A randomised trial of home vs hospital intravenous antibiotic therapy in adults with infectious diseases

Objective. Despite widespread adoption of home care services, few randomised trials have compared health outcomes in the hospital and at home. We report a prospective, randomised trial of home versus hospital therapy in adults receiving intravenous (IV) antibiotics. Our objective was to show that home care is a feasible alternative to hospitalisation over a broad range of infections, without compromise to quality of life (QOL) or clinical outcomes. Methods. Consenting adults requiring IV antibiotics were randomised to complete therapy at home or in hospital. Short Form 36 and Perceived Health Competence Scale (PHCS) were used for assessment of QOL. Statistical analysis used unpaired t-tests, Mann-Whitney tests and ANOVA. Results. One hundred and twenty-nine admissions were referred. Recruitment was hampered by patient preference for one therapy over another. 82 (62%) were included and randomised: 44 to home, 38 to hospital; the two groups had comparable characteristics. There were no differences in improvements in QOL and PHCS scores between the two groups after treatment. Treatment duration was median 11.5 days (range 3 - 57) and 11 days (range 4 - 126) for home and hospital groups, respectively. Home therapy costs, approximately, half that of hospital therapy. Time to readmission was longer after hospital therapy. Conclusion. Out study showed that home IV therapy is welt tolerated, is less costly, is not associated with any major disadvantage to QOL or clinical outcomes compared to hospital therapy, and is an appropriate treatment option for selected patients. (C) 2003 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Prospective memory rehabilitation for adults with traumatic brain injury: A compensatory training programme

Primary objective: To describe a prospective memory rehabilitation programme based on a compensatory training approach and report the results of three case studies. Research design: Programme evaluation using pre-and post-intervention assessments and telephone follow-up. Methods and procedures: Three participants with traumatic brain injury completed 8 weeks of training with 1 - 2 hour individual sessions. Assessments were formal prospective memory assessment, self-report and measures of diary use. Experimental interventions: Intervention aimed to identify potential barriers, establish self-awareness of memory deficits, introduce a customized compensatory tool, a cueing system and organizational strategies. A significant other was involved in training to assist generalization. Main outcomes and results: All three participants improved on formal prospective memory assessment and demonstrated successful diary use after the programme. Self-report of prospective memory failure fluctuated and may reflect increased self-awareness. Conclusion: A compensatory approach may be useful in improving prospective memory performance following TBI.

Urinary albumin levels in the normal range determine arterial wall thickness in adults with Type 2 diabetes: a FIELD substudy

Aim Cardiovascular disease (CVD) rates are substantially higher among patients with Type 2 diabetes than in the general population. The objective of this study was to identify the determinants of carotid intima media thickness (IMT) in patients with Type 2 diabetes. Methods We measured the thickness of the intima media layer of the carotid artery, a strong predictor of the risk of future vascular events, in 397 Type 2 diabetic patients drawn from the Fenofibrate Intervention and Event Lowering in Diabetes study, prior to treatment allocation. Results The mean IMT was 0.78 mm [interquartile range (IQR) 0.23 mm], and the maximum IMT was 1.17 mm (IQR 0.36 mm). By multivariate analysis, age, sex, duration of diabetes, triglycerides, and total cholesterol were independently correlated with IMT, as was urine albumin-creatinine ratio (ACR) (P < 0.001). The effect of ACR on IMT was further examined by tertile. Clinically significant differences in IMT were associated with ACR > 0.65 mg/mmol, approximately one-fifth the standard clinical threshold for microalbuminuria (P < 0.01). Long-term diabetes, independent of other parameters, was associated with a 50% increase in age-related thickening. Conclusions IMT in people with Type 2 diabetes is independently and continuously related to urine albumin levels and to the duration of diabetes. These results support previous data linking urine albumin measurements within the normal range with increased ischaemic cardiac mortality in the setting of Type 2 diabetes, and strongly suggest that urine albumin levels within this range should trigger a formal evaluation for CVD.

