Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline

WHAT IS THE ROLE OF DUAL ANTIPLATELET THERAPY AFTER HIGH RISK TRANSIENT ISCHAEMIC ATTACK OR MINOR STROKE? SPECIFICALLY, DOES DUAL ANTIPLATELET THERAPY WITH A COMBINATION OF ASPIRIN AND CLOPIDOGREL LEAD TO A GREATER REDUCTION IN RECURRENT STROKE AND DEATH OVER THE USE OF ASPIRIN ALONE WHEN GIVEN IN THE FIRST 24 HOURS AFTER A HIGH RISK TRANSIENT ISCHAEMIC ATTACK OR MINOR ISCHAEMIC STROKE? AN EXPERT PANEL PRODUCED A STRONG RECOMMENDATION FOR INITIATING DUAL ANTIPLATELET THERAPY WITHIN 24 HOURS OF THE ONSET OF SYMPTOMS, AND FOR CONTINUING IT FOR 10-21 DAYS CURRENT PRACTICE IS TYPICALLY TO USE A SINGLE DRUG.

Reducing Risky Sex among Rural African American Cocaine Users: A Controlled Trial

Rural African American cocaine users experience high rates of STIs/HIV. This NIDA-funded trial tested an adapted evidence-based risk reduction program versus an active control condition. Participants were 251 African American cocaine users in rural Arkansas recruited from 2009-2011. Outcomes included condom use skills and self-efficacy, sexual negotiation skills, peer norms, and self-reported risk behavior. The intervention group experienced greater increases in condom use skills and overall effectiveness in sexual negotiation skills. Both groups reported reductions in trading sex, improvements in condom use self-efficacy, and increased use of specific negotiation skills. Implications and limitations are discussed.

An unusual rash for Royal: a case series

Eight patients, whilst on exercise in Albania, presented with a blistering, erythematous and itchy rash, consistent with caustic burns, after living in dense vegetation for a few days. All patients were found to have been living and operating under fig trees and had come into contact with the sap of Ficus carica, which on exposure to ultraviolet A (UVA) radiation, can cause a process of phytophotodermatitis leading to a blistering rash.

Criminality Among Rural Stimulant Users in the United States

Despite the increase in media attention on "meth cooking" in rural areas of the United States, little is known about rural stimulant use, particularly the criminality associated with stimulant use. Data were collected from community stimulant users in rural Ohio, Arkansas, and Kentucky (N=709). Findings from three logistic regression models indicate that younger stimulant users (x =32.55, SD = 10.35), those with more convictions, and those who used crack frequently were significantly more likely to have been arrested for committing a substance-related crime, a property crime, or another crime in the 6-months before entering the study. Implications include the need for longitudinal studies to further understand rural stimulant use as well as increasing community and corrections-based drug abuse prevention and treatment interventions for stimulant users who live in rural areas.

Barriers and facilitators for alcohol treatment for women: are there more or less for rural women?

Among women at-risk for problems drinking, treatment seeking can be hindered by a complex array of issues such as a lack of transportation, social stigma, denial, fear of losing children, and reluctance of primary care physicians to refer women. This study describes the barriers/facilitators and need for treatment among a community sample of rural and urban women at-risk drinkers. Data for this study were assembled from the baseline sample of individuals who participated in a large probability sample of rural and urban at-risk drinkers (N = 733) from six Southern states: Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee. Men and women differed on perceived barriers/facilitators and need for alcohol treatment. Women differed from men on measures of treatment affordability, accessibility, acceptability and report of social support, illness severity, comorbidities, and demographic characteristics. Rural women differed from urban women on measures of treatment affordability and accessibility and report of illness severity and comorbidities.

