Controlling malaria: challenges and solutions

Antimalarial drug resistance is a major public health challenge and the principal reason for the erosion of efficacious treatments. Cost and the limited number of antimalarial drugs in current use impose considerable constraints on malaria control, especially in sub-Saharan Africa. The paper describes a multilateral, multidisciplinary research project on artemisinin-based combination therapy, which offers a new and potentially highly effective way to prevent or retard the development of drug resistance.     

Motivation and patch treatment for HIV+ smokers: a randomized controlled trial

Aims To test the efficacy of two smoking cessation interventions in a HIV positive (HIV+) sample: standard care (SC) treatment plus nicotine replacement therapy (NRT) versus more intensive motivationally enhanced (ME) treatment plus NRT. Design Randomized controlled trial. Setting HIV+ smoker referrals from eight immunology clinics in the northeastern United States. Participants A total of 444 participants enrolled in the study (mean age = 42.07 years; 63.28% male; 51.80% European American; mean cigarettes/day = 18.27). Interventions SC participants received two brief sessions with a health educator. Those setting a quit date received self‐help quitting materials and NRT. ME participants received four sessions of motivational counseling and a quit‐day counseling call. All ME intervention materials were tailored to the needs of HIV+ individuals. Measurements Biochemically verified 7‐day abstinence rates at 2‐month, 4‐month and 6‐month follow‐ups. Findings Intent‐to‐treat (ITT) abstinence rates at 2‐month, 4‐month and 6‐month follow‐ups were 12%, 9% and 9%, respectively, in the ME condition, and 13%, 10% and 10%, respectively, in the SC condition, indicating no between‐group differences. Among 412 participants with treatment utilization data, 6‐month ITT abstinence rates were associated positively with low nicotine dependence (P = 0.02), high motivation to quit (P = 0.04) and Hispanic American race/ethnicity (P = 0.02). Adjusting for these variables, each additional NRT contact improved the odds of smoking abstinence by a third (odds ratio = 1.32, 95% confidence interval = 0.99–1.75). Conclusions Motivationally enhanced treatment plus NRT did not improve cessation rates over and above standard care treatment plus NRT in this HIV+ sample of smokers. Providers offering brief support and encouraging use of nicotine replacement may be able to help HIV+ patients to quit smoking.     

New national surveillance system for hemodialysis-associated infections: initial results

BACKGROUND: Hemodialysis patients have frequent infections, especially of the vascular access site, and often harbor antimicrobial-resistant pathogens. Therefore a voluntary national system was created to monitor and prevent infections in these patients. METHODS: From October 1999 to May 2001, participating centers recorded the number of chronic hemodialysis outpatients that were treated (denominator). Several outcome events, including infections of the vascular access site, were monitored. Data were reported on paper forms or via an Internet-based data entry and analysis system. RESULTS: Among 109 participating centers, the vascular access infection rate per 100 patient-months was 3.2 overall and varied markedly by type of vascular access: 0.56 for native arteriovenous fistulas, 1.36 for synthetic arteriovenous grafts, 8.42 for cuffed catheters, and 11.98 for noncuffed catheters. Among 76 dialysis centers reporting at least 200 patient-months of data, 11 had a significantly low and 14 a significantly high rate of vascular access infection. CONCLUSION: Initial results from the first national project to monitor infections in patients undergoing hemodialysis indicate that vascular access infections were common and that risk varied substantially among different vascular access types and different dialysis centers. These results can be used for quality improvement at individual centers and to help evaluate the efficacy of specific infection control measures.     

Implementing clinical guidelines for chronic obstructive pulmonary disease: barriers and solutions

Chronic obstructive pulmonary disease (COPD) is a complex chronic lung disease characterised by progressive fixed airflow limitation and acute exacerbations that frequently require hospitalisation. Evidence-based clinical guidelines for the diagnosis and management of COPD are now widely available. However, the uptake of these COPD guidelines in clinical practice is highly variable, as is the case for many other chronic disease guidelines. Studies have identified many barriers to implementation of COPD and other guidelines, including factors such as lack of familiarity with guidelines amongst clinicians and inadequate implementation programs. Several methods for enhancing adherence to clinical practice guidelines have been evaluated, including distribution methods, professional education sessions, electronic health records (EHR), point of care reminders and computer decision support systems (CDSS). Results of these studies are mixed to date, and the most effective ways to implement clinical practice guidelines remain unclear. Given the significant resources dedicated to evidence-based medicine, effective dissemination and implementation of best practice at the patient level is an important final step in the process of guideline development. Future efforts should focus on identifying optimal methods for translating the evidence into everyday clinical practice to ensure that patients receive the best care.     

A national progress report on diabetes: successes and challenges

Over the last few decades, numerous public health agencies and other private and public organizations have sought to prevent and delay the disabling complications of diabetes by increasing the use of preventive care practices and reducing risk factors for complications among people with diabetes. Now, federal diabetes surveillance activities are yielding encouraging reports that progress is being made in increasing the use of preventive care practices, reducing risk factors for complications, and preventing or delaying diabetes complications. However, although several gains have been noted, levels of preventive care practices remain suboptimal, risk factors for diabetes complications are too prevalent, and diabetes complications are too pervasive. Furthermore, with compelling evidence that the onset of diabetes can be prevented or delayed among adults at high risk, prevention of diabetes has become a major new challenge. Additional efforts are needed to address the growing problems of obesity and physical inactivity, to identify the most efficacious and cost-effective prevention strategies and interventions, and to implement surveillance activities that allow us to gauge our success. Although progress has been made against diabetes complications, the current epidemic of diabetes increases the urgency of primary prevention efforts.     

