Intensification Of Care Research Articles

The adherence and response of a combined approach of online self-help cognitive behavioral therapy and phone-based psychological guidance among French patients with cancer with insomnia.

12100 Background: Insomnia affects 30–60% of patients with cancer. Cognitive behavioral therapy for insomnia (CBT- I) is the gold-standard treatment for insomnia. However, the uptake of CBT-I in routine care remains low. Technology can be leveraged to facilitate the access and delivery of CBT-I. Nevertheless, adherence rates to online self-help interventions seem low (50-60%), and is associated with reduced intervention efficacy. The Sleep-4-All-2.0 is a prospective multicentric single arm study that evaluated an approach that combined a validated online self-help CBT-I program (Insomnet, 6 modules) to a phone-based guidance with a psychologist (3 orientation meetings). This study assessed: 1) how this combined approach performed in terms of adherence, behavior change and insomnia remission rates compared to prior literature investigating self-help CBT-I, and 2) the patients’ characteristics that are associated with a better or a poorer response. Methods: Data were collected with online questionnaires to compare outcomes: adherence (5 to 6 modules completed), behavior change (ad hoc questionnaire), insomnia remission (Insomnia Severity Index, ISI < 8), sleep perception (ad hoc questionnaire), response to the program (changes in ISI score) at post intervention (week 6, 12 and 24). A descriptive analysis of patient characteristics at each time point was performed. Then, multivariate analyses were conducted: mixed models with a random effect at patient level (repeated measures) and fixed effects for the other variables. The following variables at baseline were used in the adjusted models: socio-demographic and clinical variables, ISI score, symptoms (ESAS), digital skills, barriers to change, motivation, social support and the referring professional. Results: Among the 348 patients included: 79% were women, 59% had breast cancer and 68% were undergoing treatment. A total of 310 patients (89%) initiated Insomnet. The adherence rate was 74% and 79% have changed their behavior. Insomnia remission rates were 34%, 46% and 50% at week 6, 12 and 24, respectively. Insomnia was no longer a problem for 48%, 63% and 66% at week 6, 12 and 24, respectively. Female gender (β=-1.22; p=0.05) and unemployed patients (β=-1.77; p<0.01) were associated with a decrease in ISI scores. Sleep medication (β=1.58; p<0.01), patients with a high sleepiness score (ESAS) (β=0.25; p=0.02) and patients with less digital skills (β=1.85; p<0.01) were associated with an increase in ISI scores. Conclusions: A combination of online self-help CBT-I with phone-based guidance showed satisfactory rates of program adherence, change behavior and insomnia remission. However, some patient profiles such as the ones with lower digital skills and severe insomnia at baseline seemed to benefit less from this approach, and may require further care intensification. Clinical trial information: CONVENTION DE RECHERCHE no. 2020-1-PL SHS-03-IGR-1.

Systems of care for ambulatory management of decompensated heart failure.

Heart failure (HF) represents a worldwide health burden and the annual per patient cost to treat HF in the US is estimated at $24,383, with most of this expense driven by HF related hospitalizations. Decompensated HF is a leading cause for hospital admissions and is associated with an increased risk of subsequent morbidity and mortality. Many hospital admissions for decompensated HF are considered preventable with timely recognition and effective intervention.Systems of care that include interventions to facilitate early recognition, timely and appropriate intervention, intensification of care, and optimization to prevent recurrence can help successfully manage decompensated HF in the ambulatory setting and avoid hospitalization.

Is It Time to Anticipate the Use of PARP Inhibition in Prostate Cancer Patients?

The increasing diffusion of genetic analysis regarding the pathogenetic variants (PVs) of genes involved in DNA Damage Repair (DDR) mechanisms and the development of Poly ADP ribose polymerase (PARP) inhibitors (PARPis) led to the first valid precision medicine option tailored toward metastatic prostate cancer (mPC). The concept of anticipation in the systemic treatment of mPC was initially adopted for androgen receptor signaling inhibitors (ARSIs) to describe the expansion of their indications, from the setting of the late-stage second-line treatment of metastatic castration-resistant prostate cancer (mCRPC) to first-line therapy in selected cases. There is already mounting evidence in favor of the anticipation of PARPis in the first line of mCRPC therapy, and further evidence in favor of mHSPC is emerging. Many studies have demonstrated the synergism between ARSIs and PARP inhibitors. Recent discoveries regarding the crosstalk between the androgen receptor (AR) and DNA repair mechanisms are disconnecting the use of PARPis from genetic analysis. The new message emerging is that the combination of PARPis with ARSIs may work independently of DDR mutational status. As a matter of fact, most of the recent trials analyzing the combination of PARPis with abiraterone or enzalutamide as a first-line therapy enrolled mCRPC patients irrespective of their mutational status. The PROPEL trial concluded that the advantage of the combination was independent of PV status, despite a higher advantage being reported in the BRCA1/2 mutated subgroup. The MAGNITUDE trial, however, showed a significant advantage only in the DDR mutated subgroup, and the DDR non-mutated cohort was closed for further enrollment. The combination of PARPis with ARSIs represents a significant strategy with a view to the anticipation and intensification of care in mPC. However, it should not nullify the advantages of precision medicine linked to the genetic analysis of DDR genes.

