Prevention of Alcohol-Related Crime and Trauma (PACT) : brief interventions in routine care pathway – a study protocol

Background Globally, alcohol-related injuries cause millions of deaths and huge economic loss each year . The incidence of facial (jawbone) fractures in the Northern Territory of Australia is second only to Greenland, due to a strong involvement of alcohol in its aetiology, and high levels of alcohol consumption. The highest incidences of alcohol-related trauma in the Territory are observed amongst patients in the Maxillofacial Surgery Unit of the Royal Darwin Hospital. Accordingly, this project aims to introduce screening and brief interventions into this unit, with the aims of changing health service provider practice, improving access to care, and improving patient outcomes. Methods Establishment of Project Governance: The project governance team includes a project manager, project leader, an Indigenous Reference Group (IRG) and an Expert Reference Group (ERG). Development of a best practice pathway: PACT project researchers collaborate with clinical staff to develop a best practice pathway suited to the setting of the surgical unit. The pathway provides clear guidelines for screening, assessment, intervention and referral. Implementation: The developed pathway is introduced to the unit through staff training workshops and associate resources and adapted in response to staff feedback. Evaluation: File audits, post workshop questionnaires and semi-structured interviews are administered. Discussion This project allows direct transfer of research findings into clinical practice and can inform future hospital-based injury prevention strategies.

The clinical utility of the Cornell Scale for Depression in Dementia as a routine assessment in nursing homes

Objective To examine the clinical utility of the Cornell Scale for Depression in Dementia (CSDD) in nursing homes. Setting 14 nursing homes in Sydney and Brisbane, Australia. Participants 92 residents with a mean age of 85 years. Measurements Consenting residents were assessed by care staff for depression using the CSDD as part of their routine assessment. Specialist clinicians conducted assessment of depression using the Semi-structured Clinical Diagnostic Interview for DSM-IV-TR Axis I Disorders for residents without dementia or the Provisional Diagnostic Criteria for Depression in Alzheimer Disease for residents with dementia to establish expert clinical diagnoses of depression. The diagnostic performance of the staff completed CSDD was analyzed against expert diagnosis using receiver operating characteristic (ROC) curves. Results The CSDD showed low diagnostic accuracy, with areas under the ROC curve being 0.69, 0.68 and 0.70 for the total sample, residents with dementia and residents without dementia, respectively. At the standard CSDD cutoff score, the sensitivity and specificity were 71% and 59% for the total sample, 69% and 57% for residents with dementia, and 75% and 61% for residents without dementia. The Youden index (for optimizing cut-points) suggested different depression cutoff scores for residents with and without dementia. Conclusion When administered by nursing home staff the clinical utility of the CSDD is highly questionable in identifying depression. The complexity of the scale, the time required for collecting relevant information, and staff skills and knowledge of assessing depression in older people must be considered when using the CSDD in nursing homes.

Development and validation of a multilevel model for predicting workload under routine and nonroutine conditions in an air traffic management center

Objective: The aim of this study was to develop a model capable of predicting variability in the mental workload experienced by frontline operators under routine and nonroutine conditions. Background: Excess workload is a risk that needs to be managed in safety-critical industries. Predictive models are needed to manage this risk effectively yet are difficult to develop. Much of the difficulty stems from the fact that workload prediction is a multilevel problem. Method: A multilevel workload model was developed in Study 1 with data collected from an en route air traffic management center. Dynamic density metrics were used to predict variability in workload within and between work units while controlling for variability among raters. The model was cross-validated in Studies 2 and 3 with the use of a high-fidelity simulator. Results: Reported workload generally remained within the bounds of the 90% prediction interval in Studies 2 and 3. Workload crossed the upper bound of the prediction interval only under nonroutine conditions. Qualitative analyses suggest that nonroutine events caused workload to cross the upper bound of the prediction interval because the controllers could not manage their workload strategically. Conclusion: The model performed well under both routine and nonroutine conditions and over different patterns of workload variation. Application: Workload prediction models can be used to support both strategic and tactical workload management. Strategic uses include the analysis of historical and projected workflows and the assessment of staffing needs. Tactical uses include the dynamic reallocation of resources to meet changes in demand.

