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Impact of Short-Term Computerized Cognitive Training on Cognition in Older Adults With and Without Genetic Risk of Alzheimer's Disease: Outcomes From the START Randomized Controlled Trial. J Am Med Dir Assoc 2024; 25:860-865. [PMID: 38642588 DOI: 10.1016/j.jamda.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVES To establish the impact of a 3-minute computerized cognitive training program (START) on cognition in older adults with and without genetic risk of Alzheimer's disease. DESIGN Two-arm randomized controlled trial of the START program. SETTING AND PARTICIPANTS Remote online trial in adults older than 50 taking part from home. METHODS The trial compared the START program with placebo in 6544 people older than 50. Primary outcome was executive function measured through Trailmaking B, with other secondary cognitive measures. Genetic risk profile and ApoE4 status were determined by Illumina Array. RESULTS START conferred benefit to executive function, attention, memory, and a composite measure, including in people with the ApoE4 genotype. CONCLUSIONS AND IMPLICATIONS The 3-minute START task offers a means of supporting cognitive health in older adults and could be used at scale and within a precision medicine approach to reduce risk of cognitive decline in a targeted way.
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Healthcare Professionals' Attitudes towards and Knowledge and Understanding of Paediatric Palliative Medicine (PPM) and Its Meaning within the Paediatric Intensive Care Unit (PICU): A Summative Content Analysis in a Tertiary Children's Hospital in Scotland-"An In Vitro Study". Healthcare (Basel) 2023; 11:2438. [PMID: 37685471 PMCID: PMC10487473 DOI: 10.3390/healthcare11172438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/17/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Background: Paediatric palliative medicine (PPM) is a holistic approach to care for children and their families. Services are growing and developing worldwide but significant disparity in service provision remains. The Paediatric Supportive and Palliative Care Team (PSPCT) at the Royal Hospital for Children in Glasgow was established in 2019, but there is still no clear integrated role within the paediatric intensive care unit (PICU) at present. Through analysing the attitudes, meaning, knowledge and understanding of PPM in the PICU environment, we hoped to explore the experiences of those providing paediatric palliative care and to identify any barriers to or facilitators of integrated working to gain a better understanding of providing this care. Methods: This qualitative study used a survey composed of five open-ended and five closed questions. Sixteen out of a possible thirty-two responses (50%) were accrued from PICU healthcare professionals, including consultants (n = 19), advanced nurse practitioners (n = 4) and band-seven nurses (n = 9). The data were comprehensively studied and analysed by two coders using summative content analysis with assistance from data management software. Codes were further developed to form categories and subcategories. Results: Two categories were found: (1) the role of palliative care and (2) experiences of providing palliative care. A total of five subcategories were found, demonstrating that the PSPCT can enhance care in PICU through collaborative working. Barriers identified included staffing, funding and stigma around palliative care. Conclusions: This study shows that PICU professionals have a good understanding of the concepts of PPM and view it as an essential part of PICU work. Barriers related to resources and misperceptions of palliative care can be overcome through improved education, funding and staff retention, but this would require buy-in from policymakers. The perspective from our relatively small team increases generalizability to growing teams across the country.
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Effect of Grazing Management on Predator Soil Mite Communities (Acari: Mesotigmata) in Some Subalpine Grasslands from the Făgăraş Mountains-Romania. INSECTS 2023; 14:626. [PMID: 37504632 PMCID: PMC10380866 DOI: 10.3390/insects14070626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/29/2023]
Abstract
For the first time in Romania, a complex study was conducted on soil mite communities from two types of managed grasslands: ungrazed and intensively grazed. The study was accomplished in August 2018, in the Făgăraş Mountains. Within the soil mite communities (Mesostigmata), 30 species were identified, from 80 soil samples. The following population parameters were investigated: species richness, numerical abundance, dominance, Shannon index of diversity, evenness and equitability. Eight environmental variables were also measured: soil and air humidity; soil and air temperature; soil pH; resistance of soil to penetration; soil electrical conductivity; and vegetation coverage. The results revealed that species richness, Shannon index of diversity, evenness and equitability indices had higher values in ungrazed grasslands, whereas in intensively grazed areas, the numerical abundance and dominance index had significantly higher values. The species Alliphis halleri was dominant in the ungrazed grasslands. Each type of managed grassland was characterised by specific environmental conditions, which had an important influence, even at the species level.
