Intervention In Daily Practice Research Articles

Changing from disease-centred to person-centred - Swedish dental hygienists' views on a theory-based behavioural intervention for improved oral hygiene among adolescents.

To explore dental hygienists' (DHs') views on (i) a person-centred, theory-based, behavioural intervention for improving oral hygiene among adolescents and (ii) professional and organizational factors to consider in the implementation of such an intervention in daily dental practice. Semi-structured interviews were conducted with 13 DHs who had applied the person-centred, theory-based, behavioural intervention directed at adolescents with poor oral hygiene in a field study within the Public Dental Service, Region Västra Götaland, Sweden. The interviews were audio-taped, transcribed verbatim and analysed using qualitative content analysis. The main theme 'From individual experts to partners - DHs changing direction from a disease-centred towards a person-centred approach' illustrated a changed professional approach among DHs, from exerting their roles as experts to encouraging partnership in treatment by supporting the adolescents in taking health behavioural decisions and responsibility for their oral health. The DHs considered the changed approach as challenging, but also more enjoyable, compared to conventional information/instruction. Adequate knowledge and skills, personal interest and willingness for a change as well as support from colleagues and clinic management were identified as prerequisites for implementing the person-centred, theory-based, behavioural intervention in daily practice, while the expenditure of time needed in relation to economic demands in care were seen as barriers. The findings elucidate that DHs considered the application of a person-centred, theory-based, behavioural intervention to be challenging but also enjoyable. For such an intervention to be implemented in daily practice, prerequisites and barriers need to be considered on both personal/professional and organizational levels.

Implementation of a lifestyle intervention for people with a severe mental illness (SMILE): a process evaluation

BackgroundSeveral interventions have been developed to improve physical health and lifestyle behaviour of people with a severe mental illness (SMI). Recently, we conducted a pragmatic cluster-randomised controlled trial which evaluated the effects of the one-year Severe Mental Illness Lifestyle Evaluation (SMILE) lifestyle intervention compared with usual care in clients with SMI. The SMILE intervention is a 12-month group-based lifestyle intervention with a focus on increased physical activity and healthy food intake. The aim of the current study was to explore the experiences of people with SMI and healthcare professionals (HCPs) regarding implementation feasibility of the SMILE intervention and the fidelity to the SMILE intervention.MethodsA process evaluation was conducted alongside the pragmatic randomized controlled trial. The experiences of clients and HCPs in the lifestyle intervention group were studied. First, descriptive data on the implementation of the intervention were collected. Next, semi-structured interviews with clients (n = 15) and HCPs (n = 13) were performed. Interviews were audiotaped and transcribed verbatim. A thematic analysis of the interview data was performed using MAXQDA software. In addition, observations of group sessions were performed to determine the fidelity to the SMILE intervention using a standardised form.ResultsTen out of 26 HCPs who conducted the group sessions discontinued their involvement with the intervention, primarily due to changing jobs. 98% of all planned group sessions were performed. Four main themes emerged from the interviews: 1) Positive appraisal of the SMILE intervention, 2) Suggestions for improvement of the SMILE intervention 3) Facilitators of implementation and 4) Barriers of implementation. Both clients and HCPs had positive experiences regarding the SMILE intervention. Clients found the intervention useful and informative. The intervention was found suitable and interesting for all people with SMI, though HCPs sometimes had to tailor the intervention to individual characteristics of patients (e.g., with respect to cognitive functioning). The handbook of the SMILE intervention was perceived as user-friendly and helpful by HCPs. Combining SMILE with daily tasks, no support from other team members, and lack of staff and time were experienced as barriers for the delivery of the intervention.ConclusionThe SMILE intervention was feasible and well-perceived by clients and HCPs. However, we also identified some aspects that may have hindered effective implementation and needs to be considered when implementing the SMILE intervention in daily practice.