Controlling routine front line service workers: an Australian retail supermarket case

Food retail is known for its use of flexible labour and for the centralisation of functions at head office, resulting in a reduction of managerial autonomy at store level. This article employs a typology of controls developed from labour process scholarship to explore how retail managers negotiate the control of their predominantly part-time workforce. Using an Australian supermarket chain as a case, and mixed methods, the article demonstrates that supermarkets use a multiplicity of forms of control across their workforce. For front line service workers, the article identifies a new configuration of controls which intersects with employment status and acts differentially for checkout operators on different employment contracts.

Infant product-related injuries: comparing specialised injury surveillance and routine emergency department data

- Objective To explore the potential for using a basic text search of routine emergency department data to identify product-related injury in infants and to compare the patterns from routine ED data and specialised injury surveillance data. - Methods Data was sourced from the Emergency Department Information System (EDIS) and the Queensland Injury Surveillance Unit (QISU) for all injured infants between 2009 and 2011. A basic text search was developed to identify the top five infant products in QISU. Sensitivity, specificity, and positive predictive value were calculated and a refined search was used with EDIS. Results were manually reviewed to assess validity. Descriptive analysis was conducted to examine patterns between datasets. - Results The basic text search for all products showed high sensitivity and specificity, and most searches showed high positive predictive value. EDIS patterns were similar to QISU patterns with strikingly similar month-of-age injury peaks, admission proportions and types of injuries. - Conclusions This study demonstrated a capacity to identify a sample of valid cases of product-related injuries for specified products using simple text searching of routine ED data. - Implications As the capacity for large datasets grows and the capability to reliably mine text improves, opportunities for expanded sources of injury surveillance data increase. This will ultimately assist stakeholders such as consumer product safety regulators and child safety advocates to appropriately target prevention initiatives.

Patient decision aids in routine maternity care: Benefits, barriers, and new opportunities

Background and aim Participation in decision-making, supported by comprehensive and quality information provision, is increasingly emphasised as a priority for women in maternity care. Patient decision aids are tools that can offer women greater access to information and guidance to participate in maternity care decision-making. Relative to their evaluation in controlled settings, the implementation of patient decision aids in routine maternity care has received little attention and our understanding of which approaches may be effective is limited. This paper critically discusses the application of patient decision aids in routine maternity care and explores viable solutions for promoting their successful uptake. Discussion A range of patient decision aids have been developed for use within maternity care, and controlled trials have highlighted their positive impact on the decision-making process for women. Nevertheless, evidence of successful patient decision aid implementation in real world health care settings is lacking due to practical and ideological barriers that exist. Patient-directed social marketing campaigns are a relatively novel approach to patient decision aid delivery that may facilitate their adoption in maternity care, at least in the short-term, by overcoming common implementation barriers. Social marketing may also be particularly well suited to maternity care, given the unique characteristics of this health context. Conclusions The potential of social marketing campaigns to facilitate patient decision aid adoption in maternity care highlights the need for pragmatic trials to evaluate their effectiveness. Identifying which sub-groups of women are more or less likely to respond to these strategies will further direct implementation.

Routine Measurement of Health-Related Quality of Life in Assessing Cost-Effectiveness in Secondary Health Care

