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BackgroundType 2 diabetes affects an estimated 347 million people worldwide and often leads to serious complications including blindness, kidney disease, and limb amputation. Comorbid dysphoria is common and is an independent risk factor for poor glycaemic control. Professional support for diabetes self-management and dysphoria has limited availability and involves high costs, especially after regular hours, and in rural and remote areas. Web-based cognitive behavior therapy offers highly accessible, acceptable, and cost-effective support for people with diabetes. This paper describes the development of OnTrack Diabetes, a self-guided, Web-based program to promote improved physical and emotional self-management in people with Type 2 diabetes. ObjectiveThe objective of the study is to describe the development of the OnTrack Diabetes program, which is a self-guided, Web-based program aimed to promote euthymia and improved disease self-management in people with Type 2 diabetes. MethodsSemistructured interviews with 12 general practitioners and 13 patients with Type 2 diabetes identified enablers of and barriers to effective diabetes self-management, requirements for additional support, and potential program elements. Existing resources and research data informed the development of content, and consultants from relevant disciplines provided feedback on draft segments and reviewed the program before release. Using a self-guided delivery format contained costs, in addition to adapting program features and modules from an existing OnTrack program. ResultsA separate paper describes the protocol for a randomized controlled trial to provide this required evaluation. ConclusionsDevelopment of the OnTrack Diabetes program demonstrates strategies that help ensure that a program is acceptable to users. The next stages involve testing users’ experiences and examining the program’s effectiveness and cost-effectiveness in randomized controlled trials. Trial RegistrationThe Australian New Zealand Clinical Trials Registry (ACTRN): 12614001126606; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12614001126606 (Archived by WebCite at http://www.webcitation.org/6U0Fh3vOj).

Objective: Parkinson's disease (PD) is one of the most prevalent neurodegenerative disorders, globally affecting approximately 120 per 100,000 people by age 70. Deep brain stimulation (DBS) is a US Federal Drug Administration (FDA)-approved and highly effective treatment for late-stage PD. However, country-specific reimbursement regulations and health policies may affect access to PD-DBS. We aimed to evaluate the uptake rate and 'treatment gap' for DBS across high-income countries. Methods: We reviewed previous literature to investigate the cost and utilisation of PD-DBS in high-income countries across Asia, Europe, Oceania, and North America (Australia, Canada, France, Germany, Hong Kong, Japan, Korea, the Netherlands, New Zealand, Norway, Spain, Switzerland, UK, and USA). Using previous estimates of DBS candidate eligibility rates, we calculated theoretical DBS uptake rates and treatment gaps nationally. Results: PD-DBS utilisation was highest in Australia and the USA and lowest in Korea and New Zealand. The total cost of PD-DBS in the first 12 months was highest in the USA and France and lowest in the UK and Germany. The utilisation rate (i.e. uptake rate) of PD-DBS (% DBS surgeries per PD case) was highest in Australia and the USA, and lowest in New Zealand and the UK, where the treatment gap reflected these trends. Conclusions: Our results highlight differences in access to DBS for PD patients among high-income countries, which we discuss in the context of health systems. Better access to effective PD treatments such as DBS is critical given the increasing prevalence of PD in an ageing world and the associated, avoidable morbidity. What is known about the topic? Deep brain stimulation (DBS) is a US Federal Drug Administration (FDA)-approved and highly effective treatment for late-stage PD; however, inequities in access to DBS for PD exist across high-income countries, likely stemming from differences in DBS cost and utilisation. What does this paper add? Our study is the first to use cost and utilisation data to calculate a PD-DBS treatment gap informing accessibility barriers. What are the implications for practitioners? The results of this study can be utilised to guide future national policy decisions and advocacy efforts by patient organisations and specialist societies. [ABSTRACT FROM AUTHOR]

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy, and their representatives to develop minimum sets of standardized outcomes and outcome measurement methods for clinical practice. Using modified Delphi consensus methods with consecutive rounds of online voting over 12 months, a core set of outcomes and corresponding measurement tool packages to capture the outcomes were identified for infants, children, and adolescents with epilepsy. Consensus methods identified 20 core outcomes. In addition to the outcomes identified for the ICHOM Epilepsy adult standard set, behavioral, motor, and cognitive/language development outcomes were voted as essential for all infants and children with epilepsy. The proposed set of outcomes and measurement methods will facilitate the implementation of the use of patient‐centered outcomes in daily practice. [ABSTRACT FROM AUTHOR]

