Clinical outcomes associated with screening and referral for depression in an acute cardiac ward

Aim.  The aim of this paper is to describe the implementation of a depression screening and referral tool in two cardiac wards of a major metropolitan public hospital. The tool consisted of two sections: (1) screening for depression risk (Cardiac Depression Scale-5) and (2) consequential referral actions.

Background.  Prior research has shown that depression in patients with heart disease is associated with significantly impaired quality of life, decreased medication adherence, increased morbidity and increased use of healthcare services.

Design.  A prospective in-patient study design.

Method.  A consecutive sample of 202 patients admitted to either the cardiac medical (n = 145) or surgical (n = 57) wards of a major Melbourne metropolitan hospital were recruited into the study over an 18-week period.

Results.  Just over half (54%) of the patients were identified as ‘at risk’ of depression. Of these, 19% were assessed as moderate risk and 35% high risk. Of those patients, 91% had the risk score documented in their medical history, 90% had engaged in discussions with clinicians regarding their risk score, 85% had their risk score communicated formally to the medical team and 25% were formally referred for appropriate follow-up – significantly more than prior to implementation of the screening and referral tool.

Conclusions.  By providing a formalised mechanism for detecting depression, documented screening and referral rates improved for those with comorbid depression and heart disease affording an opportunity for early intervention. These findings support a move towards integrated approaches to screening of depression to become standard practice in the acute cardiac setting.

Relevance to clinical practice.  Such mechanisms also have the potential to initiate the development of new models of care that acknowledge the complexity of comorbid depression and heart disease and provide pathways from speciality to primary care which integrate the physical and psychosocial domains inclusive of screening, referral, systematic monitoring and streamlined behavioural and physical care.

Application of an Adaptive Neural Network to Medical Decision Support

Medical diagnostic and prognostic problems are prime examples of decision making in the face of uncertainty. In this paper, we investigate the applicability of the Fuzzy ARTMAP neural network as an intelligent decision support system in clinical medicine. In particular, Fuzzy ARTMAP is employed as a predictive model for prognosis of complications in patients admitted to the Coronary Care Units. A number of off-line and on-line experiments have been conducted with various network parameter settings, training methods, and learning rules. The results are compared with those from other systems including the logistic regression model. In addition, the outcomes of a set of on-line learning experiments revealed the potential of employing Fuzzy ARTMAP as an autono-mously learning system that is able to learn perpetually and, at the same time, to provide useful decision support.

Anxiety disorders : assessment and management in general practice

Background: Anxiety is a normal physiological response to a threat. Anxiety disorders occur when this normal physiological response is associated with high levels of autonomic arousal, erroneous cognitions and dysfunctional coping strategies. Anxiety disorders are highly prevalent and present commonly to general practice. Anxiety disorders are often comorbid with other psychiatric and medical disorders and may be associated with significant morbidity.

Objective: This article describes the diagnosis, assessment and management of anxiety disorders in the general practice setting.

Discussion: Assessment in patients presenting with anxiety symptoms involves excluding a medical cause, identifying features of specific anxiety disorders as well as other coexisting psychiatric disorders, and assessing the degree of distress. Management options include psychoeducation, psychological treatments (particularly cognitive behaviour therapy) and pharmacological treatments. Patients with a diagnosis of an anxiety disorder can access Medicare funded psychological care under a number of Australian government initiatives. Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are the first line pharmacological agents used to treat anxiety disorders. Regular review is vital to monitor for clinical improvement and more complex presentations may require specialist psychological or psychiatric referral.

Exploring the effects of perceived service provider sincerity on consumers' emotional state and satisfaction during service consumption

A holistic approach to satisfaction and its effects seems to be particularly important in high-affect, high-involvement, and extended duration services such as those offered by many travel and tourism providers. This means understanding the complexities of service provision and its processes. Consumers value service interaction that appears sincere. For this reason, organizations expect service providers to manage their service "performance" to reflect a genuine display of positive emotions towards the customer, which has a direct impact on customer satisfaction and possibly overall life satisfaction. This study explores consumers' perception of sincerity and tests its effects on positive emotions and satisfaction in an extended duration service. The findings indicate that perceived service sincerity positively influences consumers' emotions during a service and has important direct and indirect effects on life satisfaction, service satisfaction, and intention to repurchase. Implications for managers and opportunities for further research are discussed.