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Short-term survival of patients with advanced pancreatic cancer admitted to intensive care unit: a retrospective cohort study. Ecancermedicalscience 2022; 16:1475. [PMID: 36819828 PMCID: PMC9934886 DOI: 10.3332/ecancer.2022.1475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Indexed: 11/24/2022] Open
Abstract
Background Little is known about the outcomes of patients with advanced pancreatic cancer admitted to the intensive care unit (ICU) due to medical complications. We designed a study to evaluate their short-term (30-day) survival, predictors of short-term survival and chances of additional chemotherapy. Methods We reviewed all patients with advanced (stage III or IV) pancreatic adenocarcinoma admitted to an ICU in a dedicated Brazilian cancer centre from 2009 to 2018 due to medical reasons. We fitted multivariate regression models to identify predictors of 30-day survival and additional systemic chemotherapy. Results The study population consisted of 171 patients. Ninety-four patients (55.0%) had Eastern Cooperative Oncology Group (ECOG) performance status 2-4 and 146 (85.4%) had metastatic disease. Most patients (N = 75; 43.9%) were admitted to the ICU during first-line treatment. Median overall survival was 32 days (95% confidence interval (95% CI): 20-49). Survival rate at 30 days was 50.6%. ECOG performance status 2-4 was the only variable associated with lower probability of survival at 30 days in multivariate analysis (odds ratio: 0.28; 95% CI: 0.14-0.54; p < 0.001). Overall, 58 patients (33.9%) received additional chemotherapy and among all patients, 13.5% experienced clinical benefit from this treatment. Conclusion Patients with advanced pancreatic cancer admitted to the ICU for medical reasons have a dismal prognosis. Early palliative care and refined tools to establish those who would benefit from an ICU trial could help improve patients' care.
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The influence of stocking density on behaviour, health, and production in commercial fattening turkeys - a review. Br Poult Sci 2022; 63:434-444. [PMID: 35275024 DOI: 10.1080/00071668.2022.2050673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Worldwide, there are various regulations and recommendations on the maximum stocking density. While stocking density can be determined based on the space covered by the body, a more appropriate method considers space requirements for natural behaviour.Turkeys are less likely disturbed at low stocking density as seen by increased sitting, lying, and preening behaviours, compared to animals housed at high stocking density. Furthermore, lower stocking density, together with smaller group size, species-appropriate light conditions and suitable structuring of barn housing, have been repeatedly mentioned as good strategies to prevent injurious pecking.Increased stocking density - in terms of weight and animal number per floor area - is related to increased litter moisture, which can have negative impact on animal welfare. High stocking density can lead to poor body mass gain and increased mortality, which are indicators of impaired welfare and economic losses.Based on the available scientific literature and economic aspects with regard to the above criteria, maximum stocking density for turkeys appears to be 40 kg live weight per m2 of usable floor space. However, the number of animals per square space should be limited to avoid increased litter moisture and reduced health and welfare.
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Outcomes of an interprofessional intensive comprehensive aphasia program's first five years. Top Stroke Rehabil 2021; 29:588-604. [PMID: 34698621 DOI: 10.1080/10749357.2021.1970452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVES This ICAP program is a collaboration between an institute of health professions and a rehabilitation hospital. It was a 6-week intensive treatment program for people with post-stroke aphasia designed to maximize recovery and return to activities. This retrospective study investigated outcomes of this program offered annually from 2015 to 2019. METHODS This is an analysis of existing data collected for other purposes. While conducting a therapeutic program for people with aphasia, data were not collected for the purpose of conducting research. The treatment components addressed the activity participation goals of 35 participants. Programming consisted of individual and group speech-language and occupational therapy, adaptive sports, swimming, music therapy, and a wellness mindfulness group.. Participants received a comprehensive evaluation and a treatment plan addressing their individual participation goals, delivered primarily by SLP and OT graduate students under faculty supervision. Pre- and post-treatment outcomes were measured within four WHO ICF domains: impairment, participation, environment, person. Each cohort consisted of seven or eight community-dwelling participants seen four days/week. RESULTS Significant post-treatment changes were observed on measures within the impairment domain and on self-perception measures of participation, functional communication, and communication confidence. Subsequent analyses found a subset of 15 responders (WAB Aphasia Quotient change of ≥5) drove most significant effects seen on performance-based impairment measures, but that patient-reported self-perception measures showed significant changes in both responders and non-responders. CONCLUSIONS Results support research indicating that short-term intensive, interprofessional comprehensive aphasia programs (ICAPs) are effective treatment options for people with moderate-to-severe aphasia.
