1
|
Araya R, Menezes PR, Claro HG, Brandt LR, Daley KL, Quayle J, Diez-Canseco F, Peters TJ, Vera Cruz D, Toyama M, Aschar S, Hidalgo-Padilla L, Martins H, Cavero V, Rocha T, Scotton G, de Almeida Lopes IF, Begale M, Mohr DC, Miranda JJ. Effect of a Digital Intervention on Depressive Symptoms in Patients With Comorbid Hypertension or Diabetes in Brazil and Peru: Two Randomized Clinical Trials. JAMA 2021; 325:1852-1862. [PMID: 33974019 PMCID: PMC8114139 DOI: 10.1001/jama.2021.4348] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/08/2021] [Indexed: 12/11/2022]
Abstract
Importance Depression is a leading contributor to disease burden globally. Digital mental health interventions can address the treatment gap in low- and middle-income countries, but the effectiveness in these countries is unknown. Objective To investigate the effectiveness of a digital intervention in reducing depressive symptoms among people with diabetes and/or hypertension. Design, Setting, and Participants Participants with clinically significant depressive symptoms (Patient Health Questionnaire-9 [PHQ-9] score ≥10) who were being treated for hypertension and/or diabetes were enrolled in a cluster randomized clinical trial (RCT) at 20 sites in São Paulo, Brazil (N=880; from September 2016 to September 2017; final follow-up, April 2018), and in an individual-level RCT at 7 sites in Lima, Peru (N=432; from January 2017 to September 2017; final follow-up, March 2018). Interventions An 18-session, low-intensity, digital intervention was delivered over 6 weeks via a provided smartphone, based on behavioral activation principles, and supported by nurse assistants (n = 440 participants in 10 clusters in São Paulo; n = 217 participants in Lima) vs enhanced usual care (n = 440 participants in 10 clusters in São Paulo; n = 215 participants in Lima). Main Outcomes and Measures The primary outcome was a reduction of at least 50% from baseline in PHQ-9 scores (range, 0-27; higher score indicates more severe depression) at 3 months. Secondary outcomes included a reduction of at least 50% from baseline PHQ-9 scores at 6 months. Results Among 880 patients cluster randomized in Brazil (mean age, 56.0 years; 761 [86.5%] women) and 432 patients individually randomized in Peru (mean age, 59.7 years; 352 [81.5%] women), 807 (91.7%) in Brazil and 426 (98.6%) in Peru completed at least 1 follow-up assessment. The proportion of participants in São Paulo with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 40.7% (159/391 participants) in the digital intervention group vs 28.6% (114/399 participants) in the enhanced usual care group (difference, 12.1 percentage points [95% CI, 5.5 to 18.7]; adjusted odds ratio [OR], 1.6 [95% CI, 1.2 to 2.2]; P = .001). In Lima, the proportion of participants with a reduction in PHQ-9 score of at least 50% at 3-month follow-up was 52.7% (108/205 participants) in the digital intervention group vs 34.1% (70/205 participants) in the enhanced usual care group (difference, 18.6 percentage points [95% CI, 9.1 to 28.0]; adjusted OR, 2.1 [95% CI, 1.4 to 3.2]; P < .001). At 6-month follow-up, differences across groups were no longer statistically significant. Conclusions and Relevance In 2 RCTs of patients with hypertension or diabetes and depressive symptoms in Brazil and Peru, a digital intervention delivered over a 6-week period significantly improved depressive symptoms at 3 months when compared with enhanced usual care. However, the magnitude of the effect was small in the trial from Brazil and the effects were not sustained at 6 months. Trial Registration ClinicalTrials.gov: NCT02846662 (São Paulo) and NCT03026426 (Lima).