Facilitating and Preventing Factors of Tracheostomy Patient Care by Home Caregivers: A Qualitative Study

Background: The unstable condition of tracheostomy patients and the lack of support resources for patients and their families during discharge is the biggest challenge, especially for their home and non-professional caregivers. The present study aimed to identify the factors affecting the care of tracheostomy patients provided by home caregivers. Materials and Methods: This qualitative research was conducted from September 2018 to December 2019 using the content analysis method and interviews with nine home caregivers and one professional caregiver in Lorestan Province, Iran. The required data were collected by holding in-depth semi-structured interviews and continued until reaching data saturation. Simultaneously, the gathered data were analyzed using the 5-step approach of Graneheim and Lundman (2004). Results: The results led to the extraction of 2 themes of preventing and facilitating care factors, 7 categories, and 21 subcategories. The categories related to the theme (preventing factors) of patient care challenges included neglecting the caring role of informal caregivers by the healthcare system, interaction challenges, the high pressure of caregiving, and lack of trust. The categories related to the facilitating factors theme were the experience of the care facilitating over time, the intensification of care with the aim of prevention, and hope and inner satisfaction underlying the care. Conclusion: The challenges of the family's lack of readiness to accept the new role, the exhausting nature of caregiving, and the caregivers’ lack of skills, and as a result, the imposition of a burden of caregiving, and the emergence of harmful consequences for them in various dimensions, the existence of non-governmental organizations that aim to continue to care for these patients and support their families seems necessary. With support systems and gaining experience over time, the care transition process is facilitated.

PD17-09 CD70-POSITIVE EXTRACELLULAR VESICLES FOR DETECTION OF CLEAR-CELL RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 Apr 2023PD17-09 CD70-POSITIVE EXTRACELLULAR VESICLES FOR DETECTION OF CLEAR-CELL RENAL CELL CARCINOMA Rodrigo R. Pessoa, Reza Nabavizadeh, Ali Arafa, Roxane Lavoie, Yohan Kim, Liguo Wang, Jeanette Eckel-Passow, Bradley C. Leibovich, and Fabrice Lucien Rodrigo R. PessoaRodrigo R. Pessoa More articles by this author , Reza NabavizadehReza Nabavizadeh More articles by this author , Ali ArafaAli Arafa More articles by this author , Roxane LavoieRoxane Lavoie More articles by this author , Yohan KimYohan Kim More articles by this author , Liguo WangLiguo Wang More articles by this author , Jeanette Eckel-PassowJeanette Eckel-Passow More articles by this author , Bradley C. LeibovichBradley C. Leibovich More articles by this author , and Fabrice LucienFabrice Lucien More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003272.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: One third of patients treated for localized clear-cell renal cell carcinoma (ccRCC) will eventually develop recurrent disease after surgery. Identification of patients who may benefit from intensification of care with adjuvant therapy is an important unmet need. Tumor-derived extracellular vesicles (EVs), microscopic particles released by tumor cells, have emerged as a potential biomarker in other malignancies but have not been studied in kidney cancer. Herein, we sought to characterize tumor specific EVs levels among patients undergoing radical nephrectomy for ccRCC. METHODS: We employed in silico multi-omic analysis of ccRCC tumors using TCGA KIRC (N=537 patients), CPTAC (N= 103 patients) and GTEx (N= 948 donors) to identify CD70, an integral membrane protein, as the top marker candidate for ccRCC-derived EVs. Expression of CD70+ in ccRCC-derived EVs was confirmed using freshly isolated tumor specimens. Blood levels of circulating CD70+-EVs were measured using high resolution flow cytometry in a cohort of age-matched healthy donors (HD) (N=15) and ccRCC patients (N=29) treated with radical nephrectomy. EVs levels between HD and RCC patients were compared using ANOVA test. Association between patient characteristics and EVs levels was analyzed using Pearson’s correlation and Fisher’s exact test. RESULTS: Blood levels of CD70+-EVs were significantly elevated in patients with pT1-T2 (median: 4.3×106 per mL, p<0.01) and pT3-T4 (median: 6.0×106, p<0.001) ccRCC compared with HD (median: 0.4×106, Figure 1A). High CD70+-EVs levels were associated with pT3-T4 stage (Figure 1B, p<0.0001).There was a strong positive correlation between CD70+-EVs at diagnosis and tumor size (Pearson r=0.76, p<0.0001, Figure 1C). Radical nephrectomy was associated with reduction in CD70+-EVs levels in 83.8% of patients (Figure 1D, p=0.0076). CONCLUSIONS: Patients with ccRCC, in particular those with larger and more advanced stage tumors, have high levels of circulating CD70+-EVs, which decreases significantly after surgery. CD70+-EVs levels are a marker of tumor burden in ccRCC and could be further explored as a biomarker for risk-stratification and selection of patients for additional treatment after radical nephrectomy for ccRCC. Source of Funding: Eagles 5th District Cancer Telethon - Cancer Research Fund (FL) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e499 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rodrigo R. Pessoa More articles by this author Reza Nabavizadeh More articles by this author Ali Arafa More articles by this author Roxane Lavoie More articles by this author Yohan Kim More articles by this author Liguo Wang More articles by this author Jeanette Eckel-Passow More articles by this author Bradley C. Leibovich More articles by this author Fabrice Lucien More articles by this author Expand All Advertisement PDF downloadLoading ...