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Intensive Comprehensive Aphasia Programmes: a systematic scoping review and analysis using the TIDieR checklist for reporting interventions. Disabil Rehabil 2021; 44:6471-6496. [PMID: 34445900 DOI: 10.1080/09638288.2021.1964626] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Aphasia is an acquired language disorder that typically occurs as a result of a stroke. People with aphasia experience communication difficulties and risk secondary impacts, for example, affecting social and work life and mental health. Intensive Comprehensive Aphasia Programmes (ICAPs) aims to address the multiple consequences of aphasia using intensive intervention and a wide range of therapy approaches. Although basic parameters of ICAP intervention have been defined, a fuller characterisation is needed. This systematic scoping review aimed to determine what constitutes an ICAP. METHODS Peer-reviewed and Grey databases were searched for articles on ICAPs using Joanna Brigg's Institute methodology. Data was extracted following the Template for Intervention Description and Replication (TIDieR) checklist for reporting interventions and synthesised using a narrative synthesis. RESULTS AND CONCLUSIONS 17 ICAPs were reported in 20 peer-reviewed literature sources (9 ICAPs supplemented by Grey literature sources). There were high degrees of variation in dose, professionals involved, and no qualitative data from participants. Of note, ICAP intervention was highly tailored to individual participants on the same ICAP, and intervention content varied between ICAPs. ICAPs appear to be rationalised as intensive impairment-based programmes with other components added for comprehensiveness. Stronger rationale and a logic model are required to justify the core components of ICAPs. The input of stakeholders into designing future ICAP interventions is recommended.IMPLICATIONS FOR REHABILITATIONThe ICAP model is in its infancy when it comes to mainstream clinical application as only the intensity component of the ICAP has clear theoretical underpinning as reported in the peer-reviewed literature.There have been clinical uptakes of the ICAP model which is likely to continue and is valid in the context of an under-researched area of aphasia therapy and on a background of a less than perfect relationship between evidence base and practice.Aspects of the ICAP model are valid for clinicians to implement, for example, intensive evidence-based aphasia therapy in combination with therapy which addresses some of the broader implications of aphasia, for example, social isolation.Clinicians can use the ICAP model to review their existing service provision and explore whether their service provides aphasia therapy that addresses the multiple aspects of aphasia (i.e., ensuring the focus is not only on impairment-based therapy).
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Mortality outcomes for MĀori requiring renal replacement therapy during critical illness: A single unit audit in Aotearoa New Zealand. Intern Med J 2021; 53:373-382. [PMID: 34432351 DOI: 10.1111/imj.15500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 08/14/2021] [Accepted: 08/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND MĀori in New Zealand (NZ) are disproportionately affected by chronic kidney disease (CKD), and experience lower life expectancy on community dialysis compared to non-MĀori. We previously identified higher renal replacement therapy (RRT) requirement for MĀori in our intensive care unit (ICU), the tertiary referral centre for NZ's Te Manawa Taki region. AIM Describe mortality outcomes by ethnicity in the RRT-requiring population in our ICU. METHODS Retrospective audit of the Australia and NZ Intensive Care Society database for adult admissions to our general ICU from Te Manawa Taki between 2014-2018. Patients were stratified by non-RRT requirement (non-RRT), RRT-requiring acute kidney injury (AKI-RRT), and RRT-requiring end-stage renal disease (ESRD). RESULTS Relative to the Te Manawa Taki population, MĀori were over-represented across all strata, especially ESRD (61.8%), followed by AKI-RRT (35.0%), and non-RRT (32.4%) (p<0.001). There was no excess mortality by ethnicity in any stratum. Crude in-ICU mortality was similar by ethnicity amongst AKI-RRT (30.8% amongst MĀori, vs 31.5%, p=1.000), and ESRD (16.4% amongst MĀori, vs 20.6%, p=0.826). This trend remained at 1 year. Adjusted for clinically selected variables, neither AKI-RRT nor ESRD mortality was predicted by MĀori ethnicity, both in-ICU and at 1-year. Irrespective of ethnicity, AKI-RRT patients had highest in-ICU mortality (31.2%) (p<0.001), whilst ESRD had highest 1-year mortality (46.1%) (p<0.001). CONCLUSION Increased RRT requirement amongst MĀori in our ICU is due to higher representation amongst ESRD. We did not demonstrate excess mortality by ethnicity in any stratum. AKI-RRT had higher in-ICU mortality than ESRD, but this reversed at 1-year. This article is protected by copyright. All rights reserved.
