Aim: This study compared matched samples of substance use disorder (SUD) patients in Swiss and United States (US) residential treatment programs and examined the relationship of program characteristics to patients' substance use and psychosocial functioning at a 1-year follow-up.

Design and Setting: The study used a prospective, naturalistic design and a sample of 10 public programs in the German-speaking part of Switzerland and 15 US public treatment programs.

Participants: A total of 358 male patients in Swiss programs were matched on age, marital status and education with 358 male patients in US programs. A total of 160 Swiss and 329 US patient care staff members also participated.

Measurement: Patients completed comparable inventories at admission, discharge and 1-year follow-up to assess their substance use and psychological functioning and receipt of continuing care. Staff members reported on program characteristics and their beliefs about substance use.

Findings: Compared to Swiss patients, US patients had more severe substance use and psychological problems at intake and although they did not differ on abstinence and remission at follow-up, had somewhat poorer outcomes in other areas of functioning. Swiss programs were longer and included more individual treatment sessions; US programs included more group sessions and were more oriented toward a disease model of treatment. Overall, length of program, treatment intensity and 12-step orientation were associated with better 1-year outcomes for patients in both Swiss and US programs.

Conclusions: The sample of Swiss and US programs studied here differed in patient and treatment characteristics; however, in general, there were comparable associations between program characteristics and patients' 1-year outcomes. These findings suggest that associations between treatment processes and patients' outcomes may generalize from one cultural context to another.

Objective: To determine the effects of quality improvement strategies on promoting adherence to interventions for prevention of selected (surgical site infections (SSI), central line-associated bloodstream infections (CLABSI), ventilator-associated pneumonia (VAP), and catheterassociated urinary tract infections (CAUTI)) healthcare-associated infections (HAIs), and on HAI rates.

Data Sources: MEDLINE® and Cochrane Collaboration's Effective Practice and Organisation of Care registry. We also reviewed the reference lists of systematic reviews and included studies, and contacted experts.

Search Strategy and Inclusion Criteria: We included randomized and quasi-randomized controlled trials, controlled before-after studies, interrupted time series, and simple before-after studies that reported either HAI rates or rates of adherence to target preventive quality improvement (QI) interventions for any of the four target HAIs. QI strategies were classified as clinician education, patient education, audit and feedback, clinician reminders, organizational change (including revision of professional roles, staffing changes, and total quality management/continuous quality improvement), and financial or regulatory incentives. We targeted hand hygiene as a preventive intervention for all HAIs. The target preventive interventions specific to SSI were appropriate perioperative antibiotic prophylaxis (including appropriate antibiotic selection, timing, and duration), perioperative glucose control, and decreasing shaving of the operative site. For CLABSI, we targeted adherence to maximal sterile barrier precautions, use of chlorhexidine for skin antisepsis, and avoidance of femoral catheterization. For VAP, we targeted semirecumbent patient positioning and daily assessment of readiness for ventilator weaning. For CAUTI, we targeted reduction in unnecessary catheter use and adherence to aseptic catheter insertion and catheter care. Our primary outcomes were the rate of HAI (defined as infections per 100 cases for SSI and infections per 1,000 device-days for CLABSI, VAP, and CAUTI) and the rate of adherence to preventive interventions (defined as the percentage of patients at risk who received the preventive intervention). Secondary outcomes included effects on costs and adverse effects associated with the interventions.

Data Collection and Analysis: Two reviewers independently abstracted data. Due to heterogeneity in study populations, QI strategies, preventive interventions, and outcomes, no formal quantitative analysis was attempted. We assessed study quality based on prespecified criteria for internal and external validity.

Main Results: Sixty-four studies met all inclusion criteria; 28 studies addressed prevention of SSI, 19 CLABSI prevention, 12 VAP prevention, and 10 CAUTI prevention. Three studies targeted prevention of multiple HAIs. The study methodologic quality was generally poor, as 52 of 64 included studies were simple before-after studies, and most of these (33 of 52) reported data at only one time point before and after the intervention. The majority of included studies reported infection rates, but did not report rate of adherence to preventive interventions. Baseline HAI rates were generally above the median rates reported by the Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance System (NNIS).

