Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial.

BACKGROUND: Alcohol-related hospital admissions have doubled in the last ten years to > 1.2 m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting. METHODS: One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12 months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU + AOT and CAU at 6 and 12 months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12 months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12 months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up. DISCUSSION: AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and cost-effectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first. TRIAL REGISTRATION: International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016.

The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently.

In the presence of single-use airway filters, we quantified anaesthetic circuit aerobic microbial contamination rates when changed every 24 h, 48 h and 7 days. Microbiological samples were taken from the interior of 305 anaesthetic breathing circuits over a 15-month period (3197 operations). There was no significant difference in the proportion of contaminated circuits when changed every 24 h (57/105 (54%, 95% CI 45-64%)) compared with 48 h (43/100 (43%, 95% CI 33-53%, p = 0.12)) and up to 7 days (46/100 (46%, 95% CI 36-56%, p = 0.26)). Median bacterial counts were not increased at 48 h or 7 days provided circuits were routinely emptied of condensate. Annual savings for one hospital (six operating theatres) were $AU 5219 (£3079, €3654, $US 4846) and a 57% decrease in anaesthesia circuit steriliser loads associated with a yearly saving of 2760 kWh of electricity and 48 000 l of water. Our findings suggest that extended circuit use from 24 h up to 7 days does not significantly increase bacterial contamination, and is associated with labour, energy, water and financial savings.

Twenty-five year experience with the St. Jude medical mechanical valve prosthesis.

BACKGROUND: We evaluated all adult St. Jude mechanical valve recipients at our institution since the initial implant in January 1979 and now present our 25-year experience. METHODS: Nine hundred forty-five valve recipients were followed prospectively at 12-month intervals from January 1979 to December 2007. RESULTS: Operative mortality was 3% in the aortic valve recipients and 5% in the mitral valve recipients. Follow-up was 95% complete. Among aortic valve recipients, late actuarial survival was 81% +/- 2%, 59% +/- 2%, 41% +/- 3%, 28% +/- 3%, and 17% +/- 4% at 5, 10, 15, 20, and 25 years, respectively. Twenty-five-year freedom from reoperation, thromboembolism, bleeding, and endocarditis was 90% +/- 2%, 69% +/- 5%, 67% +/- 3%, and 9% 3 +/- 2% respectively. Among mitral valve recipients late actuarial survival was 84% +/- 2%, 63% +/- 3%, 44% +/- 3%, 31% +/- 3%, and 23% +/- 4% at 5, 10, 15, 20, and 25 years, respectively. Twenty-five-year freedom from reoperation, thromboembolism, bleeding and endocarditis was 81% +/- 10%, 52% +/- 8%, 64% +/- 6%, and 97% +/- 1%. Freedom from valve-related mortality and morbidity at 25 years was 26% +/- 7% and 29% +/- 6% for aortic and mitral valve replacement, respectively. Freedom from valve-related mortality was 66% +/- 8% and 87% +/- 3% for aortic and mitral valve replacement, respectively. CONCLUSIONS: These results compare favorably with those for other mechanical prostheses. After two and a half decades of observation with close follow-up, the St. Jude mechanical valve continues to be a reliable prosthesis.

European Antibiotic Awareness Day, 2008 - the first Europe-wide public information campaign on prudent antibiotic use: methods and survey of activities in participating countries.

Antibiotic resistance is a major European and global public health problem and is, for a large part, driven by misuse of antibiotics. Hence, reducing unnecessary antibiotic use, particularly for the treatment of certain respiratory tract infections where they are not needed, is a public health priority. The success of national awareness campaigns to educate the public and primary care prescribers about appropriate antibiotic use in Belgium and France stimulated a European initiative coordinated by the European Centre for Disease Prevention and Control (ECDC), and named European Antibiotic Awareness Day (EAAD), to take place each year on 18 November. Specific campaign materials, including key messages, logos, slogans and a media toolkit, were developed and made available for use in European countries. The focus of the first EAAD campaign was about not taking antibiotics for viral infections such as colds and flu. A post-campaign survey was conducted in January 2009. Thirty-two European countries participated in the first EAAD, producing information materials and implementing activities to mark EAAD. Media coverage peaked on 18 and 19 November. At EU level, EAAD was launched at a scientific meeting in the European Parliament, Strasbourg. The event received EU political engagement through support from the EU Commissioner for Health, the Slovenian and French EU Presidencies, and Members of the European Parliament. Critical factors that led to the success of the first EAAD were good cooperation and process for building the campaign, strong political and stakeholder support and development of campaign materials based on scientific evidence. Countries indicated wide support for another EAAD in 2009. For this purpose, ECDC is developing several TV spots as well as a second set of EAAD campaign materials targeting primary care prescribers.

