Factors in the selection of patients for conditional release from their first psychiatric hospitalization

Objective: This study examined a sample of patients in Victoria, Australia, to identify factors in selection for conditional release from an initial hospitalization that occurred within 30 days of entry into the mental health system. Methods: Data were from the Victorian Psychiatric Case Register. All patients first hospitalized and conditionally released between 1990 and 2000 were identified (N = 8,879), and three comparison groups were created. Two groups were hospitalized within 30 days of entering the system: those who were given conditional release and those who were not. A third group was conditionally released from a hospitalization that occurred after or extended beyond 30 days after system entry. Logistic regression identified characteristics that distinguished the first group. Ordinary least-squares regression was used to evaluate the contribution of conditional release early in treatment to reducing inpatient episodes, inpatient days, days per episode, and inpatient days per 30 days in the system. Results: Conditional release early in treatment was used for 11 percent of the sample, or more than a third of those who were eligible for this intervention. Factors significantly associated with selection for early conditional release were those related to a better prognosis ( initial hospitalization at a later age and having greater than an 11th grade education), a lower likelihood of a diagnosis of dementia or schizophrenia, involuntary status at first inpatient admission, and greater community involvement ( being employed and being married). When the analyses controlled for these factors, use of conditional release early in treatment was significantly associated with a reduction in use of subsequent inpatient care.

Non-eating disorders psychopathology in children and adolescents with eating disorders: Implications for malnutrition and symptom severity

Objectives: To compare the general psychopathology in an eating disorders (ED) and a child mental health Outpatient sample and investigate the implications of comorbidity on psychological and physical measures of ED severity. Methods: One hundred thirty-six children and adolescents with a DSM-IV ED diagnosis were compared with age- and gender-matched controls. Measures included the Eating Disorders Examination and the Child Behavior Checklist. Results: The ED group had lower general and externalizing psychopathology scores and no difference in internalizing (anxiety-depression) symptoms. Of the anorexia nervosa group, 49% experienced comorbid psychopathology. This group had significantly higher ED psychopathology, longer duration of illness, and more gastrointestinal symptoms, but no difference in malnutrition status. Eating disorders not otherwise specified (EDNos) group measures were less influenced by comorbidity status. Conclusions: Anxiety-depressive symptoms are very common in children and adolescents with EDs. Comorbidity status influences illness severity, especially in the anorexia nervosa group. The management implications of these findings are discussed. (c) 2006 Elsevier Inc. All rights reserved.

A cost-effectiveness analysis of heroin detoxification methods in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD)

This economic evaluation was part of the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD) project. Data from four trials of heroin detoxification methods, involving 365 participants, were pooled to enable a comprehensive comparison of the cost-effectiveness of five inpatient and outpatient detoxification methods. This study took the perspective of the treatment provider in assessing resource use and costs. Two short-term outcome measures were used-achievement of an initial 7-day period of abstinence, and entry into ongoing post-detoxification treatment. The mean costs of the various detoxification methods ranged widely, from AUD $491 (buprenorphine-based outpatient); to AUD $605 for conventional outpatient; AUD $1404 for conventional inpatient; AUD $1990 for rapid detoxification under sedation; and to AUD $2689 for anaesthesia per episode. An incremental cost-effectiveness analysis was carried out using conventional outpatient detoxification as the base comparator. The buprenorphine-based outpatient detoxification method was found to be the most cost-effective method overall, and rapid opioid detoxification under sedation was the most costeffective inpatient method.

Population pharmacokinetics of itraconazole and its active metabolite hydroxy-itraconazole in paediatric cystic fibrosis and bone marrow transplant patients