Collapse
Affiliation(s)
- Ricardo Araya
- Centre for Global Mental Health, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
| | - Paulo Rossi Menezes
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
- Department of Preventive Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Heloísa Garcia Claro
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
- School of Nursing, Universidade Estadual de Campinas, Campinas, Brazil
| | - Lena R. Brandt
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Kate L. Daley
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Julieta Quayle
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Francisco Diez-Canseco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Tim J. Peters
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Daniela Vera Cruz
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Mauricio Toyama
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Suzana Aschar
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Liliana Hidalgo-Padilla
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hellen Martins
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Victoria Cavero
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Thais Rocha
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - George Scotton
- Population Mental Health Research Centre, Universidade de São Paulo, São Paulo, Brazil
| | - Ivan F. de Almeida Lopes
- Federal University of ABC, Engineering, Modeling and Applied Social Sciences Center (CECS), Santo André, Brazil
| | - Mark Begale
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - David C. Mohr
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - J. Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| |
Collapse
|
2
|
Giordan E, Marton E, Scotton G, Canova G. Outcomes and risk factors for spontaneous spondylodiscitis: Case series and meta-analysis of the literature. J Clin Neurosci 2019; 68:179-187. [PMID: 31300250 DOI: 10.1016/j.jocn.2019.06.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 06/07/2019] [Accepted: 06/21/2019] [Indexed: 11/26/2022]
Abstract
Despite recent improvements in surgical and antimicrobial therapies, few generally applicable guidelines exist for spondylodiscitis management. We reviewed a consecutive series of patients as well as the past 18 years of the literature and analyzed outcomes for either conservative or surgical treatment. We analyzed a consecutive series of adults with spontaneous spondylodiscitis treated at our institution over the last 6 years. We analyzed predictors for neurological deficits, vertebral collapse, and surgical treatment. We also performed a meta-analysis of the literature between 2000 and 2018, stratifying the results between surgical and conservative treatment outcomes. A younger age at diagnosis, cervical location, tubercular infection, coexistence of morbidities, and vertebral collapse were predictors of surgical intervention. Cervical spondylodiscitis, vertebral collapse, and epidural collection were associated with a higher risk of developing neurological deficits, while tubercular spondylodiscitis was associated with a higher risk of vertebral collapse. Based on the current literature, conservative treatment has success rates similar to those of surgical treatment but lower complication and mortality rates. In cases without an absolute indication for surgery, a conservative approach should be considered as the first-line treatment. A closer diagnostic and clinical follow-up should be recommended in patients with cervical tract or tubercular spondylodiscitis because of the higher risk of developing bone collapse and neurological deficits.
Collapse
Affiliation(s)
- E Giordan
- Department of Neurologic Surgery, Treviso Regional Hospital, Treviso, Italy.
| | - E Marton
- Department of Neurologic Surgery, Treviso Regional Hospital, Treviso, Italy
| | - G Scotton
- Department of Infectious Diseases, Treviso Regional Hospital, Treviso, Italy
| | - G Canova
- Department of Neurologic Surgery, Treviso Regional Hospital, Treviso, Italy
| |
Collapse
|
3
|
Lagunes L, Borgatta B, Martín-Gomez MT, Rey-Pérez A, Antonelli M, Righi E, Merelli M, Brugnaro P, Dimopoulos G, Garnacho-Montero J, Colombo AL, Luzzati R, Menichetti F, Muñoz P, Nucci M, Scotton G, Viscoli C, Tumbarello M, Bassetti M, Rello J. Predictors of choice of initial antifungal treatment in intraabdominal candidiasis. Clin Microbiol Infect 2016; 22:719-24. [PMID: 27432766 DOI: 10.1016/j.cmi.2016.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 06/08/2016] [Accepted: 06/11/2016] [Indexed: 12/29/2022]
Abstract
Intraabdominal candidiasis (IAC) is the second most frequent form of invasive candidiasis, and is associated with high mortality rates. This study aims to identify current practices in initial antifungal treatment (IAT) in a real-world scenario and to define the predictors of the choice of echinocandins or azoles in IAC episodes. Secondary analysis was performed of a multinational retrospective cohort at 13 teaching hospitals in four countries (Italy, Greece, Spain and Brazil), over a 3-year period (2011-2013). IAC was identified in 481 patients, 323 of whom received antifungal therapy (classified as the treatment group). After excluding 13 patients given amphotericin B, the treatment group was further divided into the echinocandin group (209 patients; 64.7%) and the azole group (101 patients; 32.3%). Median APACHE II scores were significantly higher in the echinocandin group (p 0.013), but IAT did not differ significantly with regard to the Candida species involved. Logistic multivariate stepwise regression analysis, adjusted for centre effect, identified septic shock (adjusted OR (aOR) 1.54), APACHE II >15 (aOR 1.16) and presence in surgical ward at diagnosis (aOR 1.16) as the top three independent variables associated with an empirical echinocandin regimen. No differences in 30-day mortality were observed between groups. Echinocandin regimen was the first choice for IAT in patients with IAC. No statistical differences in mortality were observed between regimens, but echinocandins were administered to patients with more severe disease. Some disagreements were identified between current clinical guidelines and prescription of antifungals for IAC at the bedside, so further educational measures are required to optimize therapies.
