Feasibility of an evidence-based literature search service for general practitioners

Objective: To test the feasibility of an evidence-based clinical literature search service to help answer general practitioners' (GPs') clinical questions. Design: Two search services supplied GPs who submitted questions with the best available empirical evidence to answer these questions. The GPs provided feedback on the value of the service, and concordance of answers from the two search services was assessed. Setting: Two literature search services (Queensland and Victoria), operating for nine months from February 1999. Main outcome measures: Use of the service; time taken to locate answers; availability of evidence; value of the service to GPs; and consistency of answers from the two services. Results: 58 GPs asked 160 questions (29 asked one, 11 asked five or more). The questions concerned treatment (65%), aetiology (17%), prognosis (13%), and diagnosis (5%). Answering a question took a mean of 3 hours 32 minutes of personnel time (95% Cl, 2.67-3.97); nine questions took longer than 10 hours each to answer, the longest taking 23 hours 30 minutes. Evidence of suitable quality to provide a sound answer was available for 126 (79%) questions. Feedback data for 84 (53%) questions, provided by 42 GPs, showed that they appreciated the service, and asking the questions changed clinical care. There were many minor differences between the answers from the two centres, and substantial differences in the evidence found for 4/14 questions. However, conclusions reached were largely similar, with no or only minor differences for all questions. Conclusions: It is feasible to provide a literature search service, but further assessment is needed to establish its cost effectiveness.

A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective

A randomized controlled trial was carried out to measure the cost-effectiveness of realtime teledermatology compared with conventional outpatient dermatology care for patients from urban and rural areas. One urban and one rural health centre were linked to a regional hospital in Northern Ireland by ISDN at 128 kbit/s. Over two years, 274 patients required a hospital outpatient dermatology referral -126 patients (46%) were randomized to a telemedicine consultation and 148 (54%) to a conventional hospital outpatient consultation. Of those seen by telemedicine, 61% were registered with an urban practice, compared with 71% of those seen conventionally. The clinical outcomes of the two types of consultation were similar - almost half the patients were managed after a single consultation with the dermatologist. The observed marginal cost per patient of the initial realtime teledermatology consultation was f52.85 for those in urban areas and f59.93 per patient for those from rural areas. The observed marginal cost of the initial conventional consultation was f47.13 for urban patients and f48.77 for rural patients. The total observed costs of teledermatology were higher than the costs of conventional care in both urban and rural areas, mainly because of the fixed equipment costs. Sensitivity analysis using a real-world scenario showed that in urban areas the average costs of the telemedicine and conventional consultations were about equal, while in rural areas the average cost of the telemedicine consultation was less than that of the conventional consultation.

Outpatient cognitive behavioural therapy programme for alcohol dependence impact of naltrexone use on outcome

Objective: Cognitive-behavioural therapy (CBT) has been effectively used in the treatment of alcohol dependence. Clinical studies report that the anticraving drug naltrexone, is a useful adjunct to treatment. Currently, few data are available on the impact of adding this medication to programmes in more typical, outpatient, and rehabilitation settings. The objective of this study was to examine the impact on outcome of adding naltrexone to an established outpatient alcohol rehabilitation program which employed CBT. Method: Fifty patients participated in an established 12-week, outpatient, 'contract'-based alcohol abstinence programme which employed CBT. They also received naltrexone 50 mg orally daily (CBT + naltrexone). Outcomes were compared with 50 historical, matched controls, all of whom participated in the same programme without an anticraving medication (CBT alone). All patients met DSM-IV criteria for alcohol dependence. Results: Programme attendance across the eight treatment sessions was lower in the CBT alone group (p < 0.001). Relapse to alcohol use occurred sooner and more frequently in the CBT alone group (p < 0.001). Rehabilitation programme completion at 12 weeks was 88% (CBT + naltrexone) compared with 36% for (CBT alone) (p < 0.001). Alcohol abstinence at 12 weeks was 76% (CBT + naltrexone) compared with 18% (CBT alone) (p < 0.001). Conclusion: When employing the same outpatient rehabilitation programme and comparing outcomes using matched historical controls, the addition of naltrexone substantially improves programme attendance, programme completion and reported alcohol abstinence. In a typical outpatient programme, naltrexone addition was associated with significantly improved programme participation, better outcomes and was well tolerated.