Clinical practice guidelines for the psychosocial care of adults with cancer

Clinical practice guidelines are increasingly being developed in medical settings to provide evidence-based recommendations to guide the clinical care of patients. The development of Clinical practice guidelines for the psychosocial care of patients with medical illness is a newer initiative, and more complex as the target audience includes health care professionals from diverse backgrounds. In Australia, the National Breast Cancer Centre and National Cancer Control Initiative have collaborated to develop Clinical practice guidelines for the psychosocial care of adults with cancer, funded by the Australian Government Department of Health and Ageing. This paper outlines the development of these guidelines in the international context, gives an overview of their content, and describes strategies for their implementation and evaluation. Copyright (c) 2005 John Wiley C Sons, Ltd.

The effect of weightbearing exercise with low frequency, whole body vibration on lumbosacral proprioception: A pilot study on normal subjects

Patients with low back pain (LBP) often present with impaired proprioception of the lumbopelvic region. For this reason, proprioception training usually forms part of the rehabilitation protocols. New exercise equipment that produces whole body, low frequency vibration (WBV) has been developed to improve muscle function, and reportedly improves proprioception. The aim of this pilot study was to investigate whether weightbearing exercise given in conjunction with WBV would affect lumbosacral position sense in healthy individuals. For this purpose, twenty-five young individuals with no LBP were assigned randomly to an experimental or control group. The experimental group received WBV for five minutes while holding a static, semi-squat position. The control group adopted the same weightbearing position for equal time but received no vibration. A two-dimensional motion analysis system measured the repositioning accuracy of pelvic tilting in standing. The experimental (WBV) group demonstrated a significant improvement in repositioning accuracy over time (mean 0.78 degrees) representing 39% improvement. It was concluded that WBV may induce improvements in lumbosacral repositioning accuracy when combined with a weightbearing exercise. Future studies with WBV should focus on evaluating its effects with different types of exercise, the exercise time needed for optimal outcomes, and the effects on proprioception deficits in LBP patients.

Rifampicin and sodium fusidate reduces the frequency of methicillin-resistant Staphylococcus aureus (MRSA) isolation in adults with cystic fibrosis and chronic MRSA infection

Nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) to patients with cystic fibrosis (CF) frequently results in chronic respiratory tract carriage. This is an increasing problem, adds to the burden of glycopeptide antibiotic use in hospitals, and represents a relative contraindication to lung transplantation. The aim of this study was to determine whether it is possible to eradicate MRSA with prolonged oral combination antibiotics, and whether this treatment is associated with improved clinical status. Adult CF patients (six mate, one female) with chronic MRSA infection were treated for six months with rifampicin and sodium fusidate. Outcome data were examined for six months before treatment, on treatment and after treatment. The patients had a mean age of 29.3 (standard deviation = 6.3) years and FEV1 of 36.1% (standard deviation = 12.7) predicted. The mean duration of MRSA isolation was 31 months. MRSA isolates identified in these patients was of the same lineage as the known endemic strain at the hospital when assessed by pulsed-field get electrophoresis. Five of the seven had no evidence of MRSA during and for at [east six months after rifampicin and sodium fusidate. The proportion of sputum samples positive for MRSA was lower during the six months of treatment (0.13) and after treatment (0.19) compared with before treatment (0.85) (P < 0.0001). There was a reduction in the number of days of intravenous antibiotics per six months with 20.3 +/- 17.6 on treatment compared with 50.7 before treatment and 33.0 after treatment (P = 0.02). There was no change in lung function. Gastrointestinal side effects occurred in three, but led to therapy cessation in only one patient. Despite the use of antibiotics with anti-staphylococcal activity for treatment of respiratory exacerbation, MRSA infection persists. MRSA can be eradicated from the sputum of patients with CF and chronic MRSA carriage by using rifampicin and sodium fusidate for six months. This finding was associated with a significant reduction in the duration of intravenous antibiotic treatment during therapy. (C) 2003 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.

Are the changes in postural control associated with low back pain caused by pain interference?