• Studies addressing surgical site infections: The majority of studies targeted provision of appropriate antibiotic prophylaxis (22 of 28 studies), using combinations of educational interventions, audit and feedback, and clinician reminders. Sixteen of these studies reported data on adherence to appropriate antibiotic prophylaxis guidelines. Clinician reminders were effective at improving appropriate prophylaxis in two controlled studies; educational interventions with audit and feedback were effective in three multicenter studies (two interrupted time series and one simple before-after study.) No QI strategies were clearly effective at reducing SSI rates or improving adherence to other targeted preventive interventions.
• Studies addressing central line-associated bloodstream infection: Active educational interventions for clinicians appeared effective at reducing CLABSI rates, based on two controlled before-after studies, one interrupted time series, and four simple before-after studies of relatively good methodologic quality. Two of these studies combined education with an explicit checklist for adherence to insertion site practices and allowed nurses to stop the procedure if the checklist was not followed, a strategy worthy of future study.
• Studies addressing ventilator-associated pneumonia: Active educational interventions (including use of Web-based and video tutorials) appeared to reduce VAP rates, based on evidence from two simple before-after studies. Conclusions in this area are especially limited as we did not identify any controlled studies.
• Studies addressing catheter-associated urinary tract infection: Printed or computer-based reminders to physicians, coupled with an "automatic stop order", appear to be effective at reducing the duration of urethral catheterization (based on two controlled studies and three simple before-after studies.)

• Use of printed or computer-based reminders with automatic stop orders to reduce unnecessary urethral catheterization.
• Printed or computer-based reminders to improve surgical antibiotic prophylaxis
• Active educational interventions with use of of checklists to improve adherence to central line insertion practices
• Active educational interventions such as tutorials to improve adherence to preventive interventions for ventilator-associated pneumonia.

Public-private partnerships have become a common approach to health care problems worldwide. Many public-private partnerships were created during the late 1990s, but most were focused on specific diseases such as HIV/AIDS, tuberculosis, and malaria.

Recently there has been enthusiasm for using public-private partnerships to improve the delivery of health and welfare services for a wider range of health problems, especially in developing countries. The success of public-private partnerships in this context appears to be mixed, and few data are available to evaluate their effectiveness.

This analysis provides an overview of the history of health-related public-private partnerships during the past 20 years and describes a research protocol commissioned by the World Health Organization to evaluate the effectiveness of public-private partnerships in a research context.

Objectives:

Despite the availability of evidence-based guidelines for the management of pediatric and adult asthma, there remains a significant gap between accepted best practices for asthma care and actual care delivered to asthma patients. The purpose of this systematic review was to evaluate the evidence that quality improvement (QI) strategies can improve the processes and outcomes of outpatient care for children and adults with asthma.

Data Sources:

We searched four literature sources: the Cochrane Effective Practice and Organization of Care (EPOC) Group database (1/1966 to 4/2006), MEDLINE® (1/1966 to 4/2006), the Cochrane Consumers and Communication Group database (1/1966 to 5/2006), and bibliographies of retrieved articles.

Review Methods:

We sought English language studies of interventions that included one or more QI strategies (e.g., patient education, provider education, audit and feedback) for the outpatient management of children or adults with asthma. Included studies were required to be either randomized controlled trials, controlled before-after trials, or interrupted time series trials. The four primary types of outcomes of interest were:

1. Measures of clinical status (e.g., asthma symptoms, spirometric measures).
2. Measures of functional status (e.g., days lost from work or school).
3. Measures of health services utilization (e.g., hospital admissions).
4. Measures of adherence to guidelines (e.g., number of patients given prescriptions for inhaled corticosteroids).

Results:

We identified 3,843 potentially relevant articles, of which 200 articles describing 171 studies met our inclusion criteria. These studies exhibited substantial variation in terms of the types of strategies evaluated. However, using broad, pragmatic categories for quality improvement strategies, 100 included at least some component of patient education, 94 studies included some component of self-monitoring or self-management, 27 included some component of organizational change, and 19 included provider education, among others. The studies also evaluated heterogeneous patient populations, but these could be broadly categorized into those that targeted children or adolescents with asthma or their families (79 studies) and outpatient populations with asthma comprised typically of adults (92 studies).

