Stepwise, Tailored Implementation of Brief Alcohol Intervention for Risky Drinkers in Health Care

Suomen liityttyä jäseneksi Euroopan Unioniin alkoholin verohelpotukset loivat uhkakuvan terveydenhuoltoon alkoholin lisääntyvästä käytöstä ja sen mukanaan tuomista haitoista. Haittoja ehkäisemään on kehitetty varhaisen puuttumisen hoitomuoto, mini-interventio, joka on todettu vaikutuksiltaan tehokkaaksi ja kustannustehokkaaksi. Mini-intervention tarkoituksena on tunnistaa alkoholin suurkulutus, antaa tietoa liiallisen alkoholin käytön terveyshaitoista ja ohjata alkoholin käyttöä maltillisempaan suuntaan, alle riskirajojen. Mini-intervention on todettu olevan terveydenhuollon rutiinikäyttöön sopiva hoitomuoto, se on helppo omaksua eikä vaadi paljon aikaa. Lupaavista tutkimustuloksista huolimatta mini-intervention käyttö on ollut vähäistä. Tämän tutkimuksen tarkoitus oli selvittää mini-intervention jalkauttamista osaksi terveydenhuollon tavanomaista toimintaa. Tutkimukseen liittyvä pohjakartoitus, jossa selvitettiin päihdeongelmien laajuutta terveydenhuollossa, tehtiin Tampereen yliopistollisessa sairaalassa. Terveydenhuollon henkilökunnan koulutuksen ja mini-interventiotoiminnan mahdollisimman hyvän käyttöönoton optimoimiseksi tehtiin Pirkanmaan sairaanhoitopiirissä kartoituskysely henkilökunnalle. Saadun tiedon perusteella organisointiin sairaanhoitopiirin alueelle toimintatutkimus mini-interventiotoiminnan saattamiseksi käytännön työvälineeksi. Tästä saadun palautteen, kahden myöhemmin järjestetyn kyselytutkimuksen ja videoitujen fokusryhmähaastatteluiden perusteella tehtiin mahdollisimman yksinkertainen ohje mini-interventioaktiivisuuden lisäämiseksi. Uusien toimintojen käyttöönotto terveydenhuollossa on hidasta ja vastaan tulee erilaisia esteitä. Terveydenhuoltohenkilöstön tarpeet ja heidän ymmärryksensä uusien asioiden tärkeydestä ovat ensiarvoisen tärkeitä otettaessa uusia toimintamalleja käyttöön. Kyseinen tutkimus osoitti alkoholin ongelmakäyttäjien suuren määrän terveydenhuollossa. Tutkimuksen suurin hyöty oli luoda pohja mini-intervention käytön laajentumiselle ja kehittämiselle Suomessa. Pirkanmaan sairaanhoitopiirissä alkanut projekti on levinnyt nyt koko maahan. Vaikka alkoholin käytön seulonta ja varhainen puuttuminen hoitomuotona ovat juurtuneet odotettua hitaammin jokapäiväisiksi toiminnoiksi terveydenhuoltoon, ovat henkilöstön asenteet muuttuneet edellä mainittuja toimintoja kohtaan positiivisemmiksi. Toisaalta kansalaisten suhtautuminen vallitsevaan alkoholipolitiikkaan on muuttunut tiukemmaksi. Kaikki edellä mainittu suosii mini-interventiotoiminnan laajentamista ja tämän kustannustehokkaan hoitomuodon käytön lisäämistä, kohteena alkoholin varhaisen vaiheen riskikäyttäjät.This study was initiated after Finland had joined the EU and the intended alcohol tax reductions caused concern both generally and willing health care. Several studies had shown that brief alcohol interventions are useful and cost-effective, and be considered feasible as part of health care professionals´ daily work as, as little time is required and the skills needed, and can be easily learned. In spite of the scientific evidence, however implementation of brief intervention activity has been slow. The objective here was to assess means of implementing this new activity, alcohol screening and brief intervention for early-phase heavy drinkers, in different health care settings in a wide geographic area in Finland. In order to motivate health care professionals to acknowledge the importance of this patient group, prevalence data were first collected (I). Six-year diagnoses in retrospective discharge data in Tampere University Hospital were compared with prospective data gathered from separately completed forms added to every outpatient´s discharge papers during an 8-week period. In the retrospective study (1988?1993) the prevalence of substance use-related diagnoses was 0.4% of all recorded diagnoses. In the prospective study (eight weeks in 1994) the corresponding figure was 1.1%. The percentage of substance use-related visits, not necessarily producing a diagnosis was even higher, 5.6%, being highest in the emergency setting (12.5%) and in psychiatry (6%). To optimize training and implementation strategies health care professionals were interviewed (II). Altogether 473 questionnaires, comprising 40 questions, each with two to six alternatives, were mailed to 