Real-world clinical and cost analysis of CT coronary angiography and CT coronary angiography-derived fractional flow reserve (FFRCT)-guided care in the National Health Service.

AIM: To quantify the real-world clinical and cost impact of computed tomography (CT) coronary angiography (CTCA)-derived fractional flow reserve (FFRCT) in the National Health Service (NHS). MATERIALS AND METHODS: Consecutive clinical CTCA examinations from September to December 2018 with ≥1 stenosis of ≥25% underwent FFRCT analysis. The Heart Team reviewed clinical data and CTCA findings, blinded to FFRCT values, and documented hypothetical consensus management. FFRCT results were then unblinded and hypothetical consensus management re-recorded. Diagnostic waiting times for management pathways were estimated. A per-patient cost analysis for diagnostic certainty regarding coronary artery disease (CAD) management was performed using 2014-2020 NHS tariffs for pre- and post-FFRCT pathways. RESULTS: Two hundred and fifty-one CTCAs were performed during the study period. Fifty-seven percent (145/251) had no CAD or stenosis <25%. One study was non-diagnostic. Of the remaining 42% (105/251), two were ineligible for FFRCT and there was a 5% (5/103) failure rate. FFRCT led to a change in hypothetical management in 65% (64/98; p<0.001) patients with a functional imaging test cancelled in 17% (17/98) and a diagnostic angiogram cancelled in 47% (46/98). FFRCT-guided management had a reduced mean time to definitive investigation compared with CTCA alone (28 ± 4 versus 44 ± 4 days; p=0.004). Using the proposed 2020/21 tariff, CTCA + FFRCT for stenosis ≥50% resulted in a diagnostic pathway £44.97 more expensive per patient than usual care without FFRCT. CONCLUSIONS: In the real-world NHS setting, FFRCT-guided management has the potential to rationalise patient management, accelerate diagnostic pathways, and depending on the stenosis severity modelled, may be cost-effective.

Effectiveness of Workplace Interventions in Return-to-Work for Musculoskeletal, Pain-Related and Mental Health Conditions: An Update of the Evidence and Messages for Practitioners.

Purpose The objective of this systematic review was to synthesize evidence on the effectiveness of workplace-based return-to-work (RTW) interventions and work disability management (DM) interventions that assist workers with musculoskeletal (MSK) and pain-related conditions and mental health (MH) conditions with RTW. Methods We followed a systematic review process developed by the Institute for Work & Health and an adapted best evidence synthesis that ranked evidence as strong, moderate, limited, or insufficient. Results Seven electronic databases were searched from January 1990 until April 2015, yielding 8898 non-duplicate references. Evidence from 36 medium and high quality studies were synthesized on 12 different intervention categories across three broad domains: health-focused, service coordination, and work modification interventions. There was strong evidence that duration away from work from both MSK or pain-related conditions and MH conditions were significantly reduced by multi-domain interventions encompassing at least two of the three domains. There was moderate evidence that these multi-domain interventions had a positive impact on cost outcomes. There was strong evidence that cognitive behavioural therapy interventions that do not also include workplace modifications or service coordination components are not effective in helping workers with MH conditions in RTW. Evidence for the effectiveness of other single-domain interventions was mixed, with some studies reporting positive effects and others reporting no effects on lost time and work functioning. Conclusions While there is substantial research literature focused on RTW, there are only a small number of quality workplace-based RTW intervention studies that involve workers with MSK or pain-related conditions and MH conditions. We recommend implementing multi-domain interventions (i.e. with healthcare provision, service coordination, and work accommodation components) to help reduce lost time for MSK or pain-related conditions and MH conditions. Practitioners should also consider implementing these programs to help improve work functioning and reduce costs associated with work disability.

Automated cell colony counting and analysis using the circular Hough image transform algorithm (CHiTA).