Telehealth and the diagnosis and management of cardiac disease

The financial and personal burden of chronic cardiac disease is high. Costs are likely to increase over the next few decades. Promising applications of telehealth have appeared in the diagnosis and management of cardiac disease and there are indications that telehealth services can improve the management of chronic cardiac disease as well as extend services to remote and rural populations. Telehealth has been applied to the capture of symptoms of cardiac disease with electrocardiography and echocardiography, to the management and rehabilitation of recently discharged patients, and in peer-to-peer consultation where remote expertise can facilitate diagnosis. Telehealth promises cost reductions in service delivery, although there is a need for properly controlled cost-effectiveness trials to underpin telehealth with a firm evidence base.

The efficiency and condition of oysters and macroalgae used as biological filters of shrimp pond effluent

Current shrimp pond management practices generally result in elevated concentrations of nutrients, suspended solids, bacteria and phytoplankton compared with the influent water. Concerns about adverse environmental impacts caused by discharging pond effluent directly into adjacent waterways have prompted the search for cost-effective methods of effluent treatment. One potential method of effluent treatment is the use of ponds or raceways stocked with plants or animals that act as natural biofilters by removing waste nutrients. In addition to improving effluent water quality prior to discharge, the use of natural biofilters provides a method for capturing otherwise wasted nutrients. This study examined the potential of the native oyster, Saccostrea commercialis (Iredale and Roughley) and macroalgae, Gracilaria edulis (Gmelin) Silva to improve effluent water quality from a commercial Penaeus japonicus (Bate) shrimp farm, A system of raceways was constructed to permit recirculation of the effluent through the oysters to maximize the filtration of bacteria, phytoplankton and total suspended solids. A series of experiments was conducted to test the ability of oysters and macroalgae to improve effluent water quality in a flow-through system compared with a recirculating system. In the flow-through system, oysters reduced the concentration of bacteria to 35% of the initial concentration, chlorophyll a to 39%, total particulates (2.28-35.2 mum) to 29%, total nitrogen to 66% and total phosphorus to 56%. Under the recirculating flow regime, the ability of the oysters to improve water quality was significantly enhanced. After four circuits, total bacterial numbers were reduced to 12%, chlorophyll a to 4%, and total suspended solids to 16%. Efforts to increase biofiltration by adding additional layers of oyster trays and macroalgae-filled mesh bags resulted in fouling of the lower layers causing the death of oysters and senescence of macroalgae. Supplementary laboratory experiments were designed to examine the effects of high effluent concentrations of suspended particulates on the growth and condition of oysters and macroalgae. The results demonstrated that high concentrations of particulates inhibited growth and reduced the condition of oysters and macroalgae. Allowing the effluent to settle before biofiltration improved growth and reduced signs of stress in the oysters and macroalgae. A settling time of 6 h reduced particulates to a level that prevented fouling of the oysters and macroalgae.

Research into telehealth applications in speech-language pathology

A literature review was conducted to investigate the extent to which telehealth has been researched within the domain of speech-language pathology and the outcomes of this research. A total of 13 studies were identified. Three early studies demonstrated that telehealth was feasible, although there was no discussion of the cost-effectiveness of this process in terms of patient outcomes. The majority of the subsequent studies indicated positive or encouraging outcomes resulting from telehealth. However, there were a number of shortcomings in the research, including a lack of cost-benefit information, failure to evaluate the technology itself, an absence of studies of the educational and informational aspects of telehealth in relation to speech-language pathology, and the use of telehealth in a limited range of communication disorders. Future research into the application of telehealth to speech-language pathology services must adopt a scientific approach, and have a well defined development and evaluation framework that addresses the effectiveness of the technique, patient outcomes and satisfaction, and the cost-benefit relationship.

