The prevalence and characteristics of alcohol-related presentations to emergency departments in rural Australia.

BACKGROUND: The burden of harm associated with alcohol misuse is disproportionately high in rural areas of Australia, and a considerable proportion of this burden is borne by the health system. The health impact of alcohol in rural areas has been measured in terms of the contribution of alcohol to hospital inpatient admissions and mortality rates, despite many more alcohol-related cases presenting to emergency departments (EDs). This study aims to estimate the proportion of presentations to EDs in rural Australia that are alcohol-related and to identify the associated patient and presentation characteristics. METHODS: Patients aged ≥14 years presenting to four EDs in rural NSW were assessed on two measures: (1) Clinician judgement of alcohol consumption, and (2) patient self-report of alcohol consumption in the 6 h preceding the onset of their condition. RESULTS: Preliminary analyses revealed sample selection biases in two of the EDs, and these samples were consequently excluded from further analyses. In the two remaining EDs, 46% of presentations were assessed, of which 9% were identified as alcohol-related. Presentations for mental disorders, those with more urgent triage categories and those occurring on weekends or at night were more often alcohol-related. CONCLUSIONS: The prevalence of alcohol-related ED presentations observed was at the lower end of the documented range, probably due to methodological differences and limitations, as well as geographic variation. Despite this, alcohol-related presentations were associated with a substantial impact on the ED. Policies and programs to reduce the impact of alcohol on rural emergency departments are needed.

Disseminating best-evidence health-care to Indigenous health-care settings and programs in Australia: identifying the gaps.

Indigenous Australians experience a disproportionately greater burden of harm from smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) than the general Australian population. A critical step in further improving efforts to reduce this harm is to review existing efforts aimed at increasing the uptake of evidence-based interventions in Indigenous-specific health-care settings and programs. This study systematically identifies and reviews published Indigenous-specific dissemination studies targeting SNAP interventions. An electronic search of eight databases and a manual search of reference lists of previous literature reviews were undertaken. Eleven dissemination studies were identified for review: six for nutrition and physical activity as a component of diabetes care, three for alcohol and two for smoking. The majority of studies employed continuing medical education (n = 9 studies), suggesting that improving health-care providers' knowledge and skills is a focus of current efforts to disseminate best-evidence SNAP interventions in Indigenous health-care settings. Only two studies evaluated reminder systems, despite their widespread use in Indigenous-specific health-care services, and only one study employed academic detailing, despite its cost-effectiveness at modifying health-care provider behavior. There is a clear need for more Indigenous-specific dissemination research targeting the uptake of secondary prevention and to establish reliable and valid measures of Indigenous-specific health-care delivery, in order to determine which dissemination strategies are most likely to be effective in Indigenous health-care settings and programs.

A study of the attitudes and perceived barriers to undertaking clinical governance activities of dietitians in a Welsh National Health Service trust.

BACKGROUND: Previous studies of National Health Service (NHS) employees have identified barriers to undertaking clinical governance activities. Little of this research has investigated dietitians; however, where dietitians were included, generally positive attitudes towards research and evidence-based practice were reported alongside the identified barriers. METHODS: A quantitative, whole population census was undertaken via a questionnaire distributed to 54 dietitians employed by Gwent Healthcare NHS Trust. RESULTS: Dietitians reported positive attitudes towards clinical governance; however, barriers to undertaking clinical governance activities were identified. The main barriers included lack of time, inadequate funding, the view that direct patient care should always be prioritised over clinical governance activities and inadequate research and critical evaluation skills. CONCLUSIONS: Findings were similar to those reported in previous studies of NHS staff. Where comparison was possible, all of the barriers identified were reported at lower levels than in previous studies. As the study was purely quantitative in nature, no understanding was gained regarding the nature of identified barriers or what factors influenced the dietitians' attitudes and perceptions. For further in-depth analysis of these factors, a qualitative study is recommended. As the study comprised a whole population census, the findings cannot be generalized to the dietetic profession as a whole, or to other staff groups within or outside of the study Trust.

Serious adverse events in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD).