A Quality Assessment of Goals of Care Forms in a Sample of Older Patients in Various Care Settings in Quebec, Canada.

The objective of this study is to assess the completion and content of the Goals of Care (GOC) forms in three care settingsinthe province of Quebec, Canada. This is a retrospective, cross-sectional, mixed methods analysis of data extracted from the charts and GOC forms of patients aged over 65 who received services during the year 2018 in one of the three following care settings: (i) long-term care facility, (ii) acute care hospital, and (iii) home support services of a regional healthcare and social services center. The completion of the GOC form includes six essential sections. If one or more of the sections were not fulfilled, we considered the form incomplete. We used descriptive analysis to look at the information in the six sections and a thematic analysis to assess the information in an open-ended section. We audited 589 charts, of which 67% contained a GOC form and only 96 (16%) a completed one. The most popular goal of care was ensuring comfort as a priority over prolonging life, selected on 40% of the forms. The majority of the included patients (89%) did not want cardiopulmonary resuscitation (CPR) to be attempted in the case of cardiac arrest. There was no indication of the use of advance medical directives, and scarce indication of the use of former GOC forms (18%) and living wills (2%) in completing the forms. Comments were included in 65% of the open-ended sections. The most frequent themes related to the use or non-use of interventions and to potential transfers to the hospital or to an intensive care unit. We found that the open-ended section was used on 24 forms to specify a different goal of care applicable in the eventof further health deterioration. A significant proportion of charts (84%) did not contain a completed GOC form; key aspects of advance care planning were rarely considered in establishing the patient's goal of care, and the form itself lacked utility given the frequency and nature of qualitative comments. As a final product of serious illness communication and decision-making, our findings suggest that there are significant quality issues, that patients are at risk of intensification of care at the end of life, and that more needs to be done to improve serious illness decision-making and documentation.

Ethical Management of COVID-19 Pandemic at a Neurological Hospital: The Ethicovid Report.

During the first wave of the coronavirus disease-2019 (COVID-19) pandemic, it was necessary to prepare for the possibility of triaging patients who could benefit from access to an intensive care unit (ICU). In our neuroscience institution, the challenge was to continue to manage usual neurological emergencies as well as the influx of COVID-19 patients. We report the experience of an ethical consulting unit to support care clinical decisions during the first wave of the pandemic (March 16 to April 30, 2020). Three objective evaluation criteria were defined: 2 of these criteria, patient's factors and general disease severity (Simplified Acute Physiology Score II), were common to all patients, and the third was the specific severity of the disease (neurological for brain injury, respiratory for COVID-19). Given our scarce resources, we used a high probability of a 3-month modified Rankin Scale ≤3 as the criterion for further resuscitation and management. A total of 295 patients were admitted during the first pandemic wave; 111 with COVID-19 and 184 with neurological emergencies. The ethical unit's expertise was sought for 75 clinical situations in 56 patients (35 COVID-19 and 21 neurological). Decisions were as follows: 11% no limitation on care, 5% expectant care with reassessment (maximum therapy to assess possible progress pending decision), 67% partial limitation (no intensification of care or no transfer to ICU), and 17% limitation of curative care. At no time did a lack of availability of ICU beds require the ethical unit to advise against admission to the ICU. Our ethical consulting unit allowed for collegial ethical decision-making in line with international recommendations. This model could be easily transferred to other triage situations, provided it is adapted to the local context.

