Determining value for money in day hospital care for the elderly

This paper describes how a prospective evaluation of the costs and effectiveness of day hospital care for the elderly and its alternatives could be undertaken. The number of day hospitals for the elderly has grown from zero to slightly over 300 in just over 20 years. Despite this there is no study in the existing literature which gives an indication of whether day hospitals provide a reasonable return on this substantial investment. The best way of determining whether day hospitals are a better investment than alternative modes of care would be a randomized controlled trial involving comparison of subgroups of day hospital patients against similar subgroups utilizing alternative modes of care, the costing of each patient's consumption of services within the treatment mode in which they commence the study plus any subsequent use of other services over a predetermined time period, the collection of clinical, social and psychological outcome data (including data on dependency) for each subgroup before, during and at the end of the study period, and some measure of patients' and relatives' satisfaction with the treatment received.     

Assuring the quality of in-home care: the "other" challenge for long-term care

Although the growth of in-home care has been praised for expanding long-term care options for people with chronic disabilities, questions surrounding the quality of in-home care have begun to arise. This paper discusses six critical factors that complicate efforts to assure quality including client and provider characteristics, fiscal constraints, inadequate regulation, lack of quality assurance methods, and lack of a coherent social policy for long-term care. A final section of the paper identifies three areas of policy to be addressed if efforts to deliver quality of care are to be successful.     

Sipuleucel-T: a prostate cancer vaccine: "instructions for use" for urologists

Sipuleucel-T is the first approved vaccine for prostate cancer, opening the pathway for this new treatment approach. The treatment process consists in isolating the patient dentritic cells via leukapherisis, stimulate and infuse them into the patient. These enhanced cells are then able to stimulate patient T lymphocytes to target the tumour cells. The median survival in the pivotal study, IMPACT, as well as in the previously reported randomised trials, was 4.1 months longer in the sipuleucel-T group. The estimated probability of survival 36 months after randomisation was 31.7% in the sipuleucel-T group and 23.0% in the placebo group. However, the median time to objective disease progression was similar in the two groups (hazard ratio: 0.95; 95% CI, 0.77 to 1.17; P=0.63). We report herein, the treatment modalities, side effects and results in the light of recently published randomised trials.     

Condom use with various types of sex partners by money boys in China

Money boys (MBs) who typically sell sex to males have not yet been extensively studied in China. In this 2009 study, 28 venue-based MBs were interviewed. We analyzed their condom use behaviors with various partners, including male and female clients, male and female casual partners, other MBs and female sex workers, and boyfriends and girlfriends. All participants were aware of the need for using condoms; however, usage with different partner types varied. The longer a relationship with a partner, the less frequent was condom use. A major reason for not using condoms was that they or their partners did not like the loss of sensation due to condom use. Other factors included sexual orientation, age, duration in commercial sex, concerns about HIV/AIDS, attractiveness of partners, and support of "mommies" (brothel supervisors). Both individual- and venue-level interventions are needed to promote condom use, and mommies need to be included in intervention strategies.     

两城市场所内男性性工作者新型毒品使用现况

目的了解场所内男性性工作者(MB)使用新型毒品的比例,并比较场所内使用和未使用新型毒品组之间感染艾滋病病毒(HIV)的风险。方法对两城市的122名MB进行面对面的横断面匿名调查。结果 122名MB中,28.7%的调查对象报告他们曾使用过新型毒品。在过去2个月中,使用和未使用新型毒品组中,分别有86.2%和84.0%自报在过去2个月中有4名及以上男性性伴,使用新型毒品组中自报有10名及以上肛交性伴的比例(64.5%)高于未使用组(47.4%)。使用新型毒品组中自报与女性性伴发生性行为时每次都使用安全套的比例(42.9%)要低于未使用组(58.6%)。结论在今后的MB干预工作中,要注意包括预防新型毒品使用的相关内容。     

Advance care planning in COPD: care versus "code status"

Chronic obstructive pulmonary disease (COPD) in advanced stages runs an unpredictable downward course with increasingly frequent, ultimately fatal exacerbations. Worldwide financial and human costs are huge. Responsibility for initiating advance care planning in COPD has usually fallen to the physicians. The tendency has been to avoid this aspect of care, which can result in inadequate, rushed, reactive, crisis decision-making in the form of a "code status" discussion. In this article, I review the relevant literature and report findings from a qualitative study designed within my doctoral program to explore the question, "What is required for meaningful and effective advance care planning in the context of advanced COPD?" I describe the "collaborative care" approach to advance care planning I used with eight patients and carers living with advanced COPD. Along with a skilled clinician facilitator, user-friendly education elements, and attention to readiness, unique aspects of the approach included a focus on caring, engaging hope, facilitator reflective praxis, and contextual sensitivity. This approach has significant potential for enhancing decision making and goal setting, efficiency of resource utilization, and satisfaction with outcomes. Done well, it may reclaim the care element in advance care planning as it addresses barriers cited by physicians and patients/families.     

Greater risk for more money: the economics of negotiating condom use amongst sex workers in South Africa

The economics of sex work and the effect on safe sex practices remain understudied. This research contributes to a better understanding of how economic opportunity and vulnerability place sex workers (SWs) at an increased risk of STI infection. Using quantitative and qualitative methods, we investigated the role of economic incentives in determining condom use among SWs. The data reveals that SWs are on average, nearly doubling their rates for condomless sex. Our findings that SWs are engaging in condomless sex to increase their earnings, illustrates the point that the context in which they operate influences condom negotiation and consequently, increases risky sexual behaviour.     

Nailfold capillaroscopy in rheumatology: ready for the daily use but with care in terminology

Clinical Rheumatology -     

Oral ofloxacin for the treatment of acute bacterial pneumonia: use of a nontraditional protocol to compare experimental therapy with "usual care" in a multicenter clinical trial

PURPOSE: This multicenter study was designed to compare an exclusively oral regimen with "usual care" in patients hospitalized with acute bacterial pneumonia. PATIENTS AND METHODS: One hundred forty-seven patients were enrolled. All patients presented with a clinical picture consistent with pneumonia: (1) clinical symptoms of a lower respiratory tract infection, such as chest pain, cough, and production of purulent sputum; (2) roentgenographic infiltrate compatible with acute infection; and (3) Gram's stain of purulent sputum or other appropriate bronchopulmonary specimen containing gram-negative organisms, staphylococci, or pneumococci. All patients required hospitalization. The design was a parallel-group, open-label study with randomization in blocks of four. Ofloxacin, a new fluoroquinolone antimicrobial agent, was administered orally or by nasogastric tube, 400 mg every 12 hours. This was compared with the individual investigator's best selection of therapy that was administered parenterally, at least initially. RESULTS: One hundred thirty-three patients were evaluable after exclusions for deviation from protocol, early death due to unrelated causes, incorrect diagnosis, or early adverse drug reactions. All 69 patients treated with ofloxacin and 61 of 64 control patients had favorable clinical and microbiologic responses. There were no statistically significant differences between the groups in terms of demographics, therapeutic outcome, and duration of therapy. There were few side effects overall and rates were similar for the two groups. CONCLUSIONS: An exclusively oral regimen, in this case ofloxacin, may be substituted for parenteral therapy in selected patients with pneumonia. This might significantly reduce costs and risks to the patient.