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Welfare assessment in intensive and semi-intensive dairy cattle management system in Sicily. Anim Sci J 2021; 92:e13546. [PMID: 33763968 DOI: 10.1111/asj.13546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 12/22/2020] [Accepted: 03/03/2021] [Indexed: 11/26/2022]
Abstract
The present study aimed to compare the welfare of dairy cows kept in two traditional husbandry systems (semi-intensive and intensive farming) in south-eastern Sicily. A total of 18 dairy farms (nine semi-intensive and nine intensive) were evaluated with a multicriteria system adapted for Sicilian conditions and obtained simplifying the model of the European Food Safety Authority (EFSA). Values of welfare measures, collected by inspections of the farms (general well-being indicators, ventilation system, resting areas [cubicles or bedding], flooring, milking parlours and waiting area, manger and watering equipment), and those of health categories (cases of abortions, hypocalcemia, displacement of abomasum, acidosis/ketosis, enteritis, hoof problems, and mastitis) obtained through the farm records, were compared using Mann-Whitney and Chi-squared tests, respectively. Data showed significant differences (p ≤ .05) about the variables related to welfare categories such as housing ventilation system, resting area, manger, and water equipment that were better in the semi-intensive system than the intensive system. No significant differences were observed about the variables related to health indicators. The results demonstrated that in Sicily the semi-intensive farm is better than the intensive to satisfy the conditions of animal welfare.
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"It's like a lifeboat": stakeholder perspectives of an intensive comprehensive aphasia program (ICAP)". APHASIOLOGY 2021; 36:10.1080/02687038.2021.1873905. [PMID: 38529517 PMCID: PMC10961968 DOI: 10.1080/02687038.2021.1873905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 01/05/2021] [Indexed: 03/27/2024]
Abstract
Background Intensive comprehensive aphasia programs (ICAPs) have gained popularity in recent years. Outcomes from ICAPs have demonstrated measurable improvements for most who take part, but how do people with aphasia and their family members experience an ICAP? Aim The aim of this paper was to explore, through qualitative interviews, the experiences of persons with aphasia and their family members who took part in an ICAP. Methods & Procedures Twelve interviews were conducted with persons with aphasia and family members regarding their experiences with the ICAP that they had just completed. Nine persons with aphasia were interviewed with their family members and three chose to take part in the interview alone. The Framework Analysis method was used to identify themes from the transcribed interviews. Outcomes & Results The interviewees discussed four themes related to treatment, psychosocial environments, physical environments, and outcomes. The interviewees remarked on the challenges that were provided by the treatment and how the treatment was different from previous treatment. Comments were made related to the relationships the participants and families developed within the context of the program. The physical environment allowed for relationships to develop. The interviewees discussed the physical and social environment as important additional factors that contribute to the overall therapeutic effect of the ICAP. Positive outcomes were noted in language skills and psychosocial contexts. Conclusions Based on interviewees' descriptions of this one ICAP, the concept of a therapeutic milieu was developed to describe how the intersection of the treatment, psychosocial interactions, and physical setting related to outcomes. Interviewees described how the therapeutic milieu of the ICAP was interwoven with the intensive therapy to create a "package" of therapy that led to improved outcomes. Implications for non-ICAP clinical practice is that participants linked more intensive therapy and greater social interactions with better outcomes.