Objective: The objective of the study was to characterise the population pharmacokinetic properties of itraconazole and its active metabolite hydroxyitraconazole in a representative paediatric population of cystic fibrosis and bone marrow transplant (BMT) patients and to identify patient characteristics influencing the pharmacokinetics of itraconazole. The ultimate goals were to determine the relative bioavailability between the two oral formulations (capsules vs oral solution) and to optimise dosing regimens in these patients. Methods: All paediatric patients with cystic fibrosis or patients undergoing BMT at The Royal Children's Hospital, Brisbane, QLD, Australia, who were prescribed oral itraconazole for the treatment of allergic bronchopulmonary aspergillosis (cystic fibrosis patients) or for prophylaxis of any fungal infection (BMT patients) were eligible for the study. Blood samples were taken from the recruited patients as per an empirical sampling design either during hospitalisation or during outpatient clinic visits. ltraconazole and hydroxy-itraconazole plasma concentrations were determined by a validated high-performance liquid chromatography assay with fluorometric detection. A nonlinear mixed-effect modelling approach using the NONMEM software to simultaneously describe the pharmacokinetics of itraconazole and its metabolite. Results: A one-compartment model with first-order absorption described the itraconazole data, and the metabolism of the parent drug to hydroxy-itraconazole was described by a first-order rate constant. The metabolite data also showed one-compartment characteristics with linear elimination. For itraconazole the apparent clearance (CLitraconazole) was 35.5 L/hour, the apparent volume of distribution (V-d(itraconazole)) was 672L, the absorption rate constant for the capsule formulation was 0.0901 h(-1) and for the oral solution formulation was 0.96 h-1. The lag time was estimated to be 19.1 minutes and the relative bioavailability between capsules and oral solution (F-rel) was 0.55. For the metabolite, volume of distribution, V-m/(F (.) f(m)), and clearance, CL/(F (.) fm), were 10.6L and 5.28 L/h, respectively. The influence of total bodyweight was significant, added as a covariate on CLitraconazoie/F and V-d(itraconazole)/F (standardised to a 70kg person) using allometric three-quarter power scaling on CLitraconazole/F, which therefore reflected adult values. The unexplained between-subject variability (coefficient of variation %) was 68.7%, 75.8%, 73.4% and 61.1% for CLitraconazoie/F, Vd(itraconazole)/F, CLm/(F (.) fm) and F-rel, respectively. The correlation between random effects of CLitraconazole and Vd((itraconazole)) was 0.69. Conclusion: The developed population pharmacokinetic model adequately described the pharmacokinetics of itraconazole and its active metabolite, hydroxy-itraconazole, in paediatric patients with either cystic fibrosis or undergoing BMT. More appropriate dosing schedules have been developed for the oral solution and the capsules to secure a minimum therapeutic trough plasma concentration of 0.5 mg/L for these patients.

Realtime telemedicine

Telemedicine conducted via prerecorded interaction is more convenient than that using realtime interaction. On the other hand, a realtime consultation allows an immediate result to be obtained and there is likely to be a strong educational component for the remote practitioner. The use of the telephone is under-rated in telemedicine. Telephones have been used in outpatient follow-up, mental health, help lines and support groups. Telephones (fixed and mobile) have also been used for data transfer (e.g. for transmission of electrocardiograms). Realtime transfer of still images has been used in telepathology for many years, and more recently for rapid assessment of injuries. Realtime transfer of video images has been widely explored, perhaps most successfully in telepsychiatry. Some realtime telemedicine applications have been taken up with enthusiasm, even if formal evidence of cost-effectiveness may be lacking. Teleradiology and telepsychiatry are two examples where widespread adoption is beginning to occur. Other forms of realtime telemedicine represent 'niche' applications. That is, they appear to be both successful and sustainable in the centres where they were pioneered, but have not been adopted elsewhere. Teledialysis and teleoncology are examples of this type. The patchy diffusion of telemedicine is something that is not yet well understood.

Quality of Life in Chinese elderly people with depression

Background Depression is the most prevalent functional mental disorder of later life. It is estimated that about 5% of the elderly population of Hong Kong are suffering from depression. Aim To investigate the self-rated quality of life of community-dwelling elderly people diagnosed with depression, and to examine the relationships between quality of life and mental, physical health, functional status and social support. Methods and results A cross-sectional descriptive survey was conducted in psychiatric outpatient clinics. A convenience sample of 80 Chinese elderly people with a diagnosis of depressive disorder was recruited. Perception of quality of life was measured by the Hong Kong Chinese World Health Organization Quality of Life Scale-Brief Version. Participants' mental status, functional abilities, physical health condition, and social support status were assessed. Sixty-one (76.3%) participants were female. They were least satisfied with meaningfulness of life, life enjoyment, concentration and thinking, energy and work capacity. Functional abilities had a positive association with participants' perceived quality of life, level of depression and number of physical health conditions had a negative association. Participants had low ratings of quality of life when compared with healthy persons and persons with chronic physical problems. Findings are discussed in light of the socio-cultural environment in Hong Kong. Conclusion Comprehensive treatment and better control of depression, including different modes of medical and psychosocial intervention, could help to improve participants' perception of quality of life. A longitudinal study with a larger sample with various levels of depression and socio-demographic characteristics is recommended. Copyright © 2006 John Wiley & Sons, Ltd.