AIMS: The study estimated serious adverse event (SAE) rates among entrants to pharmacotherapies for opioid dependence, during treatment and after leaving treatment. DESIGN: A longitudinal study based on data from 12 trials included in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). PARTICIPANTS AND SETTINGS: A total of 1244 heroin users and methadone patients treated in hospital, community and GP settings. Intervention Six trials included detoxification; all included treatment with methadone, buprenorphine, levo-alpha-acetyl-methadol (LAAM) or naltrexone. FINDINGS: During 394 person-years of observation, 79 SAEs of 28 types were recorded. Naltrexone participants experienced 39 overdoses per 100 person-years after leaving treatment (44% occurred within 2 weeks after stopping naltrexone). This was eight times the rate recorded among participants who left agonist treatment. Rates of all other SAEs were similar during treatment versus out of treatment, for both naltrexone-treated and agonist-treated participants. Five deaths occurred, all among participants who had left treatment, at a rate of six per 100 person-years. Total SAE rates during naltrexone and agonist treatments were similar (20, 14 per 100 person-years, respectively). Total SAE and death rates observed among participants who had left treatment were three and 19 times the corresponding rates during treatment. CONCLUSIONS: Individuals who leave pharmacotherapies for opioid dependence experience higher overdose and death rates compared with those in treatment. This may be due partly to a participant self-selection effect rather than entirely to pharmacotherapy being protective. Clinicians should alert naltrexone treatment patients in particular about heroin overdose risks. Duty of care may extend beyond cessation of dosing.

A curved edge moderates high pressure generated by a laparoscopic grasper.

BACKGROUND: Very high pressures are generated at the interface between the tip of laparoscopic graspers and tissue. The pressure profile suggests that the high pressure is due to stress concentration at the edge of the jaw. Stress concentration at an edge can be modified by curving the edge. This study sought to determine the effect of a curved edge on pressures generated by the jaw of a laparoscopic grasper. METHODS: Pressure generated at the instrument tissue interface was measured by a thin film pressure transducer. The two instruments that we compared were identical in every respect except the profile of the jaw edge. One was unmodified; the other had a rounded grasping edge. Load and handle pressure were constant throughout. Tissue pressures generated by the grasper were recorded as the angle of load was increased from vertical (0 degrees ) to 135 degrees. RESULTS: Localized pressures at the tip of the unmodified instrument reached a maximum of 1500 kPa. Pressures at the tip of the curved instrument reached a maximum of 920 kPa under identical conditions. CONCLUSION: High pressures generated at the tip of laparoscopic graspers can be reduced by rounding the edge of the jaw.

Appropriateness of red blood cell transfusions in major urban hospitals and effectiveness of an intervention.

OBJECTIVES: To assess the appropriateness of red blood cell (RBC) transfusions and the effectiveness of an intervention to reduce inappropriate RBC transfusions. DESIGN: Medical record audit by hospital staff using a data form, before and after randomly allocated interventions (letter only or letter+visit). Criteria for assessing appropriateness of RBC transfusions were based on a systematic literature review. SETTING: Ten major urban hospitals in Sydney, New South Wales, in 1998 and 1999. SUBJECTS: Medical records of up to 120 patients at each hospital (n=1117). INTERVENTIONS: Letter-only (5 hospitals)--results of first audit at the hospital mailed to chief executive officer of that hospital; letter+visit (5 hospitals) results of first audit at the hospital presented by the research team to a meeting of that hospital's staff, and then mailed to the chief executive officer. MAIN OUTCOME MEASURE: Proportion of RBC transfusions assessed as inappropriate. RESULTS: At first audit, 35% of RBC transfusions were assessed as inappropriate. Small reductions in inappropriate transfusions were found at the second audit, but the change was significant only for the hospitals receiving the letter-only intervention. About 5% of patients received a single RBC unit; 40% of single-unit transfusions were inappropriate. More RBC transfusions were inappropriate in surgical patients than in those treated by other specialties. CONCLUSIONS: About a third of RBC transfusions were assessed as inappropriate. The interventions had only a small effect on transfusion appropriateness.

Grasper trauma during laparoscopic cholecystectomy.