Prognostic value of copeptin and mid-regional proadrenomedullin in COVID-19-hospitalized patients.

BackgroundBiomarkers are used for diagnosis, risk stratification and medical decisions. Copeptin and mid‐regional proadrenomedullin (MR‐proADM) are markers of stress and endothelial function, respectively, which have been studied in pneumonia, sepsis and septic shock. This study aimed to assess whether copeptin and MR‐proADM could predict coronavirus disease 2019 (COVID‐19) in‐hospital outcomes, that is multi‐system complications, length of stay and mortality.MethodsCopeptin and MR‐proADM were assessed at admission in 116 patients hospitalized with COVID‐19. Data were retrospectively extracted from an online database. The primary endpoint was in‐hospital mortality. The secondary endpoints were in‐hospital complications, the composite outcome ‘death, or admission to intensive care unit, or in‐hospital complications’, and length of stay. The predictive power was expressed as area under the receiver operator characteristic curve (AUROC).ResultsCopeptin was increased in non‐survivors (median 29.7 [interquartile range 13.0–106.2] pmol/L) compared to survivors (10.9 [5.9–25.3] pmol/L, p < 0.01). The AUROC for mortality was 0.71, with a hazard ratio of 3.67 (p < 0.01) for copeptin values > 25.3 pmol/L. MR‐proADM differentiated survivors (0.8 [0.6–1.1] nmol/L) from non‐survivors (1.5 [1.1–2.8] nmol/L, p < 0.001) and yielded a AUROC of 0.79 and a hazard ratio of 7.02 (p < 0.001) for MR‐proADM values > 1.0 nmol/L. Copeptin and MR‐proADM predicted sepsis (AUROC 0.95 and 0.96 respectively), acute kidney injury (0.87 and 0.90), the composite outcome (0.69 and 0.75) and length of stay (r = 0.42, p < 0.001, and r = 0.46, p < 0.001).ConclusionsAdmission MR‐proADM and copeptin may be implemented for early risk stratification in COVID‐19‐hospitalized patients to help identify those eligible for closer monitoring and care intensification.

COVID-19: identifying the main outcome predictors. A retrospective cohort study in Northern Italy.

The need for efficient drugs and early treatment of patients with SARS-CoV-2 infection developing COVID-19 symptoms is of primary importance in daily clinical practice and it is certainly among the most difficult medical challenges in the current century. Recognizing those patients who will need stronger clinical efforts could effectively help doctors anticipate the eventual need for intensification of care (IoC) and choose the best treatment in order to avoid worse outcomes. We enrolled 501 patients, consecutively admitted to our two COVID hospitals, and collected their clinical, anamnestic and laboratory data on admission. The aim of this retrospective study was to identify those data that are strictly associated with COVID-19 outcomes (IoC and in-hospital death) and that could somehow be intended as predictors of these outcomes. This allowed us to provide a "sketch" of the patient who undergoes, more often than others, an intensification of care and/or in-hospital death. Males were found to have a double risk of needing an IoC (OR=2.11) and a significant role was played by both the PaO2/FiO2 ratio on admission (OR=0.99) and serum LDH (OR=1.01). The main predictors of in-hospital death were age (OR=1.08) and the PaO2/FiO2 ratio on admission (OR=0.99). Male patients with high serum LDH on admission are those who undergo more often an intensification of care among COVID-19 inpatients. Both age and respiratory performances on admission modify the prognosis within the hospitalization period.

COVID-19 inpatients with gastrointestinal onset: sex and care needs\u2019 differences in the district of Ferrara, Italy

BackgroundCOVID-19 is characterized by interstitial pneumonia, but a presentation of the disease with digestive symptoms only may occur.This work was aimed at evaluating: (1) the prevalence of presentation with digestive symptoms only in our cohort of COVID-19 inpatients; (2) differences between patients with and without gastrointestinal onset; (3) differences among males and females with gastrointestinal presentation; (4) outcomes of the groups of subjects with and without gastrointestinal onset.MethodWe retrospectively divided the patients hospitalized with COVID-19 into two groups: (1) the one with digestive symptoms (DSG) and (2) the other without digestive symptoms (NDSG). We compared the subjects of DSG with those of NDSG and males with females in the DSG group only, in terms of demographics (age, sex), inflammation and organ damage indexes, length of stay, in-hospital and 100-day mortality.ResultsThe prevalence of gastrointestinal symptoms at presentation was 12.5%. The DSG group showed a prevalence of females, and these tended to a shorter hospital stay; DSG patients were younger and with a higher load of comorbidities, but no differences concerning inflammation and organ damage indexes, need for intensification of care, in-hospital and 100-day mortality were detected. Among DSG patients, males were younger than females, more comorbid, with higher serum CRP and showed a longer length of hospital stay. Survival functions of DSG patients, in general, are more favourable than those of NDSG if adjusted for sex, age and comorbidities.Conclusions(1) The prevalence of gastrointestinal presentation among hospitalized COVID-19 patients was 12.5%; (2) DSG patients were on average younger, more comorbid and with a prevalence of females, with a shorter hospital stay; (3) in the DSG group, males had a higher Charlson Comorbidity Score and needed a longer hospital stay; (4) DSG subjects seem to survive longer than those of the NDSG group.

