Thromboyytic therapy for acute ischaemic stroke : successful implementation in an Australian tertiary hospital

Background: The use of tissue-type plasminogen activator (t-PA) in ischaemic stroke outside of experienced stroke centres remains controversial. The aim of this study was to present the initial experience with t-PA in patients with ischaemic stroke at an institution with no prior experience in i.v. stroke thrombolysis and to compare results to published reports.

Methods: Prospective audit of 888 patients with consecutive stroke and transient ischaemic attack admitted to a 426-bed tertiary referral hospital from March 2003 to October 2005. Main outcome measures were treatment rate, exclusion criteria, protocol violations, intracerebral haemorrhage, disability (modified Rankin scale) and mortality at 3 months.

Results: Over the study period, 72 patients received t-PA (11% of ischaemic strokes). The main reason for exclusion was presentation beyond 3 h of onset (44%); if all eligible patients had arrived within 3 h, treatment rate was estimated at 32.5%. Protocol violations occurred in 15 (21%) patients. There were seven (10%) asymptomatic intracerebral haemorrhage and one (1%) non-fatal symptomatic intracerebral haemorrhage. At 3 months, 37% had achieved excellent recovery (modified Rankin scale 0–1) and seven (10%) had died. The delivery and outcomes associated with the use of t-PA were comparable to the results of the National Institute of Neurological Disorders and Stroke trial and meta-analysis of open-labelled studies.

Conclusion: With appropriate infrastructure and protocols, previously inexperienced tertiary referral centres can replicate the experience and outcome measures reported by clinical trials of t-PA in patients with stroke.

Development and application of model of resource utilization, costs, and outcomes for stroke (MORUCOS): an Australian economic model for stroke.

Objectives: To outline the development, structure, data assumptions, and application of an Australian economic model for stroke (Model of Resource Utilization, Costs, and Outcomes for Stroke [MORUCOS]). Methods: The model has a linked spreadsheet format with four modules to describe the disease burden and treatment pathways, estimate prevalence-based and incidence-based costs, and derive life expectancy and quality of life consequences. The model uses patient-level, community-based, stroke cohort data and macro-level simulations. An interventions module allows options for change to be consistently evaluated by modifying aspects of the other modules. To date, model validation has included sensitivity testing, face validity, and peer review. Further validation of technical and predictive accuracy is needed. The generic pathway model was assessed by comparison with a stroke subtypes (ischemic, hemorrhagic, or undetermined) approach and used to determine the relative cost-effectiveness of four interventions. Results: The generic pathway model produced lower costs compared with a subtypes version (total average first-year costs/case AUD$15,117 versus AUD$17,786, respectively). Optimal evidence-based uptake of anticoagulation therapy for primary and secondary stroke prevention and intravenous thrombolytic therapy within 3 hours of stroke were more cost-effective than current practice (base year, 1997). Conclusions: MORUCOS is transparent and flexible in describing Australian stroke care and can effectively be used to systematically evaluate a range of different interventions. Adjusting results to account for stroke subtypes, as they influence cost estimates, could enhance the generic model.

Trial application of a model of resource utiliztion, costs, and outcomes for stroke (MORUCOS) to assist priority setting in stroke.

Background and Purpose— Cost-effectiveness data for stroke interventions are limited, and comparisons between studies are confounded by methodological inconsistencies. The aim of this study was to trial the use of the intervention module of the economic model, a Model of Resource Utilization, Costs, and Outcomes for Stroke (MORUCOS) to facilitate evaluation and ranking of the options.

Methods— The approach involves using an economic model together with added secondary considerations. A consistent approach was taken using standard economic evaluation methods. Data from the North East Melbourne Stroke Incidence Study (NEMESIS) were used to model "current practice" (base case), against which 2 interventions were compared. A 2-stage process was used to measure benefit: health gains (expressed in disability-adjusted life years [DALYs]) and filter analysis. Incremental cost-effectiveness ratios (ICERs) were calculated, and probabilistic uncertainty analysis was undertaken.

Results— Aspirin, a low-cost intervention applicable to a large number of stroke patients (9153 first-ever cases), resulted in modest health benefits (946 DALYs saved) and a mean ICER (based on incidence costs) of US $1421 per DALY saved. Although the health gains from recombinant tissue-type plasminogen activator (rtPA) were less (155 DALYs saved), these results were impressive given the small number of persons (256) eligible for treatment. rtPA dominates current practice because it is more effective and cost-saving.

Conclusions— If used to assess interventions across the stroke care continuum, MORUCOS offers enormous capacity to support decision-making in the prioritising of stroke services.

Paramedic identification of stroke : community validation of the Melbourne ambulance stroke screen

Background: Paramedics require an effective prehospital tool to eliminate stroke mimics and to assist in the identification of suitable candidates for thrombolytic therapy. The Faster Access to Stroke Therapies study combined two validated stroke assessment tools (the Los Angeles Prehospital Stroke Screen, LAPSS, and the Cincinnati Prehospital Stroke Scale, CPSS) to form the Melbourne Ambulance Stroke Screen (MASS), and performed an in-field validation by Australian paramedics.