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Utilization of treatment by Medicaid enrollees with opioid use disorder and co-occurring substance use disorders. Drug Alcohol Depend 2020; 217:108261. [PMID: 32979735 DOI: 10.1016/j.drugalcdep.2020.108261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/27/2020] [Accepted: 08/22/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Multiple substance use is common among adults who misuse opioids. Adverse consequences of drugs are more severe among multisubstance users than among single drug users. This study sought to determine whether adults with opioid use disorder (OUD) and at least one other substance use disorder (SUD) are less likely than adults with OUD only to receive certain services. METHODS We conducted a retrospective longitudinal study using the IBM® MarketScan® Multi-State Medicaid Database. We used logistic regression to measure associations between clinical characteristics and service utilization. The sample included non-Medicare-eligible adults aged 18-64 years with at least one claim in 2016 with a primary diagnosis of OUD who were continuously enrolled in Medicaid in 2016 and 2017. RESULTS Of the 58,745 Medicaid enrollees with an initial OUD diagnosis in 2016, 29,267 had one or more additional SUD diagnoses. In the year following diagnosis, these adults were less likely than adults with OUD only to receive OUD medication treatment (OR = 0.88, p < .0001). This was true for all specifically diagnosed co-occurring SUDS. Adults with OUD and a co-occurring SUD, however, were more likely than those with OUD only to use any type of high-intensity services. CONCLUSIONS Adults with OUD and at least one co-occurring SUD received more intensive services, which may reflect severity and lack of OUD medication treatment before misuse escalation. Programs should account for barriers to connecting these individuals to appropriate OUD treatment.
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Intensive Inpatient vs. Home-Based Rehabilitation After Hip Fracture in the Elderly Population. Front Med (Lausanne) 2020; 7:592693. [PMID: 33163503 PMCID: PMC7581791 DOI: 10.3389/fmed.2020.592693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/10/2020] [Indexed: 01/30/2023] Open
Abstract
Background: As the population ages, the rate of hip fractures and the need for rehabilitation increases. Home-based rehabilitation (HBR) is an alternative to classic inpatient rehabilitation (IR), which is an expensive framework with non-negligible risks. Methods: A retrospective study of patients 65 years and above following surgery to repair a hip fracture who underwent HBR or IR between 2016 and 2019. The two rehabilitation frameworks were compared for rehabilitation outcome and factors predicting successful rehabilitation. The outcome was determined with the Montebello Rehabilitation Factor Score-Revised (MRFS-R). Results: Data were collected for 235 patients over 3 years. The mean age was 81.3 ± 8.0 and 172 (73.3%) were women. Of these, 138 underwent IR and 97 HBR. The HBR group had better family support and fewer lived alone. There were also differences in the type of fracture and surgery. The medical condition of the IR group was more complex, as reflected in a higher Charlson's comorbidity scores, higher rates for delirium and more infectious complications, a lower Norton score, lower serum hemoglobin, and albumin levels, and higher serum creatinine and urea levels. It also had a more significant functional decline after surgery and required a longer rehabilitation period. However, no difference was found in the rehabilitation outcomes between the two groups (MRFS-R ≥ 50). The independent predictors for rehabilitation in the IR group were serum albumin level, comorbidity, and cognitive state. There were no independent predictors in the HBR group. Conclusions: In this retrospective study, there was no significant difference in short-term rehabilitation outcomes between the HBR and IR groups event though the patients in the IR group were medically more complex. This result should be taken into account when planning rehabilitation services after hip fracture and tailoring rehabilitation frameworks to patients.
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A critical reflection on intensive pork production with an emphasis on animal health and welfare. J Anim Sci 2020; 98:S15-S26. [PMID: 31784754 DOI: 10.1093/jas/skz362] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 11/28/2019] [Indexed: 12/19/2022] Open
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Outcomes of transition from premixed and intensive insulin therapies to insulin aspart/degludec co-formulation in type 2 diabetes mellitus: a real-world experience. Arch Med Sci 2020; 17:1-8. [PMID: 33488849 PMCID: PMC7811302 DOI: 10.5114/aoms.2020.93264] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/28/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION To evaluate the efficacy and safety of transition from premixed and intensive insulin to twice-daily insulin degludec/aspart (IDegAsp) co-formulation in patients with type 2 diabetes mellitus. MATERIAL AND METHODS In this 12-week study, patients receiving twice-daily premixed insulin therapy in group 1 (n = 55) were switched to twice-daily IDegAsp. In group 2 (n = 60), patients on intensive insulin therapy were switched to IDegAsp injected twice a day. Inter- and intragroup comparisons were made. RESULTS A total of 115 patients were included in the study. There was a significant improvement in glycaemic control, median daily total insulin dose, body mass, body mass index, and hypoglycaemic events in group 1 and group 2 with the switch to IDegAsp (p < 0.05). The decrease in median daily total insulin dose requirement in group 2 was higher than that of group 1 (p = 0.001). There was no difference between groups in terms of other parameters (p > 0.05). CONCLUSIONS The current analysis indicates that IDegAsp treatment improves outcomes, with the most notable differences observed in daily total insulin requirement, body mass, and hypoglycaemia.
