Emergency department based intervention with adolescent substance users: 10 year economic and health outcomes

BACKGROUND: Alcohol and other drug (AOD) use are significant cause of disease burden and costs among adolescents. METHODS: We conducted a randomized trial in hospital emergency departments (ED) following an AOD-related presentation, comparing usual care with brief advice and referral to link adolescents aged 12-19 years with external AOD services. Subsequently, we used health data linkage to assemble data on mortality, hospital admissions, ED attendances, out-patient mental health and use of opiate pharmacotherapies in the next 10 years. From these, treatment costs and rates of events were estimated and compared using generalized linear models. RESULTS: Those who received the intervention had lower costs ($22 versus$227: z=3.16, p=0.002) and rates (0.03 versus 0.25: z=2.57, p=0.010) of ED mental health AOD presentations. However, the intervention did not significantly reduce overall mean health costs per patient (intervention $58746 versus control$64833, p=0.800). Similarly, there was no significant difference in the costs associated with hospitalizations ($48920 versus$50911 p=0.924), overall ED presentations ($4266 versus$4150, p=0.916), out-patient mental health services ($4494 versus$7717, p=0.282), or opiate pharmacotherapies ($1013 versus$2054, p=0.209). Injecting drug use was a significant baseline predictor of subsequent costs in the cohort (z=2.64, p=0.008). CONCLUSIONS: An ED delivered intervention may reduce direct ED costs and subsequent ED AOD attendances. There was also some indication that overall costs may be impacted, with economically large but non-significant differences between the groups. The high costs and morbidity incurred by some of this cohort illustrate the importance of targeting high-risk adolescents

Experiments with Distributed Theatre

The Tempest was probably the last play that Shakespeare wrote alone. It is unlikely that he would contemplate it being performed 400 years later, and

Distributed Theatre: Connecting (with) Remote Audiences

In September 2014, Miracle Theatre performed “the Tempest” simultaneously at two different locations to two separate audiences. Both audiences were linked together using an advanced video system, where several cameras captured the play. This is just one example of the radical shift in performing arts, where small theatre companies can use the Internet and a range of digital tools for reaching a wider remote audience. During the last years, we have explored how tele-presence has an effect on the performing arts, on the artists, and on the audiences. This p

The organo-metal-like nature of long-range conduction in cable bacteria

Cable bacteria are filamentous, multicellular microorganisms that display an exceptional form of biological electron transport across centimeter-scale distances. Currents are guided through a network of nickel-containing protein fibers within the cell envelope. Still, the mechanism of long-range conduction remains unresolved. Here, we characterize the conductance of the fiber network under dry and wet, physiologically relevant, conditions. Our data reveal that the fiber conductivity is high (median value: 27 S cm−1; range: 2 to 564 S cm−1), does not show any redox signature, has a low thermal activation energy (Ea = 69 ± 23 meV), and is not affected by humidity or the presence of ions. These features set the nickel-based conduction mechanism in cable bacteria apart from other known forms of biological electron transport. As such, conduction resembles that of an organic semi-metal with a high charge carrier density. Our observation that biochemistry can synthesize an organo-metal-like structure opens the way for novel bio-based electronic technologies. © 2024 The Author

Evaluation of long-term clinical and health service outcomes following coronary artery revascularisation in Western Australia (WACARP): a population-based cohort study protocol

Introduction: Coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) are procedures commonly performed on patients with significant obstructive coronary artery disease to relieve symptoms of ischaemia, improve survival or both. Although the efficacy of both procedures at the individual level has been established, the impact of advances in coronary artery revascularisation procedures (CARP) on long-term outcomes and cost-effectiveness at the population level are yet to be assessed. Our aim is to evaluate a minimum of 6-year outcomes and costs for the total population of patients who had CARP in Western Australia (WA) in 2000–2005. Methods and analysis This retrospective population cohort study will link clinical and administrative health data for a previously defined cohort including all patients in WA who had a CARP in the period 2000–2005. The cohort consists of 19 014 patients who had 21 175 procedures (15 429 PCI and 5746 CABG). We are now collecting a minimum of 6 years follow-up of morbidity and mortality data for the cohort using the WA Data Linkage System, clinical registries and hospital records, with 12 years follow-up for cases in the year 2000. Comparison of long-term outcomes for different CARP will be reported (PCI vs CABG; bare metal stents vs drug-eluting stents vs CABG). Cost-effectiveness analysis of CARP from the perspective of the healthcare sector will be performed using individual level cost data and average costs from Australian Refined Diagnosis Related Groups. Ethics and dissemination This study has received ethics approval from the University of Western Australia, the Western Australian Department of Health and all participating hospitals. Being a large population cohort study, approval included a waiver of informed consent. All findings will be presented at local, national and international healthcare/academic conferences and published in peer-reviewed journals

Verklarende factoren voor de verspreiding van alken en zeekoeten op de Bruine Bank: Project Aanvullende Beschermde Gebiede Noordzee

Begin 2014 zijn twee surveys uitgevoerd in het gebied rond de Bruine Bank. De surveys waren enerzijds gericht op het in kaart brengen van de verspreiding van vogels en anderzijds op het in kaart brengen van potentiele prooisoorten. Toetsing van deze schattingen samen met alle oudere beschikbare goede aantalsschattingen aan het vernieuwde beleidskader voor Natura 2000-gebieden leidt tot de conclusie dat de Bruine Bank kan worden aangewezen als een Natura 2000-gebied onder de Vogelrichtlijn