The cost of treating addiction from the client's perspective: results from a multi-modality application of the Client DATCAP

There is a considerable disparity between the number of individuals who need substance abuse treatment and the number who actually receive it. This is partly due to the fact that many individuals with substance use disorders do not perceive a need for formal treatment. Another contributing factor, however, is a discrepancy between the real and perceived cost of services. Although many cost evaluations of substance abuse treatment have been conducted from the treatment provider perspective, less is known about the client-specific costs of attending treatment (e.g., lost work and leisure time, transportation, out-of-pocket and in-kind payments). Concerns about financial and other barriers to participating in treatment have encouraged addiction researchers to more carefully consider these previously unmeasured costs. To address this information gap, we administered the Client Drug Abuse Treatment Cost Analysis Program (Client DATCAP) to 302 clients (representing a total of 302 outpatient and 142 inpatient treatment episodes) as part of a larger study examining the cost-effectiveness of interventions designed to improve treatment linkage and engagement in Dayton, Ohio. The value of a client's time accounted for the largest component of total cost (more than 59%). The cost per visit for outpatient clients ranged from $19 for outpatient methadone to $38 for intensive outpatient/aftercare treatment. The average cost per day of treatment for inpatient clients was $235. Policy makers and treatment providers now have a broader view of the opportunity cost of addiction treatment and can use this information to support initiatives for improved treatment access and delivery.

Preference-weighted health-related quality of life measures and substance use disorder severity

AIMS

Examine the validity of preference-weighted health-related quality of life measures in a sample of substance use disorder (SUD) patients. The implications of cost-utility analyses (CUAs) of SUD interventions are discussed.

DESIGN

Cross-sectional analysis of subjects seeking SUD treatment.

SETTING

Seven SUD treatment centers in a medium-sized Midwestern metropolitan area in the United States.

PARTICIPANTS

Data from 574 SUD subjects were analyzed from a study to test interventions to improve linkage and engagement with substance abuse treatment.

MEASUREMENTS

Subjects completed the following preference-weighted measures: self-administered Quality of Well-Being scale (QWB-SA) and Medical Outcomes Study SF-12 (standard gamble weighted or SF-12 SG); and clinical measures: Addiction Severity Index (ASI) and a symptom checklist based on the DSM-IV.

FINDINGS

In unadjusted analyses, the QWB-SA was correlated significantly with six of seven ASI subscales and the SF-12 SG was correlated with four of seven. In adjusted analyses, both preference-weighted measures were significantly correlated with diagnostic, physical health, mental health and drug use measures, but not with legal or alcohol use measures. The QWB-SA was also correlated with employment problems and the SF-12 SG was correlated with family/social problems.

CONCLUSIONS

This study generally supports the construct validity of preference-weighted health-related quality of life measures in SUD patients. However, the QWB-SA and SF-12 SG did not correlate with all ASI scales. Cost-benefit analysis may be preferable when policy-makers are interested in evaluating the full range of SUD intervention outcomes.

The role of African-American clergy in providing informal services to drug users in the rural South: preliminary ethnographic findings

To date, no ethnographic studies of the role of African-American clergy in providing informal services to drug users in the rural South have been reported. We use qualitative interviews with 15 African-American ministers and 26 African-American drug users in Arkansas' Mississippi River Delta region to explore this issue. All drug users reported significant religiosity, and 9 had discussed drug problems with clergy. Every minister had provided assistance to at least one drug user or their family during the previous year, including: direct counseling; referrals to treatment programs; aiding negotiations with formal institutions; and providing for basic needs. Ministers stated that clergy are not well-prepared to address drug problems, and most acknowledged a need for professional training. They also discussed barriers to education. The findings contribute to understanding rural informal drug treatment resources. They suggest that professional treatment providers should investigate the potential benefits of improving outreach efforts to assist African-American ministers engaged in drug abuse issues.

Barriers and Pathways to Diffusion of Methamphetamine Use Among African Americans in the Rural South

There are no studies of African Americans methamphetamine use in the South where it is widespread among whites. We describe factors that inhibit or facilitate the diffusion of methamphetamine use among African Americans based on qualitative interviews with 86 drug users in rural Arkansas and Kentucky. Results suggest low prevalence of methamphetamine use among African Americans, and interviewees cited several barriers to its diffusion which were linked to the drug's ingredients, psychoactive and physiological effects, difficulty in accessing distribution networks, and established African-American preference for cocaine. Fourteen African Americans reported methamphetamine use and discussed pathways to it. Possible increases in African- American methamphetamine use merits further investigation.

Quality assurance and continuing education needs of rural and remote general practitioners: how are they changing?