Implementation of a Machine-Learning Algorithm in the Electronic Health Record for Targeted Screening for Familial Hypercholesterolemia: A Quality Improvement Study.

Implementation of a Machine-Learning Algorithm in the Electronic Health Record for Targeted Screening for Familial Hypercholesterolemia: A Quality Improvement Study.

Role of Statins in Coronavirus-Related Disease (COVID-19): A Retrospective Cohort Study in Northern Italy.

IntroductionThe outbreak by SARS-CoV-2 has rapidly spread worldwide. The need for specific treatments to adequately stop the inflammatory response and its sequelae is day by day more urgent and many therapeutic strategies were performed since COVID-19 burst in the last months. Statins were thought to be effective against this novel coronavirus for their anti-inflammatory properties, even if the real effects on COVID patients are still partially unexplored.MethodsWe retrospectively evaluated 501 adult patients, consecutively admitted to the two COVID-hospitals of Ferrara’s territory, and divided them into two groups: ST = patients on statin therapy on admission and NST=patients not on statin therapy on admission. We searched for differences between groups in terms of anamnestic, clinical and laboratory data and then in terms of COVID-19 outcomes.ResultsWe found significant differences between groups in terms of age, comorbidities, procalcitonin and CPK serum levels: ST patients were older, more comorbid, with lower procalcitonin and higher CPK serum levels. Male sex was, together with the Charlson Comorbidity Index, an independent predictor of needing intensification of care, while age only was a good predictor of in-hospital and 100-day mortality. Differences were also found in the survival functions between the two groups.ConclusionsAfter a period of observation of 100 days, ST patients, despite their older age and their greater load of comorbidities, have similar survival functions to NST patients. If adjusted for age and CCI the survival functions of ST group are considerably more favourable than those of the second group.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40292-021-00452-y.

Racial Disparities in Maternal Critical Care: Are There Racial Differences in Level of Care?

Obstetric care in the US is complicated by marked racial and ethnic disparities in maternal obstetric outcomes, including severe morbidity and mortality, which are not explained by underlying differences in patient characteristics. Understanding differences in care delivery related to clinical acuity across different racial groups may help elucidate the source of these disparities. This study examined the association of maternal race with utilization of critical care interventions. This is a retrospective cohort study conducted as a secondary analysis of a large, multicenter observational study of women undergoing cesarean delivery. All women with a known delivery date were included. The primary outcome measure, a composite of critical care interventions (CCI) at delivery or postpartum that included mechanical ventilation, central and arterial line placement, and intensive care unit (ICU) admission were compared by racial/ethnic group-non-Hispanic white, non-Hispanic black, Hispanic, Asian, and Native American. We evaluated differences in utilization of critical care with a multivariable regression model accounting for selected characteristics present at admission for delivery, including maternal age, BMI, co-morbidities, parity, and plurality. Maternal mortality was also evaluated as a secondary outcome and the frequency of CCI by significant maternal co-morbidity, specifically heart disease, renal disease, and chronic hypertension was assessed to ascertain the level of care provided to women of different race/ethnicity with specific baseline co-morbidities. 73,096 of 73,257 women in the parent trial met inclusion criteria, of whom 505 (0.7%) received a CCI and 3337 (4.6%) had a significant medical co-morbidity (1.2% heart disease, 0.8% renal disease, 2.5% chronic hypertension). The mortality rate was significantly higher among non-Hispanic black women, compared to non-Hispanic white and Hispanic women. In the adjusted model, there was no significant association between CCI and race/ethnicity. This study suggests that differences in maternal morbidity by race may be accounted for by differential escalation to higher intensity care. Further investigation into processes for care intensification may continue to clarify sources of racial and ethnic disparities in maternal morbidity and potential for improvement.

SARS-CoV-2 and finding of vein thrombosis: can IMPROVE and IMPROVEDD scores predict COVID-19 outcomes?

