Home Therapy Research Articles

The MDR Upon Admission Score: Shortening Time to Initiation of Appropriate Antimicrobial Therapy in the Era of Resistance in the Community

Background Multi-drug-resistant organisms (MDRO) pose a growing burden, including in the community. Delay in initiation of appropriate antimicrobial therapy (DAAT) is common among patients with MDRO infection. In addition, DAAT is the strongest modifiable predictor of mortality in severe sepsis. The aim of this study was to develop a prediction score for MDRO infection upon admission to hospitals, in order to shorten DAAT and reduce misuse of broad-spectrum antibiotics administered to patients with non-MDRO infection.Methods Retrospective case–control analysis was conducted at Assaf Harofeh Medical Center, Israel, for two consecutive months (08-10/2016). Adult patients with MDRO infections were compared with patients presenting with non-MDRO sepsis (i.e., patients with microbiologically confirmed non-MDRO infection, or patients with non-microbiologically confirmed diagnosis). MDROs were determined in accordance to established criteria. A prediction score was developed based on the multivariable analysis (logistic regression) of predictors for MDRO infection upon admission.ResultsThe primary dataset consisted of 677 patients, 78 had MDRO infection. The final score included nine parameters: home therapy (IV therapy, wound care, or specialized nursing care, 23 points), history of MDRO colonization (13 points), invasive procedure in the past 6 months (11 points), any antibiotics in the past 3 months (10 points), elderly (over 65 years, 8 points), severe sepsis (i.e., severe sepsis, septic shock, or multi-organ failure, 6 points), resident of long-term care facility (5 points), acute kidney injury (5 points), and congestive heart failure (3 points),. A cut-off of ≥22 points had a sensitivity of 83%, specificity of 76%, and ROC AUC = 0.86 (figure).Conclusion This study presents a novel prediction score for MDRO infection upon admission, based on parameters that could easily be extracted at bedside during the initial presentation of a patient with sepsis. A future prospective interventional study is needed in order to quantify the performances of this score in terms of shortening DAAT, curbing misappropriate use of broad-spectrum antibiotics, and improving patients’ outcomes.Disclosures All authors: No reported disclosures.

Qualitative evaluation of home therapy administration of enzymatic treatment for patients with Gaucher and Fabry disease in the Comunitat Valenciana in Spain: point of view of patients and health care professionals

Qualitative evaluation of home therapy administration of enzymatic treatment for patients with Gaucher and Fabry disease in the Comunitat Valenciana in Spain: point of view of patients and health care professionals

Propriedades físico-químicas e nutricionais de dietas enterais artesanais produzidas a partir de vegetais de baixa carga glicêmica

The purpose of this study was to elaborate handmade enteral diets for use by patients in stabilized enteral home therapy and with an expectation of extend or permanent use of the enteral route from a formulation containing vegetal sources of low glycemic load and significant levels of dietary fiber. The aim of this study was to evaluate the physicochemical and nutritional properties of handmade enteral diets produced from vegetables with low glycemic load, offering low-cost alternatives for nutrition and control of glycemic metabolism for people using enteral diets. Eighteen food combinations were established in 3 groups, using different vegetables associated with maltodextrin, albumin, soybean oil and cornstarch until the formula obtained the ratio of 1 kcal / mL. The fluidity and stability of the diets were verified, as well as the macro-micronutrient and bromatological markers. All diets formulated were characterized as normocaloric, normoprotein and normolipidic. The average dietary fiber content of the three groups of diets was 1.83 g / 100 mL, being 0.87 g (47%) of soluble fiber, reaching values close to daily recommendations. In the case of micronutrients, caloric values prescribed for one day reached 71% of recommended iron requirements, 116% of copper, 48% of zinc, 32% of calcium, 110% of phosphorus, 46% of potassium, 50% of magnesium, 90% of manganese, 25% of selenium and 39% of sodium. From the data analyzed in this study, it is possible to conclude that the formulated diets have a macronutrient profile that meets the needs of an normal adult. Regarding minerals, this availability is partial and adjustments are required. The characteristics of color, fluidity and stability make these diets an important option for home use, which may contribute to lower costs and increase the acceptance of this type of food therapy.