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Development and Trial Implementation of a 30-Day Outpatient Program for Subthreshold PTSD. Mil Med 2020; 185:e38-e42. [PMID: 31287892 DOI: 10.1093/milmed/usz165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/10/2019] [Accepted: 06/11/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Posttraumatic stress disorder (PTSD) negatively impacts service members at high rates, causing considerable physical and psychological consequences. Additionally, many service members experience subthreshold PTSD (i.e., experiencing PTSD symptoms that do not meet full diagnostic criteria), which has also been shown to cause significant functional impairment and can be a precursor to the development of full PTSD. Typically, treatment for PTSD at Walter Reed National Military Center facility includes weekly outpatient individual therapy over a three-month period or referral to an intensive outpatient program (IOP), which emphasizes group treatment. Inclusion in these programs is dependent on the severity of symptoms. Service members with subthreshold symptoms do not typically qualify for an IOP, and weekly outpatient therapy does not meet the needs of some service members or their commands. METHODS As a result, we developed an alternative program with the intention of allowing service members with subthreshold PTSD to receive treatment and return to full-duty status more rapidly. The program emphasized bi-weekly evidenced-based PTSD therapies treatment adjusted to meet the needs of each service member along with the option of adjunct individual and group treatments. RESULTS While this program is ongoing and we have not yet conducted outcome data analyses, the structure and pace of this program have the potential to produce quicker functional improvements, prevent the development of full PTSD symptoms, and reduce long-term or recurring healthcare utilization. CONCLUSION Although more research is needed, there exists preliminary empirical evidence of efficacy for an accelerated protocol of biweekly evidence-based therapy for service members with subthreshold PTSD. DISCLAIMER The opinions expressed in this abstract are those of the authors and do not necessarily represent the opinions of the Uniformed Services University of the Health Sciences, the Department of Defense, or the United States Government. Additionally, the authors have no conflicts of interests to report.
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Effect of glycaemic control on cardiovascular disease in individuals with type 2 diabetes with pre-existing cardiovascular disease: A systematic review and meta-analysis. Diabetes Obes Metab 2019; 21:732-735. [PMID: 30426626 DOI: 10.1111/dom.13581] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 11/09/2018] [Accepted: 11/09/2018] [Indexed: 11/29/2022]
Abstract
The role of intensive glucose control in people with type 2 diabetes and pre-existing cardiovascular disease (CVD) is controversial. The aim of this systematic review and meta-analysis was to determine in a subset of people with type 2 diabetes and pre-existing CVD, the CV effect of intensive glucose control versus standard of care. We searched Medline, the Cochrane library, EMBASE and the National Institutes of Health Trial registration database for randomized controlled trials that evaluated the effect of intensive glucose control versus standard glucose control in people with type 2 diabetes on incident CVD. Data were extracted using a structured form. When data were not available in the publications, authors were contacted. Eight trials involving 8339 participants were included. Among adults with type 2 diabetes and pre-existing CVD, there was no difference in the risk of CV events in those allocated to intensive glucose control compared with those in the standard care arm (relative risk 0.98, 95% confidence interval 0.87-1.09). In conclusion, in people with diabetes and pre-existing CVD, intensive glucose control versus standard care had a neutral effect on incident CV events.
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Effect of intensive blood pressure lowering on cardiovascular outcomes based on cardiovascular risk: A secondary analysis of the SPRINT trial. Eur J Prev Cardiol 2018; 26:238-245. [PMID: 30256671 DOI: 10.1177/2047487318800741] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND It is not clear whether risk stratification can help choose the most favourable systolic blood pressure target for primary prevention of cardiovascular events. DESIGN A secondary analysis of Systolic Blood Pressure Intervention Trial (SPRINT). METHODS To perform a secondary analysis, we obtained the data from SPRINT from the National Heart, Lung, and Blood Institute data repository centre. In SPRINT, an open-label trial, participants without diabetes with systolic blood pressure of ≥130 mmHg were randomly assigned to intensive and standard treatment groups with systolic blood pressure targets of <120 and <140 mmHg, respectively. The primary composite outcome was myocardial infarction and other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Here, we have analysed data from participants without cardiovascular disease and chronic kidney disease aged under 75 years categorised based on the baseline 10-year Framingham risk score (<10% (low risk); ≥10% and <15% (intermediate risk); ≥15% (high risk)). RESULTS A total of 4298 patients were included in the analysis. With intensive treatment, there was a significant reduction in the primary outcome events in patients at high risk (0.86% per year vs. 1.81% per year; hazard ratio (HR) 0.51; 95% confidence interval (CI) 0.31 to 0.85; P = 0.010), and at intermediate risk (0.60% per year vs. 1.46% per year; HR 0.37; 95% CI 0.17 to 0.82; P = 0.014) but not for those at low risk (0.75% per year vs. 0.57% per year; HR 1.14; 95% CI 0.55 to 2.38; P = 0.714). CONCLUSIONS Intensive systolic blood pressure reduction is beneficial for primary prevention of cardiovascular morbidity and mortality in patients without diabetes with more than low cardiac risk (above 10%).