Does primary medical practitioner involvement with a specialist team improve patient outcomes? A systematic review.

Patients with chronic or complex medical or psychiatric conditions are treated by many practitioners, including general practitioners (GPs). Formal liaison between primary and specialist is often assumed to offer benefits to patients The aim of this study was to assess the efficacy of formal liaison of GPs with specialist service providers on patient health outcomes, by conducting a systematic review of the published literature in MEDLINE, EMBASE, PsychINFO, CINAHL and Cochrane Library databases using the following search terms family physicians': synonyms of 'patient care planning', 'patient discharge' and 'patient care team'; and synonyms of 'randomised controlled trials'. Seven studies were identified, involving 963 subjects and 899 controls. most health outcomes were unchanged, although some physical and functional health outcomes were improved by formal liaison between GPs and specialist services, particularly among chronic mental illness patients. Some health outcomes worsened during the intervention. Patient retention rates within treatment programmes improved with GP involvement, as did patient satisfaction. Doctor (GP and specialist) behaviour changed, with reports of more rational use of resources and diagnostic tests, improved clinical skills, more frequent use of appropriate treatment strategies, and more frequent clinical behaviours designed to detect disease complications Cost effectiveness could not be determined. In conclusion, formal liaison between GPs and specialist services leaves most physical health outcomes unchanged, but improves functional outcomes in chronically mentally ill patients. It may confer modest long-term health benefits through improvements in patient concordance with treatment programmes and more effective clinical practice.

Benefits, harms and costs of screening mammography in women 70 years and over: a systematic review

Objective: To assess the (i) benefits, (ii) harms and (iii) costs of continuing mammographic screening for women 70 years and over. Data sources and synthesis: (i) We conducted a MEDLINE search (1966 - July 2000) for decision-analytic models estimating life-expectancy gains from screening in older women. The five studies meeting the inclusion criteria were critically appraised using standard criteria. We estimated relative benefit from each model's estimate of effectiveness of screening in older women relative to that in women aged 50-69 years using the same model. (ii) With data from BreastScreen Queensland, we constructed balance sheets of the consequences of screening for women in 10-year age groups (40-49 to 80-89 years), and (iii) we used a validated model to estimate the marginal cost-effectiveness of extending screening to women 70 years and over. Results: For women aged 70-79 years, the relative benefit was estimated as 40%-72%, and 18%-62% with adjustment for the impact of screening on quality of life. For women over 80 years the relative benefit was about a third, and with quality-of-life adjustment only 14%, that in women aged 50-69 years. (ii) Of 10 000 Australian women participating in ongoing screening, about 400 are recalled for further testing, and, depending on age, about 70-112 undergo biopsy and about 19-80 cancers are detected. (iii) Cost-effectiveness estimates for extending the upper age limit for mammographic screening from 69 to 79 years range from $8119 to $27 751 per quality-adjusted life-year saved, which compares favourably with extending screening to women aged 40-49 years (estimated at between $24 000 and $65 000 per life-year saved). Conclusions: Women 70 years and over, in consultation with their healthcare providers, may want to decide for themselves whether to continue mammographic screening. Decision-support materials are needed for women in this age group.

Mathematical modelling of schistosomiasis japonica: comparison of control strategies in the People's Republic of China