Deficiencies and missed opportunities to formulate clinical guidelines in Australia for withholding or withdrawing life-sustaining treatment in severely disabled and impaired infants

This paper examines the few, but important legal and coronial cases concerning withdrawing or withholding life-sustaining treatment from severely disabled or critically impaired infants in Australia. Although sparse in number, the judgements should influence common clinical practices based on assessment of “best interests” but these have not yet been adopted. In particular, although courts have discounted assessment of “quality of life” as a legitimate component of determination of “best interests,” this remains a prominent component of clinical guidelines. In addition, this paper highlights the lack of uniform clinical guidelines available to medical professionals and parents in Australia when making end-of-life decisions for severely ill infants. Thus, it is argued here that there is a need for an overarching prescriptive uniform framework or set of guidelines in end-of-life decision-making for impaired infants. This would encourage greater transparency, consistency, and some degree of objectivity in an area that often appears subjective.

Determinants of the provision of ethylene oxide medical surveillance in Massachusetts hospitals

An in-depth survey of ethylene oxide (EtO) health and safety was conducted in Massachusetts hospitals (n = 92) to investigate the determinants of the provision of medical surveillance for EtO exposure. We have evaluated the relationships between provision of EtO medical surveillance and (1) activating OSHA-specified triggers for providing EtO medical surveillance, (2) worker training on EtO health and safety, and (3) various public policy, organizational, group, and individual characteristics. Among the Occupational Safety and Health Administration's (OSHA) five specified triggers for provision of EtO medical surveillance, only accidental worker exposures were related to provision of surveillance (RR = 2.56, P < 0.001). Exceeding the Action Level for 30 or more days, one of OSHA's EtO triggers that is also used in a number of other standards, was not related to provision of surveillance (RR = 0.84, P = 0.714). Reports of coverage of EtO medical surveillance issues in worker training were also correlated with the provision of EtO medical surveillance (RR = 3.68, P < 0.001), supporting OSHA's premise that worker training plays an important role in medical surveillance implementation. The presence of detailed written EtO medical surveillance policies was positively related to the provision of EtO medical surveillance (RR = 1.81, P < 0.001). The relationships between these potential determinants and provision of medical surveillance were also validated in multivariate analyses. Implications for improvement of OSHA medical surveillance implementation through revised trigger schemes, improved worker training efforts, and other measures are discussed. Findings are relevant to the future development of medical surveillance and exposure monitoring policies and practices in both substance-specific and generic contexts.

Development and piloting of an exposure database and surveillance system for DOE cleanup operations

An industrial hygiene exposure database and surveillance system was developed in partnership between National Institute for Occupational Safety and Health (NIOSH)-funded independent investigators and practicing industrial hygienists at the Rocky Flats Environmental Technology Site (RFETS) in Golden, Colo. RFETS is a former U.S. Department of Energy nuclear weapons plant that is now in cleanup phase. This project is presented as a case study in the development of an exposure database and surveillance system in terms that are generalizable to most other industries and work contexts. Steps include gaining organizational support; defining system purpose and scope; defining database elements and coding; planning practical and efficient analysis strategies; incorporating reporting capabilities; and anticipating communication strategies that maximize the probability that surveillance findings will feed back to preventive applications. For each of these topics, the authors describe both general considerations as well as the specific choices made for this system. An important feature of the system is a two-tier task-coding scheme comprising 33 categories of task groups. Examples of grouped analyses of exposure data captured during the system pilot period demonstrate applications to exposure control, medical surveillance, and other preventive measures. Reprinted by permission of the publisher.