Background: Voluntary limb movements are associated with involuntary and automatic postural adjustments of the trunk muscles. These postural adjustments occur prior to movement and prevent unwanted perturbation of the trunk. In low back pain, postural adjustments of the trunk muscles are altered such that the deep trunk muscles are consistently delayed and the superficial trunk muscles are sometimes augmented. This alteration of postural adjustments may reflect disruption of normal postural control imparted by reduced central nervous system resources available during pain, so-called pain interference, or reflect adoption of an alternate postural adjustment strategy. Methods: We aimed to clarify this by recording electromyographic activity of the upper (obliquus extemus) and lower (transversus abdominis/obliquus internus) abdominal muscles during voluntary arm movements that were coupled with painful cutaneous stimulation at the low back. If the effect of pain on postural adjustments is caused by pain interference, it should be greatest at the onset of the stimulus, should habituate with repeated exposure, and be absent immediately when the threat of pain is removed. Sixteen patients performed 30 forward movements of the right arm in response to a visual cue (control). Seventy trials were then conducted in which arm movement was coupled with pain (pain trials) and then a further 70 trials were conducted without the pain stimulus (no pain trials). Results: There was a gradual and increasing delay of transversus abdominis/obliquus internus electromyograph and augmentation of obliquus externus during the pain trials, both of which gradually returned to control values during the no pain trials. Conclusion: The results suggest that altered postural adjustments of the trunk muscles during pain are not caused by pain interference but are likely to reflect development and adoption of an alternate postural adjustment strategy, which may serve to limit the amplitude and velocity of trunk excursion caused by arm movement.

Environmental factors that influence the community participation of adults with aphasia: The perspective of service industry workers

Background: The loss of language and the inability to communicate effectively as a result of aphasia often affects community participation. Within the World Health Organisation International Classification of Functioning, Disability and Health, disability is recognised as a dynamic interaction between the individual's health condition, such as aphasia, and his or her personal and environmental factors. There has been little research identifying the environmental facilitators and barriers to participation for people with aphasia in the community, and no research focusing on the perspective of service industry workers. Aims: This study aimed to identify barriers and facilitators to community participation for adults with aphasia from the perspective of service industry workers. Methods & Procedures: Eight focus groups were conducted with 24 service industry employees. Transcripts of the focus group discussions were analysed using qualitative content analysis procedures, and barriers to and facilitators for participation of people with aphasia were identified. Outcomes & Results: Results revealed that the participation of people with aphasia in the community can be affected by many environmental factors within three broad categories: (1) people environmental factors, (2) physical environmental factors, and (3) business or organisational environmental factors. Conclusions: Service industry employees were able to identify a range of factors that would act as barriers and facilitators for people with aphasia. Some of the more significant findings include the lack of other people's awareness about aphasia, the willingness of service industry workers at the individual level to accommodate people with aphasia, and the difficulty in making the necessary system, policy, and procedural changes at the organisational level. Speech pathologists are encouraged to assist service industry providers to be more aphasia-friendly through education and training, in addition to assisting people with aphasia to become self-advocates.

Personalised social care for adults with disabilities: A problematic concept for frontline practice

This paper explores the complexities and contradictions of frontline practice that pose problems for personalised social care through enhanced choice. It draws on semi-structured interviews with community care workers, social workers, occupational therapists and care managers in a social service department. Practitioners interviewed were asked about their current assessment and documentation system, including the assessment documents currently used; how they approached information gathering and the topics they explored with service users; and their experience of documenting assessment and care management. The paper argues that the validity and sustainability of personalised social care in frontline practice relies on developing a thorough understanding of the complex and implicit assessment processes operating at the service user/practitioner interface and the inevitable tensions that arise for practitioners associated with the organisational context and broader service environment. The findings demonstrate the variability among practitioners in how they collect information and more importantly, the critical role practitioners occupy in determining the kinds of topics to be explored during the assessment process. In so doing, it shows how practitioners can exert control over the decision-making process. More importantly, it provides some insight into how such processes are shaped by the constraints of the organisational context and broader service environment. Complexities and contradictions may be an inherent part of frontline practice. The issues discussed in this paper, however, highlight potential areas that might be targeted in conjunction with implementing personalised social care through enhanced choice for people with disabilities.