We present an automated cell colony counting method that is flexible, robust and capable of providing more in-depth clonogenic analysis than existing manual and automated approaches. The full form of the Hough transform without approximation has been implemented, for the first time. Improvements in computing speed have facilitated this approach. Colony identification was achieved by pre-processing the raw images of the colonies in situ in the flask, including images of the flask edges, by erosion, dilation and Gaussian smoothing processes. Colony edges were then identified by intensity gradient field discrimination. Our technique eliminates the need for specialized hardware for image capture and enables the use of a standard desktop scanner for distortion-free image acquisition. Additional parameters evaluated included regional colony counts, average colony area, nearest neighbour distances and radial distribution. This spatial and qualitative information extends the utility of the clonogenic assay, allowing analysis of spatially-variant cytotoxic effects. To test the automated system, two flask types and three cell lines with different morphology, cell size and plating density were examined. A novel Monte Carlo method of simulating cell colony images, as well as manual counting, were used to quantify algorithm accuracy. The method was able to identify colonies with unusual morphology, to successfully resolve merged colonies and to correctly count colonies adjacent to flask edges.

Resting energy expenditure and body mass changes in women during adjuvant chemotherapy for breast cancer.

Weight gain is a commonly reported side effect of adjuvant chemotherapy. A change in resting energy expenditure during treatment has been a suggested mechanism for weight gain. We prospectively measured resting energy expenditure, weight change, and body composition (dual-energy x-ray absorptiometry) in 10 women undergoing adjuvant chemotherapy for breast cancer. There was no change in resting energy expenditure across cycles of chemotherapy (P =.78) or from baseline to the end of treatment (1,189.68 +/- 80.27 vs 1,205.76 +/- 56.71 kcal/d; P =.74). Overall, participants did not gain weight across treatment. However, there was an overall trend toward weight gain (66.3 +/- 5.1 vs 68.2 +/- 5.0 kg; P =.09), and participants did show an increase in total fat mass (24.2 +/- 3.8 vs 26.5 +/- 3.2 kg; P =.04), whereas muscle mass remained the same. Although no change in resting energy expenditure was seen, the observed increase in total fat mass is consistent with a decrease in physical activity level commonly reported with adjuvant chemotherapy treatment of breast cancer, and these body composition changes may have important health implications for survivors.

Nutritional implications of patient-provider interactions in hospital settings: evidence from a within-subject assessment of mealtime exchanges and food intake in elderly patients.

OBJECTIVE: To examine the nutritional implications of the interactions taking place between patients and care providers during mealtimes in hospital settings. Specifically, we tested research propositions that the amount and nature of interpersonal behaviours exchanged between patients and providers impact patients' food intake. These propositions were derived from prior evidence of social influences on eating behaviour and a well-established framework that identifies two fundamental modalities of human interaction: striving for mastery and power (agency) and efforts to promote union with others (communion). DESIGN: In a within-subject naturalistic study, participants were observed on multiple meals (n=1477, 46.2 meals/participant on average), during which participants' and providers' agency- and communion-related behaviours and patients' protein and energy intake were recorded. Meal-level frequency and complementarity of patients' and providers' behaviours were computed to test research propositions. SETTING: Dining room of a geriatric rehabilitation unit. SUBJECTS: Thirty-two elderly patients (21 females, mean age:78.8, 95% CI: 76.4, 81.1). RESULTS: Meal-level frequency of patient-provider exchanges (P=0.016) and patients' agency-related behaviours (P=0.029), as well as mutual reciprocation of patients' and providers' communion-related behaviours (P=0.015) on a given meal were positively linked to protein intake. Higher energy intake was found during meals where patients expressed more agency-related behaviours (P=0.029). CONCLUSION: Results present evidence that the amount and nature of patient-provider interpersonal exchanges on a given meal influence the nutritional quality of food intake in hospitalized elderly. They provide insights into how to improve the design and delivery of routine care to this malnutrition-prone population. SPONSORSHIP: This study was supported by the Canadian Institutes of Health Research (Operating grant to Laurette Dubé, Doctoral Fellowship to Catherine Paquet) the Fonds de la Recherche en santé du Québec and by the Danone Institute (Doctoral fellowship to Danielle St-Arnaud McKenzie).

Psychological health of Australian veterans of the 1991 Gulf War: an assessment using the SF-12, GHQ-12 and PCL-S.