The Royal Australian College of General Practitioners' (RACGP) 1998 Rural Quality Assurance and Continuing Education (QA & CE) Needs Assessment Project was designed to generate sufficient data to inform strategic planning for rural and remote GPs participating in the College's QA & CE Program. Results indicated that the demand for QA & CE activities has changed over the past 12 years. Three distinct streams of continuing education emerged, where once only one was researched. This reflected a move towards continuing professional development (CPD) rather than purely continuing medical education (CME). However, differences between the CME needs identified suggested that national data could not be reduced to the local level. Data on CME in which rural and remote GPs felt underserviced, proved more useful in relation to other workforce variables such as age, length of service and gender. A broad 'rural set' of CPD topics was established, and the survey yielded information on learning format preferences that will be of use to providers of QA & CE activities for rural GPs across Australia.

Human T-cell leukemia virus type 1 Tax protein binds to assembled nuclear proteasomes and enhances their proteolytic activity

The human T-cell leukemia virus type 1 (HTLV-1) Tax protein activates the HTLV-1 long terminal repeat and key regulatory proteins involved in inflammation, activation, and proliferation and may induce cell transformation. Tax is also the immunodominant target antigen for cytotoxic T cells in HTLV-1 infection. We found that Tax bound to assembled nuclear proteasomes, but Tax could not be detected in the cytoplasm. Confocal microscopy revealed a partial colocalization of Tax with nuclear proteasomes. As Tax translocated into the nucleus very quickly after synthesis, this process probably takes place prior to and independent of proteasome association. Tax mutants revealed that both the Tax N and C termini play a role in proteasome binding. We also found that proteasomes from Tax-transfected cells had enhanced proteolytic activity on prototypic peptide substrates. This effect was not due to the induction of the LMP2 and LMP7 proteasome subunits. Furthermore, Tax appeared to be a long-lived protein, with a half-life of around 15 h. These data suggest that the association of Tax with the proteasome and the enhanced proteolytic activity do not target Tax for rapid degradation and may not determine its immunodominance.

The learning preferences of rural and remote general practitioners. A quantitative analysis and its implications for the RACGP QA&CE program

AIM

To establish the QA&CE needs of rural and remote GPs. In order to assess the fit between The Royal Australian College of General Practitioners' QA&CE program and these needs, learning preferences identified in this survey are compared to previous research published in Australia, 1987-1997, and matched against program objectives and guidelines.

METHOD

In 1998 the RACGP surveyed 900 rural general practitioners (GPs) across Australia in three randomised samples. These samples were stratified respectively by membership of the Rural Faculty of the RACGP and practice location in RRMAs 3-7. The overall response rate was 78%.

RESULTS

Self directed learning was rated by 65.3% of respondents as a preferred method of maintaining professional standards, a rating that corresponded significantly to familiarity with this approach to learning (p = 0.006), and even more so among younger GPs. This was second only to CME at 85.6%. By comparison, there was a low orientation toward some learning methods identified elsewhere as effective, such as clinical audit (15.6%) and peer review (14.5%). There were positive correlations, however, between preference and familiarity for these methods (p < 0.001).

CONCLUSIONS

The results indicate that self directed learning, a major learning preference of rural and remote GPs, may currently be underserviced by the RACGP's QA&CE program. The program also needs to promote more strongly the effectiveness of less preferred modes of education, such as peer review and clinical audit, given the stronger preference indicated for less effective modes.

A relationship between computerisation and quality in general practice

AIM

To explore whether there is an association between use of computers and compliance with The Royal Australian College of General Practitioners (RACGP) Entry Standards for General Practice.

METHOD

Participants in the RACGP Field Test of Standards were surveyed to determine their level of computerisation. These data were matched with the participants' compliance with selected standards. These standards were selected on the basis that compliance with them was relatively low and might be improved by appropriate use of information technology. Ordinal regression analyses were conducted of compliance with the selected standard and relevant levels of computerisation.

RESULTS

There was a significant relationship between having a practice computer and providing patients with written information about the practice (p < 0.0005) and systematic preventive care (p = 0.037).

DISCUSSION

There may be a relationship between quality general practice and computerisation.