Total Serum Protein as an Independent Predictor of Heart Failure with Preserved Ejection Fraction in Obese Pediatric Population

Objectives: We aimed to clarify the prognostic role of Total Serum Protein (TSP) in obese children with HFpEF and its using as an effective and noninvasive approach for screening of target population. Methods: In total, 587 patients who enrolled in our unique program aimed for children’s obesity treatment were referred. Among these patients, we identified and retrospectively studied 64 patients who met our criteria and compared them with 24 lean healthy subjects. Baseline examination, routine blood testing and transthoracic echocardiography were obtained. Results: We revealed that obese patients had higher TSP levels compared to them with normal weight. They also had worse echocardiographic results including a lower Left Ventricular Ejection Fraction (LVEF) and E/A ratio. Positive correlations between TSP and Pulmonary Artery Systolic Pressure (PASP), Left Atrial Volume Index (LAVI), and Interventricular Septal Systolic/Diastolic Dimension (IVSs, IVSd) and negative TSP correlations with LVEF and E/A ratio were found, too. Compared to the commonly used Albumin-to-Globulin Ratio (AGR), the TSP was a better metabolic predictor. There were more significant correlations in obese subgroup with HFpEF than to those without HFpEF. Conclusions: We first indicated that higher TSP levels are positively associated with obesity and HFpEF in children and could be used as a more easily available biomarker which provides a more-accurate HFpEF risk evaluation of obese pediatric population group than other objective indices, possibly allowing early implementation of appropriate intervention in daily practice and leads to better outcomes and early prevention in patients with higher HF risk.

Function focused care in hospital: A mixed-method feasibility study.

During hospitalization patients frequently have a low level of physical activity, which is an important risk factor for functional decline. Function Focused Care (FFC) is an evidence-based intervention developed in the United States to prevent functional decline in older patients. Within FFC, nurses help older patients optimally participate in functional and physical activity during all care interactions. FFC was adapted to the Dutch Hospital setting, which led to Function Focused Care in Hospital (FFCiH). FFCiH consists of four components: (1) 'Environmental and policy assessment'; (2) 'Education'; (3) 'Goal setting with the patient' and (4) 'Ongoing motivation and mentoring'. The feasibility of FFCiH in the Dutch hospital setting needs to be assessed. Introduce FFCiH into Dutch hospital wards, to assess the feasibility of FFCiH in terms of description of the intervention, implementation, mechanisms of impact, and context. Mixed method design. A Neurological and a Geriatric ward in a Dutch Hospital. 56 Nurses and nursing students working on these wards. The implementation process was described and the delivery was studied in terms of dose, fidelity, adaptions, and reach. The mechanisms of impact were studied by the perceived facilitators and barriers to the intervention. Qualitative data were collected via focus group interviews, observations, and field notes. Quantitative data were collected via evaluation forms and attendance/participation lists. A detailed description of FFCiH in terms of what, how, when, and by whom was given. 54 Nurses (96.4%) on both wards attended at least 1 session of the education or participated in bedside teaching. The nurses assessed the content of the education sessions with a mean of 7.5 (SD 0.78) on a 0-10 scale. The patient files showed that different short and long-term goals were set. Several facilitators and barriers were identified, which led to additions to the intervention. An important facilitator was that nurses experienced FFCiH as an approach that fits with the principles underpinning their current working philosophy. The experienced barriers mainly concern the implementation elements of the FFCiH-components 'Education' and 'Ongoing motivation and mentoring'. Optimizing the team involvement, improving nursing leadership during the implementation, and enhancing the involvement of patients and their family were activities added to FFCiH to improve future implementation. FFCiH is feasible for the Dutch hospital setting. Strong emphasis on team involvement, nursing leadership, and the involvement of patients and their families is recommended to optimize future implementation of FFCiH in Dutch hospitals.What is already known•Function Focused Care is an evidence-based intervention that prevents functional decline among hospitalized elderly;•It is proven to be effective in assistant living facilities, nursing homes, home care, and acute care settings in the United States;•It is unknown if the intervention can be implemented in the Dutch Hospital Setting.What this paper adds•This study showed the feasibility of Function Focused Care in Hospital and the challenges in some elements of the intervention;•Optimizing the team involvement, improving nursing leadership during the implementation, and enhancing the involvement of patients and their family were added to FFCiH to improve future implementation.•This feasibility study can guide the use of process evaluation in examining the feasibility of an intervention in daily practice.

