Syringe exchange in Germany

Syringe exchange in Germany is clearly linked to a recent shift of local responses to drug-use(r) associated problem. Since the end of the 1980s, metropolitan communities in Northern and Central Germany-concerned by the emergence of "Open Drug Scenes," increasing HIV and mortality rates among drug users, and drug-use-related property crime-began to favor measures of survival-oriented drug-user help. While the Federal Government still favors repression and law enforcement efforts, they nevertheless made syringe exchange explicitly legal in 1992-some 5 years after the creation of local Syringe Exchange Programs. In general, the new approach of local authorities includes a variety of services, such as housing facilities, crisis intervention centers, primary medical care, maintenance with substitute drugs, and syringe exchange programs. The creation of pilot heroin maintenance programs is planned for Frankfurt and Hamburg. While the established programs are successfully functioning in large cities such as Hamburg, Bremen, and Frankfurt, the demand for sterile needles and syringes remains unmet in smaller cities and in the conservative governed Bundeslander (states), where pharmacies remain the primary and often single legal supply source for syringes. Another major problem continues to be the drug-use situation in prisons. Although injection drug use is common in prisons, injection equipment is not legally available for the 10,000 injecting drug users imprisoned at any given time. Two of Germany's 220 prisons started an experimental syringe exchange in 1996.

The transfer of child patients from the community dental service to the general dental service

OBJECTIVE

To determine an effective strategy for the transfer of children from the CDS to the GDS.

DESIGN

Single centre study comprising a retrospective analysis of a 50% random sample of dental records for children transferred from CDO to GDP.

SETTING

Community dental clinic in an urban area of south Manchester with relatively little material deprivation.

SUBJECTS AND METHODS

Between 1990 and 1995, a GDP worked up to 5 hours a week in the CDS clinic seeing routine child patients referred by the CDO.

MAIN OUTCOME MEASURES

Numbers of children registered with a GDP after varying periods of time. Attendance records of children transferred from CDS to GDS and rates of failed appointments.

RESULTS

After 4 1/2 years, 264 child patients had been registered with the GDP under capitation and a further 55 adults were registered under continuing care. The majority of children had retained registration for more than 2 1/2 years. The mean rate of failed appointments was 16%.

CONCLUSION

Children can be transferred successfully from the CDS to the GDS if the GDP works at the community clinic and there are further benefits which accrue to the scheme.

Dental caries in developing countries. Preventive and restorative approaches to treatment

The rate of dental caries in developing countries is rising. Because more than 80 percent of the world's children live in these countries, this alarming trend is of great concern from a public health standpoint. Currently, most dental care in developing nations consists of dental surgery in urban areas. Decay is usually left untreated until it becomes so extensive and/or painful that extraction is the only option. Traditional approaches to treating carious lesions have met with marginal success. There is a need for widespread implementation of preventive strategies, which have proven extremely effective in industrialized nations. Also, promising new techniques and materials are being developed that are enabling dentists and dental personnel to make less costly treatment of dental caries more readily available to underserved populations.

EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system

OBJECTIVE

The use of automatic external defibrillators (AEDs) by EMS initial responders is widely advocated. Evidence supporting the use of AEDs is based largely on the experience of one metropolitan area, with effect on survival in many systems not yet proved. We conducted this study to determine whether the addition of AEDs to an EMS system with a response time of 4 minutes for first-responder emergency medical technicians (FREMTs) and 10 minutes for paramedics would affect survival from cardiac arrest.

METHODS

This prospective, controlled, crossover study (AED versus no AED) of consecutive cardiac arrests managed by 24 FREMT fire companies took place from 1992 to 1995 in Charlotte, North Carolina, a city of 455,000. Patients were stratified using the Utstein criteria. The primary endpoint was survival to hospital discharge among patients with bystander-witnessed arrests of cardiac origin.

RESULTS

Of the 627 patients, 243 were bystander-witnessed arrests of cardiac origin. Survival to hospital discharge was accomplished in 5 of 110 patients (4.6%; 95% confidence interval [CI] 0.6% to 8.4%) with AED compared with 7 of 133 (5.3%, 95% CI 1.5% to 9.1%) without AED (P = .8). Both groups were comparable with regard to age, gender, history of myocardial infarction, congestive heart failure or diabetes, arrest at home, bystander CPR, and whether or not ventricular fibrillation (VF) was the initial rhythm. For arrests of any cause, witnessed by bystanders or EMS personnel, with an initial rhythm of VF or ventricular tachycardia (VT), 5 of 77 (6.5%, 95% CI 1.0% to 12.0%) with AED survived compared with 8 of 105 patients (7.6%, 95% CI 2.5% to 12.7%) without AED (P = .8). Statistically significant differences were noted in race and EMS response times between the two groups, which did not affect survival.