Effects of genetic engineering on the pharmacokinetics of antibodies

Monoclonal antibodies (MAbs) may be considered 'magic bullets' due to their ability to recognize and eradicate malignant cells. MAbs, however, have practical limitations for their rapid application in the clinics. The structure of antibody molecules can be engineered to modify functional domains such as antigen-binding sites and/or effector functions. Advances in genetic engineering have provided rapid progress in the development of new immunoglobulin constructs of MAbs with defined research and therapeutic application. Recombinant antibody constructs are being engineered, such as human-mouse chimeric, domain-dispositioned, domain-deleted, humanized and single-chain Fv fragments. Genetically-engineered antibodies differ in size and rate of catabolism. Pharmacokinetic studies show that the intact IgG (150 kD), enzymatically derived fragments Fab' (50 kD) and single chain Fv (28 kD) have different clearance rates. These antibody forms clear 50% from the blood pool in 2.1 days, 30 minutes and 10 minutes, respectively. Genetically-engineered antibodies make a new class of immunotherapeutic tracers for cancer treatment.

National standards for general practice

A set of standards for Australian general practices has been developed through a 4 year project conducted by The Royal Australian College of General Practitioners. An orderly, iterative process was adopted to ensure comprehensive consultation with general practitioners, other health professionals, consumers and governments. The draft standards were field tested in 199 randomly selected urban and rural practices. Results of this field testing showed that the standards have content validity, that they can be measured reliably and that the practice visit protocol is feasible. The standards are calibrated to define the minimum acceptable features of general practices expected for the mid 1990s. The standards have been adopted by Australian General Practice Accreditation Limited as the basis for a voluntary system of practice accreditation.

Controlling for selection bias in the evaluation of Alcoholics Anonymous as aftercare treatment

OBJECTIVE

The purpose of this research was to control for self-selection bias in the evaluation of Alcoholics Anonymous (AA) as aftercare treatment. Observational studies of alcoholism aftercare treatment are subject to selection bias whenever the self-selection process results in important differences in unobserved casemix dimensions between treatment groups.

METHOD

The sample included 118 male veterans discharged from inpatient alcohol treatment, 85% of whom were followed-up at 3 months. Drinking outcomes were measured by self-reported abstinence in the third month after discharge. The aftercare treatment effect of AA was estimated using standard logistic regression analysis and instrumental variables analysis. Instruments included the subject's ability to drive oneself to AA meetings and the presence/absence of an AA meeting in the subject's town of residence. A Hausman exogeniety test was used to determine whether the standard logistic regression results were subject to self-selection bias.

RESULTS

Estimates from the standard logistic regression yielded a positive (OR = 3.7) and significant (p = .018) treatment effect for AA attendance. However, the instrumental variables analysis yielded a smaller (OR* = 1.7) and insignificant treatment effect estimate (p = .782). The Hausman exogeniety test indicated that the treatment effect estimate from the standard logistic regression was subject to significant self-selection bias (chi2 = 83.9, 1 df, p <.01).

CONCLUSIONS

The AA aftercare treatment effect observed in this sample was due to differences in unobserved casemix factors between the treatment groups. Results suggest that previous AA aftercare research may have also been subject to self-selection bias. Researchers of substance abuse outcomes should consider analyzing nonexperimental data using instrumental variables methodologies.

The national asthma audit. Bridging the gap between guidelines and practice

OBJECTIVE

This pilot study was undertaken to assess the need and acceptability of a theoretically based audit model to assist GPs improve their asthma care.

METHOD

Seventeen GPs from two GP divisions conducted a chart audit and patient survey of asthma patients presenting during the 8 week audit period. Audit results were discussed at a workshop providing a forum for GP peer groups to review their asthma care against current guidelines. This workshop allowed the GPs to develop strategies to improve their asthma care in the context of the resources of their individual practice, GP division, local community and health services.

RESULTS

Of the 243 asthma patients audited 177 (72.8%) had a review of their asthma recorded in the past 12 months, 138 (56.8%) were prescribed regular preventive therapy and 118 (48.2%) had been given an asthma action plan. Despite the time commitment required to participate in the activity, 16 respondents who answered the audit evaluation questionnaire reported that the audit was a useful process and 15 (93.8%) stated that it had motivated them to change their practice.

CONCLUSION

The results confirmed the need for improved asthma care in general practice and demonstrated the feasibility of the GP-peer led, regionally coordinated, audit-workshop model.

