Clinicians' attitudes to clinical practice guidelines

To the Editor: In their systematic review of clinicians' attitudes to clinical practice guidelines, Farquhar et al1 found that, although healthcare providers reported high satisfaction with guidelines, a significant number also expressed concerns about their practicality, their role in cost-cutting and their potential for increasing litigation. The review, however, did not address other potentially significant concerns of clinicians regarding the perceived validity of guidelines and the influence of external agencies (such as the pharmaceutical industry) on treatment recommendations.

Effectiveness of case management and post-acute services in older people after hospital discharge

Objective: To evaluate the benefits of coordinating community services through the Post-Acute Care (PAC) program in older patients after discharge from hospital. Design: Prospective multicentre, randomised controlled trial with six months of follow-up with blinded outcome measurement. Setting: Four university-affiliated metropolitan general hospitals in Victoria. Participants: All patients aged 65 years and over who were discharged between August 1998 and October 1999 and required community services after discharge. Interventions: Participants were randomly allocated to receive services of a Post-Acute Care (PAC) coordinator (intervention) versus usual discharge planning (control). Main outcome measures: Comparison of quality of life and carer stress at one-month post-discharge, mortality, hospital readmissions, use of community services and community and hospital costs over the six months post-discharge. Results: 654 patients were randomised, and 598 were included in the analysis (311 in the PAC group and 287 in the control group). There was no difference in mortality between the groups (both 6%), but significantly greater overall quality-of-life scores at one-month follow-up in the PAC group. There was no difference in unplanned readmissions, but PAC patients used significantly fewer hospital bed-days in the six months after discharge (mean, 3.0 days; 95% CI, 2.1-3.9) than control patients (5.2 days; 95% CI, 3.8-6.7). Total costs (including hospitalisation, community services and the intervention) were lower in the PAC than the control group (mean difference, $1545; 95% CI, $11-$3078). Conclusions: The PAC program is beneficial in the transition from hospital to the community in older patients.

The regulation of complementary health: sacrificing integrity?

In response to the increasing use of complementary and alternative medicine (CAM), governments are exploring ways to ensure patients' safety and respond to complaints. One solution is to establish registration boards and procedures based on the model of existing health practitioner Acts. Registration will require defined minimum standards for competence, which will have to be based on scientific evidence. As scientific evidence accumulates, these modalities are likely to lose their identities as alternative and become assimilated into Western medicine.

Left ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation

We evaluated patients with end-stage heart failure who have a high likelihood of response to cardiac resynchronization therapy (biventricular pacing). It appears that 20% of patients do not respond to this expensive therapy despite the use of selection criteria (dilated cardiomyopathy, heart failure, New York Heart Association class II or IV, left ventricular election fraction 120 ms). The presence of left ventricular dys-synchrony is needed to result in improvement after cardiac resynchronization therapy. (C)2003 by Excerpta Medica, Inc.

Usefulness of myocardial tissue Doppler echocardiography to evaluate left ventricular dyssynchrony before and after biventricular pacing in patients with idiopathic dilated cardiomyopathy

Tissue Doppler imaging allows assessment of left ventricular dyssynchrony and resynchronization after biventricular pacing.

Overweight and obesity in Australia: The 1999-2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab)

Objective: To measure the prevalence of obesity in Australian adults and to examine the associations of obesity with socioeconomic and lifestyle factors. Design: AusDiab, a cross-sectional study conducted between May 1999 and December 2000, involved participants from 42 randomly selected districts throughout Australia. Participants: Of 20 347 eligible people aged greater than or equal to 25 years who completed a household interview, 11247 attended the physical examination at local survey sites (response rate, 55%). Main outcome measures: Overweight and obesity defined by body mass index (BMI; kg/m(2)) and waist circumference (cm); sociodemographic factors (including smoking, physical activity and television viewing time). Results: The prevalence of overweight and obesity (BMI greater than or equal to 25.0 kg/m(2); waist circumference greater than or equal to 80.0 cm [women] or greater than or equal to 94.0 cm [men]) in both sexes was almost 60%, defined by either BMI or waist circumference. The prevalence of obesity was 2.5 times higher than in 1980. Using waist circumference, the prevalence of obesity was higher in women than men (34.1% v 26.8%; P < 0.01). Lower educational status, higher television viewing time and lower physical activity time were each strongly associated with obesity, with television viewing time showing a stronger relationship than physical activity time. Conclusions: The prevalence of obesity in Australia has more than doubled in the past 20 years. Strong positive associations between obesity and each of television viewing time and lower physical activity time confirm the influence of sedentary lifestyles on obesity, and underline the potential benefits of reducing sedentary behaviour, as well as increasing physical activity, to curb the obesity epidemic.