Parent-implemented home therapy programmes for speech and language: a systematic review.

Parent-delivered home programmes are frequently used to remediate speech and language difficulties in young children. However, the evidence base for this service delivery model is limited. The aim of this systematic review is to investigate the effectiveness of parent-implemented home programmes in facilitating the development of children's speech and language skills, and to evaluate the cost-effectiveness and feasibility of this service delivery method. A systematic search of the PsycINFO, CINAHL and ERIC databases was conducted. Quality appraisal of individual studies was conducted. Findings from each of the studies were then integrated to report on outcomes for the child, the parent and the service. There is preliminary evidence that home programmes can lead to growth in a child's speech and language skills and are more effective than no intervention, provided the home programmes are used with high dosage rates and direct parent training. Home programmes are a potentially useful service delivery model, but caution should be exercised when considering their use to address broader service delivery challenges. Further high-level evidence is needed across all facets of this service delivery model.

Evidence-Based Psychosocial Treatments for Pediatric Elimination Disorders

Pediatric elimination disorders are common in childhood, yet psychosocial correlates are generally unclear. Given the physiological concomitants of both enuresis and encopresis, and the fact that many children with elimination disorders are initially brought to their primary care physician for treatment, medical evaluation and management are crucial and may serve as the first-line treatment approach. Scientific investigation on psychological and behavioral interventions has progressed over the past couple of decades, resulting in the identification of effective treatments for enuresis and encopresis. However, the body of literature has inherent challenges, particularly given the multicomponent nature of many of the treatment packages. This review identified 25 intervention studies—18 for nocturnal enuresis and 7 for encopresis—over the past 15 years and classified them according to the guidelines set forth by the Task Force on the Promotion and Dissemination of Psychological Procedures. For nocturnal enuresis, the urine alarm and dry-bed training were identified as well-established treatments, Full Spectrum Home Therapy was probably efficacious, lifting was possibly efficacious, and hypnotherapy and retention control training were classified as treatments of questionable efficacy. For encopresis, only two probably efficacious treatments were identified: biofeedback and enhanced toilet training (ETT). Best practice recommendations and suggestions for future research are provided to address existing limitations, including heterogeneity and the multicomponent nature of many of the interventions for pediatric elimination disorders.

Effectiveness of an Activity-Based Home Therapy Program for Stroke Patients in Singapore

Effectiveness of an Activity-Based Home Therapy Program for Stroke Patients in Singapore

Effectiveness of temporary positive expiratory pressure (T-PEP) at home and at hospital in patients with severe chronic obstructive pulmonary disease.

Temporary positive airway pressure (T-PEP) is a tool recently introduced in the treatment of chronic obstructive pulmonary disease (COPD) or bronchiectasis. It demonstrated encouraging results also in severe COPD patients. The aim of this study is verify if adding T-PEP to best bronchodilator therapy both in clinic and home administering could reduce disease exacerbations and improve lung function in patients with severe COPD. A total of 142 patients with severe COPD (FEV1 <50%) were enrolled; 120 were randomized in three groups: a group treated with T-PEP at home, a group with T-PEP at hospital and a group with medical therapy only (control group). Number of acute exacerbations COPD (AECOPD) after 1 month and 3 months were the primary outcomes. Secondary outcomes were changes in respiratory function parameters (FVC, FEV1, TLC, RV), arterial blood gases, dyspnea and health status assessment scales (Modified Medical Research Council (MMRC), Breathlessness, Cough and Sputum scale (BCSS) and COPD Assessment Test (CAT). The time of daily use of the T-PEP was registered as well as its acceptance using a Likert scale. Ninety-nine patients completed the study. Both the groups who used T-PEP showed a statistical lower number of AECOPD after 1 month and 3 months (P<0.01). Some respiratory functional parameters improved in the two groups treated with T-PEP (FVC, FEV1, RV) (P<0.02) and dyspnea and health status assessment scales (MMRC, BCSS, CAT) (P<0.04; P<0.01; P<0.009). The time of daily using was similar in the two T-PEP groups. Patients treated at home showed a greater acceptance than those treated at hospital (Likert scale 4.7 vs. 5.9) (P<0.01). Patients treated with T-PEP showed a lower number of AECOPD. T-PEP improves functional respiratory parameters and improves dyspnea and health status assessment scales. No adherence difference in hospital and home treatment was found. Patients preferred home treatment.

