Conditional release: A less restrictive alternative to hospitalization?

Objective: This study examined conditional release - that is, involuntary outpatient commitment orders upon release from hospitalization - as a least restrictive alternative to psychiatric hospitalization in Victoria, Australia. Methods: Records were obtained from the Victorian Psychiatric Case Register for patients who experienced psychiatric hospitalization: between 1990 and 2000 a total of 8,879 patients were given conditional release and 16,094 were not. Results: Compared with the group that was hospitalized but did not receive a conditional release, the group that received a conditional release was more likely to have more prior hospitalizations of greater than average duration. Patients with schizophrenia were more likely to be given conditional release. Patients given conditional release experienced a care pattern involving briefer inpatient episodes (8.3 fewer days per episode), more inpatient days, and longer duration of restrictive care - that is, combined inpatient and conditional release periods (5.1 more days per month in care). Conclusions: For patients at risk of long-term hospitalization, conditional release may help to shorten inpatient episodes by providing a least restrictive alternative to continued hospitalization. However, patients who were given conditional release doubled the amount of days they spent under restrictive care, compared with the amount of time they previously spent in the hospital before entering a period of combined inpatient and conditional release commitment. Additional oversight may have led to more frequent hospitalization. This consequence raises new questions regarding the possible benefits of such extended oversight and new challenges for release planning using conditional release as a least restrictive method of care.

Effect of conditional release from hospitalization on mortality risk

Objectives: This study considered the protective value provided by conditional release. It assessed the contribution of conditional release to mortality risk among patients with mental disorders severe enough to require psychiatric hospitalization during a mental health treatment span of 13.5 years in Victoria, Australia. Methods: Death records were obtained from the Australian National Death Index for a sample of 24,973 Victorian Psychiatric Case Register patients with a history of psychiatric hospitalizations: 8,879 had experienced at least one conditional release during community care intervals and 16,094 had not. Risk of death was assessed with standardized mortality ratios of the general population of Victoria. Relative risk of death among patients with and without past experience of conditional release was computed with risk and odds ratios. The contribution of conditional release to mortality, taking into account use of community care services, age, gender, inpatient experience, and diagnosis, as well as other controls, was assessed with logistic regression. Results: Patients who had been hospitalized showed higher mortality risk than the general population. Sixteen percent ( 4,034) died. Patients exposed to conditional release, however, had a 14 percent reduction in probability of noninjury-related death and a 24 percent reduction per day on orders in the probability of death from injury compared with those not offered such oversight throughout their mental health treatment, all other factors taken into account. Conclusions: Conditional release can offer protective oversight for those considered dangerous to self or others and appears to reduce mortality risk among those with disorders severe enough to require psychiatric hospitalization.

Factors in the selection of patients for conditional release from their first psychiatric hospitalization

Objective: This study examined a sample of patients in Victoria, Australia, to identify factors in selection for conditional release from an initial hospitalization that occurred within 30 days of entry into the mental health system. Methods: Data were from the Victorian Psychiatric Case Register. All patients first hospitalized and conditionally released between 1990 and 2000 were identified (N = 8,879), and three comparison groups were created. Two groups were hospitalized within 30 days of entering the system: those who were given conditional release and those who were not. A third group was conditionally released from a hospitalization that occurred after or extended beyond 30 days after system entry. Logistic regression identified characteristics that distinguished the first group. Ordinary least-squares regression was used to evaluate the contribution of conditional release early in treatment to reducing inpatient episodes, inpatient days, days per episode, and inpatient days per 30 days in the system. Results: Conditional release early in treatment was used for 11 percent of the sample, or more than a third of those who were eligible for this intervention. Factors significantly associated with selection for early conditional release were those related to a better prognosis ( initial hospitalization at a later age and having greater than an 11th grade education), a lower likelihood of a diagnosis of dementia or schizophrenia, involuntary status at first inpatient admission, and greater community involvement ( being employed and being married). When the analyses controlled for these factors, use of conditional release early in treatment was significantly associated with a reduction in use of subsequent inpatient care.

Identification of genes implicated in toxin production in the cyanobacterium Cylindrospermopsis raciborskii

Cylindrospermopsis raciborskii is a bloom-forming cyanobacterium found in both tropical and temperate climates which produces cylindrospermopsin, a potent hepatotoxic secondary metabolite. This organism is notorious for its association with a significant human poisoning incident on Palm Island, Australia, which resulted in the hospitalization of 148 people. We have screened 13 C. raciborskii isolates from various regions of Australia and shown that both toxic and nontoxic strains exist within this species. No association was observed between geographical origin and toxin production. Polyketide synthases (PKSs) and peptide synthetases (PSs) are enzymes involved in secondary metabolite biosynthesis in cyanobacteria. Putative PKS and PS genes from C. raciborskii strains AWT205 and CYPO2OB were identified by PCR using degenerate primers based on conserved regions within each gene. Examination of the strain-specific distribution of the PKS and PS genes in C. raciborskii isolates demonstrated a direct link between the presence of these two genes and the ability to produce cylindrospermopsin. Interestingly, the possession of these two genes was also linked. They were also identified in an Anabaena bergii isolate that was demonstrated to produce cylindrospermopsin. Taken together, these data suggest a likely role for these determinants in secondary metabolite and toxin production by C. raciborskii. (C) 2001 John Wiley & Sons, Inc.