A review of drainage and spontaneous rupture in free standing thin films with tangentially immobile interfaces

A review of spontaneous rupture in thin films with tangentially immobile interfaces is presented that emphasizes the theoretical developments of film drainage and corrugation growth through the linearization of lubrication theory in a cylindrical geometry. Spontaneous rupture occurs when corrugations from adjacent interfaces become unstable and grow to a critical thickness. A corrugated interface is composed of a number of waveforms and each waveform becomes unstable at a unique transition thickness. The onset of instability occurs at the maximum transition thickness, and it is shown that only upper and lower bounds of this thickness can be predicted from linear stability analysis. The upper bound is equivalent to the Freakel criterion and is obtained from the zeroth order approximation of the H-3 term in the evolution equation. This criterion is determined solely by the film radius, interfacial tension and Hamaker constant. The lower bound is obtained from the first order approximation of the H-3 term in the evolution equation and is dependent on the film thinning velocity A semi-empirical equation, referred to as the MTR equation, is obtained by combining the drainage theory of Manev et al. [J. Dispersion Sci. Technol., 18 (1997) 769] and the experimental measurements of Radoev et al. [J. Colloid Interface Sci. 95 (1983) 254] and is shown to provide accurate predictions of film thinning velocity near the critical thickness of rupture. The MTR equation permits the prediction of the lower bound of the maximum transition thickness based entirely on film radius, Plateau border radius, interfacial tension, temperature and Hamaker constant. The MTR equation extrapolates to Reynolds equation under conditions when the Plateau border pressure is small, which provides a lower bound for the maximum transition thickness that is equivalent to the criterion of Gumerman and Homsy [Chem. Eng. Commun. 2 (1975) 27]. The relative accuracy of either bound is thought to be dependent on the amplitude of the hydrodynamic corrugations, and a semiempirical correlation is also obtained that permits the amplitude to be calculated as a function of the upper and lower bound of the maximum transition thickness. The relationship between the evolving theoretical developments is demonstrated by three film thickness master curves, which reduce to simple analytical expressions under limiting conditions when the drainage pressure drop is controlled by either the Plateau border capillary pressure or the van der Waals disjoining pressure. The master curves simplify solution of the various theoretical predictions enormously over the entire range of the linear approximation. Finally, it is shown that when the Frenkel criterion is used to assess film stability, recent studies reach conclusions that are contrary to the relevance of spontaneous rupture as a cell-opening mechanism in foams. (C) 2003 Elsevier Science B.V. All rights reserved.

Evidence and information for health policy: a decade of change

Over the past decade or so, there has been increasing demand for greater clarity about the major causes of disease and injury, how these differentially affect populations, and how they are changing. In part, this demand has been motivated by resource constraints and a realisation that better health is possible with more informed allocation of resources. At the same time, there has been a change in the way population health and its determinants are quantified, with a much closer integration of the quantitative population sciences (such as epidemiology, demography and health economics) to strengthen and broaden the evidence base for healthcare policy.

D. José da Costa Nunes - A Patriarch who cared for more than souls: A case of caesaro-papism in Portuguese India, 1942-1953

É pouco conhecido que durante vários séculos e até ao fim do colonialismo português no Oriente seguiu-se a prática de enviar bispos açorianos. Eram brancos e não tinham outra língia e cultura que não fossem portuguesas. Eram critérios suficientes para serem preferidos a candidatos asiáticos mesmo com formação superior e conhecedores das línguas e culturas dos seus povos. Desconfiava-se da sua lealdade e patriotismo. Isto era particularmente crucial quando se iniciaram movimentos independentistas na Ásia. D. José da Costa Nunes é estudado neste ensaio como um paradigma desta política colonial.