139 units in the Pirkanmaa Health Care District, i.e. all primary and occupational health care units and each department in specialized health care in hospitals. Health care professionals´ attitudes, knowledge and skills were asked and analysed in relation to alcohol-related matters. Altogether 59% of health care professionals in primary, occupational and specialized health care were positive in the matter of asking patients´ alcohol consumption and 68% could bring up alcohol problems for discussion. Nonetheless only 18% of respondents found it fully acceptable to discuss patients´ alcohol consumption, and only 19% believed that they could influence patients´ drinking very or quite well. Respondents´ own alcohol consumption did not correlate with attitudes, knowledge or skills. They also thought that patients´ attitudes towards inquiry into alcohol consumption were positive (II). Based on observed needs (II), information from the field (I, II), and earlier scientific evidence on implementation, practical education and implementation were organized (III). The key issues in this action research project were engaging leaders, keeping training short, affecting attitudes and acting on feedback. Leaders had separate half-day sessions and other professionals had five half-day seminars with the same content in different parts of the region. The aim was to reach at least one nurse and one physician from every municipality. Participants came from 26/34 municipalities, altogether 50 physicians and 117 nurses. It was hoped that this key group would deliver information in their own centers. They were also provided with all the material used in session. To respond to the need from the field a practical video, two posters and an AUDIT (Alcohol Use Disorders Identification Test) booze quiz leaflet were produced. To activate the public to assess about their alcohol consumption and ask for help, if needed the AUDIT pamphlet was delivered to every household (90 000) in Tampere as part of the Booze Weeks action project (IV). Using the Telephone Interview system questionnaire data from 500 randomly selected inhabitants were collected. This material included twenty-two questions covering respondents´ own alcohol consumption and questions on their awareness of the AUDIT pamphlet and the Booze Weeks and whether this had any effect on their alcohol use. Those who drank most frequently were also most likely to have noticed the Booze Weeks campaign and felt most concern about their drinking. To facilitate activity in the field the final brief intervention instructions were drawn up(V). These were based on feedback from the whole action research project (III), on two questionnaires, one for health care professionals and one for patients, and on six video-taped focus groups including primary health care professionals. Qualitative analysis of this information led to a "mini-model" formulating the least that should be done for early-phase heavy drinkers in health care. Implementation of a new activity in health care is slow and fraught with obstacles. Awareness of the needs of professionals and their perception of the importance of the activity are crucial for implementation. The present study brought on the high prevalence of cases of heavy drinking in health care. It evaluated the views of professionals and public with an eye to implementing brief interventions and used feedback to create the final instructions for action. The main contribution of the present study was in laying a basis for future development in Finland and worldwide. It activated a new study which became part of and gave content to the WHO Phase IV project, "WHO Collaborative Project on Detection and Management of Alcohol-related Problems in Primary Health Care". This was subsequently followed by a nationwide Finnish project supported by the Government. Since the present project work to prevent alcohol-related harm in health care has expanded from the Pirkanmaa hospital region to national level. Even if alcohol screening and brief intervention have been slower than hoped in becoming part of health care professionals´ daily work, their attitudes have gradually become more favourable. Also public opinions on alcohol policy have become stricter. These developments have served to facilitate the continuation and expansion this cost-effective activity to manage the growing patient group of hazardous drinkers