The global burden of disease study: implications for neurology.

Because of the epidemiological transition, the global burden of illness has changed. Several factors have contributed to this change, including improvements in maternal and child health, increasing age of populations, and newly recognized disorders of the nervous system. It is now evident that neurologic disorders have emerged as priority health problems worldwide. This is reflected in the Global Burden of Disease Study, jointly published by the World Health Organization and other groups. The proportionate share of the total global burden of disease resulting from neuropsychiatric disorders is projected to rise to 14.7% by 2020. Although neurologic and psychiatric disorders comprise only 1.4% of all deaths, they account for a remarkable 28% of all years of life lived with a disability. This study provides compelling evidence that one cannot assess the neurologic health status of a population by examining mortality statistics alone. Health ministries worldwide must prioritize neurologic disorders, and neurologists must be prepared to provide care for increased numbers of people individually and in population groups.

Managed care organization liabilities.

While certain efficiencies and cost savings have been achieved, Managed Care Organizations (MCOs) have risk exposures never before considered. MCOs provide a number of services for their clients. Specifically, they are involved in credentialing, network development, utilization review, and the hiring and firing of physicians and other allied medical professionals subject to rather complex and detailed contractual arrangements. The insurance industry has responded to the increase in claim exposure associated with the aforementioned activities by providing any number of insurance products. Depending on the insurance provider, a number of different coverages are available. The final decision as to which coverage to purchase will be governed by the risks associated with a particular MCO, contractual protections, available cash flow, protections under federal and state laws. The point of this article is to apprise MCOs of the claims now starting to develop against MCOs as well as alternative insurance products that can be purchased in order to protect both the firm's assets as well as those of individual directors and officers.

Radioactivity in two tide-washed marsh areas in the eastern Irish Sea: a radiological assessment.

The doses received by man from exposure to artificial radionuclides deposited onto marsh land during tidal inundation on the English side of the Solway Firth and the Dee Estuary have been assessed. The range of total doses received by the different marsh user groups was similar in both study areas, varying from < 1 microSv year-1 to approximately 55 microSv year-1, with total dose dominated by the contribution from external exposure (generally 80% of the total). The maximum doses in both study areas were received by people working on the marshes and are well below the annual dose limit recommended by ICRP for members of the public (1 mSv year-1). The largest dose estimated (56 microSv year-1) is only 6% of the recommended dose limit.

"Best-of-breed" vs. monolithic solutions. Roundtable discussion.

The debate is hotter now than it was when we alluded to it in our June issue's "round table." CIOs and IS directors still wonder about the strategic advantages of single-vendor solutions vs. the best-of-breed approach. In June we noted that this dynamic has driven system acquisitions for several years. Since then we have witnessed what amounts to a feeding frenzy. We asked a few experts to discuss their perceptions of the controversy. Their comments follow.

Information industry leaders share visions of future. Interview by Carolyn Dunbar and Michael L. Laughlin.

Computers in Healthcare editors Carolyn Dunbar and Michael L. Laughlin spoke to nearly a hundred exhibitors during the 1992 Healthcare Information and Management Systems Society last February in Tampa, Fla. The themes of these conversations invariably turned to patient-focused systems, standards, integration and, of course, controlling healthcare costs. Many HIMSS participants offered valuable insights, and unfortunately space does not permit us to run every interview. In the following interviews, however, three industry leaders share visions of where their companies--and the industry--are headed.

Parental education and child mortality in Burundi.

This paper examines the relationship between parental education and child mortality in Burundi using data collected in the 1987 Demographic and Health Survey. Proportional hazards models are estimated to examine this relationship, while holding constant other known child mortality determinants. Parental education proves to be a key factor in explaining differences in child mortality, the effect of maternal education being particularly strong compared to paternal education.