In Australia are people born in other countries at higher risk of road trauma than locally born people?

This study examined whether people born in other countries had higher rates of death and hospitalization due to road crashes than people born in Australia. Data on deaths that occurred in the whole of Australia between 1994 and 1997 and hospitalizations that occurred in the state of New South Wales, Australia, between I July 1995 and 30 June 1997 due to road crashes were analyzed. The rates of death and hospitalization, adjusted for age and area of residence, were calculated using population data from the 1996 Australian census. The study categorized people born in other countries according to the language (English speaking, non-English speaking) and the road convention (left-hand side, right-hand side) of their country of birth. Australia has the left-hand side driving convention. The study found that drivers born in other countries had rates of death or hospitalization due to road trauma equal to or below those of Australian born drivers. In contrast, pedestrians born in other countries, especially older pedestrians had higher rates of death and hospitalization due to road crashes. Pedestrians aged 60 years or more born in non-English speaking countries where traffic travels on the right-hand side of the road had risks about twice those of Australian born pedestrians in the same age group. (C) 2003 Elsevier Ltd. All rights reserved.

Declining rates of coronary heart disease in New Zealand and Australia, 1983-1993

The authors report the results of 10 years of monitoring of trends in the rates of major nonfatal and fatal coronary events and in case fatality in Auckland, New Zealand, and in Newcastle and Perth, Australia. Continuous surveillance of all suspected myocardial infarctions and coronary deaths in people aged 35-64 years was undertaken in the three centers as part of the World Health Organization's Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Project, For nonfatal definite myocardial infarction, there were statistically significant declines in rates in all centers in both men and women, with estimated average changes between 2.5% and 3.7% per year during the period 1984-1993, Rates of all coronary deaths also declined significantly in all three populations for both men and women. In absolute terms, there was, in general, a greater reduction in prehospital deaths than in deaths after hospitalization. Although 28-day case fatality remains high at between 35% and 50%, in the Australian centers it declined significantly by between 1.0% and 2.9% per year, and in Auckland there was also a small decline, However, since most deaths occur outside the hospital in people without a previous history of coronary heart disease, an increased emphasis on primary prevention is necessary.

Post-traumatic amnesia: Consistency-of-recovery and duration-to-recovery following traumatic brain impairment

The aim of this research was to examine the nature and order of recovery of orientation and memory functioning during Post-Traumatic Amnesia (PTA) in relation to injury severity and PTA duration. The Westmead PTA Scale was used across consecutive testing days to assess the recovery of orientation and memory during PTA in 113 patients. Two new indices were examined: a Consistency-of-Recovery and a Duration-to-Recovery index. a predictable order of recovery was observed during PTA: orientation-to-person recovered sooner and more consistently than the following cluster; orientation-to-time, orientation-to-place, and the ability to remember a face and name. However, the type of memory functioning required for the recall face and name task recovered more consistently than that required for memorizing three pictures. An important overall finding was that the order-of-recovery'' of orientation and memory functioning was dependent upon both the elapsed days since injury, and the consistency of recovery. The newly developed indices were shown to be a valuable means of accounting for differences between groups in the elapsed days to recovery of orientation and memory. These indices also clearly increase the clinical utility of the Westmead PTA Scale and supply an objective means of charting (and potentially predicting) patients' recovery on the different components of orientation and memory throughout their period of hospitalization.

High prevalence of asthma in five remote indigenous communities in Australia

Data on the prevalence of asthma in children residing in remote indigenous communities in Australia are sparse, despite the many reports of high prevalence in nonindigenous children of this country. Two previous Australian studies have had poor participation rates, limiting interpretation of their results. A study of children in the Torres Strait and Northern Peninsula Area of Australia was conducted to document the prevalence of asthma symptoms. Five indigenous communities were randomly selected and trained interviewers, who were local indigenous health workers, recruited participants using a house-by-house approach. Information was collected by a structured face-to-face interview based on standardized questionnaire constructed from the protocol International Study of Asthma and Allergy in Childhood; 1,650 children were included in the study with a 98% response rate. Overall, the prevalence of self-reported ever wheezing was 21%,; 12% reported wheezing in the previous year; and 16%, reported ever having asthma, There was significant variation in the prevalence of asthma symptoms between communities. It is concluded that there are significant intercommunity variations in the prevalence of asthma symptoms in remote communities and that the prevalence in these communities is as high as in nonindigenous groups.