An approach to designing a national climate service

Climate variability and change are considerably important for a wide range of human activities and natural ecosystems. Climate science has made major advances during the last two decades, yet climate information is neither routinely useful for nor used in planning. What is needed is a mechanism, a national climate service (NCS), to connect climate science to decision-relevant questions and support building capacity to anticipate, plan for, and adapt to climate fluctuations. This article contributes to the national debate for an NCS by describing the rationale for building an NCS, the functions and services it would provide, and how it should be designed and evaluated. The NCS is most effectively achieved as a federal interagency partnership with critically important participation by regional climate centers, state climatologists, the emerging National Integrated Drought Information System, and the National Oceanic and Atmospheric Administration (NOAA) Regional Integrated Sciences Assessment (RISA) teams in a sustained relationship with a wide variety of stakeholders. Because the NCS is a service, and because evidence indicates that the regional spatial scale is most important for delivering climate services, given subnational geographical/geophysical complexity, attention is focused on lessons learned from the University of Washington Climate Impacts Group's 10 years of experience, the first of the NOAA RISA teams.     

Use of nicotine replacement therapy for smoking reduction and during enforced temporary abstinence: a national survey of English smokers

Aims To assess the prevalence of nicotine replacement therapy (NRT) use for smoking reduction (SR) and temporary abstinence (TA), the association between the two and the strength of the association between NRT use for SR or TA and socio‐demographic characteristics, cigarette consumption and past quit attempts. Design Cross‐sectional monthly surveys. Setting England. Participants A total of 11 414 smokers. Measurements Participants were asked (i) whether they were reducing the amount they smoked: if so, whether they used NRT; and (ii) whether they used NRT for TA. Demographic characteristics, daily cigarette consumption and whether a quit attempt had been made in the past 12 months were also assessed. Findings Of the participants, 56% were attempting SR, 14% were using NRT for SR and 14% were using NRT for TA. Use of NRT for SR and TA were highly correlated. The nicotine patch was the most commonly used form of NRT. The use of NRT for SR, compared with unassisted SR, was more common among older smokers, while the use of NRT for TA was more common among women. Cigarette consumption was higher in those using NRT for SR than those attempting SR without NRT. The use of NRT for SR and TA was associated positively with past quit attempts. Conclusions Nicotine replacement therapy use for smoking reduction and temporary abstinence is common in England. The use of NRT for SR and TA does not appear to be associated with lower cigarette consumption relative to SR or TA without NRT, but is associated with a higher rate of past quit attempts.     

HIV prevention and drug treatment services for drug misusers: a national study of community pharmacists' attitudes and their involvement in service specific training

Aims. To investigate the attitudes of community pharmacists towards HIV prevention services for drug misusers and the relationship between these and their involvement in service provision. Design. Postal survey of a one in four random sample of community pharmacies (N = 2654) in England and Wales, stratified by Family Health Service Authority, in 1995, using up to four mailshots. Setting. Community pharmacies in England and Wales. Participants. The community pharmacist in charge of the dispensary at the random sample of community pharmacies. Measurements. Information on attitudes and behaviour were collected through self-completion and postal return of structured questionnaires using questions with both category responses and Likert scales. Findings. A 74.8% response rate was achieved. Community pharmacists were positive about their role in HIV prevention and the provision of clean injecting equipment to injecting drug users—positive attitudes that were more evident among those pharmacists already providing these services. However, they had concerns over the effect drug misusers may have on business and indicated a need for more training and for more role support. Only a minority had taken pan in training on drug misuse and HIV prevention (34.7% and 21.3%, respectively). Many community pharmacists supported the proposal that there should be extensions of their involvement, to include services such as supervising the consumption of methadone in the pharmacy (38.6%) and collecting used prescribed ampoules front patients (33.8%). Positive relationships were identified between training and attitude, and between attitude and service provision. Changes in attitude responses between this 1995 survey and the earlier 1988 survey are also presented. Conclusions. Recommendations are made for further training and greater communication between prescriber/carer and the community pharmacists, for involvement of community pharmacies in new possible forms of service provision, and for there to be greater attention to the value of role support.     

Profiles of smokers and non-smokers with type 2 diabetes: initial visit at a diabetes education centers

Aims

This study explores differences in psychosocial, behavioral and clinical characteristics among smoking and non-smoking individuals with diabetes attending diabetes education centers (DEC).

Methods

A questionnaire was administered to 275 individuals with type 2 diabetes attending two DECs between October 2003 and 2005. The participants’ characteristics were analyzed and multivariable linear and ordinal regressions were performed to adjust for variables correlated with smoking.

Results

Findings revealed that smokers, compared to non-smokers, had lower outcome expectations of the benefits of self-management, lower diastolic blood pressure, and followed their recommended diet and tested blood glucose levels less often than non-smokers. Smokers also had lower intentions to use resources outside and within the DEC.

Conclusions

Results demonstrate poorer self-care behaviors among smokers compared to non-smokers and further suggest cognitive and behavioral differences between smokers and non-smokers regarding participation and attitudes toward self-management practices. These findings identify issues that need to be addressed in diabetes self-management programs to allow for more effective interventions tailored to the healthcare needs of this specific population.     

Implementing effective hypertension quality improvement strategies: barriers and potential solutions

Many quality improvement strategies have focused on improving blood pressure control, and these strategies can target the patient, the provider, and/or the system. Strategies that seem to have the biggest effect on blood pressure outcomes are team change, patient education, facilitated relay of clinical information, and promotion of self-management. Barriers to effective blood pressure control can affect the patient, the physician, the system, and/or "cues to action."We review the barriers to achieving blood pressure control and describe current and potential creative strategies for optimizing blood pressure control. These include home-based disease management, combined patient and provider education, and automatic decision support systems. Future research must address which components of quality improvement interventions are most successful in achieving blood pressure control.