Diffuse thrombosis represents one of the most predominant causes of death by COVID-19 and SARS-CoV-2 infection seems to increase the risk of developing venous thromboembolic diseases (VTE). Aim of this study is to analyze the relationship between validated predictive scores for VTE such as IMPROVE and IMPROVEDD and: (1) Intensification of Care (IoC, admission to Pulmonology Department or Intensive Care Unit) (2) in-hospital mortality rate 3) 30-days mortality rate. We retrospectively evaluated 51 adult patients with laboratory diagnosis of SARS-CoV-2 infection and calculated IMPROVE and IMPROVEDD scores. All patients underwent venous color-Doppler ultrasound of the lower limbs to assess the presence of superficial vein thrombosis (SVT) and/or deep vein thrombosis (DVT). Patients with normal values of D-dimer did not receive heparin therapy (LMWH); patients with ≥ 4 ULN values of D-dimer or with a diagnosis of DVT were treated with therapeutic LMWH dosage, while the remaining patients were treated with prophylactic LMWH dosages. We found strong relations between IMPROVE score and the need for IoC and with the in-hospital mortality rate and between the IMPROVEDD score and the need for IoC. We defined that an IMPROVE score greater than 4 points was significantly associated to in-hospital mortality rate (p = 0.05), while an IMPROVEDD score greater than 3 points was associated with the need for IoC (p = 0.04). Multivariate logistic analysis showed how IMPROVE score was significantly associated to in-hospital and 30-days mortality rates. IMPROVE score can be considered an independent predictor of in-hospital and 30-days mortality.

Risk scores for predicting early antiretroviral therapy mortality in sub-Saharan Africa to inform who needs intensification of care: a derivation and external validation cohort study

BackgroundClinical scores to determine early (6-month) antiretroviral therapy (ART) mortality risk have not been developed for sub-Saharan Africa (SSA), home to 70% of people living with HIV. In the absence of validated scores, WHO eligibility criteria (EC) for ART care intensification are CD4 < 200/μL or WHO stage III/IV.MethodsWe used Botswana XPRES trial data for adult ART enrollees to develop CD4-independent and CD4-dependent multivariable prognostic models for 6-month mortality. Scores were derived by rescaling coefficients. Scores were developed using the first 50% of XPRES ART enrollees, and their accuracy validated internally and externally using South African TB Fast Track (TBFT) trial data. Predictive accuracy was compared between scores and WHO EC.ResultsAmong 5553 XPRES enrollees, 2838 were included in the derivation dataset; 68% were female and 83 (3%) died by 6 months. Among 1077 TBFT ART enrollees, 55% were female and 6% died by 6 months. Factors predictive of 6-month mortality in the derivation dataset at p < 0.01 and selected for the CD4-independent score included male gender (2 points), ≥ 1 WHO tuberculosis symptom (2 points), WHO stage III/IV (2 points), severe anemia (hemoglobin < 8 g/dL) (3 points), and temperature > 37.5 °C (2 points). The same variables plus CD4 < 200/μL (1 point) were included in the CD4-dependent score. Among XPRES enrollees, a CD4-independent score of ≥ 4 would provide 86% sensitivity and 66% specificity, whereas WHO EC would provide 83% sensitivity and 58% specificity. If WHO stage alone was used, sensitivity was 48% and specificity 89%. Among TBFT enrollees, the CD4-independent score of ≥ 4 would provide 95% sensitivity and 27% specificity, whereas WHO EC would provide 100% sensitivity but 0% specificity. Accuracy was similar between CD4-independent and CD4-dependent scores. Categorizing CD4-independent scores into low (< 4), moderate (4–6), and high risk (≥ 7) gave 6-month mortality of 1%, 4%, and 17% for XPRES and 1%, 5%, and 30% for TBFT enrollees.ConclusionsSensitivity of the CD4-independent score was nearly twice that of WHO stage in predicting 6-month mortality and could be used in settings lacking CD4 testing to inform ART care intensification. The CD4-dependent score improved specificity versus WHO EC. Both scores should be considered for scale-up in SSA.

Development and validation of prediction rules to target care intensification in veteran patients with diabetes

BackgroundDiabetes affects 30.3 million people in the USA. Among these people, a major risk factor for microvascular complications is having a glycated haemoglobin (HbA1c) value of ≥75 mmol/mol; therefore, it...

Interventions to improve adherence to lipid-lowering medication.