Effects of a lifestyle counselling intervention on adherence to lifestyle changes 7 years after stroke - A quasi-experimental study

Background Adherence to medication and healthy lifestyle is crucial for preventing secondary strokes and other vascular events. However, there is not enough evidence on the long-term effects of hospital-initiated lifestyle counselling. Aim To determine the effects of The Risk Factor Targeted Lifestyle Counselling Intervention, which is implemented during acute hospitalisation, on adherence to lifestyle changes 7 years after stroke or TIA. Methods Quasi-experimental design with 7-year follow-up period. Baseline data (n = 150) were gathered from a neurology unit in Finland between 2010 and 2011. Patients received either the studied intervention (n = 75) or the prevailing form of counselling at the time (n = 75). Data concerning lifestyle and clinical values were measured at the baseline time point, while adherence to lifestyle changes was assessed 7 years later (2017-2018). Analysis of covariance and multivariate ordinal logistic regression were used to describe the mean differences between the intervention and control groups. Results Several between-group differences were detected, namely, members of the intervention group reported consuming less alcohol and having lost more weight during hospitalisation relative to the control group. No between-group differences in the prevalence of smokers were found, but the intervention group reported a greater number of daily cigarettes than the control group. Adherence to medication, importance of adherence to a healthy lifestyle, support from family and friends, and support from nurses were all significantly higher in the intervention group than in the control group. Conclusions The results suggest that the lifestyle counselling intervention was effective in decreasing alcohol use and weight, as well as increasing factors that are known to support adherence to a healthy lifestyle. Relevance to clinical practice The results indicate that the adherence process already begins during acute phase counselling. To ensure long-lasting lifestyle changes, counselling should be started at the hospital, after which it can be provided by friends and family members.</p

Factors Affecting Revision Rate of Chronic Rhinosinusitis

Peer reviewe

Clinical characteristics and evaluation of the incidence of cryptococcosis in Finland 2004-2018

Background Cryptococcosis is one of the major causes of mortality among HIV patients worldwide. Though most often associated with late stage HIV infection/AIDS, a significant number of cases occur in other immunocompromised patients such as solid organ transplant recipients and patients with hematological malignancies. Immunocompromised patients are a heterogeneous group and their number increases constantly. Since little is known about the incidence and the clinical features of cryptococcosis in Northern Europe, our aim was to investigate the clinical characteristics of cryptococcosis patients in Finland. Methods We retrospectively reviewed the laboratory confirmed cryptococcosis cases in Finland during 2004-2018. Only those who were treated for cryptococcosis were included in the study. Initial laboratory findings and medical records were also collected. Results A total of 22 patients with cryptococcosis were included in our study. The annual incidence of cryptococcosis was 0.03 cases per 100,000 population. Ten patients were HIV-positive and 12 out of 22 were HIV-negative. Hematological malignancy was the most common underlying condition among HIV-negative patients. Conclusions To our knowledge, this is the first study of the clinical presentation and incidence of cryptococcosis in Finland. We demonstrate that invasive cryptococcal infection occurs not only in HIV/AIDS patients or otherwise immunocompromised patients but also in immunocompetent individuals. Even though cryptococcosis is extremely rare in Finland, its recognition is important since the prognosis depends on rapid diagnostics and early antifungal therapy.Peer reviewe

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear : a 2-year follow-up of the randomised controlled trial

Objective To assess if arthroscopic partial meniscectomy (APM) is superior to placebo surgery in the treatment of patients with degenerative tear of the medial meniscus. Methods In this multicentre, randomised, participant-blinded and outcome assessor-blinded, placebo-surgery controlled trial, 146 adults, aged 35-65 years, with knee symptoms consistent with degenerative medial meniscus tear and no knee osteoarthritis were randomised to APM or placebo surgery. The primary outcome was the between-group difference in the change from baseline in the Western Ontario Meniscal Evaluation Tool (WOMET) and Lysholm knee scores and knee pain after exercise at 24 months after surgery. Secondary outcomes included the frequency of unblinding of the treatment-group allocation, participants' satisfaction, impression of change, return to normal activities, the incidence of serious adverse events and the presence of meniscal symptoms in clinical examination. Two subgroup analyses, assessing the outcome on those with mechanical symptoms and those with unstable meniscus tears, were also carried out. Results In the intention-to-treat analysis, there were no significant between-group differences in the mean changes from baseline to 24 months in WOMET score: 27.3 in the APM group as compared with 31.6 in the placebo-surgery group (between-group difference, -4.3; 95% CI, -11.3 to 2.6); Lysholm knee score: 23.1 and 26.3, respectively (-3.2; -8.9 to 2.4) or knee pain after exercise, 3.5 and 3.9, respectively (-0.4; -1.3 to 0.5). There were no statistically significant differences between the two groups in any of the secondary outcomes or within the analysed subgroups. Conclusions In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from APM.Peer reviewe