Among all studies of pediatric asthma evaluating self-monitoring, self-management, or patient education interventions, those directed at parents or caregivers, as opposed to at the children themselves and not their parents, were more likely to be associated with a statistically significant improvement in clinical outcomes (e.g., improvements in asthma symptoms or spirometric measures (p=0.02)). Self-monitoring, self-management, or patient education interventions for general populations or adults with asthma were associated with improvements in percent predicted forced expiratory volume in one second, or FEV1 (weighted mean difference: 2.92 percent predicted FEV1; 95% CI 0.92, 4.92; p=0.004), and mean peak flow (weighted mean difference: 27.95 L/min; 95% CI 10.75, 45.15; (p=0.01).

QI interventions that are based explicitly on a theoretical framework, provide multiple educational sessions, have longer durations, and use combinations of instructional modalities (e.g., small group teaching with role-playing and handouts) are more likely to result in improvements for patients than interventions lacking these characteristics. When taken as a group, the improvements reported in the included studies were often statistically significant but possibly only of borderline clinical significance.

Conclusions:

A wide variety of types of QI interventions have been found to improve the outcomes and processes of care for children and adults with asthma. Young children with asthma benefit most from QI strategies that also include their caregivers or parents. General populations with asthma can have clinically significant improvements in spirometric measures after participating in self-monitoring, self-management, or patient education interventions-especially interventions that are based on theoretical frameworks, are of relatively long durations, and utilize combinations of educational modalities.

Abstract

PURPOSE:

To provide the first national data on the nature, extent, and consequences of withholding among life science trainees.

METHOD:

In 2003, the authors surveyed 1,077 second-year doctoral students and postdoctoral fellows in life sciences at 50 U.S. universities, with a comparison group of trainees in computer science and chemical engineering. The study variables examined trainees' exposure to and the consequences of data withholding.

RESULTS:

Two hundred forty-six trainees (23.0%) reported that they had asked for and been denied access to information, data, materials, or programming associated with published research and 221 (20.6%) to unpublished research. Eighty-five trainees (7.9%) reported that they had denied another academic scientist's request(s) related to their own published research. Five hundred thirty-three trainees (50.8%) reported that withholding had had a negative effect on the progress of their research, 508 (48.5%) on the rate of discovery in their lab/research group, 472 (45.0%) on the quality of their relationships with academic scientists, 346 (33.0%) on the quality of their education, and 299 (28.5%) on the level of communication in their lab/research group. Trainees denied access to research were significantly more likely to report that data withholding had had a negative effect on several aspects of the educational experience.

CONCLUSIONS:

Data withholding had demonstrated negative effects on trainees. The life sciences, more so than chemical engineering or computer science, will have to address this issue among its trainees. Failure to do so could result in delayed research, inefficient training, and a culture of withholding among future life scientists.

BACKGROUND: A genome-wide association study identified 13 single-nucleotide polymorphisms (SNPs) significantly associated with Parkinson's disease. Small-scale replication studies were largely non-confirmatory, but a meta-analysis that included data from the original study could not exclude all SNP associations, leaving relevance of several markers uncertain. METHODS: Investigators from three Michael J Fox Foundation for Parkinson's Research-funded genetics consortia-comprising 14 teams-contributed DNA samples from 5526 patients with Parkinson's disease and 6682 controls, which were genotyped for the 13 SNPs. Most (88%) participants were of white, non-Hispanic descent. We assessed log-additive genetic effects using fixed and random effects models stratified by team and ethnic origin, and tested for heterogeneity across strata. A meta-analysis was undertaken that incorporated data from the original genome-wide study as well as subsequent replication studies. FINDINGS: In fixed and random-effects models no associations with any of the 13 SNPs were identified (odds ratios 0.89 to 1.09). Heterogeneity between studies and between ethnic groups was low for all SNPs. Subgroup analyses by age at study entry, ethnic origin, sex, and family history did not show any consistent associations. In our meta-analysis, no SNP showed significant association (summary odds ratios 0.95 to 1.08); there was little heterogeneity except for SNP rs7520966. INTERPRETATION: Our results do not lend support to the finding that the 13 SNPs reported in the original genome-wide association study are genetic susceptibility factors for Parkinson's disease.