BACKGROUND: Elevated rates of psychological morbidity and symptomatology have been widely reported in 1991 Gulf War veterans. The present study used brief self-report instruments to compare the psychological health of Australian Gulf War veterans with that of a randomly sampled military comparison group. METHOD: The 12-item Short Form Health Survey (SF-12), 12-item General Health Questionnaire (GHQ-12), Posttraumatic Stress Disorder Checklist--Specific (PCL-S) and Military Service Experience (MSE) questionnaire were administered to 1424 male Australian Gulf War veterans and 1548 male Australian Defence Force members who were operational at the time of the Gulf War conflict, but were not deployed there. RESULTS: The Gulf War veterans exhibited poorer psychological health, as measured by the above three instruments, than the comparison group members. For Gulf War veterans, the number of stressful experiences, as measured by the MSE questionnaire, was correlated with scores on the three instruments. SF-12 mental health component summary scores and PCL-S caseness, but not GHQ-12 caseness, differed significantly between Gulf War veterans and comparison group members who had been on at least one active deployment. CONCLUSIONS: More than a decade after the 1991 Gulf War, Australian Gulf War veterans are exhibiting higher levels of current (past month) psychological ill-health, as measured using the GHQ-12 and PCL-S, as well as lower mental health status, as measured by the SF-12, than the comparison group. Although not a replacement for formal psychiatric diagnosis, instruments such as those above may aid in the assessment of veterans' psychological health.

Effects of fexofenadine, diphenhydramine, and alcohol on driving performance. A randomized, placebo-controlled trial in the Iowa driving simulator.

BACKGROUND: Sedating antihistamines may impair driving performance as seriously as alcohol. OBJECTIVE: To compare the effects of fexofenadine, diphenhydramine, alcohol, and placebo on driving performance. DESIGN: Randomized, double-blind, double-dummy, four-treatment, four-period crossover trial. SETTING: The Iowa Driving Simulator. PARTICIPANTS: 40 licensed drivers with seasonal allergic rhinitis who were 25 to 44 years of age. INTERVENTION: One dose of fexofenadine (60 mg), diphenhydramine (50 mg), alcohol (approximately 0.1% blood alcohol concentration), or placebo, given at weekly intervals before participants drove for 1 hour in the Iowa Driving Simulator. MEASUREMENTS: The primary end point was coherence, a continuous measure of participants' ability to match the varying speed of a vehicle that they were following. Secondary end points were drowsiness and other driving measures, including lane keeping and response to a vehicle that unexpectedly blocked the lane ahead. RESULTS: Participants had significantly better coherence after taking alcohol or fexofenadine than after taking diphenhydramine. Lane keeping (steering instability and crossing the center line) was impaired after alcohol and diphenhydramine use compared with fexofenadine use. Mean response time to the blocking vehicle was slowest after alcohol use (2.21 seconds) compared with fexofenadine use (1.95 seconds). Self-reported drowsiness did not predict lack of coherence and was weakly associated with minimum following distance, steering instability, and leftlane excursion. CONCLUSIONS: Participants had similar performance when treated with fexofenadine or placebo. After alcohol use, participants performed the primary task well but not the secondary tasks; as a result, overall driving performance was poorer. After participants took diphenhydramine, driving performance was poorest, indicating that diphenhydramine had a greater impact on driving than alcohol did. Drowsiness ratings were not a good predictor of impairment, suggesting that drivers cannot use drowsiness to indicate when they should not drive.

The validity of medicaid pharmacy claims for estimating drug use among elderly nursing home residents: The Oregon experience.

This study compared computerized Medicaid pharmacy claims data for nursing home residents with chart data to establish how well the claims data identified those receiving drugs within three different psychoactive drug classes (yes/no for each class) and how well the claims estimated total within-class average daily dose. Percent agreement, positive predictive value (PPV), and negative predictive value (NPV) for drug exposure were over 85% for each class. Kappas were excellent for antipsychotics and antidepressants, and good for anxiolytics. Correspondence was lower for average daily dose. Using an algorithm that credits some but not all doses associated with overlapping claims, correlations ranged from 0.97 to 0.66. Agreement on therapeutic dose was excellent for antipsychotics (kappa = 0.81) and fair to good for antidepressants and anxiolytics (kappa = 0.63, and kappa = 0.52, respectively). The findings suggest that Medicaid pharmacy claims data are reasonably accurate for quality assurance and accreditation purposes.

The influence of client's ethnicity on psychotropic medication management in community mental health services.

