of diabetic foot ulcers: an economic analysis of treatment alternatives and strategies.

In a prospective study, 314 patients with diabetic foot ulcers were followed and 40 patients died before healing occurred. In those patients who healed, a retrospective economic analysis of the costs for topical treatment was performed. The aim of the study was to analyse the costs and discuss how different treatment strategies influence total costs. Data collected for each patient were total time to healing, treatment time for each type of dressing, and the frequency of dressing changes. Material costs for the dressings, labour, and travelling costs were calculated separately. A formula for simulation of economic consequences of different treatment strategies including the introduction of new strategies was designed. The cost for topical treatment was strongly related to the severity of the ulcer and wound healing time. The average weekly cost per patient for topical treatment varied between 40.3 pounds and 385 pounds. The dominating costs for topical treatment were expenses for staff and transportation. The most important factor to reduce costs is the frequency of dressing changes. The study emphasizes the need for prospective comparative studies of cost effectiveness in topical treatment strategies.

CT assessment of subarachnoid haemorrhage. A comparison between different CT methods of grading subarachnoid haemorrhage.

A number of different CT classifications of subarachnoid haemorrhage (SAH) were applied to a consecutive series of 50 patients with aneurysmal SAH. The best correlation with delayed ischaemic deficits (DID) was obtained with a score formed by the sum of the individual cisternal grades except that of the cortical subarachnoid space. The findings emphasize the significance of the extent of the SAH, rather than the presence of a localized cisternal clot with regard to the development of DID.

Nutritional assessment and muscle energy metabolism in severe chronic congestive heart failure--effects of long-term dietary supplementation.

In order to investigate nutritional status in relation to the metabolic state of skeletal muscle in patients with severe congestive heart failure, and to explore the influence of long-term dietary supplementation, 22 patients were randomized in a double-blind study to receive either a placebo (n = 13) or high caloric fluid (n = 9). Before treatment, the muscle content of adenosine triphosphate (ATP), creatine and glycogen was lower than in healthy individuals, and muscle biopsies revealed an excess of water. Two patients were found to be malnourished according to nutritional assessment criteria. Following study treatment, no significant changes occurred, either within or between the two subgroups. Thus, patients with severe congestive heart failure displayed metabolic derangement in skeletal muscle which did not seem to be explained by malnutrition.

Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation.

OBJECTIVES: To perform an economic analysis of primary healing and healing with amputation in diabetic patients with foot ulcers. DESIGN: A retrospective economic analysis based on a prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer. SETTING: A multidisciplinary foot-care team. SUBJECTS: A total of 314 consecutively presenting diabetic patients with foot ulcers. Forty patients died before healing occurred. In those patients who healed primarily (n = 197) or after amputation (n = 77), a retrospective economic analysis was performed. INTERVENTIONS: All patients were treated by a multidisciplinary foot care team consisting of diabetologist, orthopaedic surgeon, diabetes nurse, podiatrist and orthotist both as in- and out-patients. The patients were followed by the team from admittance until final outcome, i.e. primary healing or healing with amputation or death. MAIN OUTCOME MEASURES: Data from both the prospectively collected patient material and from patient records were used to estimate the cost for hospital care, antibiotics, surgery, out-patient care, staff attendance, drugs and material for ulcer dressings, and orthopaedic appliances. RESULTS: The total costs were SEK 51,000 (3000-808,000) for patients with primary healing and SEK 344,000 (27,000-992,000) for healing with amputation. Costs for in-patient care were 37% of total average costs for primary healing and 82% for patients with amputation. The costs for topical treatment of the ulcers in out-patient care were 45% of the total average cost for primary healed and 13% for patients who healed with amputation. The costs for products used for ulcer dressings were 21% of total costs for topical treatment, i.e. 9% and 3% of total average costs for primary healing and healing with amputation, respectively. Costs for visits to the foot care team, antibiotics and orthopaedic appliances were low in relation to total costs. CONCLUSION: Treatment of diabetic patients with foot ulcers in a multidisciplinary system was associated with relatively low costs. Healing with amputation was associated with high costs mainly due to multiple and extended hospitalization. These findings indicate the potential cost savings of preventive and multidisciplinary foot care.