Long-term Noninvasive Ventilation in COPD Associated With Non-Cystic Fibrosis Bronchiectasis: Is High-Intensity NIV the Right Way to Go?

SESSION TITLE: Airways 5 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM PURPOSE: Purpose:Recognition of bronchiectasis among patients with COPD is important because its presence is associated with worse outcomes.Specifically ,intubated intensive care unit(ICU) patients with overlapping bronchiectasis and COPD experience prolonged couses of mechanical ventilation,extended ICU and hospital-of -stay,and increased rates of ventilator -associated pneumonia.In COPD patients ,only recently has evidence showing benefits of long-term NIV become available.However,the application of long-term NIV in patients with severe COPD associated with bronchiectasis should be considered because overlapping condition as usual associated with hypercapnic respiratory failure.The aim of our study was to assess the impact of high intensity NIV to the lung function ,arterial gas content,exacerbation and hospitalization rate in patients with severe COPD associated with non-cystic fibrosis(non-CF) bronchiectasis. METHODS: From February 2014 to April 2015 were investigated 49 outpatient patients with severe COPD associated with non-CF bronchiectasis whom identified chronic hypercapnic respiratory faulire .Depends on treatment regime all patients were divided into two groups:1)26 patients who have received high intensity NIV(29±4.2 mb) with long-term oxygen therapy and 2) 23 patients who recived long-term oxygen home therapy without NIV. RESULTS: Results:Our investigation shown that nocturnal long-term high-intensity NIV adding to the long term oxygen therapy improved lung function comparison with patients without NIV(FEV1-42±6.5 % vs 35±3.9% p<0.05) and arterial blood gas (PaCO2 deacreased from 60.6± 6.6mmHg to 47±5.8mmHg p<0.001: in patients without NIV PaCO2 decreased from 60.2 mmHg to 57.8mmHg p>0.05).One of most imortant benefit of chronic NIV was a significantly decreased of exacerbation rate of overlapping condition(1.2±0.5 vs 3.5±0.9 per one year : p<0.001).Our study also showed markedly reduced of hospitalization rate among patients who have received high-intensity NIV(1.1±0.3 vs 3.1±0.5: p<0.001).Inpatients group with NIV significantly decreased the rate of ICU admission during observational period. CONCLUSIONS: Our investigation shown that nocturnal long-term use of high-intensity NIV may be benefical for patients with severe COPD associated with non-CF bronchiectasis with chronic hypercapnic respiratory failure .The long-term use of high intensity NIV in such patients significanly increased lung function and markedly reduced the PaCO2 in the blood with improved of clinical features of the disease.Nocturnal long-term use of NIV decreased the rate of exacerbations of the disease and also redused the hospitalization rate with markedly reduction of ICU addmission of patients CLINICAL IMPLICATIONS: Clinicians ,intensive and critical care physicians DISCLOSURE: The following authors have nothing to disclose: Alizamin Sadigov No Product/Research Disclosure Information

High attack frequency in patients with angioedema due to C1-inhibitor deficiency is a major determinant in switching to home therapy: a real-life observational study.