Non-hyperaemic coronary pressure measurements to guide coronary interventions.

Evidence supporting the use of coronary physiology as an adjunct to coronary angiography to guide percutaneous coronary interventions has accumulated over the past 25years. The fractional flow reserve has dominated this evolving physiological guidance of coronary intervention and its use is supported by large clinical outcome trials. However, despite clinical practice guidelines advocating its use in most patients with coronary stenosis who are eligible for coronary intervention, the uptake of a physiology-guided approach remains limited. The use of non-hyperaemic coronary pressure measurements to guide coronary interventions was introduced in an attempt to simplify the routine application of coronary physiology-guided intervention in daily practice. Over the past decade, a large scientific effort has focused on the development of several non-hyperaemic pressure ratios. Inthis Review, we detail the basic principles of coronary physiology in non-hyperaemic conditions, the rationale for the use of non-hyperaemic coronary pressure measurements for stenosis evaluation, the current evidence base for the available non-hyperaemic coronary pressure ratios, the basis for the discordance between non-hyperaemic coronary pressure ratios and fractional flow reserve, and the potential advantages of these new parameters over fractional flow reserve.

Rapid antigen test use for the management of group A streptococcal pharyngitis in community pharmacies.

Despite group A streptococci being an infrequent cause of pharyngitis in adult outpatients, sore throat remains a common indication for antibiotic prescription. This prospective multicentre non-randomised study describes a community pharmacy-based antimicrobial stewardship intervention consisting in the implementation of rapid antigen testing (RAT) for the management of adults with sore throat. Trained pharmacists triaged patients presenting with symptoms of pharyngitis using the modified Centor score. Those at risk for streptococcal infection were tested with RAT. Patients with a positive RAT were invited to consult a physician, whereas others were offered a symptomatic treatment. All patients received educational leaflets and were asked to fill in a follow-up form 7days later. Ninety-eight pharmacies in one French region participated, and 559 patients were included over 6months. RAT was proposed in 367 (65.7%) cases, and it was positive in 28 (8.3%). The follow-up form was returned by 140 (38.5%) participants. Of these, 10/10 patients with positive RAT further consulted a physician and were prescribed an antibiotic treatment, whereas 96.5% (110/114) of patients with negative results and not having any other reason to seek for doctor's advice did not consult. All participants found the intervention useful. Pharmacists spent 6-15min to perform the intervention, and 98.6% (73/74) of pharmacists giving a feedback declared to be ready to implement this intervention in daily practice, if endorsed and reimbursed. Our results suggest that a pharmacy-based programme for the management of sore throat is feasible and could increase adherence to guidelines.

Ethical acceptability of offering financial incentives for taking antipsychotic depot medication: patients\u2019 and clinicians\u2019 perspectives after a 12-month randomized controlled trial

BackgroundA randomized controlled trial ‘Money for Medication’(M4M) was conducted in which patients were offered financial incentives for taking antipsychotic depot medication. This study assessed the attitudes and ethical considerations of patients and clinicians who participated in this trial.MethodsThree mental healthcare institutions in secondary psychiatric care in the Netherlands participated in this study. Patients (n = 169), 18–65 years, diagnosed with schizophrenia, schizoaffective disorder or another psychotic disorder who had been prescribed antipsychotic depot medication, were randomly assigned to receive 12 months of either treatment as usual plus a financial reward for each depot of medication received (intervention group) or treatment as usual alone (control group). Structured questionnaires were administered after the 12-month intervention period. Data were available for 133 patients (69 control and 64 intervention) and for 97 clinicians.ResultsPatients (88%) and clinicians (81%) indicated that financial incentives were a good approach to improve medication adherence. Ethical concerns were categorized according to the four-principles approach (autonomy, beneficence, non-maleficence, and justice). Patients and clinicians alike mentioned various advantages of M4M in clinical practice, such as increased medication adherence and improved illness insight; but also disadvantages such as reduced intrinsic motivation, loss of autonomy and feelings of dependence.ConclusionsOverall, patients evaluated financial incentives as an effective method of improving medication adherence and were willing to accept this reward during clinical treatment. Clinicians were also positive about the use of this intervention in daily practice. Ethical concerns are discussed in terms of patient autonomy, beneficence, non-maleficence and justice. We conclude that this intervention is ethically acceptable under certain conditions, and that further research is necessary to clarify issues of benefit, motivation and the preferred size and duration of the incentive.Trial registrationNederlands Trial Register, number NTR2350.

