Economic constraints and quality assurance in mental health services: sensitive indicators

Clinicians in the field of mental health are met with the dual challenge of increased accountability and shrinking resources. Funds are often allocated through the use of crude administrative monitors. This is of little solace to the clinician faced with unmet patients' wants and needs. A set of clinical monitors is outlined requiring the practitioner's cooperation. The presentation of an accurate composite picture is a must in the process of resource allocation. Such clinical monitors include the analysis of characteristics of patients such as the repeaters at emergency, "the revolving door" pool of patients and those falling in between networks. Reviews of waiting lists and lengths of stay, an evaluation of nursing care variables, the auditing of the choice of therapeutic modalities and the use of restraints are other suggested contributors to the assessment of service needs.     

Does spaced education improve clinical knowledge among Family Medicine residents? A cluster randomized controlled trial

Advances in Health Sciences Education - Spaced education is a learning strategy to improve knowledge acquisition and retention. To date, no robust evidence exists to support the utility of spaced...     

Peripherally inserted central catheters for parenteral nutrition: a comparison with centrally inserted catheters

BACKGROUND: Central venous access is crucial for the provision of adequate parenteral nutrition (PN). The type of central venous access device (CVAD) has evolved over the past 10 years. The most recent trend has been to use peripherally inserted central catheters (PICCs). This development has occurred without controlled clinical trials. METHODS: Over a 10-year period, the nutrition support service at a single institution has prospectively collected data on CVADs used for providing PN. The types of CVAD used for providing PN were analyzed, and the major complications associated with CVADs, thrombosis and line sepsis, were compared over three different time periods: 1988-1989; 1992-1993; 1996-1997. In addition, complications associated with PICCs were compared with other CVADs. RESULTS: The following were the dominant CVADs over each of the three time periods: 1988-1989: tunneled catheters, 80%; 1992-1993: nontunneled catheters, 46%; and 1996-1997: PICCs, 48%. There was a decreased incidence of sepsis and pneumothorax in 1996-1997 and an increase in severed or leaking catheters and phlebitis. In a comparison of PICC and non-PICC catheters over the past 3 years, there was a trend toward decreasing sepsis with PICC catheters but an increase in malposition, inadvertent removal, and severed or leaking catheters. CONCLUSIONS: PICCs have replaced tunneled and nontunneled central catheters as the most commonly used CVAD for providing PN. PICCs do not result in increased line sepsis or thrombosis but have an increased incidence of local complications such as leaking catheters, phlebitis, and malposition.     

Open sky bone grafting in the treatment of infected non unions and extensive saucerizations

Starting in 1960, a prospective study was initiated in Notre-Dame Hospital in Montreal so as to shorten the long classical treatment of this affection. Two open sky excision-reconstruction techniques were designed and used in cases with large bone defects after saucerizations (excision or complete resection). Only autogenous cancellous bone was used for reconstruction and primarily the wound was left open. Late skin coverage was used on granulation tissue. First results on 39 cases were published in 1979. In 1988, we reviewed 87 cases. These types of treatment were successful in 95% of the cases and the late recurrences were relatively few.     

Amniotic membrane is a potential regenerative option for chronic non‐healing wounds: a report of five cases receiving dehydrated human amnion/chorion membrane allograft

A case series of five patients with a total of six chronic non‐healing wounds (>30 day duration) were non‐randomly selected to evaluate the performance, safety and handling properties of dehydrated human amnion/chorion membrane allograft, an amniotic membrane scaffolding product. The patients had lower extremity wounds that had previously failed standard of care within a university outpatient/inpatient wound healing programme. Five wounds treated with dehydrated amnion/chorion membrane allograft showed a mean 43% area reduction from baseline (51% median) at 3 weeks into treatment and completely healed with a 64‐day median time to closure (SD ±27·6 days). One wound worsened at 3 weeks and was found to have a complete central vein obstruction that was treated with long‐term mild compression but still eventually healed at 6 months. Removing this outlier, the four responding wounds had a 72% mean and 69% median change in area from baseline, at the 3 week point. All five patients received only one application of dehydrated human amnion/chorion membrane allograft, and there were no adverse events. The product was easy to use, administer and handle. In summary, dehydrated human amnion/chorion membrane allograft appears to be a safe, effective and easy to use therapy for chronic non‐healing wounds. This study describes the details of these clinical cases and provides an overview of the current evidence on the use of amniotic tissue in clinical practice.     

The prevalence of coagulation abnormalities in hospitalized patients receiving lipid-based parenteral nutrition

BACKGROUND: Vitamin K is not a component of the multivitamin preparation added to parenteral nutrition (PN) solutions, and hospitalized patients receiving parenteral nutrition support are at risk of developing vitamin K deficiency. METHODS: In this study, 84 consecutive patients receiving PN were followed up prospectively to determine the incidence of a raised international normalized ratio (INR). All patients received lipid in their PN, which contains approximately 30 microg of vitamin K/100 mL. RESULTS: Patients were followed up for the course of PN or up to 4 weeks if they needed longer total parenteral nutrition. A raised INR compared with baseline developed in 3.6% of patients. All elevations were mild, and no patients developed clinical bleeding. CONCLUSIONS: It may be unnecessary to routinely supplement patients with vitamin K if they are receiving a lipid emulsion containing significant amounts of vitamin K. For patients receiving warfarin therapy, it will be important for nutrition support services to be aware of the vitamin K content of the lipid emulsion they are using as patients receiving a multivitamin preparation containing vitamin K and lipid emulsion may receive increased amounts of vitamin K, which could lead to warfarin resistance.     

The stakes of online gambling in Canada: a public health analysis

Available data show that online gamblers spend more money and dedicate more time to playing compared to gamblers who do not play online, and are more likely to experience gambling problems. Among online players, young people and poker players show higher rates of gambling problems. These observations can be explained in part by such dangerous aspects of online gambling (and also electronic gaming machines) as: immediate and convenient accessibility; ability to pay electronically and to play on credit; anonymity; and the possibility for players to consume alcohol or other drugs while playing. These are elements that could facilitate the development or the intensification of problem gambling. This being said, the public discourse about the inevitability of legalized online gambling is quite unanimous and built upon such arguments as: the imperative duty of the state to protect the population against the dangers of the online gambling black market; and the fact that the medium in itself provides excellent consumer safeguards. A growing number of legislators are following the trend and choosing to establish state control over online gambling. We present some epidemiological and analytical data that challenge some of these assertions and decisions. We recommend a better integration of public health arguments into the commercialization and marketing of online gambling.