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. Therefore, the International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy and their representatives to develop minimum sets of standardized outcomes and outcomes measurement methods for clinical practice that support patient–clinician decision‐making and quality improvement. Consensus methods identified 20 core outcomes. Measurement tools were recommended based on their evidence of strong clinical measurement properties, feasibility, and cross‐cultural applicability. The essential outcomes included many non‐seizure outcomes: anxiety, depression, suicidality, memory and attention, sleep quality, functional status, and the social impact of epilepsy. The proposed set will facilitate the implementation of the use of patient‐centered outcomes in daily practice, ensuring holistic care. They also encourage harmonization of outcome measurement, and if widely implemented should reduce the heterogeneity of outcome measurement, accelerate comparative research, and facilitate quality improvement efforts. [ABSTRACT FROM AUTHOR]

Scope of practice regulation in medicine is crucial for ensuring patient safety, access to care and professional autonomy. This paper explores the impact of scope of practice regulation on healthcare delivery, professional responsibilities and patient outcomes. It discusses the variability in standards for safe practice, the challenges in defining boundaries between medical specialties and the recent controversies in cosmetic surgery practice. The paper also examines the potential benefits and drawbacks of rigorous scope of practice regulations, including their impact on clinical innovation, flexibility and access to care. Furthermore, it delves into the implications of defensive medicine and the consequences of restrictive regulations on patient care. The author proposes implementing a proactive, national, artificial intelligence-powered, real-time outcome monitoring system to address these challenges. This system aims to cover every patient undergoing a surgical procedure and could be gradually extended to non-surgical conditions, benefiting all key stakeholders in the health system. The paper emphasises the need for a balanced approach to scope of practice regulation to avoid stifling clinical innovation and professional autonomy, while ensuring patient safety and professional accountability. [ABSTRACT FROM AUTHOR]

Health interventions vary substantially in the degree of effort required to implement them. To some extent this is apparent in their financial cost, but the nature and availability of non-financial resources is often of similar importance. In particular, human resource requirements are frequently a major constraint. We propose a conceptual framework for the analysis of interventions according to their degree of technical complexity; this complements the notion of institutional capacity in considering the feasibility of implementing an intervention. Interventions are categorized into four dimensions: characteristics of the basic intervention; characteristics of delivery; requirements on government capacity; and usage characteristics. The analysis of intervention complexity should lead to a better understanding of supply- and demand-side constraints to scaling up, indicate priorities for further research and development, and can point to potential areas for improvement of specific aspects of each intervention to close the gap between the complexity of an intervention and the capacity to implement it. The framework is illustrated using the examples of scaling up condom social marketing programmes, and the DOTS strategy for tuberculosis control in highly resource-constrained countries. The framework could be used as a tool for policy-makers, planners and programme managers when considering the expansion of existing projects or the introduction of new interventions. Intervention complexity thus complements the considerations of burden of disease, cost-effectiveness, affordability and political feasibility in health policy decision-making. Reducing the technical complexity of interventions will be crucial to meeting the health-related Millennium Development Goals.

INTRODUCTION: This case describes a young flight instructor who suffered an embolic ischemic stroke with punctate lesions in his right motor and superior parietal cortex. Investigations revealed a small patent foramen ovale (PFO). BACKGROUND: Stroke in young patients is frequently associated with a PFO. Controversy exists over whether the PFO is a cause, a risk factor, or an incidental finding in these cases. Estimating the individualised risk of stroke recurrence is difficult to ascertain. This has implications for medical certification for pilots following recovery. CASE PRESENTATION: A 28-year-old male recreational flight instructor held a Commercial Pilot Licence with approximately 2000 hours of flight experience. He presented to the hospital with sudden onset left-sided facial paraesthesia, left hand weakness and blurred vision, accompanied by gradual onset, moderate severity, bilateral headache. The cranial symptoms resolved within 30 minutes. The left hand weakness persisted for three days. MRI revealed two punctate ischemic foci in the right precentral gyrus and superior parietal lobe. Vasculitis and thrombophilia screen, CT angiography, lower limb Doppler, 7-day Holter monitoring, and stress echocardiogram were normal. Transesophageal echocardiogram revealed a PFO with small bidirectional shunt. The cardiologist and neurologist opined that the PFO was unlikely to have caused his stroke and estimated an annual recurrence rate of <1.8%. The pilot was placed on life-long aspirin and atorvastatin. He was offered PFO closure but declined. Under Recreational Aviation Australia rules, he was able to return to flying light sport aircraft. However, an enduring co-pilot restriction for general aviation activities was placed on his Class 1 and 2 Aviation Medical by the Australian Civil Aviation Safety Authority. Following a review two years later, the restriction was upheld despite no stroke recurrence. DISCUSSION: This case highlights the difficulty in determining individualised risk for pilots recovering from a stroke associated with a small PFO. Whilst treatment with aspirin and a statin or PFO closure reduces the risk of stroke recurrence, these treatments carry a risk of side effects. Further evidence is required to better individualise risk for stroke patients with a small PFO to determine optimal treatment options and to stratify their suitability for medical aviation re-certification. Learning Objectives 1. Understand the relevance of the finding of a patent foramen ovale following ischemic stroke in young patients. 2. Appreciate the current difficulties in stratifying and individualising stroke recurrence risk in patients with patent foramen ovale and the implications this has on aeromedical re-certification following recovery. 3. Develop an awareness of different aeromedical certification standards based on activity type and jurisdiction. [ABSTRACT FROM AUTHOR]