Methods: Over a 12-month period, 18 paramedics participated in the Faster Access to Stroke Therapies study and prospectively collected data contained in the MASS on all stroke dispatches, and for other patients with a focal neurological deficit. Sensitivity and specificity analysis of the LAPSS, CPSS and MASS was calculated and equivalence analysis performed.

Results: Paramedics completed 100 MASS assessments for 73 (73%) stroke/transient ischemic attack patients and 27 (27%) stroke mimics. The sensitivity of the MASS (90%, 95% CI: 81-96%) showed statistical equivalence to the sensitivity of the CPSS (95%, p = 0.45) and superiority to the LAPSS (78%, p = 0.008). The specificity of the MASS (74%, 95% CI: 53-88%) was equivalent to that of the LAPSS (85%, p = 0.25) and superior to the CPSS (54%, p = 0.007). All patients misidentified by the MASS (7 strokes, 7 mimics) were ineligible for thrombolytic therapy.

Conclusion: The MASS is simple to use, with accurate prehospital identification of stroke. It distinguishes stroke mimics, with good recognition of suitable patients for thrombolytic therapy.

Evaluation of a cognitive behavior therapy program for people with sexual dysfunction

This article reports on an evaluation of a cognitive behavioral program for the treatment of sexual dysfunction. Frequency data are provided on the sexual dysfunction of 95 males (mean age = 41.6 years) and 105 females (mean age = 36.4 years). The effectiveness of a cognitive behavioral program among 45 sexually dysfunctional males (mean age = 39.9 years) and 54 sexually dysfunctional females (mean age = 36.2 years) was assessed. The results demonstrated that, after therapy, respondents experienced lower levels of sexual dysfunction, more positive attitudes toward sex, perceptions that sex was more enjoyable, fewer affected aspects of sexual dysfunction in their relationship, and a lower likelihood of perceiving themselves as a sexual failure. The implications of these findings for the treatment of sexual dysfunction are discussed.

"I will start treatment when I think the time is right":HIV-positive gay men talk about their decision not to access antiretroviral therapy.

In a qualitative study, 20 HIV-infected Australian gay men were interviewed about their decision not to access antiretroviral drug therapy. The main reasons given for the decision were fear of side effects; fear of long-term damage to body organs; the inconvenience of the treatment regimens; belief that the regimen's demands would be a threat to morale; and belief that there was no reason to start therapy in the absence of AIDS-related symptoms. Actions taken by the men to monitor and maintain their health included seeing a doctor regularly; having regular T-cell and viral load tests; and trying to maintain a positive outlook by not letting HIV/AIDS 'take over' their lives. Almost half the men considered they had been subjected to unreasonable pressure to access therapy and there was considerable pride at having resisted this pressure. The findings suggest that the men disagreed with the biomedical model for managing HIV/AIDS only on the question of if and when to access therapy. They also suggest that underlying the men's dissent from the biomedical model was a different mode of thinking than is required by the model: while the model demands thinking that is abstract, the men focused strongly on factors close to the 'here and now' of immediate experience. The practical implications of the findings are explored.

The meaning of professional excellence for private practitioners in occupational therapy

OT AUSTRALIA's Accredited Occupational Therapist Program is promoted using the message 'Assuring professional excellence'. It is widely assumed that professional excellence is understood. Yet, this concept encompasses complex themes, including competence and clinical reasoning. In this paper, the meaning of professional excellence is examined by investigating the perspectives of private practitioners. Private practitioners were chosen as they represent the diversity of the occupational therapy field, and may pre-empt trends within broader practice. Sixteen key informants were interviewed to obtain their perspectives on professional excellence. Common themes that arose from the findings include the significance of experience in practice, and the importance of understanding one's limitations in knowledge and expertise. Findings are discussed in relation to OT AUSTRALIA's aim to assure standards of practice.

Outdoor education and bush adventure therapy: A social-ecological approach to health and wellbeing.

Together, outdoor education and bush adventure therapy can be seen to constitute a population-wide health intervention strategy. Whether in educational or therapeutic settings, the intentional use of contact with nature, small groups, and adventure provides a unique approach in the promotion of health and wellbeing for the general population, and for individuals with identified health vulnerabilities. This paper explicitly emphasises human and social health, however, an integral assumption is that a healthy and sustainable environment is dependent on healthy human relationships with nature. We invite outdoor educators and bush adventure therapy practitioners to examine the proposition that healthy interactions with nature can create a unique stream of socio-ecological interventions. A spectrum of outdoor adventure programs is provided, allowing outdoor educators and bush adventure therapy practitioners to locate their work according to program context and aims, and participant aims and needs.