Surveillance colonoscopy after endoscopic treatment for colorectal neoplasia: From the standpoint of the Asia–Pacific region

Colonoscopy is considered the gold standard to detect and remove colorectal neoplasia. The efficacy of colonoscopy with polypectomy to reduce colorectal cancer incidence and mortality has been demonstrated. Recently, post-polypectomy surveillance colonoscopy has become a necessary intervention in daily practice not only in Western countries but also in the Asia-Pacific region. Therefore, it is crucial to establish new clinical practice guidelines to reduce the number of unnecessary surveillance colonoscopies in order to create space for screening colonoscopy. The Asia-Pacific Consensus group recommended that surveillance colonoscopy interval should be tailored according to risk level of index colonoscopy. However, precise guidelines on interval of surveillance cannot be given because of a lack of prospective data. According to Korean and Australian guidelines, surveillance intervals after index colonoscopy of 5years for low-risk subjects and 3years for high-risk subjects are recommended in Asia-Pacific regions at present. Prospective data including long-term outcomes from the Japan Polyp Study, which is a multicenter randomized control trial, would be useful to establish the Asia-Pacific consensus in the near future.

Comparison of conventional compressive dressings vs. wristband devices after catheterization by radial approach

ABSTRACT Background Wristband devices used in the compression of the radial puncture site add cost to the procedure and have not been adequately compared with conventional compressive dressings. This study evaluated the effectiveness and safety of both forms of hemostasis in patients undergoing coronary angiography and/or percutaneous coronary intervention in daily practice. Methods A prospective, multicenter, nonrandomized study, which included consecutive patients who underwent procedures through radial access. The type of compression was at the interventionist's discretion and the availability of wristband devices. The main objective was to compare the patency of the radial artery on the 7 th day after the procedure, measured by Doppler. Secondarily, the authors evaluated the occurrence of bleeding/hematoma at the puncture site during compression, after removal of the device and on the 7 th day after the procedure. Results This study evaluated 528 patients, 416 using conventional compressive dressings and 112 using wristband devices. When the sheath was removed and soon after its removal, a higher incidence of bleeding in the conventional compressive dressings group was observed (13.4% vs. 0%; p p = 0.20). Conclusions The use of wristband devices for radial artery hemostasis did not result in higher rates of late arterial patency when compared to conventional compressive dressings.

Resultados Clínicos Tardios do Stent Farmacológico Liberador de Sirolimus Firebird® no Tratamento de Pacientes com Doença Arterial Coronária na Prática Diária – Seguimento de 24 Meses do Registro CLARIFIRE