OBJECTIVES: The aim of this study was to investigate whether people born in non-English-speaking countries differed from clients born in Australia on quality of medication management, measured by mean neuroleptic dose, method of administration, use of atypical antipsychotics and perceived compliance with medication, and to investigate the influence of matching the client with a case manager from the same ethnic background on these measures. METHOD: Information about medication and perceived compliance was provided for 168 clients of five community mental health services in Melbourne. Chlorpromazine equivalent doses (CPZe) were calculated, and average dose, route of administration, percentage receiving atypical antipsychotics and perceived compliance with medication were analysed by country of birth and preferred language. Each analysis was repeated for clients matched to a case manager from the same ethno-linguistic background compared to those with 'unmatched' case managers. RESULTS: While non-English-speaking background (NESB) clients generally did not receive different dose sizes, those born in Vietnam had a lower mean dose. People born in a non-English-speaking country tended to be more likely than the Australian born to receive a depot injection, although this was not quite statistically significant. Twenty-seven percent of clients received an atypical neuroleptic; age was a significant factor, with older clients less likely to receive an atypical. There was no difference in receipt of atypicals or perceived compliance by country of birth, language or gender. Matching for a case manager of the same background had no effect except for route of administration, with matched clients less likely to receive depot medication than unmatched. CONCLUSIONS: Generally, the ethnic background of clients had little influence on the quality of medication management they received from community mental health services.

Comparing correlated kappas by resampling: is one level of agreement significantly different from another?

Researchers comparing diagnostic systems or screening tests frequently need to compare indices of agreement such as the kappa coefficient. While asymptotic methods exist for comparing kappas derived from independent samples, no satisfactory approach exists for comparing kappas derived from the same or related samples. Resampling methods for comparing kappa coefficients obtained from the same sample are presented. Easily undertaken using readily available software, these methods are illustrated by application to a small sample of psychiatric data, as well as to several thousand samples of simulated data. An acceptable type I error rate was exhibited. Resampling techniques-easily implemented and making few assumptions-deserve wider application in psychiatric research.

The metabolic cost of two kayaking techniques.

A common technique employed in flatwater kayak and canoe races is "wash riding", in which a paddler positions his/her boat on the wake of a leading boat and, at a strategic moment, drops off the wake to sprint ahead. It was hypothesized that this manoeuver was energy efficient, analogous to drafting in cycling. To study this hypothesis, minute ventilation (VE), heart rate (HR) and oxygen consumption (VO2) were measured in 10 elite male kayak paddlers (age = 25 +/- 6.5 yrs, height = 183.6 +/- 4.4 cm, mass = 83.9 +/- 6.1 kg) during steady-state exercise at a standardized velocity in conditions of "wash riding" (WR) and "non-wash riding" (NWR). The data were collected in field conditions using a portable telemetric metabolic system (Cosmed K2). Statistical analysis of the mean values for VE, VO2 and HR was performed using the Hotelling's T2 statistic and revealed significant (p < 0.05) differences between the WR and NWR trials for all three dependent variables. Mean values for VE (l/min) were WR = 113 +/- 16.5, NWR = 126.3 +/- 15.7; for VO2 (l/min) were WR = 3.22 +/- 0.32, NWR = 3.63 +/- 0.3; and for HR (bpm) were WR = 167 +/- 9.9, NWR = 174 +/- 8.0. It was concluded that wash riding during kayak paddling confers substantial metabolic savings at the speeds tested. This has implications for the design of training programs and competitive strategies for flatwater distance kayak racing.

Software compensation for lung volume in assessment of inspiratory muscle strength and endurance.

BACKGROUND: To increase the sensitivity of measurements of maximal inspiratory pressure (MIP) as a test of inspiratory muscle strength and endurance, software was developed to correct for variation in lung volume. METHODS: Using a body plethysmograph to determine absolute lung volume during each manoeuvre, values for MIP were expressed as a percentage of the pressure "expected" from the unfatigued MIP/lung volume relation in each subject. RESULTS: The method reduced the variance in peak and average pressure during a series of 18 MIP manoeuvres of 10 seconds duration separated by rest intervals of 10 seconds. CONCLUSIONS: The correlation between average pressure and contraction number was improved significantly by the MIP/lung volume correction. This simple correction has many applications in measurements of the MIP.