We present the first mathematical model on the transmission dynamics of Schistosoma japonicum. The work extends Barbour's classic model of schistosome transmission. It allows for the mammalian host heterogeneity characteristic of the S. japonicum life cycle, and solves the problem of under-specification of Barbour's model by the use of Chinese data we are collecting on human-bovine transmission in the Poyang Lake area of Jiangxi Province in China. The model predicts that in the lake/marshland areas of the Yangtze River basin: (1) once-early mass chemotherapy of humans is little better than twice-yearly mass chemotherapy in reducing human prevalence. Depending on the heterogeneity of prevalence within the population, targeted treatment of high prevalence groups, with lower overall coverage, can be more effective than mass treatment with higher overall coverage. Treatment confers a short term benefit only, with prevalence rising to endemic levels once chemotherapy programs are stopped (2) depending on the relative contributions of bovines and humans, bovine treatment can benefit humans almost as much as human treatment. Like human treatment, bovine treatment confers a short-term benefit. A combination of human and bovine treatment will dramatically reduce human prevalence and maintains the reduction for a longer period of time than treatment of a single host, although human prevalence rises once treatment ceases; (3) assuming 75% coverage of bovines, a bovine vaccine which acts on worm fecundity must have about 75% efficacy to reduce the reproduction rate below one and ensure mid-term reduction and long-term elimination of the parasite. Such a vaccination program should be accompanied by an initial period of human treatment to instigate a short-term reduction in prevalence, following which the reduction is enhanced by vaccine effects; (4) if the bovine vaccine is only 45% efficacious (the level of current prototype vaccines) it will lower the endemic prevalence, but will not result in elimination. If it is accompanied by an initial period of human treatment and by a 45% improvement in human sanitation or a 30% reduction in contaminated water contact by humans, elimination is then possible. (C) 2002 Elsevier Science B.V. All rights reserved.

Quality of Life and Colorectal Cancer: a Review

Objectives: To describe what is known of quality of life for colorectal cancer patients, to review what has been done in the Australian setting and to identify emerging directions for future research to address current gaps in knowledge. Method: A literature search (using Medline, PsychInfo, CINAHL and Sociological Abstracts) was conducted and 41 articles identified for review. Results: Three key areas relating to quality of life in colorectal cancer patients emerged from the literature review: the definition and measurement of quality of life; predictors of quality of life; and the relationship of quality of life to survival. Results of existing studies are inconsistent in relation to quality of life over time and its relationship to survival. Small sample sizes and methodological limitations make interpretation difficult. Conclusions: There is a need for large-scale, longitudinal, population-based studies describing the quality of life experienced by colorectal cancer patients and its determinants. Measurement and simultaneous adjustment for potential confounding factors would productively advance knowledge in this area, as would an analysis of the economic cost of morbidity to the community and an assessment of the cost effectiveness of proposed interventions. Implications: As the Australian population ages, the prevalence of colorectal cancer within the community will increase. This burden of disease presents as a priority area for public health research. An improved understanding of quality of life and its predictors will inform the development and design of supportive interventions for those affected by the disease.

Predictors of Successful Weight Control: Cross-Cultural Moderators of Treatment Outcomes

Given the heterogeneity of effect sizes within the population for any treatment, identifying moderators of outcomes is critical [1]. In weight management programs, there is a high individual variability in terms of weight loss and an overall modest success [2]. Some people will adopt and sustain attitudes and behaviors associated with weight loss, while others won’t [3]. To predict weight loss outcome just from the subject’s baseline information would be very valuable [4,5]. It would allow to: - Better match between treatments and individuals - Identify the participants with less probability of success (or potential dropouts) in a given treatment and direct them to alternative therapies - Target limited resources to those most likely to succeed - Increase cost-effectiveness and improve success rates of the programs Few studies have been dedicated to describe baseline predictors of treatment success. The Healthy Weight for Life (USA) study is one of the few. Its findings are now being cross-validated in Portuguese samples. This paper describes these cross-cultural comparisons.

Digital radiology and Picture Archiving and Communication System (PACS)

Plain radiography still accounts for the vast majority of imaging studies that are performed at multiple clinical instances. Digital detectors are now prominent in many imaging facilities and they are the main driving force towards filmless environments. There has been a working paradigm shift due to the functional separation of acquisition, visualization, and storage with deep impact in the imaging workflows. Moreover with direct digital detectors images are made available almost immediately. Digital radiology is now completely integrated in Picture Archiving and Communication System (PACS) environments governed by the Digital Imaging and Communications in Medicine (DICOM) standard. In this chapter a brief overview of PACS architectures and components is presented together with a necessarily brief account of the DICOM standard. Special focus is given to the DICOM digital radiology objects and how specific attributes may now be used to improve and increase the metadata repository associated with image data. Regular scrutiny of the metadata repository may serve as a valuable tool for improved, cost-effective, and multidimensional quality control procedures.