Bioactive glass ions induce efficient osteogenic differentiation of human adipose stem cells encapsulated in gellan gum and collagen type I hydrogels

Background: Due to unmet need for bone augmentation, our aim was to promote osteogenic differentiation of human adipose stem cells (hASCs) encapsulated in gellan gum (GG) or collagen type I (COL) hydrogels with bioactive glass (experimental glass 2-06 of composition [wt-%]: Na2O 12.1, K2O 14.0, CaO 19.8, P2O5 2.5, B2O3 1.6, SiO2 50.0) extract based osteogenic medium (BaG OM) for bone construct development. GG hydrogels were crosslinked with spermidine (GG-SPD) or BaG extract (GG-BaG). Methods: Mechanical properties of cell-free GG-SPD, GG-BaG, and COL hydrogels were tested in osteogenic medium (OM) or BaG OM at 0, 14, and 21d. Hydrogel embedded hASCs were cultured in OM or BaG OM for 3, 14, and 21d, and analyzed for viability, cell number, osteogenic gene expression, osteocalcin production, and mineralization. Hydroxyapatite-stained GG-SPD samples were imaged with Optical Projection Tomography (OPT) and Selective Plane Illumination Microscopy (SPIM) in OM and BaG OM at 21d. Furthermore, Raman spectroscopy was used to study the calcium phosphate (CaP) content of hASC-secreted ECM in GG-SPD, GG-BaG, and COL at 21d in BaG OM. Results: The results showed viable rounded cells in GG whereas hASCs were elongated in COL. Importantly, BaG OM induced significantly higher cell number and higher osteogenic gene expression in COL. In both hydrogels, BaG OM induced strong mineralization confirmed as CaP by Raman spectroscopy and significantly improved mechanical properties. GG-BaG hydrogels rescued hASC mineralization in OM. OPT and SPIM showed homogeneous 3D cell distribution with strong mineralization in BaG OM. Also, strong osteocalcin production was visible in COL. Conclusions: Overall, we showed efficacious osteogenesis of hASCs in 3D hydrogels with BaG OM with potential for bone-like grafts.peerReviewe

Clinical characteristics and evaluation of the incidence of cryptococcosis in Finland 2004-2018

Background: Cryptococcosis is one of the major causes of mortality among HIV patients worldwide. Though most often associated with late stage HIV infection/AIDS, a significant number of cases occur in other immunocompromised patients such as solid organ transplant recipients and patients with hematological malignancies. Immunocompromised patients are a heterogeneous group and their number increases constantly. Since little is known about the incidence and the clinical features of cryptococcosis in Northern Europe, our aim was to investigate the clinical characteristics of cryptococcosis patients in Finland.Methods: We retrospectively reviewed the laboratory confirmed cryptococcosis cases in Finland during 2004-2018. Only those who were treated for cryptococcosis were included in the study. Initial laboratory findings and medical records were also collected.Results: A total of 22 patients with cryptococcosis were included in our study. The annual incidence of cryptococcosis was 0.03 cases per 100,000 population. Ten patients were HIV-positive and 12 out of 22 were HIV-negative. Hematological malignancy was the most common underlying condition among HIV-negative patients.Conclusions: To our knowledge, this is the first study of the clinical presentation and incidence of cryptococcosis in Finland. We demonstrate that invasive cryptococcal infection occurs not only in HIV/AIDS patients or otherwise immunocompromised patients but also in immunocompetent individuals. Even though cryptococcosis is extremely rare in Finland, its recognition is important since the prognosis depends on rapid diagnostics and early antifungal therapy.</p