Aims: The aims of this study were 1) to identify and describe health economic studies that have used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL); 2) to test the feasibility of routine collection of health-related quality of life (HRQoL) data as an indicator of effectiveness of secondary health care; and 3) to establish and compare the cost-utility of three large-volume surgical procedures in a real-world setting in the Helsinki University Central Hospital, a large referral hospital providing secondary and tertiary health-care services for a population of approximately 1.4 million. Patients and methods: So as to identify studies that have used QALYs as an outcome measure, a systematic search of the literature was performed using the Medline, Embase, CINAHL, SCI and Cochrane Library electronic databases. Initial screening of the identified articles involved two reviewers independently reading the abstracts; the full-text articles were also evaluated independently by two reviewers, with a third reviewer used in cases where the two reviewers could not agree a consensus on which articles should be included. The feasibility of routinely evaluating the cost-effectiveness of secondary health care was tested by setting up a system for collecting HRQoL data on approximately 4 900 patients' HRQoL before and after operative treatments performed in the hospital. The HRQoL data used as an indicator of treatment effectiveness was combined with diagnostic and financial indicators routinely collected in the hospital. To compare the cost-effectiveness of three surgical interventions, 712 patients admitted for routine operative treatment completed the 15D HRQoL questionnaire before and also 3-12 months after the operation. QALYs were calculated using the obtained utility data and expected remaining life years of the patients. Direct hospital costs were obtained from the clinical patient administration database of the hospital and a cost-utility analysis was performed from the perspective of the provider of secondary health care services. Main results: The systematic review (Study I) showed that although QALYs gained are considered an important measure of the effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited. Of the reviewed full-text articles, only 70 reported QALYs based on actual before after measurements using a valid HRQoL instrument. Collection of simple cost-effectiveness data in secondary health care is feasible and could easily be expanded and performed on a routine basis (Study II). It allows meaningful comparisons between various treatments and provides a means for allocating limited health care resources. The cost per QALY gained was 2 770 for cervical operations and 1 740 for lumbar operations. In cases where surgery was delayed the cost per QALY was doubled (Study III). The cost per QALY ranges between subgroups in cataract surgery (Study IV). The cost per QALY gained was 5 130 for patients having both eyes operated on and 8 210 for patients with only one eye operated on during the 6-month follow-up. In patients whose first eye had been operated on previous to the study period, the mean HRQoL deteriorated after surgery, thus precluding the establishment of the cost per QALY. In arthroplasty patients (Study V) the mean cost per QALY gained in a one-year period was 6 710 for primary hip replacement, 52 270 for revision hip replacement, and 14 000 for primary knee replacement. Conclusions: Although the importance of cost-utility analyses has during recent years been stressed, there are only a limited number of studies in which the evaluation is based on patients own assessment of the treatment effectiveness. Most of the cost-effectiveness and cost-utility analyses are based on modeling that employs expert opinion regarding the outcome of treatment, not on patient-derived assessments. Routine collection of effectiveness information from patients entering treatment in secondary health care turned out to be easy enough and did not, for instance, require additional personnel on the wards in which the study was executed. The mean patient response rate was more than 70 %, suggesting that patients were happy to participate and appreciated the fact that the hospital showed an interest in their well-being even after the actual treatment episode had ended. Spinal surgery leads to a statistically significant and clinically important improvement in HRQoL. The cost per QALY gained was reasonable, at less than half of that observed for instance for hip replacement surgery. However, prolonged waiting for an operation approximately doubled the cost per QALY gained from the surgical intervention. The mean utility gain following routine cataract surgery in a real world setting was relatively small and confined mostly to patients who had had both eyes operated on. The cost of cataract surgery per QALY gained was higher than previously reported and was associated with considerable degree of uncertainty. Hip and knee replacement both improve HRQoL. The cost per QALY gained from knee replacement is two-fold compared to hip replacement. Cost-utility results from the three studied specialties showed that there is great variation in the cost-utility of surgical interventions performed in a real-world setting even when only common, widely accepted interventions are considered. However, the cost per QALY of all the studied interventions, except for revision hip arthroplasty, was well below 50 000, this figure being sometimes cited in the literature as a threshold level for the cost-effectiveness of an intervention. Based on the present study it may be concluded that routine evaluation of the cost-utility of secondary health care is feasible and produces information essential for a rational and balanced allocation of scarce health care resources.