CONCLUSION

Addition of AEDs to this EMS system did not improve survival from sudden cardiac death. The data do not support routinely equipping initial responders with AEDs as an isolated enhancement, and raise further doubt about such expenditures in similar EMS systems without first optimizing bystander CPR and EMS dispatching.

A comparative evaluation of collaborative prenatal care

OBJECTIVE

To evaluate the effectiveness of an advanced-practice nurse-obstetrician collaborative prenatal practice.

METHODS

A group of 194 consecutively enrolled medically low-risk obstetric patients was identified between January 1, 1994 and December 31, 1994 at Neighborhood Pregnancy Care, a collaborative-practice site. An equal number of medically low-risk patients attending the Louisiana State University obstetric clinic at the Medical Center of Louisiana at New Orleans was selected randomly from among those registering the same month. The two groups were compared on the primary outcome variable, low birth weight. Data were analyzed by chi2, Fisher exact test, t test, and regression models.

RESULTS

We compared 179 collaborative-care and 181 university patients with retrievable information. By univariate analysis, collaborative-care patients more often were teenagers and black, and less likely to be married or employed. Collaborative-care patients had more prenatal visits and were more likely to participate in Medicaid, but less likely to deliver at the Medical Center of Louisiana at New Orleans. Birth weight and gestational age at delivery were greater. Both delivery before 37 weeks (7.3% versus 17.7%, P < .001) and birth weight less than 2500 g (8.9% versus 19.3%, P < .001) were less common. When differences identified at the initial obstetric visit were considered, multivariate weighted logistic regression confirmed the importance of prenatal care at the collaborative-practice program for low birth weight (odds ratio [OR] 0.37; 95% confidence interval [CI] 0.19, 0.71) and preterm delivery (OR 0.36; 95% CI 0.16, 0.78). When all differences were entered, low birth weight remained a significantly less likely occurrence at the collaborative-practice site (OR 0.46; 95% CI 0.23, 0.92).

CONCLUSION

An advanced-practice nurse-obstetrician collaborative practice may be implemented successfully and lead to acceptable perinatal outcomes, as judged by low birth weight and prematurity.

Are we providing for ethnic diversity in accident & emergency (A&E) departments?

OBJECTIVES

The aim of the study was to find what data on ethnicity are collected in North Thames Accident & Emergency (A&E) departments. Also to investigate how the data are used, what staff recruitment and training policies were in place, and to discover whether written material in different languages and interpreters were available.

METHODS

This was a qualitative study using semi-structured questionnaires. A range of staff working in A&E departments in North Thames (that had a primary care initiative in place) were interviewed.

RESULTS

Ethnic origin was recorded in all units but not on every patient. Only one unit had actively recruited staff from an ethnic minority. None of the units had formal training in place for staff to gain an appreciation of issues facing patients from ethnic minorities. Interpreters and written material in appropriate languages were available in all units.

CONCLUSIONS

Whilst the needs of patients from ethnic minorities were recognised in all of the units there appeared to be scope for further research and development. There is a need for providers to undertake comprehensive studies on the utilisation and health needs of ethnic minorities attending both primary care and A&E services. Only with this information can more appropriate services be provided.

Mammography use among women attending an inner-city clinic

BACKGROUND

Low-income, minority, and inner city women have breast cancer screening rates that are below those of the general population.

METHODS

The authors surveyed women who received primary care at Seattle's county hospital about their mammography behaviors in early 1995. Data were analyzed within the context of the PRECEDE framework.

RESULTS

Only half (48%) of the women were obtaining regular screening. Breast cancer and mammography beliefs differed by racial group. The following factors differentiated between inner-city women who were and were not regular users: mammography beliefs concerning early detection of disease, pressure from the machine causing breast cancer, and cost (these were less important among white women than members of other racial groups); previous physician discussions, concerns about appointment scheduling, and transportation problems; and social support from physicians, family, and friends.

CONCLUSION

Interventions to encourage regular screening among inner-city women should address predisposing, enabling, and reinforcing factors.

Determinants of general practitioner recognition of psychological problems in a multi-ethnic inner-city health district

BACKGROUND

With few exceptions, evaluation of the capacity of general practitioners (GPs) to recognise psychiatric disorder in their patients has failed to consider the role of ethnic diversity in the consultation process and whether such knowledge can improve understanding of the degree to which psychiatric morbidity is recognised within GP settings.

METHODS

This research was completed in five general practices representative of all those within an inner-city health district. Psychiatric morbidity in patients consecutively attending the practices was then assessed using the General Health Questionnaire; in addition, GPs were asked to complete a checklist of current problems identified during each consultation.

RESULTS

Analysis suggested that Asian and Black patients were less likely than White patients to have psychological problems identified; that social problems and a psychiatric history facilitated recognition; and that current physical illness hindered recognition.