Remote monitoring system enabling cloud technology upon smart phones and inertial sensors for human kinematics

Stroke is a common neurological condition which is becoming increasingly common as the population ages. This entails healthcare monitoring systems suitable for home use, with remote access for medical professionals and emergency responders. The mobile phone is becoming the easy access tool for self-evaluation of health, but it is hindered by inherent problems including computational power and storage capacity. This research proposes a novel cloud based architecture of a biomedical system for a wearable motion kinematic analysis system which mitigates the above mentioned deficiencies of mobile devices. The system contains three subsystems: 1. Bio Kin WMS for measuring the acceleration and rotation of movement 2. Bio Kin Mobi for Mobile phone based data gathering and visualization 3. Bio Kin Cloud for data intensive computations and storage. The system is implemented as a web system and an android based mobile application. The web system communicates with the mobile application using an encrypted data structure containing sensor data and identifiable headings. The raw data, according to identifiable headings, is stored in the Amazon Relational Database Service which is automatically backed up daily. The system was deployed and tested in Amazon Web Services.

Diabetes in older people: new insights and remaining challenges

Diabetes in ageing communities imposes a substantial personal and public health burden by virtue of its high prevalence, its capacity to cause disabling vascular complications, the emergence of new non-vascular complications, and the effects of frailty. In this Review, we examine the current state of knowledge about diabetes in older people (aged ≥75 years) and discuss how recognition of the effect of frailty and disability is beginning to lead to new management approaches. A multidimensional and multidisciplinary assessment process is essential to obtain information on medical, psychosocial, and functional capabilities, and also on how impairments of these functions could limit activities. Major aims of diabetes care include maintenance of independence, functional status, and quality of life by reduction of symptom and medicine burden, and active identification of risks. Linking of therapeutic targets to individual functional status is mandatory and very tight glucose control is often not necessary. Hypoglycaemia remains an important avoidable iatrogenic event. Quality diabetes care in older people remains an important challenge for health professionals.

Relationships between inventory, sales and service in a retail chain store operation

Effective inventory management is critical to retailing success. Surprisingly, there islittle published empirical research examining relationships between retail inventory, sales andcustomer service. Based on a survey of 101 chain store units, this paper develops and tests aseries of hypotheses about retail inventory. Seventy-five percent of the store owners/managersresponded to the mail survey. As expected, significant positive relationships were found betweeninventory, service and sales. Specifically, support was found for the theory that inventory is afunction of the square root of sales. Also, greater product variety leads to higher inventory, andservice level is an exponential function of inventory. Finally, demand uncertainty was found tohave no apparent effect on inventory levels.

The strategy of global branding and brand equity

This book offers a way to predict which brand a buyer will purchase. It looks at brandperformance within a product category and tests it in different countries with verydifferent cultures. Following the Predictive Brand Choice (PBC) model, this book seeks to predict a consumer’s loyalty and choice. Results have shown that PBC can achieve a high level of predictive accuracy, in excess of 70% in mature markets. This accuracy holds even in the face of price competition from a less preferred brand.PBC uses a prospective predicting method which does not have to rely on a brand’spast performance or a customer’s purchase history for prediction. Choice data isgathered in the retail setting – at the point of sale. The Strategy of Global Brandingand Brand Equity presents survey data and quantitative analyses that prove themethod described to be practical, useful and implementable for both researchers and practitioners of commercial brand strategies.

Critically impaired infants and end of life decision making : resource allocation and difficult decisions

Decisions to withdraw or withhold life-sustaining treatment are contentious, and offer difficult moral dilemmas to both medical practitioners and the judiciary. This issue is exacerbated when the patient is unable to exercise autonomy and is entirely dependent on the will of others.This book focuses on the legal and ethical complexities surrounding end of life decisions for critically impaired and extremely premature infants. Neera Bhatia explores decisions to withdraw or withhold life-sustaining treatment from critically impaired infants and addresses the controversial question, which lives are too expensive to treat? Bringing to bear such key issues as clinical guidance, public awareness, and resource allocation, the book provides a rational approach to end of life decision making, where decisions to withdraw or withhold treatment may trump other competing interests.The book will be of great interest and use to scholars and students of bioethics, medical law, and medical practitioners.