BackgroundHereditary angioedema with C1-inhibitor deficiency (C1-INH-HAE) is characterized by recurrent attacks of swelling that affect various body sites. Such attacks are a frequent cause of visits to the emergency department and are often treated in the hospital. In recent years, self-administration of C1-inhibitor (C1-INH) concentrates at home has become an increasingly used option, with a positive impact on patient outcomes and quality of life.MethodsThis was an observational study of 6 months’ duration in 56 patients with C1-INH-HAE referred to a HAE center in southern Italy. The patients received three types of treatment for their swelling attacks: C1-INH concentrates administered at home (n = 25); icatibant administered at home (n = 12); and C1-INH concentrates administered in the hospital (n = 19). The objectives of this observational study were to compare therapy compliance (defined as the proportion of treated attacks) and quality of life in home- and hospital-treated patients, and to identify factors associated with the decision to use home therapy.ResultsOverall, 918 attacks were reported over 6 months, of which 544 (59.2 %) were treated. Total number of reported attacks and the mean (±SD) number of attacks per patient, respectively, in the three groups were: 611 and 24.4 (±26.1) for home-based C1-INH; 191 and 15.9 (±12.0) for home-based icatibant; 166 and 6.1 (±6.5) for hospital-based C1-INH. Differences in attack frequency between home- and hospital-based treatments were statistically significant (p = 0.002), while patient demographic characteristics and the disease severity score did not correlate with the use of home therapy. Compliance with therapy was significantly better with home-based therapy (71.2 % of treated attacks with C1-INH and 44.0 % with icatibant) than with hospital-based therapy (21.6 %, p = 0.003). Quality of life showed an opposite trend, with patients on hospital-based treatment reporting the highest quality of life.ConclusionsHome-based therapy was associated with better compliance compared with hospital-based therapy. The choice to adopt home-based therapy appeared to correlate with a high attack frequency. Home-based therapy is a valid treatment option for patients with C1-INH-HAE and should be offered to all such patients, and especially to those with high attack frequency.

Cost-Effectiveness of High Dose Hemodialysis in Comparison to Conventional In-Center Hemodialysis in the Netherlands.

In the Netherlands, the current standard of care for treating patients with end-stage renal disease is three sessions of in-center hemodialysis (conventional ICHD). However, the literature indicates that high dose hemodialysis (high dose HD) may provide better health outcome such as survival and quality of life. The objective of this study was to determine the cost-effectiveness of high dose HD, both in-center and at home, in comparison to conventional ICHD from a Dutch payer's perspective over a 5year period. Additionally, the cost-effectiveness of conventional HD at home in comparison to conventional ICHD will be analysed. A Markov model was developed assuming 28-day treatment cycles and was populated with data from Dutch and international renal registries, official tariffs and medical literature. Univariable and probabilistic sensitivity analyses were performed to test the robustness of the results. Using publicly available tariffs from the Dutch Healthcare Authority (Nederlandse Zorgautoriteit) of 2015, doing high dose ICHD instead of conventional ICHD shows an incremental cost-effectiveness ratio (ICER) of €275,747 per quality-adjusted life year (QALY) gained. In contrast, the ICER of high dose HD at home in comparison to conventional ICHD is €3248 per gained QALY. The final analysis shows that conventional HD at home is less costly per patient (-€3063) than conventional ICHD and results in health benefit improvement (+0.249 QALYs), and is therefore regarded as cost saving. Treating dialysis patients with conventional HD at home shows to be cost saving in comparison to conventional ICHD. However, the magnitude of clinical benefit of high dose HD at home is over two times greater than the clinical benefit of conventional HD at home. According to our analysis, from a payer's perspective, high dose HD should be offered as a home therapy to obtain its clinical benefits in a cost-effective manner. Future research should consider our findings alongside societal factors, such as patient preference, monitoring cost for the home patient, productivity loss and capacity. Baxter BV, The Netherlands.

Self-administered C1 esterase inhibitor concentrates for the management of hereditary angioedema: usability and patient acceptance.