BACKGROUND: The present study characterized the histopathological nature of laparoscopic grasper trauma during laparoscopic cholecystectomy in a prospective, blinded trial in order to establish a model for laparoscopic grasper trauma. The null hypothesis that graspers cause no histologically distinct tissue injury was tested. METHODS: The gall bladders of 19 patients undergoing laparoscopic cholecystectomy were examined. The area of gall bladder that had been grasped by Debakey laparoscopic forceps was excised (sample), along with an area of gall bladder that had not been grasped (control). Paired specimens were examined by a pathologist (blinded) to identify which was 'sample' and which was 'control' and to assess for histological markers of crushed tissue injury. The data were analysed by chi-squared or Fisher's exact tests. RESULTS: The pathologist was able to identify the sample (gripped) specimen in 13 of the 19 cases. In the remaining six cases the pathologist was unable to determine the specimen that had been gripped due to either absence of damage (four cases), or severe inflammation precluding assessment (two cases). The ability of the pathologist to distinguish the sample from the control specimen was significant (chi-squared test, P = 0.003). Of the histological markers of crushed tissue injury, focal thinning of the gall bladder wall and epithelial loss were present in significantly more sample (gripped) specimens than control specimens (chi-squared test, P = 0.0002 and P < 0.0001, respectively). CONCLUSIONS: Laparoscopic graspers cause tissue trauma that can be assessed histologically. The current study presents a relevant, reproducible, ethically acceptable human model for assessing the interaction between laparoscopic graspers and soft tissues.

A comparison of two retrospective measures of weekly alcohol consumption: diary and quantity/frequency index.

There is currently uncertainty regarding the relative performance of a retrospective diary (RD) and a quantity-frequency index (QFI) measure of weekly alcohol consumption. While some previous studies have found more consumption reported on an RD than a QFI, others have found the reverse. As yet, however, no study has compared computerized versions of these two measures. This cross-sectional study involved administration of a computerized survey in a community-based drug and alcohol treatment setting. Five hundred and eighty-six clients (420 males) attending counselling for a range of drug- and alcohol-related issues agreed to participate in the study. The major finding was that more alcohol consumption was reported on the RD, than on the QFI. Similarly, the RD detected a greater proportion of both heavy and high-risk drinkers than the QFI. It is argued that the RD may be preferable to the QFI as a measure of weekly alcohol consumption, for use in community-based treatment settings.

High pressures are generated at the tip of laparoscopic graspers.

BACKGROUND: Despite its importance the interface between tissue and instrument is poorly understood. METHODS: A thin film pressure transducer was deployed between the jaws of eight different laparoscopic instruments and a simulated tissue to study the forces generated at the tip of laparoscopic graspers and the effect of a change in angle of tissue tension at the interface between tissue and laparoscopic grasper. RESULTS: Pressure was concentrated at the tip of the instrument. Localized pressures increased on average from 210 kPa to 650 kPa as the angle of grasp was increased from 0 to 135 degrees. There was a wide variation between instruments with some exhibiting increases in tip pressure of a factor of eight as the angle was increased. CONCLUSION: High pressures are generated at the tip of laparoscopic graspers. Pressures increase as the angle of incidence of the grasper in relation to the tissue increases. The changes in pressure with change in angle are independent of load and handle pressure.

Computers in community-based drug and alcohol clinical settings: are they acceptable to respondents?

The use of computer technology is not new in the delivery of health services. Previous studies have assessed the reliability and validity of computerised surveys, relative to pen and paper versions or interviews or the acceptability of computers in a range of treatment settings. Generally, these studies have reported that the reliability, validity and acceptability of computer surveys is at least comparable to more traditional survey methods. This study provides evidence for the appropriateness of using computers in community-based drug and alcohol clinical settings, reporting a high level of computer acceptability among clients. The advantages of utilising computers in clinical settings, for researchers and clinicians, are discussed.

Behavioural alcohol research: new directions or more of the same?

AIM: Despite a large body of literature, a substantial burden of illness related to the abuse of alcohol, as well as significant economic and social costs, persist. As such, a critical examination of the type of research being published in relation to alcohol misuse seems appropriate, particularly since some experts in the field have expressed the view that the current distribution of research types may not be optimal. FINDINGS: The types of research conducted in two separate years, 1983 and 1993, were examined critically. Generally, the types of research conducted in both years was found to be similar: the majority of published alcohol research is behavioural, the majority of published behavioural alcohol research is descriptive and the majority of published behavioural intervention alcohol research represents tertiary prevention studies. Although the reasons for this distribution of research types are undoubtedly numerous and complex, some possible explanations are discussed. CONCLUSIONS: Overall, it is concluded that the current approach to alcohol research may have engendered a distribution of research types which is somewhat less than ideal and that, as such, a new approach may be indicated. Some strategies that may assist in redressing the perceived imbalance are considered.