Effectiveness of brief alcohol interventions in primary care populations.

Excessive drinking contributes significantly to social problems, physical and psychological illness, injury and death. Hidden effects include increased levels of violence, accidents and suicide. Most alcohol-related harm is caused by excessive drinkers whose consumption exceeds recommended drinking levels, not the drinkers with severe alcohol dependency problems. One way to reduce consumption levels in a community may be to provide a brief intervention in primary care over one to four sessions. This is provided by healthcare workers such as general physicians, nurses or psychologists. In general practice, patients are routinely asked about alcohol consumption during registration, general health checks and as part of health screening (using a questionnaire). They tend not to be seeking help for alcohol problems when presenting. The intervention they are offered includes feedback on alcohol use and harms, identification of high risk situations for drinking and coping strategies, increased motivation and the development of a personal plan to reduce drinking. It takes place within the time-frame of a standard consultation, 5 to 15 minutes for a general physician, longer for a nurse.A total of 29 controlled trials from various countries were identified, in general practice (24 trials) or an emergency setting (five trials). Participants drank an average of 306 grams of alcohol (over 30 standard drinks) per week on entry to the trial. Over 7000 participants with a mean age of 43 years were randomised to receive a brief intervention or a control intervention, including assessment only. After one year or more, people who received the brief intervention drank less alcohol than people in the control group (average difference 38 grams/week, range 23 to 54 grams). For men (some 70% of participants), the benefit of brief intervention was a difference of 57 grams/week, range 25 to 89 grams (six trials). The benefit was not clear for women. The benefits of brief intervention were similar in the normal clinical setting and in research settings with greater resources. Longer counselling had little additional benefit.This resource was contributed by The National Documentation Centre on Drug Use.

The effectiveness of brief alcohol interventions in primary care settings: A systematic review

Numerous studies have reported that brief interventions delivered in primary care are effective in reducing excessive drinking. However, much of this work has been criticised for being clinically unrepresentative. This review aimed to assess the effectiveness of brief interventions in primary care and determine if outcomes differ between efficacy and effectiveness trials. Approach. A pre-specified search strategy was used to search all relevant electronic databases up to 2006. The authors also hand-searched the reference lists of key articles and reviews. They included randomised controlled trials (RCT) involving patients in primary care who were not seeking alcohol treatment and who received brief intervention. Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, subgroup and sensitivity analyses and meta-regression were conducted.This resource was contributed by The National Documentation Centre on Drug Use.

Learning collaboration in General Internal Medicine: a pilot project for undergraduate students in nursing, physiotherapy and medicine

Background: A form of education called Interprofessional Education (IPE) occurs when two or more professions learn with, from and about each other. The purpose of IPE is to improve collaboration and the quality of care. Today, IPE is considered as a key educational approach for students in the health professions. IPE is highly effective when delivered in active patient care, such as in clinical placements. General internal medicine (GIM) is a core discipline where hospital-based clinical placements are mandatory for students in many health professions. However, few interprofessional (IP) clinical placements in GIM have been implemented. We designed such a placement. Placement design: The placement took place in the Department of Internal Medicine at the CHUV. It involved students from nursing, physiotherapy and medicine. The students were in their last year before graduation. Students formed teams consisting of one student from each profession. Each team worked in the same unit and had to take care of the same patient. The placement lasted three weeks. It included formal IP sessions, the most important being facilitated discussions or "briefings" (3x/w) during which the students discussed patient care and management. Four teams of students eventually took part in this project. Method: We performed a type of evaluation research called formative evaluation. This aimed at (1) understanding the educational experience and (2) assessing the impact of the placement on student learning. We collected quantitative data with pre-post clerkship questionnaires. We also collected qualitative data with two Focus Groups (FG) discussions at the end of the placement. The FG were audiotaped and transcribed. A thematic analysis was then performed. Results: We focused on the qualitative data, since the quantitative data lacked of statistical power due to the small numbers of students (N = 11). Five themes emerged from the FG analysis: (1) Learning of others' roles, (2) Learning collaborative competences, (3) Striking a balance between acquiring one's own professional competences and interprofessional competences, (4) Barriers to apply learnt IP competences in the future and (5) Advantages and disadvantages of IP briefings. Conclusions: Our IP clinical placement in GIM appeared to help students learn other professionals' roles and collaborative skills. Some challenges (e.g. finding the same patient for each team) were identified and will require adjustments.