The short-term effects of a routine poisoning campaign on the movements and detectability of a social top-predator

Top-predators can be important components of resilient ecosystems, but they are still controlled in many places to mitigate a variety of economic, environmental and/or social impacts. Lethal control is often achieved through the broad-scale application of poisoned baits. Understanding the direct and indirect effects of such lethal control on subsequent movements and behaviour of survivors is an important pre-requisite for interpreting the efficacy and ecological outcomes of top-predator control. In this study, we use GPS tracking collars to investigate the fine-scale and short-term movements of dingoes (Canis lupus dingo and other wild dogs) in response to a routine poison-baiting program as an example of how a common, social top-predator can respond (behaviourally) to moderate levels of population reduction. We found no consistent control-induced differences in home range size or location, daily distance travelled, speed of travel, temporal activity patterns or road/trail usage for the seven surviving dingoes we monitored immediately before and after a typical lethal control event. These data suggest that the spatial behaviour of surviving dingoes was not altered in ways likely to affect their detectability, and if control-induced changes in dingoes' ecological function did occur, these may not be related to altered spatial behaviour or movement patterns.

Diffusing research into routine midwifery practice

This research applied Greenhalgh et al's (2005) organisational change theoretical framework and a case study method approach to explore the process of implementing a smoking cessation intervention for pregnant women. The study was carried out according to the principles laid down in the National statement on ethical conduct in human research, produced by the National Health and Medical Research Council, Australia. Ethical approval for the research was sought and received from Queensland University of Technology human research ethics committee, prior to the start of the study. The sample constituted four participants who had been involved in the process of disseminating a training programme for midwives to implement a smoking cessation intervention. Eight semi-structured interviews were undertaken with these participants and the interviews and background programme data were subjected to theoretical analysis. The data were analysed through the lens of the Greenhalgh et al (2005) framework. The result was a disaggregation and (re)aggregation of data in the formation of an analytical outcome (Charmaz, 2006).

Health-Related Quality of Life, Costs and Treatment of Inflammatory Rheumatic Diseases in Routine Practice : With special emphasis on biological drugs

Rheumatoid arthritis (RA) and other chronic inflammatory joint diseases already begin to affect patients health-related quality of life (HRQoL) in the earliest phases of these diseases. In treatment of inflammatory joint diseases, the last two decades have seen new strategies and treatment options introduced. Treatment is started at an earlier phase; combinations of disease-modifying anti-rheumatic drugs (DMARDs) and corticosteroids are used; and in refractory cases new drugs such as tumour necrosis factor (TNF) inhibitors or other biologicals can be started. In patients with new referrals to the Department of Rheumatology of the Helsinki University Central Hospital, we evaluated the 15D and the Stanford Health Assessment Questionnaire (HAQ) results at baseline and approximately 8 months after their first visit. Altogether the analysis included 295 patients with various rheumatic diseases. The mean baseline 15D score (0.822, SD 0.114) was significantly lower than for the age-matched general population (0.903, SD 0.098). Patients with osteoarthritis (OA) and spondyloarthropathies (SPA) reported the poorest HRQoL. In patients with RA and reactive arthritis (ReA) the HRQoL improved in a statistically significant manner during the 8-month follow-up. In addition, a clinically important change appeared in patients with systemic rheumatic diseases. HAQ score improved significantly in patients with RA, arthralgia and fibromyalgia, and ReA. In a study of 97 RA patients treated either with etanercept or adalimumab, we assessed their HRQoL with the RAND 36-Item Health Survey 1.0 (RAND-36) questionnaire. We also analysed changes in clinical parameters and the HAQ. With etanercept and adalimumab, the values of all domains in the RAND-36 questionnaire increased during the first 3 months. The efficacy of each in improving HRQoL was statistically significant, and the drug effects were comparable. Compared to Finnish age- and sex-matched general population values, the HRQoL of the RA patients was significantly lower at baseline and, despite the improvement, remained lower also at follow-up. Our RA patients had long-standing and severe disease that can explain the low HRQoL also at follow-up. In a pharmacoeconomic study of patients treated with infliximab we evaluated medical and work disability costs for patients with chronic inflammatory joint disease during one year before and one year after institution of infliximab treatment. Clinical and economic data for 96 patients with different arthritis diagnoses showed, in all patients, significantly improved clinical and laboratory variables. However, the medical costs increased significantly during the second period by 12 015 (95% confidence interval, 6 496 to 18 076). Only a minimal decrease in work disability costs occurred mean decrease 130 (-1 268 to 1 072). In a study involving a switch from infliximab to etanercept, we investigated the clinical outcome in 49 patients with RA. Reasons for switching were in 42% failure to respond by American College of Rheumatology (ACR) 50% criteria; in 12% adverse event; and in 46% non-medical reasons although the patients had responded to infliximab. The Disease Activity Score with 28 joints examined (DAS28) allowed us to measure patients disease activity and compare outcome between groups based on the reason for switching. In the patients in whom infliximab was switched to etanercept for nonmedical reasons, etanercept continued to suppress disease activity effectively, and 1-year drug survival for etanercept was 77% (95% CI, 62 to 97). In patients in the infliximab failure and adverse event groups, DAS28 values improved significantly during etanercept therapy. However, the 1-year drug survival of etanercept was only 43% (95% CI, 26 to 70) and 50% (95% CI, 33 to 100), respectively. Although the HRQoL of patients with inflammatory joint diseases is significantly lower than that of the general population, use of early and aggressive treatment strategies including TNF-inhibitors can improve patients HRQoL effectively. Further research is needed in finding new treatment strategies for those patients who fail to respond or lose their response to TNF-inhibitors.