Seqüência de drogas consumidas por usuários de crack e fatores interferentes

OBJETIVO: Identificar, entre usuários de crack, uma progressão no uso de drogas e seus fatores interferentes. MÉTODOS: Utilizou-se metodologia qualitativa para uma investigação mais profunda, considerando o ponto de vista que o entrevistado tem do fenômeno. Foram aplicados entrevistas de longa duração e questionários semi-estruturados. Foi delineada uma amostra intencional, e uma amostragem com critérios foi conseguida. Para atingir a saturação teórica, foram entrevistados 31 usuários ou ex-usuários de crack. RESULTADOS: Foram detectadas duas fases distintas de uso de drogas. A primeira, com drogas lícitas, sendo o cigarro e o álcool as mais citadas pela amostra. Parentes e amigos dos entrevistados foram os incentivadores do consumo, e o motivo alegado para o uso dessas substâncias foi a necessidade de autoconfiança. A idade precoce do consumo e o uso pesado de uma ou ambas as drogas foram determinantes para o início de uma escalada de drogas ilícitas. A maconha foi a primeira droga dessa segunda fase. Uma postura mais ativa na busca da droga como fonte de prazer passou a ser o motivo do consumo. CONCLUSÕES: O estudo revela que a identificação de uma seqüência de drogas parece estar mais associada a fatores externos (pressões de grupo, influência do tráfico etc.) do que à preferência do usuário. Foram identificadas duas progressões diferentes: entre os mais jovens (=30 anos), cuja a escalada começou com o cigarro e/ou álcool e passou pela maconha e cocaína aspirada até o uso de crack; e os mais velhos (>30 anos), que iniciaram o uso de drogas pelo cigarro e/ou álcool, seguido de maconha, medicamentos endovenosos, cocaína aspirada, cocaína endovenosa e, por fim, crack.

Solubility of red 153 and blue 1 in supercritical carbon dioxide

Solubilities of red 153, (3-[[4-[[5,6(or 6,7)-dichloro-2-benzothiazolyl]azo]phenyl]ethylamino]propanenitrile), an azo compound, and disperse blue1 (1,4,5,8-tetraaminoantraquinone) in supercritical carbon dioxide (SC CO(2)) were measured at T = (333.2 to 393.2) K over the pressure range (12.0 to 40.0) MPa by a flow type apparatus. The solubility of red 153 (0.985. 10(-6) to 37.2. 10(-6)) in the overall region of measurements is found to be significantly higher than that of disperse blue 1 (1.12.10(-7) to 4.89.10(-7)). The solubility behavior of disperse red 153 follows the general solubility trend displayed by disperse dyes with a crossover pressure at about 20 MPa. On the other hand, blue 1, which is a disperse anthraquinone dye, exhibits unexpected behavior not recorded previously there is no crossover pressure at the temperature and pressure ranges studied, and the dye's solubility at T = 333.2 K practically does not increase with pressure. To the best of our knowledge, there are no previous measurements of blue 1 solubility in SC CO(2) reported in the literature. The experimental data were correlated by using the Soave Redlich Kwong equation of state (EoS) with the one-fluid van der Waals mixing rule, and an acceptable correlation of the solubility data for both dyes was obtained.

Razões para o não-uso de drogas ilícitas entre jovens em situação de risco

OBJETIVO: Embora existam muitos estudos a respeito dos fatores de risco ao uso de drogas, pouco se sabe sobre as razões que mantêm jovens afastados do seu consumo. O objetivo do estudo foi identificar, entre adolescentes de baixo poder aquisitivo, quais os motivos que os impediriam a experimentação e o conseqüente uso de drogas psicotrópicas, mesmo quando submetidos a constante oferta. MÉTODOS: Adotou-se metodologia qualitativa, com amostra intencional selecionada por critérios. Foram entrevistados 62 jovens, com idade entre 16 e 24 anos, de classe social baixa, que nunca experimentaram drogas psicotrópicas ilícitas (32 sujeitos) ou que delas fizeram uso pesado (30 sujeitos). Cada entrevista durou, em média, 110 minutos. RESULTADOS: Entre não-usuários, a disponibilidade de informações e estrutura familiar protetora foram observadas como razões no afastamento dos jovens das drogas. A informação completa sobre as conseqüências do uso de drogas e os laços afetivos entre pais e filhos, garantidos por sentimentos como a cumplicidade e respeito, parecem ser importantes para a negação da droga. A importância desses fatores como razões do afastamento de jovens das drogas é enfatizada quando sua ausência é relatada e criticada entre os usuários de drogas. CONCLUSÕES: Torna-se necessária a inclusão do ponto de vista daqueles que nunca experimentaram drogas e das motivações que permitiriam tal atitude em programas de prevenção para adolescentes de baixa condição socioeconômica.