Identification of Anopheles (Nyssorhynchus) albitarsis complex species (Diptera: Culicidae) using rDNA internal transcribed spacer 2-based polymerase chain reaction primes

Anopheles (Nyssorhynchus) marajoara is a proven primary vector of malaria parasites in Northeast Brazil, and An. deaneorum is a suspected vector in Western Brazil. Both are members of the morphologically similar Albitarsis Complex, which also includes An. albitarsis and an undescribed species, An. albitarsis "B". These four species were recognized and can be identified using random amplified polymorphic DNA (RAPD) markers, but various other methodologies also point to multiple species under the name An. albitarsis. We describe here a technique for identification of these species employing polymerase chain reaction (PCR) primers based on ribosomal DNA internal transcribed spacer 2 (rDNA ITS2) sequence. Since this method is based on known sequence it is simpler than the sometimes problematical RAPD-PCR. Primers were tested on samples previously identified using RAPD markers with complete correlation.

Low-income Groups and Behaviour Change Interventions: A review of intervention content and effectiveness

This is the second paper in a series, Kicking Bad Habits, on how people can be encouraged to adopt healthy behaviour. Looking at interventions targeted specifically at low-income groups, this paper asks which interventions are effective in getting people to quit smoking, eat healthily and exercise. It reveals that the most frequently used techniques are providing information and encouraging people to set goals, which can be particularly effective at changing behaviour in disadvantaged groups.

Comparative effectiveness research across two spine registries.

BACKGROUND: Comparative effectiveness research in spine surgery is still a rarity. In this study, pain alleviation and quality of life (QoL) improvement after lumbar total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF) were anonymously compared by surgeon and implant. METHODS: A total of 534 monosegmental TDAs from the SWISSspine registry were analyzed. Mean age was 42 years (19-65 years), 59% were females. Fifty cases with ALIF were documented in the international Spine Tango registry and used as concurrent comparator group for the pain analysis. Mean age was 46 years (21-69 years), 78% were females. The average follow-up time in both samples was 1 year. Comparison of back/leg pain alleviation and QoL improvement was performed. Unadjusted and adjusted probabilities for achievement of minimum clinically relevant improvements of 18 VAS points or 0.25 EQ-5D points were calculated for each surgeon. RESULTS: Mean preoperative back pain decreased from 69 to 30 points at 1 year (ØΔ 39pts) after TDA, and from 66 to 27 points after ALIF (ØΔ 39pts). Mean preoperative QoL improved from 0.34 to 0.74 points at 1 year (ØΔ 0.40pts). There were surgeons with better patient selection, indicated by lower adjusted probabilities reflecting worsening of outcomes if they had treated an average patient sample. ALIF had similar pain alleviation than TDA. CONCLUSIONS: Pain alleviation after TDA and ALIF was similar. Differences in surgeon's patient selection based on pain and QoL were revealed. Some surgeons seem to miss the full therapeutic potential of TDA by selecting patients with lower symptom severity.

Health inequalities intervention tool: cost effectiveness of interventions

This note sets out the cost effectiveness performance of the interventions currently presented in the Health inequalities intervention tool . These interventions have been chosen for their cost effectiveness performance as health interventions as well as for their impact on the life expectancy gap.

Field evaluation of effectiveness of the BG-Sentinel, a new trap for capturing adult Aedes aegypti (Diptera: Culicidae)

In recent years, the development of new tools to gather field information about vector ecological parameters has increased. This report evaluated the BG-Sentinel Trap (BGS-Trap), a promising new attempt to improve collection of the dengue vector, Aedes aegypti. The efficacy of the BGS-Trap was compared with the CDC backpack aspirator, one of the commonest used methods for capturing adult mosquitoes. BGS-Traps captured significantly more Ae. aegypti males (chi2 = 21.774, df = 1, P < 0.05) and females (chi2 = 56.007, df = 1, P < 0.05) than CDC aspirator during all days of field collection. However, CDC aspirator was significantly more efficient to capture Culex quinquefasciatus males (chi2 = 5.681, df = 1, P < 0.05) and females (chi2 = 6.553, df = 1, P < 0.05). BGS-Traps captured host-seeking females (varying between 68.75 to 89.8%) in detriment of females in other behavioral and physiological stages. BGS-Traps proved to be efficient and can be used for monitoring adult mosquito populations.