Collapse
Affiliation(s)
- L Lagunes
- Critical Care Department, Vall d'Hebron University Hospital, Barcelona, Spain; Medicine Department, Universitat Autónoma de Barcelona, Spain.
| | - B Borgatta
- Critical Care Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - M T Martín-Gomez
- Microbiology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - A Rey-Pérez
- Critical Care Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - M Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of Rome, A. Gemelli Hospital, Rome, Italy
| | - E Righi
- IAC Study Coordinator, Santa Maria Misericordia University Hospital, Infectious Diseases Division, Udine, Italy
| | - M Merelli
- IAC Study Coordinator, Santa Maria Misericordia University Hospital, Infectious Diseases Division, Udine, Italy
| | - P Brugnaro
- Venezia Hospital, Infectious Diseases Division, Venice, Italy
| | - G Dimopoulos
- Attikon University Hospital, Critical Care Department, Athens, Greece
| | - J Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena Instituto de Biomedicina de Sevilla, Seville, Spain
| | - A L Colombo
- Escola Paulista de Medicina UNIFESP, Sao Paulo, Brazil
| | - R Luzzati
- University Hospital of Trieste, Trieste, Italy
| | - F Menichetti
- Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
| | - P Muñoz
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Microbiology and Infectious Diseases Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain
| | - M Nucci
- University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - C Viscoli
- Azienda Ospedaliera Universitaria, Genoa, Italy
| | - M Tumbarello
- Sacro Cuore Catholic University Hospital, Rome, Italy
| | - M Bassetti
- IAC Study Coordinator, Santa Maria Misericordia University Hospital, Infectious Diseases Division, Udine, Italy
| | - J Rello
- Medicine Department, Universitat Autónoma de Barcelona, Spain; University Hospital of Trieste, Trieste, Italy
| | | |
Collapse
|
4
|
Lagunes L, Borgatta B, Antonelli M, Bassetti M, Brugnaro P, Dimopoulos G, Diaz-Martin A, Colombo AL, Luzzati R, Menichetti F, Muñoz P, Nucci M, Palacios-Garcia I, Scotton G, Viscoli C, Tumbarello M, Rello J. Differences between intraabdominal candidiasis in regular wards versus intensive care unit. Intensive Care Med Exp 2015. [PMCID: PMC4798462 DOI: 10.1186/2197-425x-3-s1-a115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
|
5
|
Girelli ME, Busnardo B, Amerio R, Scotton G, Casara D, Betterle C, Piccolo M, Pelizzo MR. Serum thyroglobulin levels in patients with well-differentiated thyroid cancer during suppression therapy: study on 429 patients. Eur J Nucl Med 1985; 10:252-4. [PMID: 3987701 DOI: 10.1007/bf00254469] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
UNLABELLED Serum thyroglobulin (Tg) was measured in 429 patients with well-differentiated thyroid carcinoma, during thyroid hormone suppression therapy. 324 patients out of 429 were considered free of disease; 44 had only remnants in the thyroid bed; 61 had metastases, of them 40 were detected by TBS and 21 were nonfunctioning and were detected by other diagnostic procedures. Tg was measured by a RIA method in 257 patients and by an IRMA method in 277 patients. The correlation between the two methods was very good (r = 0.914) for values higher than 25 ng/ml with the RIA method. The cut-off limit to distinguish pathological from nonpathological values was considered the mean value found in the patients free of disease plus 2SD. The cut-off limit for the RIA method was 24.2 ng/ml and 3.0 ng/ml for the IRMA method. Of patients with high Tg levels 92% had metastases, either nodal or distant; only 8% had remnants in the thyroid bed. Tg levels were high in 80% of the patients with metastases, all but two of the patients with metastases and low Tg levels had nodal metastases. Moreover, Tg levels were high in 76% of the patients with metastases unable to take up radioiodine. IN CONCLUSION patients with low levels of serum Tg during suppression therapy have a high probability of being free of disease, even though the presence of tumors cannot be excluded. On the other hand a value greater than the cut-off limit suggests the presence of metastases despite a negative scan.
Collapse
|