Invasive pneumococcal infections in Finland before routine use of conjugate vaccines : opportunities for prevention

Streptococcus pneumoniae is a leading cause of pneumonia, meningitis and bacteremia worldwide. The 23-valent pneumococcal polysaccharide vaccine (PPV23) is recommended for adults less than 65 years old with certain chronic medical conditions and for all elderly persons because of high rates of invasive pneumococcal infections (IPI) and increased risk of death. This study provides a comprehensive picture of the epidemiology of pneumococcal infections in Finland before the introduction of childhood pneumococcal conjugate vaccines, focusing on disease rates, risk factors, clinical outcome, and healthcare associated infections. This study was based on national, population-based laboratory surveillance for IPI. Information on all episodes of IPI was collected from the primary diagnostic laboratory. A case with IPI was defined as the isolation of S. pneumoniae from blood or cerebrospinal fluid during 1995-2002. Information on comorbidities and underlying conditions for IPI patients was obtained by linking the IPI surveillance database to other national, population-based health registries using each patient’s unique national identity code. In total, 4357 cases of IPI were identified. The overall annualized IPI incidence increased by 35% during the study period and was 10.6 per 100 000 population. The temporal increase in disease rates was associated with higher blood culturing rates over time. In working age adults, two-thirds of severe infections and one half of fatal cases occurred in persons with no recognized PPV23 indication. Persons with asthma were at increased risk for IPI and this new risk factor accounted for 5% of the overall disease burden. One tenth of pneumococcal bacteremias were healthcare-associated, and mortality among these patients was over twice as high as among patients with community-associated bacteremia. Most patients with nosocomial infections had underlying conditions for which PPV23 is recommended. The incidence of IPI in Finland has increased and the overall disease burden is higher than previously reported. The findings of this study underscore the urgent need for improved prevention efforts against pneumococcal infections in Finland through increased use of PPV23 in adult risk groups and introduction of childhood immunization with pneumococcal conjugate vaccine.

A simple miniature furnace for routine collection of single crystal x-ray data up to 1000°C on the Hilger and Watts linear diffractometer

A miniature furnace suitable for routine collection of x-ray data up to 1000°C from single crystals on the Hilger and Watts linear diffractometer, without restricting the normally allowed region of reciprocal space on the diffractometer, is described. The crystal is heated primarily by radiation from a surrounding current-heated, stationary platinum coil wound on a silica bracket. The coil is split at its middle to provide a 4 mm gap for crystal mounting and x-irradiation. The crystal, mounted on a standard goniometer head, can be rotated and centred freely, as in the room temperature case. There is no need for any radiation shields or water-cooling arrangement. Investigations up to 1500°C are possible with slight modifications of the furnace.