The second internal transcribed spacer of nuclear ribosomal DNA as a tool for Latin American anopheline taxonomy: a critical review

Among the molecular markers commonly used for mosquito taxonomy, the internal transcribed spacer 2 (ITS2) of the ribosomal DNA is useful for distinguishing among closely-related species. Here we review 178 GenBank accession numbers matching ITS2 sequences of Latin American anophelines. Among those, we found 105 unique sequences corresponding to 35 species. Overall the ITS2 sequences distinguish anopheline species, however, information on intraspecific and geographic variations is scarce. Intraspecific variations ranged from 0.2% to 19% and our analysis indicates that misidentification and/or sequencing errors could be responsible for some of the high values of divergence. Research in Latin American malaria vector taxonomy profited from molecular data provided by single or few field capture mosquitoes. However we propose that caution should be taken and minimum requirements considered in the design of additional studies. Future studies in this field should consider that: (1) voucher specimens, assigned to the DNA sequences, need to be deposited in collections, (2) intraspecific variations should be thoroughly evaluated, (3) ITS2 and other molecular markers, considered as a group, will provide more reliable information, (4) biological data about vector populations are missing and should be prioritized, (5) the molecular markers are most powerful when coupled with traditional taxonomic tools.

Changes induced in Biomphalaria glabrata (Say, 1818) following trials for artificial stimulation of its internal defense system

Biomphalaria glabrata can react through different pathways to Schistosoma mansoni miracidium penetration, according to the degree of resistance/susceptibility presented by different snail strains, which is a genetically determined character, resistance being the dominant feature. However, it has been observed that previous susceptible snail strain may change its reactive behavior along the course of infection, exhibiting later a pattern of cercarial shedding and histopatopathological picture compatible with high resistance. Such observation suggests the possibility of B. glabrata to develop a sort of adaptative immunity face a schistosome infection. To explore on this aspect, the present investigation looked for the behavior of S. mansoni infection in B. glabrata previously subjected to different means of artificial stimulation of its internal defense system. Snails previously inoculated with irradiated miracídia (Group I); treated with S. mansoni antigens (Group II) or with a non-related parasite antigen (Group III) were challenged with 20 viable S. mansoni miracidia, and later looked for cercarial shedding and histopathologic changes at different times from exposition. Nodules of hemocyte accumulations were found at the site of antigen injection. These nodules resembled solid granulomas, and were larger and more frequent in snails injected with S. mansoni products as compared to those injected with Capillaria hepatica. However, the presence of such granulomas did not avoid the S. mansoni challenge infection from developing in a similar way as that seen in controls. The data are indicative that hemocytes are able to proliferate locally when stimulated, such capacity also remaining localized, not being shared by the population of hemocytes located elsewhere within the snail body.

Four whole-istic aspects of schistosome granuloma biology: fractal arrangement, internal regulation, autopoietic component and closure

This paper centers on some whole-istic organizational and functional aspects of hepatic Schistosoma mansoni granuloma, which is an extremely complex system. First, it structurally develops a collagenic topology, originated bidirectionally from an inward and outward assembly of growth units. Inward growth appears to be originated from myofibroblasts derived from small portal vessel around intravascular entrapped eggs, while outward growth arises from hepatic stellate cells. The auto-assembly of the growth units defines the three-dimensional scaffold of the schistosome granulomas. The granuloma surface irregularity and its border presented fractal dimension equal to 1.58. Second, it is internally regulated by intricate networks of immuneneuroendocrine stimuli orchestrated by leptin and leptin receptors, substance P and Vasoactive intestinal peptide. Third, it can reach the population of ± 40,000 cells and presents an autopoietic component evidenced by internal proliferation (Ki-67+ Cells), and by expression of c-Kit+ Cells, leptin and leptin receptor (Ob-R), granulocyte-colony stimulating factor (G-CSF-R), and erythropoietin (Epo-R) receptors. Fourth, the granulomas cells are intimately connected by pan-cadherins, occludin and connexin-43, building a state of closing (granuloma closure). In conclusion, the granuloma is characterized by transitory stages in such a way that its organized structure emerges as a global property which is greater than the sum of actions of its individual cells and extracellular matrix components.

A randomized controlled trial of the effectiveness of a Computer-Assisted Cognitive Remediation (CACR) program in adolescents with psychosis or at high risk of psychosis: Short term and long term outcomes