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Blood pressure reduced to new guideline goals in patients with high-normal glucose further reduces cardiovascular events. J Clin Hypertens (Greenwich) 2018. [PMID: 29532984 DOI: 10.1111/jch.13242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Effects of Intensive Blood Pressure Control in Patients with Evident Cardiovascular Disease: An Investigation Using the SPRINT Study Data. Curr Vasc Pharmacol 2018; 17:298-306. [PMID: 29512468 DOI: 10.2174/1570161116666180305160116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent data advocate adoption of a more intensive treatment strategy for management of blood pressure (BP). OBJECTIVE We investigated whether the overall effects of the Systolic Blood Pressure Intervention Trial (SPRINT) are applicable to cardiovascular disease (CVD) patients. METHODS In a post hoc analysis we analyzed data from SPRINT that randomly assigned 9361 individuals to a systolic BP (SBP) target of <120 mmHg (intensive treatment) or <140 mmHg (standard treatment). 1562 patients had clinically evident CVD (age=70.3±9.3 years, 24% females) at study entry and were followed for 3.1 years. Further, we assessed the effect of low (<150 mmHg) baseline SBP on outcome. RESULTS In CVD patients, there was no benefit from the intensive treatment regarding all endpoints, except for a marginally significant benefit on all-cause mortality (hazard ratio [HR]: 0.67; 95% confidence interval [CI], 0.45 to 1.00; p=0.0509). Further, while there was no increase in serious adverse events (SAE) in the intensive group, there was increased risk for study-related SAE, acute renal failure and electrolyte abnormalities. In patients with low baseline SBP there was a beneficial effect on allcause mortality (HR: 0.56; 95% CI: 0.33 to 0.96; p=0.033), but with greater stroke incidence (HR: 2.94; 95% CI: 1.04 to 8.29; p=0.042). CONCLUSION We confirm the beneficial effect of the intensive strategy in SPRINT study on all-cause mortality and the harmful effect on specific adverse outcomes in patients with CVD. However, in patients with low baseline SBP stroke may increase.
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Massed versus spaced practice in vocology: effect of a short-term intensive voice training versus a longer-term traditional voice training. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2018; 53:393-404. [PMID: 29205707 DOI: 10.1111/1460-6984.12358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND In contrast with most medical and pharmaceutical therapies, the optimal dosage for voice therapy or training is unknown. AIMS The aim of this study was to compare the effect of a short-term intensive voice training (IVT) with a longer-term traditional voice training (TVT) on the vocal quality and vocal capacities of vocally healthy non-professional voice users. METHODS & PROCEDURES A pre-/post-test randomized control group design with follow-up measurements was used. Twenty healthy female non-professional voice users with a mean age of 21.7 years (range = 20-24 years) were randomly assigned into a short-term IVT group (n = 10) or a longer-term TVT group (n = 10). Both groups received an identical 6-h lasting voice training. Only the distribution of practice varied between the groups: 2 h a day for 3 consecutive days for the IVT group versus two 30-min sessions a week for 6 weeks for the TVT group. In both groups, a voice assessment protocol consisting of subjective (questionnaire, participant's self-report, auditory-perceptual evaluation) and objective (maximum performance task, acoustic analysis, voice range profile, dysphonia severity index) measurements and determinations was used to evaluate the participants' voice pre- and post-training and at 6 weeks follow-up. Groups were compared over time using linear mixed models and generalized linear mixed models. Within-group effects of time were determined using post-hoc pairwise comparisons with Bonferroni corrections. OUTCOMES & RESULTS No significant time-by-group interactions were found for any of the outcome measures, indicating no significant differences in evolution over time between the groups. Significant time effects were found for maximum phonation time, lowest intensity, lowest frequency, highest frequency and dysphonia severity index, all improving over time in both groups. More in-depth within-group analyses indicate a preference for the IVT group regarding the evolution of maximum phonation time, lowest frequency and dysphonia severity index, and a preference for the TVT group regarding the evolution of lowest intensity. CONCLUSIONS & IMPLICATIONS Short-term IVT may be equally, or even more, effective in training vocally healthy non-professional voice users compared with longer-term TVT.