We present a case of a patient with metastatic lung adenocarcinoma who developed severe right lower limb radicular pain in a L5-S1 dermatomal distribution 5months into treatment with carboplatin, pemetrexed and pembrolizumab. MRI of the lumbar spine demonstrated contrast enhancement of the right L5 nerve root consistent with neuritis. The patient was treated with intravenous methylprednisolone 2mg/kg/day for 3days, followed by oral prednisolone 1mg/kg/day with a slow wean over 6weeks. There was no improvement and their performance status deteriorated to an Eastern Cooperative Oncology Group (ECOG) score of 3, representing capability of only limited self-care. We commenced induction therapy with intravenous immunoglobulin 2g/kg over 5days, which resulted in complete resolution of pain sustained for 3weeks before recurrence of symptoms. We continued maintenance therapy with intravenous immunoglobulin 0.4g/kg over 2days at 4–5 weekly intervals, which led to resolution of symptoms and ECOG score to 1. [ABSTRACT FROM AUTHOR]

Abstract Background In 2001, the Government of Thailand introduced a universal coverage scheme with the aim of ensuring equitable health care access for even the poorest citizens. For a flat user fee of 30 Baht per consultation, or for free for those falling into exemption categories, every scheme participant may access registered health services. The exemption categories include children under 12 years of age, senior citizens aged 60 years and over, the very poor, and volunteer health workers. The functioning of these exemption mechanisms and the effect of the scheme on health service utilisation among the poor is controversial. Methods This cross-sectional study investigated the prevalence of 30-Baht Scheme registration and subsequent self-reported health service utilisation among an urban poor population in the Teparuk community within the Mitrapap slum in Khon Kaen city, northeastern Thailand. Furthermore, the effectiveness of the exemption mechanisms in reaching the very poor and the elderly was examined. Factors for users' choice of health facilities were identified. Results Overall, the proportion of the Teparuk community enrolled with the 30-Baht Scheme was high at 86%, with over one quarter of these exempted from paying the consultation fee. User fee exemption was significantly more frequent among households with an above-poverty-line income (64.7%) compared to those below the poverty line (35.3%), χ2 (df) = 5.251 (1); p-value = 0.018. In addition, one third of respondents over 60 years of age were found to be still paying user fees. Self-reported use of registered medical facilities in case of illness was stated to be predominantly due to the service being available through the scheme, with service quality not a chief consideration. Overall consumer satisfaction was high, especially among those not required to pay the 30 Baht user fee. Conclusion Whilst the 30-Baht Scheme seems to cover most of the poor population of Mitrapap slum in Khon Kaen, the user fee exemption mechanism only works partially with regard to reaching the poorest and exempting senior citizens. Service utilisation and satisfaction are highest amongst those who are fee-exempt. Service quality was not an important factor influencing choice of health facility. Ways should be sought to improve the effectiveness of the current exemption mechanisms.

Background Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016–2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs. Methods A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices. Results Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices. Conclusions A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs. [ABSTRACT FROM AUTHOR]

A 48-year-old man who worked in mining in remote, northern Australia was transferred from a rural hospital 5 days after the onset of headaches, subjective fevers and flaccid paralysis of the left upper limb. Initial investigations demonstrated inflammatory cerebrospinal fluid (CSF) changes and a longitudinally extensive cervical cord lesion. Given two serial negative blood and CSF cultures, he was treated as inflammatory myelitis with intravenous methylprednisolone. Despite the initial improvement in pain and left arm power, the patient’s neurological deficit plateaued and then deteriorated with worsening neck pain, diaphragmatic dysfunction and dysphagia requiring intubation and respiratory support. A third CSF culture isolated Burkholderia pseudomallei confirming a diagnosis of neuro-melioidosis. Repeat imaging revealed the rostral extension of the original spinal cord lesion into the medulla and pons. Over the next 4 weeks, the patient’s neurological deficits slowly improved with continued intravenous antibiotic therapy with meropenem and oral trimethoprim/ sulfamethoxazole. [ABSTRACT FROM AUTHOR]

Byline: Martin Goette (1), Christian Gericke (1) Author Affiliation: (1) Lehrstuhl Management im Gesundheitswesen, WHO Collaborating Centre for Health Systems Research and Management, Technische Universitat Berlin, Strasse des 17. Juni 145, D-10623, Berlin, Germany Article History: Registration Date: 03/01/2006 Online Date: 24/02/2006