Hereditary angioedema (HAE) is a rare genetic disease characterized by episodic subcutaneous or submucosal swelling. The primary cause for the most common form of HAE is a deficiency in functional C1 esterase inhibitor (C1-INH). The swelling caused by HAE can be painful, disfiguring, and life-threatening. It reduces daily function and compromises the quality of life of affected individuals and their caregivers. Among different treatment strategies, replacement with C1-INH concentrates is employed for on-demand treatment of acute attacks and long-term prophylaxis. Three human plasma-derived C1-INH preparations are approved for HAE treatment in the US, the European Union, or both regions: Cinryze®, Berinert®, and Cetor®; however, only Cinryze is approved for long-term prophylaxis. Postmarketing studies have shown that home therapy (self-administered or administered by a caregiver) is a convenient and safe option preferred by many HAE patients. In this review, we summarize the role of self-administered plasma-derived C1-INH concentrate therapy with Cinryze at home in the prophylaxis of HAE.

Postoperative Treatment of Distal Radius Fractures Using Sensorimotor Therapy

Objective/Hypothesis: Proprioception and sensorimotor modalities have been used in rehabilitation to treat neurological and joint injuries. Following distal radius fractures (DRF), there is a temporary sensorimotor loss that should be addressed during postoperative therapy. We designed an evaluation and treatment protocol aimed at sensorimotor evaluation and treatment and trialed it on a pilot series of patients following surgery for DRF. The purpose of this prospective study was to compare the outcomes of patients following surgery for DRF treated using our specific sensorimotor treatment protocol with patients treated after surgery according to postoperative standard of care. We hypothesized that patients treated using our treatment protocol will have better functional results at 3 months postsurgery. Methods: Because sensorimotor response loops are complex and it is difficult to isolate the effect of the different types of input, both the evaluation and the treatment protocols included a comprehensive sensorimotor panel. The patients were treated once a week in therapy and pursued a home therapy protocol. Thirty-four patients following surgery for DRF were randomized into a focused sensorimotor postoperative protocol and the standard of care protocol. Exclusion criteria included inability to attend therapy or comply with the home therapy protocol and patients with preceding injuries and deficits in the wrist and hand. Patients were evaluated initially in the first days after the operation, at 6 weeks, and at 4 months postsurgery. Results: All patients following surgery for DRF demonstrated similar initial significant deficits in proprioception (72%), stereognosis (36%), and the Moberg pick-up test (30 seconds vs 10.8 seconds). There was documented sensorimotor and functional improvement in both groups with treatment in range of motion (ROM), strength, and sensorimotor testing. The Disabilities of the Arm, Shoulder and Hand (DASH) score was 10.8 (14.2) in the trial group at 3 months and 29.2 (9.6) in the control group P = .05. Wrist ROM at 3 months was significantly better in the trial group ( P = .003). We had no cases of chronic regional pain syndrome (CRPS). Conclusions: (1) Patients after surgery for DRF demonstrate significant sensorimotor deficits that should be evaluated and addressed in therapy. (2) These deficits and function seem to improve more at 3 months when utilizing a comprehensive sensorimotor treatment protocol. (3) Further study is ongoing to evaluate the value of the treatment protocol and to provide sensorimotor therapeutic guidelines following surgery for DRF.

What is the Best Strategy to Minimize After-Care Costs for Total Joint Arthroplasty in a Bundled Payment Environment?

BackgroundThe post-acute care strategies after lower extremity total joint arthroplasty including the use of post-acute rehabilitation centers and home therapy services are associated with different costs. Providers in bundled payment programs are incentivized to use the most cost-effective strategies. MethodsWe used decision analysis to examine the impact of extending the inpatient hospital stay to avoid discharge of patients to a post-acute rehabilitation facility. ResultsThe results of this decision analysis show that extended acute hospital care for up to 5.2 extra days to allow for home discharge, rather than discharge to a post-acute inpatient facility can be financially preferable, provided quality is not negatively impacted. ConclusionThe data demonstrate that because the cost of additional acute care hospital days is relatively small and because the cost of an extended post-acute inpatient rehabilitation facility is high, keeping patients in the acute facility for a few extra days and then discharging them directly to home may result in an overall lower cost than discharge after a shorter hospital stay to an expensive post-acute facility. However, this approach will have challenges, and future studies are needed to evaluate this change in strategy.