Genetic risk prediction of atrial fibrillation

Background—Atrial fibrillation (AF) has a substantial genetic basis. Identification of individuals at greatest AF risk could minimize the incidence of cardioembolic stroke. Methods—To determine whether genetic data can stratify risk for development of AF, we examined associations between AF genetic risk scores and incident AF in five prospective studies comprising 18,919 individuals of European ancestry. We examined associations between AF genetic risk scores and ischemic stroke in a separate study of 509 ischemic stroke cases (202 cardioembolic [40%]) and 3,028 referents. Scores were based on 11 to 719 common variants (≥5%) associated with AF at P-values ranging from <1x10-3 to <1x10-8 in a prior independent genetic association study. Results—Incident AF occurred in 1,032 (5.5%) individuals. AF genetic risk scores were associated with new-onset AF after adjusting for clinical risk factors. The pooled hazard ratio for incident AF for the highest versus lowest quartile of genetic risk scores ranged from 1.28 (719 variants; 95%CI, 1.13-1.46; P=1.5x10-4) to 1.67 (25 variants; 95%CI, 1.47-1.90; P=9.3x10-15). Discrimination of combined clinical and genetic risk scores varied across studies and scores (maximum C statistic, 0.629-0.811; maximum ΔC statistic from clinical score alone, 0.009-0.017). AF genetic risk was associated with stroke in age- and sex-adjusted models. For example, individuals in the highest versus lowest quartile of a 127-variant score had a 2.49-fold increased odds of cardioembolic stroke (95%CI, 1.39-4.58; P=2.7x10-3). The effect persisted after excluding individuals (n=70) with known AF (odds ratio, 2.25; 95%CI, 1.20-4.40; P=0.01). Conclusions—Comprehensive AF genetic risk scores were associated with incident AF beyond associations for clinical AF risk factors, though offered small improvements in discrimination. AF genetic risk was also associated with cardioembolic stroke in age- and sex-adjusted analyses. Efforts are warranted to determine whether AF genetic risk may improve identification of subclinical AF or help distinguish between stroke mechanisms

The transition to clinical expert: Enhanced decision making for children aged less than 5years attending the paediatric ED with acute respiratory conditions

© Published by the BMJ Publishing Group Limited. Background Rates of unplanned paediatric admissions are persistently high. Many admissions are short-stay events, lasting less than 48 hours. Objective This qualitative research explores factors that influence clinical decision making in the paediatric ED (PED) for children under 5 attending with acute respiratory conditions, focusing on how management decisions adapt with increasing experience. Method Semi-structured interviews were conducted with 15 PED clinicians (doctors, emergency nurse practitioners and registered nurses) with varying levels of experience in paediatric emergency medicine (PEM), emergency medicine or paediatrics. Audio-recorded interviews were transcribed and analysed thematically. Results There were clear differences in decision-making approaches between experienced clinicians and junior staff. The latter were more risk adverse, relying heavily on guidelines, set admission criteria, clinical theory and second opinions. This was particularly true for doctors. 'Informal' learning was apparent in accounts from less-experienced doctors and nurses, whereby tacit knowledge and risk management played an increasing role in the development of clinical intuition that permitted rapid assessment and treatment of young patients. Conclusions The emergence of intuition entwined with approaches to risk management and the role of these skills in clinical decision making, carry implications for the development of training programmes for clinicians working in PEM. Enhanced training for such groups to permit development of the supplementary skills described in this study could have the ability to improve care delivery and even reduce paediatric admissions

Targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent atrial fibrillation:Results of the RACE 3 trial

Aims: Atrial fibrillation (AF) is a progressive disease. Targeted therapy of underlying conditions refers to interventions aiming to modify risk factors in order to prevent AF. We hypothesised that targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent AF. Methods and results: We randomized patients with early persistent AF and mild-to-moderate heart failure (HF) to targeted therapy of underlying conditions or conventional therapy. Both groups received causal treatment of AF and HF, and rhythm control therapy. In the intervention group, on top of that, four therapies were started: (i) mineralocorticoid receptor antagonists (MRAs), (ii) statins, (iii) angiotensin converting enzyme inhibitors and/or receptor blockers, and (iv) cardiac rehabilitation including physical activity, dietary restrictions, and counselling. The primary endpoint was sinus rhythm at 1 year during 7 days of Holter monitoring. Of 245 patients, 119 were randomized to targeted and 126 to conventional therapy. The intervention led to a contrast in MRA (101 [85%] vs. 5 [4%] patients, P < 0.001) and statin use (111 [93%] vs. 61 [48%], P < 0.001). Angiotensin converting enzyme inhibitors/angiotensin receptor blockers were not different. Cardiac rehabilitation was completed in 109 (92%) patients. Underlying conditions were more successfully treated in the intervention group. At 1 year, sinus rhythm was present in 89 (75%) patients in the intervention vs. 79 (63%) in the conventional group (odds ratio 1.765, lower limit of 95% confidence interval 1.021, P = 0.042). Conclusions: RACE 3 confirms that targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent AF. Trial Registration number: Clinicaltrials.gov NCT00877643