The present study investigates the short- and long-term outcomes of a computer-assisted cognitive remediation (CACR) program in adolescents with psychosis or at high risk. 32 adolescents participated in a blinded 8-week randomized controlled trial of CACR treatment compared to computer games (CG). Clinical and neuropsychological evaluations were undertaken at baseline, at the end of the program and at 6-month. At the end of the program (n = 28), results indicated that visuospatial abilities (Repeatable Battery for the Assessment of Neuropsychological Status, RBANS; P = .005) improved signifi cantly more in the CACR group compared to the CG group. Furthermore, other cognitive functions (RBANS), psychotic symptoms (Positive and Negative Symptom Scale) and psychosocial functioning (Social and Occupational Functioning Assessment Scale) improved signifi cantly, but at similar rates, in the two groups. At long term (n = 22), cognitive abilities did not demonstrated any amelioration in the control group while, in the CACR group, signifi cant long-term improvements in inhibition (Stroop; P = .040) and reasoning (Block Design Test; P = .005) were observed. In addition, symptom severity (Clinical Global Improvement) decreased signifi cantly in the control group (P = .046) and marginally in the CACR group (P = .088). To sum up, CACR can be successfully administered in this population. CACR proved to be effective over and above CG for the most intensively trained cognitive ability. Finally, on the long-term, enhanced reasoning and inhibition abilities, which are necessary to execute higher-order goals or to adapt behavior to the ever-changing environment, were observed in adolescents benefi ting from a CACR.

The cost-effectiveness and public health benefit of nalmefene added to psychosocial support for the reduction of alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels: a Markov model.

OBJECTIVES: To determine whether nalmefene combined with psychosocial support is cost-effective compared with psychosocial support alone for reducing alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels (DRLs) as defined by the WHO, and to evaluate the public health benefit of reducing harmful alcohol-attributable diseases, injuries and deaths. DESIGN: Decision modelling using Markov chains compared costs and effects over 5 years. SETTING: The analysis was from the perspective of the National Health Service (NHS) in England and Wales. PARTICIPANTS: The model considered the licensed population for nalmefene, specifically adults with both alcohol dependence and high/very high DRLs, who do not require immediate detoxification and who continue to have high/very high DRLs after initial assessment. DATA SOURCES: We modelled treatment effect using data from three clinical trials for nalmefene (ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941)). Baseline characteristics of the model population, treatment resource utilisation and utilities were from these trials. We estimated the number of alcohol-attributable events occurring at different levels of alcohol consumption based on published epidemiological risk-relation studies. Health-related costs were from UK sources. MAIN OUTCOME MEASURES: We measured incremental cost per quality-adjusted life year (QALY) gained and number of alcohol-attributable harmful events avoided. RESULTS: Nalmefene in combination with psychosocial support had an incremental cost-effectiveness ratio (ICER) of £5204 per QALY gained, and was therefore cost-effective at the £20,000 per QALY gained decision threshold. Sensitivity analyses showed that the conclusion was robust. Nalmefene plus psychosocial support led to the avoidance of 7179 alcohol-attributable diseases/injuries and 309 deaths per 100,000 patients compared to psychosocial support alone over the course of 5 years. CONCLUSIONS: Nalmefene can be seen as a cost-effective treatment for alcohol dependence, with substantial public health benefits. TRIAL REGISTRATION NUMBERS: This cost-effectiveness analysis was developed based on data from three randomised clinical trials: ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941).

Trends in the main diseases in an internal medicine ward, 2003-2011

Introduction : Population aging leads to a considerable increase in the prevalence of specific diseases. We aimed to assess if those changes were already reflected in an Internal Medicine ward. Methods : Anonymous data was obtained from the administrative database of the department of internal medicine of the Lausanne University Hospital (CHUV). All hospitalizations of adult (>=18 years) patients occurring between 2003 and 2011 were included. Infections, cancers and diseases according to body system (heart, lung...) were defined by the first letter of the ICD-10 code for the main cause of hospitalization. Specific diseases (myocardial infarction, heart failure...) were defined by the first three letters of the ICD-10 codes for the main cause of hospitalization. Results : Data from 32,741 hospitalizations occurring between 2003 and 2011 was analyzed. Cardiovascular (ICD-10 code I) and respiratory (ICD-10 code J) diseases ranked first and second, respectively, and their ranks did not change during the study period (figure). Digestive and endocrine diseases decreased while psychiatric diseases increased from rank 9 in 2003 to rank 6 in 2011 (figure). Among specific diseases, pneumonia (organism unspecified, code J18) ranked first in 2003 and second in 2011. Acute myocardial infarction (code I21) ranked second in 2003 and third in 2011. Chronic obstructive pulmonary disease with acute lower respiratory infection (code J44) ranked third in 2003 and decreased to rank 8 in 2011. Conversely, heart failure (code I50) increased from rank 8 in 2003 to rank 1 in 2011 and delirium (not induced by alcohol and other psychoactive substances, code F05) increased from below rank 20 in 2003 to rank 4 in 2011. For more details, see table. Conclusion : In less than 10 years, considerable changes occurred in the presentation of patients attending an Internal Medicine ward. The changes in diseases call for adaptations in hospital staff and logistics.