Gesture Analysis For Yoga Alignment

INTRODUCTION: Yoga Therapy research has recently become the focus of rigorous scientific inquiry in the interest of understanding and quantifying its benefits for a wide variety of medical conditions. There remains a disparity between segments of the population who can readily access yoga classes and therapies. For difficult to reach individuals, Yoga in an exergame format could be utilized in clinical or home environments. The purpose of this study was to analyze Yoga posture alignment using a gesture analysis program in order to produce a yoga exergame using the Microsoft Kinect. We captured six yoga postures demonstrated by an advanced yoga teacher, as a gold standard for comparison purposes. METHODS: Six yoga postures were selected for the basis of the training set using Microsoft Visual Gesture Builder (VGB). Programs utilized were included in Kinect version 2 SDK and ran on a PC. RESULTS: Three 3D video clips of the six yoga postures were captured from the yoga teacher, two for VGB training and one for validation. We found that adding the second training clip increased performance accuracy for four out of the six postures. The forward bend and arms up postures might improve with additional training clips. Our prior research has shown that the Kinect skeleton algorithms become confused with yoga postures that change the usual orientation of the head. A convenience sample of undergraduate students with various levels of yoga experience, were recorded executing the same 6 postures before, at the mid-point and at the conclusion of a 10-week yoga class series. We assessed the longitudinal correlation points between yoga experience level and VGB posture accuracy. CONCLUSION: Gesture analysis for yoga alignment training may be a useful tool for the development of home and clinical yoga therapy for hard to reach populations. The Kinect sensor provides a tool that could score the performance of yoga therapy and provide quantitative measures of posture adherence and improvement.

Home treatment of haemarthrosis with recombinant activated factor VII in patients with haemophilia A or B and inhibitors: experience from developing countries.

Home therapy for uncomplicated mild/moderate bleeding can decrease healthcare burden, promote self-esteem, reduce complications, and provide near-normal quality of life. To evaluate recombinant activated factor VII (rFVIIa) as home therapy for joint bleeds in Algeria, Morocco, Oman, Saudi Arabia, and United Arab Emirates. Twenty-seven patients aged more than 2 years with congenital haemophilia and inhibitors were monitored for up to 8 months after a first haemarthrosis episode treated with rFVIIa. Assessments were made by patients/caregivers with a standardized diary. The main measures included home-managed bleeds, haemostasis, and pain relief within 9 h after first injection. Additional analyses included convenience, time to pain resolution, and doses given within 48 h. Of 132 bleeds, 84 (63.6%) were managed at home. Of these, successful haemostasis (partial or complete) was achieved at 9 h in 87.8%, with pain relief for 84.0%. For all treatment settings, successful haemostasis at 9 h was achieved for 86.3% of bleeds, with pain relief achieved for 74.8% of bleeds. Higher initial dosing was associated with fewer injections. Median time to complete haemostasis was 48 h (spontaneous bleeds) and 24 h (traumatic bleeds). Median time to complete pain relief was 24 h for both bleed types. Satisfaction with treatment was high. No safety concerns were reported. Results from this observational study agree with previous data on the safety and efficacy of home treatment with rFVIIa and will help to increase awareness and aggregate experience, fostering confidence in home management of haemophilia patients with inhibitors in developing countries.

Patient Education and Peritoneal Dialysis Modality Selection: A Systematic Review and Meta-analysis.