Reality therapy and the human energy field : working with needs that influence mind and body

There is accumulating evidence that body and mind, or rather the physical and the non-physical, are intrinsically connected. The mechanisms through which reality therapy works on mind and body may be explained via positive dynamics in the central nervous system, the body's biochemistry and the human energy field. The purpose of this paper is to show the relationship between choice theory and the nature of the power centers in the human energy field. Understanding the drivers behind human behavior and facilitating the choice to think realistically and to make responsible choices assists wholeness and enhances the physical, mental and spiritual health.

Professional competence for private practitioners in occupational therapy

The aim of the present study was to investigate the meaning of professional competence for occupational therapy private practitioners and their experience of the barriers to professional competence. Semi-structured interviews with 16 key informants from private practice in Victoria elicited diverse opinions and experiences. However, the difficulty of assessing competence, and the lack of standards that identify competent practice for occupational therapy were major themes in the findings. The role of theory in competent practice was evident in discussion but it was not clearly articulated by many participants. Experiences of professional socialisation varied yet participants perceived input from peers as contributing to assuring competence. Major barriers to professional competence were identified as professional isolation, time and finances. The present study highlights the complexity of current attempts to assess professional competence for practising occupational therapists including the implementation of an accreditation program by The Australian Association of Occupational Therapists Inc. (OT AUSTRALIA), the peak body representing occupational therapists.

Will he get back to normal? survival and functional status after intensive care therapy

The study aim was to address healthcare workers’ and patients’ questions about the likely level of recovery at 6 months of patients admitted to an Australian intensive care unit (ICU). Ninety-three consecutive, eligible adults were identified and followed prospectively. Severity of illness on admission was assessed using Acute Physiological and Chronic Health Evaluation (APACHE II), while functional status at 6 months was evaluated using the Sickness Impact Profile (SIP). Cumulative mortality was 25%. Admission severity of illness was associated with survival at 6 months (P≤0.001). Fifty-one (78%) of the 70 survivors were interviewed. Admission severity of illness scores correlated with functional status at 6 months (r=0.34, P=0.01), a finding reported in only one other study. More than half of those interviewed had returned to near pre-admission functional status. Those with poor functional status included high proportions of people with chronic illness and head injury. Overall, physical recovery was more complete than psychosocial recovery. The findings provide useful information for addressing questions relating to physical and psychosocial recovery, appetite, sleep patterns and return to work post discharge.

Testosterone replacement therapy-perceptions of recipients and partners

Background. The androgenic hormones are important determinants of sexual behaviour in men. Testosterone replacement is important treatment for pituitary disease to maintain normal functioning. Although the physical effects of testosterone replacement have been well documented, little is known about the effects on relationships, particularly from the point of view of the sexual partners of men receiving testosterone replacement.

Aims. This paper reports a study exploring the perceptions of testosterone replacement on well-being and sexual functioning.

Methods. Semi-structured interviews were conducted with five men receiving testosterone implants (recipients), their permanent partners, and five recipients without partners. Recipient serum testosterone concentration was measured at 0, 1 and 4 months after testosterone implantation.

Results. The three groups reported similar effects of testosterone on well-being and sexual functioning. Recipient and partner ratings were also similar. Strength was less affected by decreasing testosterone concentration than energy in men with partners, but both strength and energy declined in men without partners. Decreased testosterone levels had a statistically significantly different effect on libido at time zero between men with and without partners (P < 0·015) and on ability to sustain an erection, but the ability to achieve an erection persisted over the 6 months in both male groups. Intercourse frequency increased from once per week at time 0 to ≥3 per week between 1 and 4 months after implant in men with partners. There were important effects of testosterone deficiency on general and sexual relationships, and these differed between men with partners and those without.

Conclusions. Testosterone has important physical and psychological benefits that may be related to the age at which testosterone replacement commences and the indications for its use. The small sample size may limit the ability to generalize the findings outside the study.

Systematic review and meta-analysis of evidence for increasing numbers of drugs in antiretroviral combination therapy

Objective: To assess the evidence for the effectiveness of increasing numbers of drugs in antiretroviral combination therapy.

Design: Systematic review, meta-analysis, and meta-regression of fully reported randomised controlled trials. All studies included compared quadruple versus triple therapy, triple versus double therapy, double versus monotherapy, or monotherapy versus placebo or no treatment.

Participants: Patients with any stage of HIV infection who had not received antiretroviral therapy.

Main outcome measures: Changes in disease progression or death (clinical outcomes); CD4 count and plasma viral load (surrogate markers).
Search strategy: Six electronic databases, including Medline, Embase, and the Cochrane Library, searched up to February 2001.

Results: 54 randomised controlled trials, most of good quality, with 66 comparison groups were included in the analysis. For both the clinical outcomes and surrogate markers, combinations with up to and including three (triple therapy) were progressively and significantly more effective. The odds ratio for disease progression or death for triple therapy compared with double therapy was 0.6 (95% confidence interval 0.5 to 0.8). Heterogeneity in effect sizes was present in many outcomes but was largely related to the drugs used and trial quality.

Conclusions: Evidence from randomised controlled trials supports the use of triple therapy. Research is needed on the effectiveness of quadruple therapies and the relative effectiveness of specific combinations of drugs.