Morbidity of homebound versus inpatient elderly psychiatric patients

This study compares the demographic and clinical characteristics of homebound (HB) elders referred for psychiatric services (N = 251) with those of inpatients (IP) admitted to a geriatric psychiatry unit (N = 594). Demographically, HB patients were older (78.8 vs 74.7 years), were more likely to be women (83% vs 68%), were widowed (54% vs. 44%), and had fewer years of education (10.3 vs. 11.1), but were similar in race, income, and proportion living alone. Clinically, HB patients had less functional disability, less severe depression, less cognitive impairment, and fewer medical problems. However, they were similar in the distribution of most psychiatric diagnoses except dementia (higher in the IP group) and dementia with depression (higher in the HB group). Outcome data for the HB group over 15 (range, 1 to 38) months revealed medical hospitalization in 20.7%, psychiatric hospitalization in 16.3%, nursing home placement in 9.2% and mortality in 8.4%. These preliminary data show that the HB group had psychiatric problems that were comparable to those of the IP group but were not as severely impaired.

The development of general practice standards in Australia. Royal Australian College of General Practitioners

The Royal Australian College of General Practitioners has spent 4 years developing a set of entry standards which define the minimum features of general practices expected for the mid-1990s. The project design followed a slow, iterative process, with several opportunities for wide consultation with professional, consumer and Government groups. The draft standards were piloted in 25 volunteer practices, modified and then field-tested in 200 randomly selected practices representing urban and rural practices. Results of this field testing showed that the standards had content validity and that reliable measures were possible using triangulation from several data sources. The current version of the standards has been distributed widely for voluntary application in Australian general practices from early 1997.

Personality, social networks, and perceived social support among alcoholics: a structural equation analysis

In this study we tested relations among personality characteristics, social network properties, and perceived social support both concurrently and prospectively. A sample of 294 men in treatment at a Department of Veterans Affairs Alcohol Treatment Unit was assessed during treatment and 3 months after discharge. Results of the cross-sectional structural equation analyses indicated that the personality characteristics of extraversion and neuroticism were related to both social network properties and perceived social support. Characteristics of the alcoholic's social network were also related to perceived availability of support. Longitudinal analyses of perceived social support after treatment indicated that two social network properties (size of the network and the proportion of confidants) were predictive net of initial levels of social support. Extraversion and neuroticism were found to be indirectly related to perceived social support at Time 2 through their effects on social network properties and perceived social support during treatment. Implications of these findings for models of the nature and determinants of perceived social support are discussed.

From the Journals

VENOUS LEG ULCERS AND SQUAMOUS CELL CARCINOMA LEG ULCER MANAGEMENT IN THE COMMUNITY A REAWAKENING OF TRACE-ELEMENT WOUND RESEARCH.

From the Journals

PSYCHOSOCIAL FACTORS AND LEG ULCER HEALING IN OLDER PATIENTSM

THE USE OF NON-ADHERENT DRESSINGS IN SKIN-GRAFT MANAGEMENT

VIDEO TECHNIQUE FOR MEASURING WOUND SIZE

COMPRESSION HOSIERY AND VENOUS LEG ULCERS

VENOUS LEG ULCERS AND QUALITY OF LIFE

PRESSURE SORE GRADING SCALES AND INTER-RATER RELIABILITY

VITAMIN SUPPLEMENTS AND DIETARY INTAKE IN OLDER PEOPLE

Latex allergy: a growing problem in health care

Incidence of latex allergy appears to be growing among health-care professionals. More research is required into prevalence and prevention strategies. Nurses should minimize their risk of sensitisation by wearing latex gloves only when necessary. Employers and the DoH need to take steps to minimise the problem.

The euthanasia debate: how NT readers view the issues

In Nursing Times of May 17, 1995, Clinical Reports covered the important subject of euthanasia. Three papers examined the case for and against euthanasia. They provided some helpful background history to the subject and clarified the position as it currently exists in the Netherlands. A fourth paper, while not addressing the subject of euthanasia directly, examined the issue of resuscitation and emphasised the important ethical principle of respect for autonomy. It is always wise to bear this principle in mind whenever practitioners in the health professions are considering what they perceive to be in the best interests of the patient. The papers were followed by a questionnaire which readers were invited to complete and return, thus enabling them to make a contribution to the debate on this important issue. The results have now been analysed and in this paper the author comments on the findings. In order to do so, he has considered the information in the original papers and urges readers to do the same.