Educational interventions are increasingly used to promote peritoneal dialysis (PD), the most common form of home therapy for end-stage renal disease. A systematic review of the evidence in support of dialysis modality education is needed to inform the design of patient-targeted interventions to increase selection of PD. We performed a systematic review and meta-analysis to characterize the relationship between patient-targeted educational interventions and choosing and receiving PD. Systematic review and meta-analysis. Published original studies and abstracts. We searched MEDLINE, EMBASE, CINAHL and EBMR. We included controlled observational studies and randomized trials of educational interventions designed to increase PD selection. Predialysis educational interventions. The primary outcome was choosing PD, defined as intention to use PD regardless of whether PD was ever used. The secondary outcome, receiving PD, was defined as an individual receiving PD as his or her treatment. Of 3,540 citations, 15 studies met our inclusion criteria, including 1 randomized trial. In the single randomized trial (N=70), receipt of an educational intervention was associated with a more than 4-fold increase in the odds of choosing PD (OR, 4.60; 95% CI, 1.19-17.74). Based on results from 4 observational studies (N=7,653), patient-targeted educational interventions were associated with a 2-fold increase in the odds of choosing PD (pooled OR, 2.15; 95% CI, 1.07-4.32; I(2)=76.7%). Based on results from 9 observational studies (N=8,229), patient-targeted educational intervention was associated with a 3-fold increase in the odds of receiving PD as the initial treatment modality (OR, 3.50; 95% CI, 2.82-4.35; I(2)=24.9%). Most studies were observational studies, which can establish an association between education and choosing PD or receiving PD, but does not establish causality. This systematic review demonstrates a strong association between patient-targeted education interventions and the subsequent choice and receipt of PD.

Home Nutrition Support: Ethics and Reimbursement.

Ethical dilemmas challenge providers on both sides of the hospital and clinic doors. In addition to establishing the nutrition care plan and guiding the client into the home setting with safe and effective parenteral or enteral nutrition therapy, procuring home nutrition support involves meeting documentation requirements and verifying that clients meet reimbursement criteria for home therapy based on third-party payer criteria. Providers have entered a realm for which training has been scarce and they face moral and ethical dilemmas involving serving as patient advocates, possibly stretching the truth to fit the clinical documentation to criteria vs maintaining professional integrity. Nutrition research and evidence-based practice have outpaced modifications to policies including Medicare's national and local coverage determinations, the bulk of which have not seen revisions in 32 years. This review elucidates clinical dilemmas and urges a political call to action to advocate for changes in current, outdated requirements for reimbursement. Given the current healthcare environment and trend toward expedited hospital stays, patients may be better served (and nourished) with revised guidelines.

Effectiveness of Temporary Positive Expiratory Pressure (T-PEP) at Home and at Hospital in Patients With Severe COPD

SESSION TITLE: Pulmonary Rehabilitation SESSION TYPE: Original Investigation Poster PRESENTED ON: Saturday, April 16, 2016 at 11:45 AM - 12:45 PM PURPOSE: Temporary positive airway pressure (T-PEP) is a tool recently introduced in the treatment of obstructive pulmonary diseases such as chronic obstructive pulmonary disease (COPD) or bronchiectasis. It demonstrated encouraging results also in severe COPD patients. The aim of this study is verify if adding T-PEP to best bronchodilator therapy both in clinic and home administering could reduce disease exacerbations and improve lung function in patients with severe COPD METHODS: 142 patients with severe COPD (FEV1 < 50%) were enrolled;120 were randomized in three groups: a group treated with T-PEP at home, a group with T-PEP at hospital and a group with medical therapy only (control group). Number of exacerbations after 1 month,3 months and 6 months was the primary outcome. Secondary outcomes were changes in respiratory function parameters (FVC, FEV1, TLC, RV), arterial blood gases analysis, dyspnea and quality of life scales (Modified Medical Research Council (MMRC), Breathlessness, Cough and Sputum scale (BCSS) and COPD Assessment Test (CAT). The time of daily use of the T-PEP was registered as well as its acceptance using a Likert scale RESULTS: 99 patients completed the study. Both the groups who used T-PEP showed a statistical reduction in exacerbations after 3 months (p<0.03) and 6 months (p<0.003). Some respiratory functional parameters improved in the two groups treated with T-PEP (FVC, FEV1, RV) (p<0.001) and dyspnea and quality of life scales (MMRC, BCSS, CAT) (p<0.001). The daily using was similar in the two T-PEP groups. Patients treated at home showed a greater acceptance than those treated at hospital (Likert scale 5.2 vs 5.7) (p<0.01) CONCLUSIONS: Treatment with T-PEP demonstrated efficacy to reduce exacerbations in patients with severe COPD. T-PEP improves functional respiratory parameters and improves dyspnea and quality of life scales. No adherence difference in hospital and home treatment was found. Patients preferred home treatment CLINICAL IMPLICATIONS: Adding an airway clearence tool to medical treatment can reduce exacerbations, improve functional lung parameters, quality of life scores in patients with severe COPD both at clinic and at home. DISCLOSURE: The following authors have nothing to disclose: Ines Piroddi, Antonello Nicolini, Giovanni Veronesi No Product/Research Disclosure Information