CONCLUSIONS

GP recognition of psychological problems varies according to patient ethnicity but can be substantially masked by both the physical and social circumstances of patients at consultation.

The use of TRISS methodology to validate prehospital intubation by urban EMS providers

The purpose of this study was to determine the impact of field orotracheal intubation (OI) by urban emergency medical technician-paramedics (EMT-Ps) on outcome compared with trauma score and injury severity score (TRISS) expectations. The records of all trauma patients intubated by EMT-Ps or hospital personnel were abstracted for OI attempts/ successes, use of neuromuscular blockade (NMB), scene time, discharge neurological status, and hospital survival compared with TRISS. EMT-Ps attempted 43% of all intubations; 81% were successful versus 98% by hospital staff (P < .05). NMB was used by 76% of hospital intubations versus none by EMS (P < .05). Scene time was 10.3 +/- 3.2 minutes versus 11.6 +/- 2.1 for patients intubated by emergency medical services (EMS) and hospital staff (P < .05). Sixty percent of patients intubated by EMS versus 68% by hospital staff had good/moderate discharge neurological status. Survival for patients intubated by EMS versus hospital staff was 11% and 40%, respectively, compared with 2% and 45% expected by TRISS. Field OI by urban EMT-Ps has a favorable impact on survival with good neurological outcome (P < .05).

Practice profile differences among Swedish dentists. A questionnaire study with special reference to prosthodontics

A questionnaire measuring differences in prosthodontic practice profiles was sent to 2100 Swedish dentists working as general practitioners. The response rate was 76%. Among the responders, 58% were men and 42% women. Fifty per cent were private practitioners, the other 50% being publicly employed. The practice profile variables showed a great variation, and several of the distributions differed with regard to sex and dental care system. The working hours per week the time spent on prosthodontics were on average higher for men than for women. Private practitioners more frequently worked in large communities and cities than did dentists working in the Public Dental Health Service. Practically all (98%) of the private practitioners used more than 75% of their clinical time on treating adults, compared with less than half of the dentists in the Public Dental Health Service. Male dentists reported higher percentage figures with regard to clinical time used for dental care of adults and for prosthodontic services than did female dentists. The figures for fixed prosthodontic service rates varied in the same manner. Fixed prosthodontic services were much more common in private practice than in the Public Dental Health Service, in which more removable dentures were made. Even though private practitioners used more time for prosthodontic services, they referred fewer patients to specialists in prosthodontics and consulted a specialist less often than did the dentists in the Public Dental Health Service.

Controlling tuberculosis in an urban emergency department: a rapid decision instrument for patient isolation

OBJECTIVES

This study examined whether data routinely available in emergency departments could be used to improve isolation decisions for tuberculosis patients.

METHODS

In a large emergency department in New York City, we compared the exposure histories of tuberculosis culture-positive and culture-negative patients and used these data to develop a rapid decision instrument to predict culture-positive tuberculosis. The screen used only data that are routinely available to emergency physicians.

RESULTS

The method had high sensitivity (.96) and moderate specificity (.54).

CONCLUSIONS

The method is easily adaptable for a broad range of settings and illustrates the potential benefits of applying basic epidemiologic methods in a clinical setting.

Changes in advance care planning in nursing homes before and after the patient Self-Determination Act: report of a 10-state survey

OBJECTIVE

The Patient Self-Determination Act (PSDA) implemented in 1991 has focused national attention on the right of patients to be involved in decision-making and on the use of written advance directives. We report changes in advance care planning with the PSDA and other historical events in nursing homes in 10 states.

DESIGN

Pre- and Post-observational cohort study.

PATIENTS

Nursing home residents, residing in 270 long-term care facilities in 10 states, stratified to ensure representation of urban and rural facilities in each state. In 1990, 2175 patients were sampled, and 2088 different patients from the same facilities were sampled in 1993. Six-month follow-up was obtained at both time periods.

MAIN OUTCOME MEASURES

Advance care planning was defined as the documentation in the medical record of a living will, a durable power of attorney, a "Do Not Resuscitate" (DNR) order, a "Do Not Hospitalize" (DNH) order, or an order to forgo artificial nutrition or hospitalization.

RESULTS

The rate of chart documentation of living wills increased from 4.2% in 1990 to 13.3% in 1993, and DNR orders increased dramatically from 31.1% to 51.5%. The rates of DNH and orders to forgo artificial hydration and nutrition remained less than 8% in both years. We found striking variations in advance care planing among the 10 states. In 1990, having a DNR order varied from 10.1% to 69.2% across the 10 states. With the exception of Oregon, where 69.2% of patients already had a DNR order, the states saw a 1.5 to 3.1 times increase in the rate of DNR orders in 1993 compared with 1990.