Introducao: O stent farmacologico liberador de sirolimus Firebird® ja demonstrou eficacia na inibicao de hiperplasia neointimal em pacientes selecionados submetidos a intervencao coronaria percutânea. Nosso objetivo foi avaliar o desempenho e o resultado clinico tardio do dispositivo Firebird® em pacientes submetidos a intervencao coronaria percutânea na pratica diaria nacional. Metodos: O Registro CLARIFIRE foi um estudo prospectivo, nao randomizado, multicentrico, que incluiu 455 pacientes (536 lesoes) em 14 centros no Brasil entre dezembro de 2008 e maio de 2011. O seguimento clinico foi realizado aos 1, 6, 12 e 24 meses, e os eventos adversos foram adjudicados por um Comite de Eventos Clinicos independente. Resultados: A media das idades foi de 61,1 ± 10,4 anos, 30,8% eram do sexo feminino, 41,9% tinham diabetes e 58,2% apresentaram-se com angina estavel. O vaso-alvo mais prevalente foi a arteria descendente anterior (46,5%), 29,9% eram lesoes reestenoticas e 8% lesoes em bifurcacao. Foram implantados 613 stents e as medias de extensao e diâmetro nominal dos stents foram 22,0 ± 6,4 mm e 2,90 ± 0,40 mm, respectivamente. O sucesso do procedimento foi de 97,6%. A taxa cumulativa de eventos cardiacos adversos maiores aos 12 meses (desfecho primario) foi 8,1%. Considerando-se os eventos pos-hospitalizacao ate 24 meses (409/455), observaram-se eventos cardiacos adversos maiores em 9,8%, morte cardiaca em 3,9% e revascularizacao do vaso-alvo em 7,6%. Ja a trombose de stent (definitiva/provavel) ocorreu em nove casos (2%) ate 30 dias, sem ocorrencias subsequentes. Conclusoes: O stent farmacologico liberador de sirolimus Firebird ® demonstrou desempenho favoravel, Alem de seguranca e eficacia sustentadas no tratamento de pacientes da pratica diaria, conforme evidenciado pela elevada taxa de sucesso do procedimento e pela ocorrencia relativamente baixa de eventos adversos ao final de 2 anos.

Comments on ‘The use of propensity scores and observational data to estimate randomized controlled trial generalizability bias’ by Taylor R. Pressler and Eloise E. Kaizar,Statistics in Medicine 2013

It has been widely accepted that most randomized control trials (RCTs) include patient groups that are not a representative sample of the patients who will receive the intervention in daily practice [1–3]. This has raised concerns about the generalizability of RCT results. Recently, Pressler and Kaizar [4] enriched the discussion by asserting that the bias that results from a lack of generalizability can be quantified. They define two populations: the first consisting of subjects fulfilling the inclusion criteria of an RCT (in their notation group I) and the second group (group E) comprising subjects not meeting the inclusion criteria. They propose to estimate the treatment effects in both groups ( O .I / and O .E/, respectively) using nonrandomized (i.e., observational) data. Assuming equal amounts of confounding in both groups, Ǒ D O .I / O .E/ provides an unbiased estimate of how much treatment effect modification there exists between included and excluded subjects. If the interest is in estimating the ‘population average treatment effect’ (PATE), weighing Ǒ by the proportion of E among the total population of interest O D nE n provides an estimate O D O Ǒ of how much ‘generalizability bias’ is created by relying on O .I / to estimate the PATE. This weighing of Ǒ is necessary because if there is treatment effect modification between groups I and E, the PATE is dependent on the proportionate size of both groups. While we acknowledge the relevance of the approach suggested by Pressler and Kaizar, we wish to touch upon some concerns and discuss alternative strategies for exploring generalizability. First, Pressler and Kaizar fail to address why one would be interested in the treatment effect in group E. For example, if we explore the effectiveness of a new antihypertensive drug and E comprises subjects without hypertension, it seems illogical to try to estimate treatment effect modification between groups I and E. Second, using nonrandomized data to estimate O or Ǒ only results in an unbiased estimate if the amount of confounding is equal in both groups E and I. This assumption is not testable, as the authors acknowledge, and results in a problem encountered in virtually all nonrandomized studies, that

A simple tool with which to study the course of chronic hand eczema in clinical practice: a reduced‐item score

Physicians need a simple, disease-specific tool with which to assess disease severity and the effect of therapeutic intervention in patients with chronic hand eczema. The currently available clinical scoring systems include numerous items, which makes them laborious to complete and limit their use in daily practice. To develop a simple tool with which to assess disease severity of patients with chronic hand eczema. We evaluated two tools, the Hand Eczema Severity Index (HECSI) and the Hand Eczema Area and Severity score, to determine their ability to predict the Investigator's Global Assessment (IGA) of disease severity in patients with moderate to severe hand eczema. We used a stepwise reduction analysis to determine a minimal set of significantly contributing items for predicting IGA. A three-item score, based on the highest observed value of induration, fissuring, and scaling, predicted IGA with a correlation of 0.667. The HECSI predicted the IGA with a correlation of 0.675. On the basis of this analysis, we propose a simple tool for clinical decision-making and evaluation of therapeutic intervention in daily practice.