Randomized Single Blind Sham Controlled Trial of Adjunctive Home-Based tDCS after rTMS for Mal De Debarquement Syndrome: Safety, Efficacy, and Participant Satisfaction Assessment.

Mal de debarquement syndrome is a medically refractory disorder characterized by chronic rocking dizziness that occurs after exposure to passive motion. Repetitive transcranial magnetic stimulation (rTMS) can acutely suppress the rocking dizziness but treatment options that extend the benefit of rTMS are needed. 1) To determine whether transcranial direct current stimulation (tDCS) added after rTMS can extend the benefit of rTMS; 2) to determine whether participants can safely perform tDCS at home. Participants were given five days of rTMS (1 Hz right DLPFC/10 Hz left DLPFC in right-handers, vice versa in left-handers), according to a previously piloted protocol. They received three days of training on tDCS self-administration and were then randomized to either real or sham tDCS for four-weeks (anode left DLPFC/cathode right DLPFC for right-handers, vice versa for left-handers). Twenty-three participants completed the study. Those who received real tDCS after rTMS showed significant improvements in the degree of rocking perception as measured by the MdDS Balance Rating Scale and anxiety ratings by Week 4 of tDCS and a trend for improvement on the Dizziness Handicap Inventory. Two rTMS non-responders responded well to subsequent open-label tDCS. Side effects were mild and not different between real and sham tDCS. There were no episodes of skin burns in a group total of 556 sessions of tDCS. Satisfaction was rated high. Home-based tDCS can be performed safely and may be beneficial in selected individuals. Adequate teaching, automatic device safety features, and a good communications infrastructure are components of successful home therapy.

Definition of an organisational model for the prevention and reduction of health and social impacts of inherited bleeding disorders.

Due to the increase in life expectancy, patients with haemophilia and other inherited bleeding disorders are experiencing age-related comorbidities that present new challenges. In order to meet current and emerging needs, a model for healthcare pathways was developed through a project funded by the Italian Ministry of Health. The project aimed to prevent or reduce the social-health burden of the disease and its complications. The National Blood Centre appointed a panel of experts comprising clinicians, patients, National and Regional Health Authority representatives. Following an analysis of the scientific and regulatory references, the panel drafted a technical proposal containing recommendations for Regional Health Authorities, which has been formally submitted to the Ministry of Health. Finally, a set of indicators to monitor haemophilia care provision has been defined. In the technical document, the panel of experts proposed the adoption of health policy recommendations summarised in areas, such as: multidisciplinary integrated approach for optimal healthcare provision; networking and protocols for emergency care; home therapy; registries/databases; replacement therapy supply and distribution; recruitment and training of experts in bleeding disorders. The recommendations became the content of proposal of agreement between the Government and the Regions. Monitoring and evaluation of haemophilia care through the set of established indicators was partially performed due to limited available data. The project provided recommendations for the clinical and organisational management of patient with haemophilia. A particular concern was given to those areas that play a critical role in the comorbidities and complications prevention. Recommendations are expected to harmonise healthcare care delivery across regional networks and building the foundation for the national haemophilia network.