CONCLUSION

With the implementation of the PSDA, there was modest increase in documentation of living wills, but DNH and orders to forgo artificial hydration and nutrition remained the same. There was a substantial increase in DNR orders that began before the PSDA implementation. This increase was associated both with the implementation of the PSDA and the increased debate about the appropriateness of CPR for nursing home residents. This increase varied considerably among geographic areas from the 10 states. Future research is needed to understand this geographic variation.

Are scene flights for penetrating trauma justified?

OBJECTIVE

To evaluate the medical efficacy of helicopter scene flights for patients with noncranial penetrating injuries.

DESIGN

A retrospective review of 122 consecutive victims of noncranial penetrating injuries evacuated by helicopter from the scene of injury to a level I trauma center. There were no medical criteria for accepting or rejecting a request for a scene flight by any public safety agency or emergency medical service (EMS). Flights were dispatched if the weather permitted and if a helicopter was available.

RESULTS

The majority of patients were critically wounded. Their average Revised Trauma Score was 10.6, and 15.6% of the patients died (19 of 122), including all 11 patients who required prehospital cardiopulmonary resuscitation. Helicopter transport from the scene did not hasten trauma center arrival for any of the 122 patients. Ninety-two of the first-responder EMS units (75.4%) were advanced life support units (ALS) with crews of paramedics. The remaining 30 (24.6%) first-responder EMS units were basic life support units (BLS) with crews of emergency medical technicians (EMTs). Six of 122 patients (4.9%) required medical interventions by the medical flight crews beyond the capabilities of the ground EMS personnel. Only 3 of the 92 patients (3.3%) treated by first-responding paramedics received medical interventions by the medical flight crews beyond those authorized for paramedics (one cricothyroidotomy and two needle thoracenteses). Two of the 30 patients (6.7%) treated by first-responding EMTs received medical interventions by the medical flight crews not authorized for the EMTs. The on-scene paramedics performed endotracheal intubation on 10 patients. However, because of subsequent clinical deterioration, the medical flight crews performed endotracheal intubations on nine additional patients. In addition, two patients intubated by the first-responding paramedics required reintubation by the medical flight crews.

CONCLUSIONS

Scene flights in this metropolitan area for patients who suffered noncranial penetrating injuries demonstrated that these flights were not medically efficacious. This conclusion rests on the findings that arrival at a trauma center was not hastened by scene flights and that only 4.9% of patients required prehospital care by the medical flight crew beyond the capabilities of the first-responding EMS personnel (2.5 and 6.7% for ALS and BLS responders, respectively). Based on this experience, we believe that in metropolitan areas, scene flights for victims of noncranial penetrating injuries should be restricted to critically injured patients likely to require prehospital care by the medical flight crew that is beyond the capabilities of the first responders or when the scene flight is likely to significantly hasten the arrival of the injured patient to an appropriate trauma center.

On the road with MGMA (Medical Group Management Association)

Preparing for the annual conference, members of the 1996 Annual Conference Committee traveled the country interviewing members. They discovered innovative work in rural and urban settings, multispecialty practice and physician-directed insurance companies. Richard Hansen presents his snapshots from the trip.

Specialty mental health services in metropolitan and nonmetropolitan areas: 1983 and 1990

This paper provides information about the changes between 1983 and 1990 in the availability and volume of specialty mental health services in counties with different levels of metropolitanization and urbanization. The analysis uses the 1983 county metropolitan and urbanization designations for both 1983 and 1990 in order to obtain an accurate determination of the changes that occurred in the 7-year period. The results indicate that during the study period, metropolitan counties experienced increasing availability of specialty mental health services, while nonmetropolitan counties did not. Implications for future rural mental health policy are discussed.

A pilot study of cervical screening in an inner city area--lessons for a national programme

The objectives of this study were to examine aspects of organization of a proposed national screening programme based in general practice. The target population of women aged 25-59 years and their general practitioners (GPs), in a defined inner city area, was identified from a population register of persons eligible for free medical services; a computerized system was developed for invitations and record linkage of cytology results. Smears were examined in one laboratory and follow up of women with abnormal smears was undertaken by one gynaecologist. A random sample of non-responders was surveyed by questionnaire. Response following two invitations was only 20%. Practices with male doctors only had significantly lower response rates (P < 0.001) than those with a female doctor/nurse. A survey of non-responders showed that over 20% of addresses were incorrect and 16% of those interviewed were ineligible for smear tests. A preference for a female to undertake smears was expressed by 67%, and 77% believed that the purpose of the cervical smear was to detect cancer. An accurate population register, health promotion, support for GP practices, provision of alternative venues for smear tests, development of computer systems, accurate data entry and fail-safe follow up are aspects of a cervical screening service which must be addressed prior to setting up a national service.