Six cases of coagulase-negative staphylococcal mediastinitis were identified in the latter half of 1999. A new preoperative cleansing solution was suspected by hospital staff to be a factor in the outbreak. We evaluated this possible risk factor along with other known and suspected surgical site infection risk factors in this case-control study.

Although gastric hypochlorhydria is a risk factor for gastroenteritis and for gastric cancer, no reliable, inexpensive, noninvasive test exists for screening or epidemiologic studies. We aimed to evaluate the sensitivity and specificity of the blood quininium resin test (bQRT) for hypochlorhydria, against pH monitoring. Twelve fasting adult volunteers-seven with and five without H. pylori infection-ingested 80 mg/kg of quininium resin twice, once with and once without acid suppression. Gastric pH was monitored for 75 minutes; serum samples were obtained at times 0 and 75 minutes. The bQRT levels were compared to gastric pH, controlling for omeprazole use and H. pylori infection. Subjects with a median recorded pH > or =3.5 were considered hypochlorhydric. Using a bQRT level of 10 as a cutoff for hypochlorhydria, the sensitivity and specificity of the bQRT were 100% and 37.5%, respectively. The bQRT predicted omeprazole use more accurately than pH monitoring. In conclusions, The bQRT has a high sensitivity for hypochlorhydria, making it potentially useful in populations with a high prevalence of hypochlorhydria. In its current formulation, the bQRT's low specificity makes it less useful in low-risk population.

Objective: To compare and contrast proposed definitions of metabolic syndrome in pediatrics, and to determine prevalence of metabolic syndrome in preadolescent females when applying different criteria.

Study Design: A literature review on definitions of metabolic syndrome and cardiovascular "risk factor clustering" in children and adolescents published in the past decade. Pediatric definitions of metabolic syndrome were then applied to a community-based study of 261 black preadolescent females (Girls Health Enrichment MultiSite studies [GEMS]) and a school-based, cross-sectional study of 240 ethnically-diverse preadolescent females (Girls Activity, Movement and Environmental Strategy [GAMES]) who had a baseline physical examination and fasting morning blood sample.

Results: Agreement among pediatric definitions of metabolic syndrome was poor. The prevalence of MS and cardiovascular risk factor clustering ranged from 0.4% to 23.0% for GEMS and 2.0% to 24.6% for GAMES with definitions adapted from the National Cholesterol Education Program Adult Treatment Panel III, and 0% to 15.3% for GEMS and 0.4% to 15.8% for GAMES using modified criteria from the World Health Organization.

Conclusions: The prevalence of metabolic syndrome in preadolescent girls varies widely because of disagreement among proposed definitions of metabolic syndrome in pediatrics. Further investigation is needed to determine which metabolic factors and their respective cut points should be used to identify children at risk for development of clinical disease.

Although most of Helicobacter pylori-related diseases are associated with male gender, the role of gender as a risk factor for H. pylori infection is still debated. To assess the true association between H. pylori and gender, we conducted a meta-analysis of large, population-based studies where the measure of association had been adjusted at least for age and socioeconomic status, and obtained primary data from authors when information on gender associations were not presented. In 18 adult populations, the test of heterogeneity was not significant and male gender was significantly associated with H. pylori infection (summary odds ratio [OR] 1.16 [95% confidence interval (CI) 1.11, 1.22]). In 10 pediatric populations, the test of heterogeneity was of borderline significance, and the summary OR computed using a random effect model was close to 1 (summary OR 1.03 [95% CI 0.91, 1.17]). This study confirms the male predominance of H. pylori infection in adults as a global and homogeneous phenomenon; such predominance is not apparent in children. Differential antibiotic exposure or differential protective immunity between genders may explain the different results observed between children and adult studies.