Patients with coronary stenosis and a fractional flow reserve of ≥0.75 measured in daily practice at the VU University Medical Center.

Objectives. The aim of this study was to analyse the rate of major adverse clinical events in patients with coronary artery disease and a fractional flow reserve (FFR) of ≥0.75 and deferred for coronary intervention in daily practice. Methods. From 1 January to 31 December 2006, FFR measurement was initiated in 122 patients (5%) out of 2444 patients referred for coronary angiography. In two patients FFR measurement failed and in one patient the FFR value could no longer be traced in the documents. Thus, 119 patients (84 men, 64 years, range 41-85) were included in the evaluation (145 lesions). Major adverse clinical events (death, myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG)) and the presence of angina were evaluated at follow-up. Furthermore a cost-effectiveness analysis was performed.Results. In 93 patients (76%) the FFR value was ≥0.75. Seventy of these 93 patients (76%) were treated with medication alone or underwent PCI for a different lesion (medical treatment group). Average duration of follow-up of all 119 patients was 22 months (range 4 days to 30 months). In the medical treatment group seven patients (10%) experienced a major adverse clinical event related to the FFR-evaluated lesion during follow-up. In this study population, the use of FFR measurement is cost-reducing provided that at least 65% of the patients in the medical treatment group has had a PCI with stent implantation when the use of FFR measurement is impossible. In this case, the decision to use PCI with stent implantation is purely based on the angiogram. Conclusions. In patients with a coronary stenosis based on visual assessment and an FFR of ≥0.75 deferral of PCI or CABG is safe in daily clinical practice and saves money. (Neth Heart J 2010;18:402-7.).

Navigation und Robotik an der Otobasis

Computer-aided microscopic surgery of the lateral skull base is a rare intervention in daily practice. It is often a delicate and difficult minimally invasive intervention, since orientation between the petrous bone and the petrous bone apex is often challenging. In the case of aural atresia or tumors the normal anatomical landmarks are often absent, making orientation more difficult. Navigation support, together with imaging techniques such as CT, MR and angiography, enable the surgeon in such cases to perform the operation more accurately and, in some cases, also in a shorter time. However, there are no internationally standardised indications for navigated surgery on the lateral skull base. Miniaturised robotic systems are still in the initial validation phase.

AS-234: Safety and Feasibility of Left Transradial Coronary Intervention in Daily Practice

AS-234: Safety and Feasibility of Left Transradial Coronary Intervention in Daily Practice

Computerassistierte Chirurgie der Nasennebenhöhlen und der vorderen Schädelbasis

Endoscopic or microscopic surgery for chronic rhinosinusitis with or without nasal polyps is a routine intervention in daily practice. It is often a delicate and difficult minimally invasive intervention in a narrow space, with a tunnel view of 4 mm in the case of endoscopy and frequent bleeding in chronically inflamed tissue. Therefore, orientation in such a "labyrinth" is often difficult. In the case of polyp recurrence or tumors, the normal anatomical landmarks are often missing, which renders orientation even more difficult. In such cases, computer-aided navigation together with images such as those from computed tomography or magnetic resonance imaging can support the surgeon to make the operation more accurate and, in some cases, faster. Computer-aided surgery also has great potential for education.

Nurse adherence to a minimal‐contact smoking cessation intervention on cardiac wards

Health promotion interventions are often underused by care practitioners and, therefore, are not effective. In this study, we assessed nurses' use of a smoking cessation intervention in Dutch cardiac wards and factors associated with their adherence. Ninety-four of 206 nurses did not fully apply the intervention in daily practice; they did not always provide patients with self-help guides, discuss smoking cessation aids, or provide follow-up care. The significant factors in our integrated change model accounted for 52% of the variance in adherence. Adherence was most likely if nurses consistently used an intervention card, perceived advantages of the intervention, had other nurses around them who used it, and had been involved in decision-making.