Lipid-lowering drugs are widely underused, despite strong evidence indicating they improve cardiovascular end points. Poor patient adherence to a medication regimen can affect the success of lipid-lowering treatment. To assess the effects of interventions aimed at improving adherence to lipid-lowering drugs, focusing on measures of adherence and clinical outcomes. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and CINAHL up to 3 February 2016, and clinical trials registers (ANZCTR and ClinicalTrials.gov) up to 27 July 2016. We applied no language restrictions. We evaluated randomised controlled trials of adherence-enhancing interventions for lipid-lowering medication in adults in an ambulatory setting with a variety of measurable outcomes, such as adherence to treatment and changes to serum lipid levels. Two teams of review authors independently selected the studies. Three review authors extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the quality of the evidence using GRADEPro. For this updated review, we added 24 new studies meeting the eligibility criteria to the 11 studies from prior updates. We have therefore included 35 studies, randomising 925,171 participants. Seven studies including 11,204 individuals compared adherence rates of those in an intensification of a patient care intervention (e.g. electronic reminders, pharmacist-led interventions, healthcare professional education of patients) versus usual care over the short term (six months or less), and were pooled in a meta-analysis. Participants in the intervention group had better adherence than those receiving usual care (odds ratio (OR) 1.93, 95% confidence interval (CI) 1.29 to 2.88; 7 studies; 11,204 participants; moderate-quality evidence). A separate analysis also showed improvements in long-term adherence rates (more than six months) using intensification of care (OR 2.87, 95% CI 1.91 to 4.29; 3 studies; 663 participants; high-quality evidence). Analyses of the effect on total cholesterol and LDL-cholesterol levels also showed a positive effect of intensified interventions over both short- and long-term follow-up. Over the short term, total cholesterol decreased by a mean of 17.15 mg/dL (95% CI 1.17 to 33.14; 4 studies; 430 participants; low-quality evidence) and LDL-cholesterol decreased by a mean of 19.51 mg/dL (95% CI 8.51 to 30.51; 3 studies; 333 participants; moderate-quality evidence). Over the long term (more than six months) total cholesterol decreased by a mean of 17.57 mg/dL (95% CI 14.95 to 20.19; 2 studies; 127 participants; high-quality evidence). Included studies did not report usable data for health outcome indications, adverse effects or costs/resource use, so we could not pool these outcomes. We assessed each included study for bias using methods described in the Cochrane Handbook for Systematic Reviews of Interventions. In general, the risk of bias assessment revealed a low risk of selection bias, attrition bias, and reporting bias. There was unclear risk of bias relating to blinding for most studies. The evidence in our review demonstrates that intensification of patient care interventions improves short- and long-term medication adherence, as well as total cholesterol and LDL-cholesterol levels. Healthcare systems which can implement team-based intensification of patient care interventions may be successful in improving patient adherence rates to lipid-lowering medicines.

Nurses, Doctors, and the Cardiac Arrest Paradigm: A Collaborative Endeavor.

This article explores the collaboration of doctors and nurses in establishing the Cardiac Arrest Paradigm (Paradigm), an intellectual and institutional framework that has shaped the practice of medicine for the past fifty years. An important manifestation of the Paradigm was the intensification of care, particularly at the end of life, whether or not it would help the patient. Paradigm also tended to narrow the physician's clinical gaze to single-organ systems, with the application of therapies based on narrow indications, often without regard to the whole patient. Cardiac arrest/resuscitation represents the quintessential indication/therapy dyad of the Paradigm and was formative in its creation. I argue that the interprofessional interactions between doctors and nurses constitute one of several factors that promoted the Paradigm within mid-twentieth-century medicine.Many of the underlying principles of the therapy for cardiac arrest were already established by the mid-twentieth century, when resuscitation still involved cutting open the body and squeezing the heart-open cardiac massage-and started moving out of the operating room onto the wards of the hospital in the 1950s. But the Paradigm clicked into existence after closed chest compressions and cardiopulmonary resuscitation (CPR) became the norm in the 1960s. At this time, a constellation of forces made resuscitation the default therapy for every patient whose heart stopped in the hospital, regardless of its expected efficacy, and cardiac arrest became the clinical condition we recognize today. This development marked a pivotal transformation in the history of medicine, not so much for the new technology-resuscitation had been practiced in various overlapping ways since the late eighteenth century-but because CPR and its indication, cardiac arrest, helped establish a model of care, a Paradigm that has gone largely unchallenged to the present day.A 1962 Circulation editorial on CPR is revealing. Most people who experience sudden stoppage or disruption of the heart beat (cardiac arrest) cannot be saved even under ideal circumstances in a hospital.1 authors specify the limited efficacy of CPR and infer in the next line that CPR had not yet become the default therapy for everyone whose heart stopped. The least measure of success has been experienced in coronary 'attack' cases. That this group experienced the least success implies that the comparison group was most likely patients whose heart stopped in the operating room, where cardiac resuscitation was initially developed and almost exclusively practiced until the 1950s. If everyone whose heart stopped in the hospital had been included in the resuscitation efforts, then those with cardiac arrest from other problems, including terminal conditions surely would have had the least measure of success. Although some patients from this group may have undergone resuscitation in 1962, it appears that they did not all receive resuscitation; CPR was not yet the default.One way of getting to the core of the Paradigm is to ask how a procedure that would not benefit most patients became the default treatment for everyone whose heart stopped in the hospital. accepted explanation for this phenomenon is the need for fire drill-like orchestration for the cardiac arrest team.2 Although precise and routinized execution of the therapy is doubtless a factor in the development of the Paradigm, there were many other forces that also drove it forward (see Table 1). One of the important forces in the early days of CPR was the interprofessional collaboration between nurses and physicians.Curiously, the 1962 Circulation editorial provided no additional guidance concerning who should and who should not receive CPR. Instead, the limitation is placed on who should perform it, with the last line stating, The undersigned organizations joining in the statement believe that emphasis should be placed at this time on training physicians, dentists, nurses, and specially qualified emergency personnel, so that the procedure will become more widely available. …