Management of Routine in Two Chinese Kindergartens - An Ethnographic Study

Based on a one-month long ethnographic study conducted in two Chinese kindergartens, this study aims to understand the issue of discipline in the Chinese preschool setting through an examination of practices teachers use to manage everyday routines in the kindergarten. It also seeks to understand teachers’ values behind their choices of practices. Data of this study are comprised of three parts - notes of participant observation in eight classrooms with a focus on teacher-child interaction; interviews with nine teachers and directors of the two kindergartens; and written accounts of four teachers collected after the fieldwork in order to understand the particular practices of teachers’ praising and criticizing children. A grounded theory approach is applied to code and analyze data. Results of analysis are structured as followed. First the concept of routine is clarified based on teachers’ definition of it and observation notes on its main components, namely the timetable of everyday activities; general behavioral rules in the kindergarten; and detailed rules and procedures for various activities in the kindergarten. Then practices for managing routines are examined – how teachers organize children in activities, enforce routines, and restore routines when they are not followed well. After that, the matter of self-control is examined in relation with external control. Then teachers’ perception of their roles as the manager, director and executor of routines is presented in a discourse of control in which the values behind practices are found to be embedded. The next section of analysis examines the role of routine in relation with other activities in the kindergarten. Results indicate that routine which is supposed to be the foundation of other activities is in conflict with other activities. The last section of analysis provides some reflections on the rational of routine management in Chinese kindergartens in relation with the overall goals of Chinese preschool education. It also provides some reflections on the effect current mode of teacher-child interactions may have on children's self construction and their understanding of self in relation with the society. As a conclusion, this study suggests that the current mode of routine management in Chinese kindergartens relies heavily on teachers' control, leaving great room for better acknowledging children's agency.

Dissolved oxygen probes: making oxygen measurements routine like temperature, St Petersburg, Florida, January 4-6, 2006: workshop proceedings

The Alliance for Coastal Technologies (ACT) Workshop "Making Oxygen Measurements Routine Like Temperature" was convened in St. Petersburg, Florida, January 4th - 6th, 2006. This event was sponsored by the University of South Florida (USF) College of Marine Science, an ACT partner institution and co-hosted by the Ocean Research Interactive Observatory Networks (ORION). Participants from researcldacademia, resource management, industry, and engineering sectors collaborated with the aim to foster ideas and information on how to make measuring dissolved oxygen a routine part of a coastal or open ocean observing system. Plans are in motion to develop large scale ocean observing systems as part of the US Integrated Ocean Observing System (100s; see http://ocean.us) and the NSF Ocean Observatory Initiative (001; see http://www.orionprogram.org/00I/default.hl). These systems will require biological and chemical sensors that can be deployed in large numbers, with high reliability, and for extended periods of time (years). It is also likely that the development cycle for new sensors is sufficiently long enough that completely new instruments, which operate on novel principles, cannot be developed before these complex observing systems will be deployed. The most likely path to development of robust, reliable, high endurance sensors in the near future is to move the current generation of sensors to a much greater degree of readiness. The ACT Oxygen Sensor Technology Evaluation demonstrated two important facts that are related to the need for sensors. There is a suite of commercially available sensors that can, in some circumstances, generate high quality data; however, the evaluation also showed that none of the sensors were able to generate high quality data in all circumstances for even one month time periods due to biofouling issues. Many groups are attempting to use oxygen sensors in large observing programs; however, there often seems to be limited communication between these groups and they often do not have access to sophisticated engineering resources. Instrument manufacturers also do not have sufficient resources to bring sensors, which are marketable, but of limited endurance or reliability, to a higher state of readiness. The goal of this ACT/ORION Oxygen Sensor Workshop was to bring together a group of experienced oceanographers who are now deploying oxygen sensors in extended arrays along with a core of experienced and interested academic and industrial engineers, and manufacturers. The intended direction for this workshop was for this group to exchange information accumulated through a variety of sensor deployments, examine failure mechanisms and explore a variety of potential solutions to these problems. One anticipated outcome was for there to be focused recommendations to funding agencies on development needs and potential solutions for 02 sensors. (pdf contains 19 pages)