Web-based alcohol screening and brief intervention for university students: a randomized trial

IMPORTANCE: Unhealthy alcohol use is a leading contributor to the global burden of disease, particularly among young people. Systematic reviews suggest efficacy of web-based alcohol screening and brief intervention and call for effectiveness trials in settings where it could be sustainably delivered. OBJECTIVE: To evaluate a national web-based alcohol screening and brief intervention program. DESIGN, SETTING, AND PARTICIPANTS: A multisite, double-blind, parallel-group, individually randomized trial was conducted at 7 New Zealand universities. In April and May of 2010, invitations containing hyperlinks to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screening test were e-mailed to 14,991 students aged 17 to 24 years. INTERVENTIONS: Participants who screened positive (AUDIT-C score ≥4) were randomized to undergo screening alone or to 10 minutes of assessment and feedback (including comparisons with medical guidelines and peer norms) on alcohol expenditure, peak blood alcohol concentration, alcohol dependence, and access to help and information. MAIN OUTCOMES AND MEASURES: A fully automated 5-month follow-up assessment was conducted that measured 6 primary outcomes: consumption per typical occasion, drinking frequency, volume of alcohol consumed, an academic problems score, and whether participants exceeded medical guidelines for acute harm (binge drinking) and chronic harm (heavy drinking). A Bonferroni-corrected significance threshold of .0083 was used to account for the 6 comparisons and a sensitivity analysis was used to assess possible attrition bias. RESULTS: Of 5135 students screened, 3422 scored 4 or greater and were randomized, and 83% were followed up. There was a significant effect on 1 of the 6 prespecified outcomes. Relative to control participants, those who received intervention consumed less alcohol per typical drinking occasion (median 4 drinks [interquartile range {IQR}, 2-8] vs 5 drinks [IQR 2-8]; rate ratio [RR], 0.93 [99.17% CI, 0.86-1.00]; P = .005) but not less often (RR, 0.95 [99.17% CI, 0.88-1.03]; P = .08) or less overall (RR, 0.95 [99.17% CI, 0.81-1.10]; P = .33). Academic problem scores were not lower (RR, 0.91 [99.17% CI, 0.76-1.08]; P = .14) and effects on the risks of binge drinking (odds ratio [OR], 0.84 [99.17% CI, 0.67-1.05]; P = .04) and heavy drinking (OR, 0.77 [99.17% CI, 0.56-1.05]; P = .03) were not significantly significant. In a sensitivity analysis accounting for attrition, the effect on alcohol per typical drinking occasion was no longer statistically significant. CONCLUSIONS AND RELEVANCE: A national web-based alcohol screening and brief intervention program produced no significant reductions in the frequency or overall volume of drinking or academic problems. There remains a possibility of a small reduction in the amount of alcohol consumed per typical drinking occasion. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12610000279022.

Hierarchical gene selection and genetic fuzzy system for cancer microarray data classification

This paper introduces a novel approach to gene selection based on a substantial modification of analytic hierarchy process (AHP). The modified AHP systematically integrates outcomes of individual filter methods to select the most informative genes for microarray classification. Five individual ranking methods including t-test, entropy, receiver operating characteristic (ROC) curve, Wilcoxon and signal to noise ratio are employed to rank genes. These ranked genes are then considered as inputs for the modified AHP. Additionally, a method that uses fuzzy standard additive model (FSAM) for cancer classification based on genes selected by AHP is also proposed in this paper. Traditional FSAM learning is a hybrid process comprising unsupervised structure learning and supervised parameter tuning. Genetic algorithm (GA) is incorporated in-between unsupervised and supervised training to optimize the number of fuzzy rules. The integration of GA enables FSAM to deal with the high-dimensional-low-sample nature of microarray data and thus enhance the efficiency of the classification. Experiments are carried out on numerous microarray datasets. Results demonstrate the performance dominance of the AHP-based gene selection against the single ranking methods. Furthermore, the combination of AHP-FSAM shows a great accuracy in microarray data classification compared to various competing classifiers. The proposed approach therefore is useful for medical practitioners and clinicians as a decision support system that can be implemented in the real medical practice.