Evaluation of the changes of landscape types of Slovakia

In the last period landscape protection, its representative types more and more comes to the limelight. In October 2000 the European Landscape Convention - also known as the Florence Convention was adopted. The aims of this Convention are to promote landscape protection, management and planning, and to organise European co-operation on landscape issues. Contracting states ought to analyse the landscape types on the whole area of their countries, to analyse their features, record their changes, specify motive power and pressure forming them and assess selected types with respect to special values attributed by engaged participants and inhabitants. Knowledge and identification of single landscape types enable the intensification of care of diversity of single landscape types and landscape biodiversity. It is an unavoidable condition in the strategic planning process and effective protection of regionally special landscape. Slovakia signed ELC in 2005 and became an active participant in its implementation. The Institute of the Landscape Ecology of Slovak Academy of Sciences elaborated methodology for specification and evaluation of the representative landscape types of Slovakia (RLTS). RLTS are defined as homogeneous units considering the landscape character, functions and current land-use. GIS (Geographical Information Systems) tool was used to create RLTS, in particular by overlaying of abiotic landscape structure (type of relief, quaternary deposits, climatic regions, and soil types) and land-cover map (CORINE Land Cover 2006 - CLC) at national scale. This process yielded to a patched map of homogeneous areas, which were further interpreted, generalized, and regionalized to a final map of RLTS. Landscape types of Slovakia were defined by the synthesis of the mentioned maps. Totally there were identified 126 basic landscape types. Each landscape type represents unique combination of land-use in different abiotic conditions and gives the unique environment for nature development In the second stage typing rare and unique landscape types of Slovakia have been marked. Following, all RLTS were evaluated from the point of view nature protection and recent degradation and threats. In the meantime main changes of RLES were identified, taken into account also key driving forces of landscape changes and consequent pressures on the landscape. The final step included preparation of management proposal with aim to maintain all representative landscape types and to secure their sustainable development and protection.

Pneumonia and Mortality Risk in Continuous Ambulatory Peritoneal Dialysis Patients with Diabetic Nephropathy

BackgroundAlthough clinical experience suggests that patients with diabetes mellitus are more susceptible to several types of infections, the overall scope of pneumonia in continuous ambulatory peritoneal dialysis (CAPD) patients with diabetic nephropathy (DN) has received little attention.MethodsThis was a prospective observational cohort study in CAPD patients in which prognostic risks of pneumonia were evaluated in DN and non-DN patients by Cox regression analysis. Hazard ratios of pneumonia events, all-cause and pneumonia-related mortality were calculated by Kaplan-Meier curves and the Cox proportional hazards model for DN versus non-DN patients.ResultsA total of 1148 patients (58.6% male, 48.34±15.78 years) had a median follow-up of 23.8 months and a maximum follow-up of 72.0 months. The pneumonia incidence rate of 62.3/1,000 patient-years in CAPD patients with DN was significantly higher than that of 28.5/1,000 patient-years in non-DN patients. On multivariate analysis, independent predictors of pneumonia occurrence in CAPD patients with DN were high body mass index (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.01–1.31; P = 0.037) and low serum albumin level (HR, 0.87; 95% CI, 0.78–0.98; P = 0.014). Older age (HR, 1.63; 95% CI, 1.35–1.96; P<0.001) was an independent risk factor for the presence of pneumonia in non-DN patients. CAPD patients with DN had higher pneumonia-related mortality (HR, 4.424; 95% CI, 1.871–10.461; P<0.001) and all-cause mortality (HR, 2.608; 95% CI, 1.890–3.599; P<0.001) hazards than their non-DN counterparts, even when extensive demographics, comorbidities, and lab adjustments were made.ConclusionsThe pneumonia and all-cause mortality risks were strikingly higher in CAPD patients with DN than in non-DN counterparts, which may warrant further investigation and therapeutic care intensification.