Heart failure management programmes in Europe

Background The ESC guidelines recommend that an organised system of specialist heart failure (HF) care should be established to improve outcomes of HF patients. The aim of this study was therefore to identify the number and the content of HF management programmes in Europe. Method A two-phase descriptive study was conducted: an initial screening to identify the existence of HF management programmes; and a survey to describe the content in countries where at least 30% of the hospitals had a programme. Results Of the 43 European countries approached, 26 (60%) estimated the percentage of HF management programmes. Seven countries reported that they had such programmes in more than 30% of their hospitals. Of the 673 hospitals responding to the questionnaire, 426 (63%) had a HF management programme. Half of the programmes (n = 205) were located in an outpatient clinic. In the UK a combination of hospital and home-based programmes was common (75%). The most programmes included physical examination, telephone consultation, patient education, drug titration and diagnostic testing. Most (89%) programmes involved nurses and physicians. Multi-disciplinary teams were active in 56% of the HF programmes. The most prominent differences between the 7 countries were the degree of collaboration with home care and GP's, the role in palliative care and the funding. Conclusion Only a few European countries have a large number of organised programmes for HF care and follow up. To improve outcomes of HF patients throughout Europe more effort should be taken to increase the number of these programmes in all countries.

Health system reform in Mexico 5: Assessing the effect of the 2001-06 Mexican health reform: an interim report card

Since 2001, Mexico has been designing, legislating, and implementing a major health-system reform. A key component was the creation of Seguro Popular, which is intended to expand insurance coverage over 7 years to uninsured people, nearly half the total population at the start of 2001. The reform included five actions: legislation of entitlement per family affiliated which, with full implementation, will increase public spending on health by 0.8-1.0% of gross domestic product; creation of explicit benefits packages; allocation of monies to decentralised state ministries of health in proportion to number of families affiliated; division of federal resources flowing to states into separate funds for personal and non-personal health services; and creation of a fund to protect families against catastrophic health expenditures. Using the WHO health-systems framework, we used a wide range of datasets to assess the effect of this reform on different dimensions of the health system. Key findings include: affiliation is preferentially reaching the poor and the marginalised communities; federal non-social security expenditure in real per-head terms increased by 38% from 2000 to 2005; equity of public-health expenditure across states improved; Seguro Popular affiliates used more inpatient and outpatient services than uninsured people; effective coverage of 11 interventions has improved between 2000 and 2005-06; inequalities in effective coverage across states and wealth deciles has decreased over this period; catastrophic expenditures for Seguro Popular affiliates are lower than for uninsured people even though use of services has increased. We present some lessons for Mexico based on this interim evaluation and explore implications for other countries considering health reforms.

Online referral and OPD booking from the GP desktop

The Brisbane Inner South E-referral Project (BISEP) developed an application which allowed general practitioners, from their desktop, to successfully search for and book an available hospital outpatient appointment for patients with suspected cancer, send the referral electronically, and inform the patient of both the appointment and referral during the consultation. The hospital changed their outpatient department processes to allow such functionality for local GPs with patients with suspected cancer, working from a mutually agreed set of best practice referral criteria. A group of 19 GPs participated in an 11-week pilot implementation of the application, and were enthusiastic about continuing and expanding the approach. Patient satisfaction measures post intervention indicated that they perceived no major disadvantage in this form of outpatient department referral.

Methicillin-resistant Staphylococcus aureus in the Australian community: an evolving epidemic