Análise da eficiência energética num estabelecimento de ensino

Devido à crescente preocupação com a racionalização energética, torna-se importante adequar os edifícios à sua utilização futura, procedendo à escolha acertada de materiais e técnicas a utilizar na construção e/ou na remodelação. Atualmente, com o desenvolvimento tecnológico, os serviços profissionais e os materiais existentes ao dispor dos projectistas e construtores permitem a implementação eficaz de soluções de elevado impacto a nível da eficiência energética dos edifícios de uma forma acessível e não muito dispendiosa. Nesta área, a regulamentação é essencial para controlar e catalogar energeticamente os sistemas, mitigando o seu sobredimensionamento e consequentes desperdícios, de forma a contribuir eficazmente para as melhorias ambientais e económicas pretendidas. Sem dúvida, que a preocupação consiste em tornar a médio/longo prazo o investimento numa poupança acrescida, proporcionando os mesmos níveis de conforto. As técnicas de climatização e todo o equipamento que está associado têm um peso importante nos custos e na exploração ao longo do tempo. Os sistemas de gestão técnica só poderão tirar partido de toda a estrutura, tornando-a confiável, se forem corretamente projetados. Com este trabalho, pretende-se sensibilizar o leitor sobre as questões práticas associadas ao correto dimensionamento de soluções que contribuam para a eficiência energética dos edifícios, exemplificando-se com um caso de estudo: um edifício de um centro escolar construído obedecendo aos requisitos listados no programa de renovação do parque escolar que o governo incentivou. A sensibilização passa por propostas objetivas de soluções alternativas que poderiam ter sido adotadas ainda na fase de projeto do caso de estudo, tendo em conta os custos e operacionalidade dos sistemas e o local em que se encontram, e que poderiam ter contribuído para melhorar a eficiência energética de todo o edifício, bem como por soluções transversais que se poderiam aplicar em outras situações. Todas as sugestões passam pela simplificação, com o objetivo de contribuir para uma melhor racionalização a curto e longo prazo dos recursos disponibilizados.

Factores de rentabilização do processo de serragem de granitos com engenhos multi-lâminas

Este trabalho visa apresentar um enquadramento da realidade económica e industrial do sector transformador de granitos ornamentais em Portugal e fazer uma análise do processo de serragem, com engenhos multi-lâminas e granalha de aço, na medida em que este é o método de seccionamento de blocos de granito mais utilizado pelas grandes indústrias do sector. Tendo em conta a importância económica desta operação produtiva na indústria em causa, foi definido como fito deste projecto a análise estatística dos custos de produção; a definição de fórmulas de cálculo que permitam prever o custo médio de serragem; e o estudo de soluções economicamente viáveis e ambientalmente sustentáveis para o problema das lamas resultantes do expurgo dos engenhos. Para a persecução deste projecto foi realizada uma recolha de dados implementando rotinas de controlo e registo dos mesmos, em quadros de produção normalizados e de fácil preenchimento, pelos operadores destes equipamentos. Esta recolha de dados permitiu isolar, quantificar e formular os factores de rentabilização do processo de serragem selecionando, dentro da amostra de estudo obtida, um conjunto de serragens com características similares e com valores próximos dos valores da média estatística. Apartir dos dados destas serragens foram geradas curvas de tendência polinomial com as quais se analisaram as variações provocadas no custo médio de serragem, pelas variações do factor em estudo. A formulação dos factores de rentabilização e os dados estatísticos obtidos permitiram depois o desenvolvimento de fórmulas de cálculo do custo médio de serragem que establecem o custo de produção diferenciado em função das espessuras com, ou sem, a incorporação dos factores de rentabilização. Como consequência do projecto realizado obteve-se um conjunto de conclusões util, para o sector industrial em causa, que evidencia a importancia da Ocupação dos engenhos e rentabilização de um espaço confinado, da Resistência oferecida à serragem pelos granitos, e da Diferença de altura entre os blocos de uma mesma carga, nos custos de transformação.