Safety and efficacy of low anterior en bloc resection as part of cytoreductive surgery for patients with ovarian cancer

Objective. To examine the feasibility and safety of a low anterior resection of the rectosigmoid plus adjacent pelvic tumour as part of primary cytoreduction for ovarian cancer. Methods. This study included 65 consecutive patients with primary ovarian cancer who had debulking surgery from 1996 through 2000. All patients underwent an en bloc resection of ovarian cancer and a rectosigmoid resection followed by an end-to-end anastomosis. Parameters for safety and efficacy were considered as primary statistical endpoints for the aim of this analysis. Results. Postoperative residual tumour was nil, 1 cm in 14, 34, and 14 patients, respectively. The median postoperative hospital stay was 11 days (range, 6 to 50 days). Intraoperative complications included an injury to the urinary bladder in one patient. Postoperative complications included wound complications (n=14, 21.5%), septicemia (n=9, 13.8%), cardiac complications (n=7, 10.8%), thromboembolic complications (n=5, 7.7%) ileus (n=2, 3.1%) anastomotic leak (n=2, 3.1%) and fistula (n=1, 1.5%). Reasons for a reoperation during the same admission included repair of an anastomotic leak (n=1), postoperative hemorrhage (n=1), and wound debridement (n=1). Wound complications, septicemia, and anastomotic leak formation were more frequent in patients who had a serum albumin level of less than or equal to 30 g/L preoperatively. There was one surgically related mortality in a patient who died from a cerebral vascular accident 2 days postoperatively. Conclusions. An en bloc resection as part of primary cytoreductive surgery for ovarian cancer is effective and its morbidity is acceptably low. (C) 2001 Academic Press.

Advances in neurotrauma in Australia 1970-2000

The management of neurotrauma in Australia has been one of the significant public health triumphs during the last 30 years of the 20th century. State and national government agencies act in a coordinated fashion to collect data and to promote research on how to manage neurotrauma patients. Between 1970 and 1995, fatalities from road accidents decreased by 47%. Hospital admissions have decreased by 40% despite a 40% increase in the population and a 120% increase in registered vehicles. Fatalities per 10,000 registered vehicles were 8.05% in 1970 and they fell to 1.84% per vehicles in 1995, while fatalities per 10;000 population were 3 in 1970 falling to 1.11 in 1995. Hospitalization from road crashes decreased 23% between March 1988 and March 1997. Public education has steadily improved, backed by the state public health sources. A uniform code of road safety laws has been adopted, backed by legislation and legal penalties and increasing police enforcement. Clinical care of patients has improved as a result of faster communications, tele-medicine, trauma systems, the CT scanner; intensive care units, and improved monitoring. Patient rehabilitation and counseling are now carried out at units accredited by the Australian Council on Health Care Standards.

Brain natriuretic peptide: Disease marker or more in cardiovascular medicine?

Brain natriuretic peptide (BNP) is predominantly a cardiac ventricular hormone that promotes natriuresis and diuresis, inhibits the renin-anglotensin-aldosterone axis, and is a vasodilator. Plasma BNP levels are raised in essential hypertension, and more so in left ventricular (LV) hypertrophy and heart failure. Plasma BNP levels are also elevated in ischemic heart disease. Attempts have been made to use plasma BNP levels as a marker of LV dysfunction, but these have shown that plasma BNP levels are probably not sensitive enough to replace echocardiography in the diagnosis of LV dysfunction. Pericardial BNP or N-BNP may be more suitable markers of LV dysfunction. Plasma BNP levels are also elevated in right ventricular dysfunction, pregnancy-induced hypertension, aortic stenosis, age, subarachnoid hemorrhage, cardiac allograft rejection and cavopulmonary connection, and BNP may have an important pathophysiological role in some or all of these conditions. Clinical trials have demonstrated the natriuretic, diuretic and vasodilator effects, as well as inhibitory effects on renin and aldosterone of infused synthetic human BNP (nesiritide) in healthy humans. BNP infusion improves LV function in patients with congestive heart failure via a vasodilating and a prominent natriuretic effect. BNP infusion is useful for the treatment of decompensated congestive heart failure requiring hospitalization. The clinical potential of BNP is limited as it is a peptide and requires infusion. Drugs that modify the effects of BNP are furthering our understanding of the pathophysiological role and clinical potential of BNP. Increasing the effects of BNP may be a useful therapeutic approach in heart failure involving LV dysfunction. The levels of plasma BNP are increased by blockers, cardiac glycosides and vasopeptidase inhibitors, and this may contribute to the usefulness of these agents in heart failure. (C) 2001 Prous Science. All rights reserved.

High circulating levels of the dengue virus nonstructural protein NS1 early in dengue illness correlate with the development of dengue hemorrhagic fever

Infection with any 1 of 4 dengue viruses produces a spectrum of clinical illness ranging from a mild undifferentiated febrile illness to dengue fever (DF) to dengue hemorrhagic fever (DHF), a potentially life-threatening disease. The morbidity and mortality of DHF can be reduced by early hospitalization and careful supportive care. To determine its usefulness as a predictor of DHF, plasma levels of the secreted dengue virus nonstructural protein NS1 (sNS1) were measured daily in 32 children with dengue-2 virus infections participating in a prospective, hospital-based study. Free sNS1 levels in plasma correlated with viremia levels and were higher in patients with DHF than in those with DF. An elevated free sNS1 level (greater than or equal to600 ng/mL) within 72 h of illness onset identified patients at risk for developing DHF.