Spurious precision: procedural validity of diagnostic assessment in psychotic disorders.

OBJECTIVE: Very few studies have quantified the level of agreement among alternative diagnostic procedures that use a common set of fixed operational criteria. The authors examined the procedural validity of four independent methods of assigning DSM-III-R diagnoses of psychotic disorders. METHOD: The research was conducted as a satellite study to the DSM-IV Field Trial for Schizophrenia and Related Psychotic Disorders. The setting was the National Health and Medical Research Council Schizophrenia Research Unit's Early Psychosis Prevention and Intervention Centre, which focuses on first-episode psychosis. Consecutively admitted patients (N = 50) were assessed by independent raters who used four different procedures to determine a DSM-III-R diagnosis. These procedures were 1) the diagnostic instrument developed for the DSM-IV field trial, 2) the Royal Park Multidiagnostic Instrument for Psychosis, 3) the Munich Diagnostic Checklists, and 4) a consensus DSM-III-R diagnosis assigned by a team of clinician researchers who were expert in the use of diagnostic criteria. RESULTS: Concordance between pairs of diagnostic procedures was only moderate. Corresponding levels of percent agreement, however, ranged from 66% to 76%, with converse misclassification rates of 24%-34% (assuming one procedure to be "correct"). CONCLUSIONS: These findings have significant research and clinical implications. Despite the introduction of operationally defined diagnoses, there remained an appreciable level of differential classification or misclassification arising from variability in the method of assigning the diagnostic criteria rather than the criteria themselves. Such misclassification may impede neurobiological research and have harmful clinical effects on patients with first-episode psychosis.

The laboratory assessment of endurance performance in cyclists.

Performance in endurance activities depends on maximal aerobic capacity (VO2max) and the ability to sustain a high percentage of VO2max over time. This study examined whether noninvasive laboratory measures would be valid predictors of endurance performance in an individual-start bicycle race (TT). Eight experienced male cyclists (age = 25.1 +/- 3.3 years, weight = 75.0 +/- 5.7 kg, VO2max = 5.05 +/- 0.4 L.min-1) performed a progressive incremental exercise test to exhaustion on a cycle ergometer. VO2max, maximum power output, and ventilatory threshold were determined. Later the subjects completed a 40-km TT. Power output at the ventilatory threshold (VT watts) was correlated with race performance time and calculated power output during the competition (r = -0.81; r = 0.82). VT watts and VO2max accounted for 75% of the variance between subjects (r = 0.91) in performance time. These data indicate that simple laboratory measures can predict TT performance in trained cyclists. Individual differences may be accounted for by motivation, aerodynamic position, and efficiency.

The role of alcohol providers in prevention: an evaluation of a server intervention programme.

Server intervention is a relatively new approach in the attempt to reduce the incidence of drinking and driving. Although a number of evaluations have suggested that the approach may be effective, there have been few comprehensive evaluations of such programmes. The present study utilized process evaluation techniques to assess reactions to a programme developed by the Addiction Research Foundation, and a quasi-experimental design to determine the impact of the programme on the serving practices of servers. Actors portrayed behaviours often faced by servers, and observers rated the reactions of the servers, who were unaware of the simulations, to these situations. The programme appears to have been effective in changing behaviour, in that trained servers exhibited less inappropriate responses than did untrained servers. In addition the results suggested that the programme increased servers' knowledge about their obligations and potential strategies for dealing with these situations. The implications of these findings for future implementations of such programmes are discussed.

Constructing a minimal diagnostic decision tree.

Classification trees and discriminant function analysis were employed in order to ascertain whether a small number of diagnostic decision rules could be extracted from a large inventory of items. Several models, involving up to 17 symptoms, that led to a broad psychiatric diagnosis were then tested on a small validation sample of 53 patients. All methods, with the exception of CART used without any pruning, generated identical trees involving four items. Almost 90% of the validation sample was able to be correctly classified by all methods although poor classification performance was noted in the case of one particular diagnosis, Schizoaffective Psychosis. In contrast, stepwise linear discriminant analysis originally selected 17 items, although three out of the first four items selected were identical to those chosen by the tree-building methods. Although more research is required, there are indications that the latter methods may be usefully employed in constructing parsimonious decision trees.