PIP: Data collected in Burundi as part of the 1987 Demographic and Health Survey confirm an inverse relationship between parental education and child mortality that persists even when a variety of socioeconomic factors are controlled. Burundi is characterized by low levels of educational attainment (80% of women have never attended school and 65% are illiterate) and high child morality (185.5/1000 live births in 1977- 86). There were 8895 births to the 3970 respondents in the 1987 survey, and 1415 (16%) of these children had died by their 5th birthday. Cox's proportional hazards model was used to assess the effect of maternal education on child mortality. Control variables included father's education, mother's age at time of birth, rural-urban residence, region, child's gender, period of birth, and length of the preceding birth interval. The relative risk of a child death was 0.43 among mothers with a secondary education and 0.90 for those with a primary education compared to a baseline value of 1.0 for those with no education. Paternal education demonstrated the same effect, but was not as significant as maternal education. A surprising finding was the unimportance of birth order, when demographic and socioeconomic variables were held constant, to child survival status. Other variables that conferred a lower (although not as significant) child mortality risk were urban residence, maternal age 20-34 years, birth between 1983-1987, and birth intervals exceeding 2 years.

Are international patients the answer to American hospitals' problems?

American hospitals hoping to capitalize on the lucrative market for international patients may be in for some surprises. Not only is this market limited, but also the drawbacks may outweigh the potential benefits for hospitals seeking to enter this business.

Evaluation of a scoring system for extracranial carotid atherosclerosis extent with B-mode ultrasound.

We have developed a scoring system to quantify extent of extracranial carotid artery atherosclerosis using real-time ultrasound (B-mode). To evaluate repeatability of this scoring system we correlated repeat scores obtained within a short interval of one another (6 months) in 52 individuals. We compared repeatability of extent measurements with repeatability of a measure of severity (single most severe lesion). Correlations between first and second studies for severity were weak (r2 = 0.20) but significant (p less than 0.001). Extent scores correlated much better (r2 = 0.77, p less than 0.001). In another group of 22 patients we found that the extent of atherosclerosis decreased following endarterectomy. We used this method to determine changes in extent of carotid atherosclerosis with age in two sets of individuals. One consisted of a cohort of 22 patients who underwent repeat B-mode studies separated by 1 1/2-3 years. This cohort demonstrated an increase in carotid score with age (p less than 0.05). In a second group of volunteers undergoing cardiac catheterization and B-mode evaluation of the carotid system, carotid scores could be compared in individuals with age differences that averaged 15 years. Extent of carotid atherosclerosis was significantly greater in older individuals (p less than 0.01) and differences in extent with age were exaggerated in patients with coronary disease compared to coronary disease free controls.

Community Hospital-based Stroke Programs: North Carolina, Oregon, and New York. II: Description of study population.

The three Community Hospital-based Stroke Programs collected data on 4132 stroke patients admitted to acute care hospitals during 1979 and 1980. White female stroke patients were older than the white male, nonwhite female and nonwhite male stroke patients. Nearly one-fourth (23%) of stroke patients were employed at the time of the event. Most (77%) of the patients were hospitalized for first stroke episodes. Eighty-three percent of the patients had at least one of the four major risk factors for stroke, namely, hypertension, diabetes, transient ischemic attacks and cardiac disease. Half (49%) of the patients were alert at the time of admission. The three diagnostic categories included infarction (60%), stroke not otherwise specified (30%) and hemorrhage (10%). Fourteen days was the median length of hospitalization; 50% of the stroke patients were discharged to a home setting, 31% were institutionalized and 19% died while in the hospital. The mean Barthel Index score for 2400 patients at the time of discharge was 61.8 (normal is 100). Of those patients who were working at the time of the stroke, 22% returned to work. In comparison to the patients in the National Survey of Stroke, patients in this Study were less severe at the time of admission (49% of patients in the National Survey of Stroke were stuporous or comatose compared to 21% of the patients in the current Study). The inhospital fatality was 30.7% in the National Survey of Stroke, and 19.7% in the current Study.