Objective: To describe antimicrobial resistance and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) isolated in community settings in Australia. Design and setting: Survey of S. aureus isolates collected prospectively Australia-wide between July 2004 and February 2005; results were compared with those of similar surveys conducted in 2000 and 2002. Main outcome measures: Up to 100 consecutive, unique clinical isolates of S. aureus from outpatient settings were collected at each of 22 teaching hospital and five private laboratories from cities in all Australian states and territories. They were characterised by antimicrobial susceptibilities (by agar dilution methods), coagulase gene typing, pulsed-field gel electrophoresis, multilocus sequence typing, SCCmec typing and polymerase chain reaction tests for Panton-Valentine leukocidin (PVL) gene. Results: 2652 S. aureus isolates were collected, of which 395 (14.9%) were MRSA. The number of community-associated MRSA (CA-MRSA) isolates rose from 4.7% (118/2498) of S. aureus isolates in 2000 to 7.3% (194/2652) in 2004 (P=0.001). Of the three major CA-MRSA strains, WA-1 constituted 45/257 (18%) of MRSA in 2000 and 64/395 (16%) in 2004 (P=0.89), while the Queensland (OLD) strain increased from 13/257 (5%) to 58/395 (15%) (P=0.0004), and the south-west Pacific (SWP) strain decreased from 33/257 (13%) to 26/395 (7%) (P=0.01). PVL genes were detected in 90/195 (46%) of CA-MRSA strains, including 5/64 (8%) of WA-1, 56/58 (97%) of OLD, and 25/26 (96%) of SWP strains. Among health care-associated MRSA strains, all AUS-2 and AUS-3 isolates were multidrug-resistant, and UK EMRSA-15 isolates were resistant to ciprofloxacin and erythromycin (50%) or to ciprofloxacin alone (44%). Almost all (98%) of CA-MRSA strains were non-multiresistant. Conclusions: Community-onset MRSA continues to spread throughout Australia. The hypervirulence determinant PVL is often found in two of the most common CA-MRSA strains. The rapid changes in prevalence emphasise the importance of ongoing surveillance.

Combined acamprosate and naltrexone, with cognitive behavioural therapy is superior to either medication alone for alcohol abstinence: A single centres' experience with pharmacotherapy

Aims: To compare treatment outcomes amongst patients offered pharmacotherapy with either naltrexone or acamprosate used singly or in combination, in a 12-week outpatient cognitive behavioural therapy (CBT) programme for alcohol dependence. Methods: We matched 236 patients across gender, age group, prior alcohol detoxification, and dependence severity and conducted a cohort comparison study of three medication groups (CBT+acamprosate, CBT+naltrexone, CBT+combined medication) which included 59 patients per group. Outcome measures included programme attendance, programme abstinence and for those who relapsed, cumulative abstinence duration (CAD) and days to first breach (DFB). Secondary analyses compared the remaining matched 59 subjects who declined medication with the pharmacotherapy groups. Results: Across medication groups, CBT+ combined medication produced the greatest improvement across all outcome measures. Although a trend favoured the CBT+ combined group, differences did not reach statistical significance. Programme attendance: CBT + Acamprosate group (66.1%), CBT + Naltrexone group (79.7%), and in the CBT + Combined group (83.1%). Abstinence rates were 50.8, 66.1, and 67.8%, respectively. For those that did not complete the programme abstinent, the average number of days abstinent (CAD) were 45.07, 49.95, and 53.58 days, respectively. The average numbers of days to first breach (DFB) was 26.79, 26.7, and 37.32 days. When the focal group (CBT + combined) was compared with patients who declined medication (CBT-alone), significant differences were observed across all outcome indices. Withdrawal due to adverse medication effects was minimal. Conclusions: The addition of both medications (naltrexone and acamprosate) resulted in measurable benefit and was well tolerated. In this patient population naltrexone with CBT is as effective as combined medication with CBT, but the trend favours combination medication.

Psychotropic medication utilization in a child and adolescent mental health service

Objectives: This study aimed to identify rates and correlates of psychotropic drug utilization in children and adolescents in inpatient and outpatient settings. Methods: A retrospective chart review examined 122 inpatient and 126 outpatient charts from a metropolitan child and youth mental health service in Brisbane, Australia. Results: Inpatients received more psychotropic medication than outpatients (71% vs. 25%; p < 0.01). Patients receiving medication were older, had longer hospital admissions, and more complex presentations, including history of abuse or suicide attempts and more diagnoses (all p < 0.01). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently used drug class (44% inpatients; 14% outpatients), primarily indicated for mood disorders (31%). SSRIs and newer antidepressants (ADs) were used more frequently in patients with a high suicide risk (p < 0.01). Atypical antipsychotics (APs) were also used (inpatients 23%; outpatients 3%), primarily for behavioral disturbances. Half of those receiving medication (51%) received polypharmacy (> 1 concurrent drug), with up to four drugs used at one time. Rates of polypharmacy were highest among patients receiving antipsychotics. Conclusions: Use of psychotropic medication is frequent in this population. Future research should initially focus on inpatients and intensive treatment settings and examine both safety and efficacy of interventions for depression in young people, atypical antipsychotics for behavioral disturbances, and polypharmacy.

A comparison of telepaediatric activity at two regional hospitals in Queensland

We conducted a 15-month feasibility study of telepaediatrics. A novel service was offered to two hospitals in Queensland (Mackay and Hervey Bay). We used data from all other hospitals throughout the state as the control group. Although both intervention hospitals were provided with the same service, the telepaediatric activity generated and the effect on admissions and outpatient activity were markedly different. There was a significant decrease in the number of patient admissions to Brisbane from the Mackay region. In addition, there was an increase in the number of Mackay patients treated locally (as outpatients). In contrast, little change was observed in Hervey Bay. We assessed whether the observed differences between the two hospitals were due to various factors which influenced the use of the telepaediatric service. These factors included the method of screening patients before transfer to the tertiary centre and the physical distance between each facility and the tertiary centre. We believe that the screening method used for patient referrals was the most important determinant of the use of the telepaediatric service.

Asma, abitudini e stile di vita "Analisi retrospettiva di un campione di pazienti asmatici seguito in ambulatorio di terzo livello"

Growing evidence suggest the importance of different environments in promoting the pathogenesis and/or exacerbation of asthma. Indoor air pollution is a major contributor to human exposure, since people spend up to 90% of their day indoors. Apart from active smoking, indoor pollution is considered one of the major preventable risk factors of chronic respiratory diseases. The professional activity can also be dangerous because it exposes the subject to environments that can promote the onset of asthma or worsening of the latter in those already affected. Even bad habits such as incorrect diet, lead to more difficulty in controlling their disease. However asthma is a multifactorial disease in nature so it is not easy to distinguish the role of occupational exposure, pollution and normal habits such as smoking, nutrition, sports, etc. This retrospective study was conducted on a sample of asthma patients residing in the metropolitan area of Parma. 116 patients were selected among those who are followed up at least two years at the Asthma outpatient Clinic of Parma University Hospital. The sample in question is therefore closely controlled and monitored; it comes to patients who are well educated on the control of their disease, are able to take appropriate measures to minimize the symptomatology. With this tight approach is proposed to minimize the effect of confounding and then traced with greater certainty the possible cause of the failure to control the disease. For this purpose, each patient was subjected to regular checkups; we took as a reference the period of time between April and October 2015. During each visit, in addition to general data for each patient, we were collected personal information about their habits and way of life through a validated questionnaire delivered and completed by the patient during the visit in the presence of the permanent staff. The questionnaire covers mainly the qualification of the patient, its possible occupational exposure, his home, with information about nearby traffic, time spent outside, physical activity (place and time), exposure to chemicals, exposure to various fumes (fireplace or stove) and cigarette smoke, comorbidities and any drugs taken during the visits considered. Regarding the respiratory conditions of patients during every examination we were considered: Asthma Control Test (a test performed by patients to assess the state of the disease during the month preceding the test), the measurement of exhaled nitric oxide (FeNO) as an index of airways inflammation, measuring the resistance level of small airways (R5-R20) and some spirometric values observed in experiment; in particular the forced vital capacity (FVC), forced expiratory volume in the first second (FEV 1), FEV1/FVC ratio, forced expiratory flow rate over the middle 50% of the FVC (FEF25–75) and FEF25-75/FVC were recorded. The sample has been studied considering both the changes of the respiratory parameters for every patient in their examinations, and the respiratory parameters of all the examinations took as a whole in relation with the variables considered. From the results obtained, the patients are clinically stable; their adopted lifestyle and the exposure to possible sources of outdoor pollution, seems not affect the overall control of their disease. Some findings of our study are of interest. First, the subjects who carry a steroid therapy show a clinical worst, as revealed by the decrease of most spirometric indices, particularly FEF25, FEF75, FEF25-75 and R5-R20; also, the presence of comorbidities and the subsequent intake of other drugs, in addition to normal therapy for asthma, seem to be conditions associated with poorer performance in the functional respiratory parameters in particular FEV1/FVC, FEF75 and FEF25-75. Spirometric indexes that are down are mainly those related to obstruction imposed on small airways; this suggests a neglect to the latter on the contrary should be further explored and treated accordingly. It is also observed that both patients are overweight than those living on the lower floors and/or who have the most windows exposed to traffic, showed a decrease of pulmonary function, especially those relate to an obstruction at the small airways level. In conclusion, our results provided the evidence that a most appropriate therapy, specific to reach the small airways, associated with a healthy lifestyle, can help improve the management of asthma.