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Protocolised early goal-directed therapy in patients with sepsis/septic shock does not result in improved survival compared with usual care with less invasive resuscitation strategies. ACTA ACUST UNITED AC 2017; 22:223. [PMID: 29056602 DOI: 10.1136/ebmed-2017-110805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2017] [Indexed: 11/03/2022]
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Abstract
Clinical question Is intensive blood pressure (BP) treatment (systolic BP target 110-139 mm Hg) better than standard antihypertensive treatment (systolic BP target 140-179 mm Hg) in reducing mortality and disability in patients with acute intracerebral hemorrhage (ICH)? Article chosen Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med 2016;375(11):1033-43. OBJECTIVE To determine the therapeutic benefit of intensive BP treatment compared to standard BP treatment in reducing death and disability after 3 months of follow-up among patients with ICH treated within 4.5 hours from onset of symptoms.
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Characteristics and outcomes of older patients with secondary acute myeloid leukemia according to treatment approach. Cancer 2017; 123:3050-3060. [PMID: 28387922 DOI: 10.1002/cncr.30704] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 02/20/2017] [Accepted: 03/07/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The development of newer strategies to improve outcomes for older patients with secondary acute myeloid leukemia (s-AML) is a critical unmet need. Establishing baseline metrics for evaluating newer approaches is important. METHODS s-AML was defined as 1 or more of the following: a history of an antecedent hematologic disorder (AHD), a diagnosis of therapy-related acute myeloid leukemia (AML), and AML with karyotype abnormalities characteristic of myelodysplastic syndrome. Newly diagnosed s-AML patients aged 60 to 75 years were grouped into 5 treatment cohorts: 1) patients receiving high- or intermediate-dose cytarabine-based intensive chemotherapy (IC), 2) patients receiving a hypomethylating agent (HMA) or HMA combinations, 3) patients receiving low-dose cytarabine (LDAC) combinations, 4) patients receiving CPX-351, and 5) patients receiving investigational (INV) agents. Nine hundred thirty-one patients met the age and s-AML criteria. RESULTS Complete remission rates were statistically lower in the HMA group (36%) versus the IC (46%), CPX-351 (45%), and LDAC groups (43%). Patients receiving less intensive regimens (the HMA and LDAC groups combined) had superior overall survival (OS) in comparison with patients receiving IC-based regimens (median 6.9 vs 5.4 months; P = .048). Only 4.3% of the IC patients proceeded to transplantation, whereas 10.3% of the patients on lower intensity regimens did (P = .001). There was no difference in median survival between patients treated with CPX-351 and patients treated with conventional lower intensity approaches (P = .75). Age > 70 years, an adverse karyotype, and a prior AHD were associated with decreased OS in a multivariate analysis. CONCLUSIONS Lower intensity approaches are associated with lower early mortality rates and improved OS in comparison with intensive regimens. OS is poor with currently available therapies with a median OS of 6 months (5.4-7.6 months across regimens). Unsatisfactory outcomes with other INV agents underscore the need for more effective therapies. Cancer 2017;123:3050-60. © 2017 American Cancer Society.
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Cost-Effectiveness of Intensive Vs. Standard Follow-Up Models for Patients with Breast Cancer in Shiraz, Iran. Asian Pac J Cancer Prev 2016; 17:5309-5314. [PMID: 28125878 PMCID: PMC5454675 DOI: 10.22034/apjcp.2016.17.12.5309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Breast cancer is the most common type of cancer amongst women throughout the world. Currently, there are various follow-up strategies implemented in Iran, which are usually dependent on clinic policies and agreement among the resident oncologists. Purpose: A cost-effectiveness analysis was performed to assess the cost-effectiveness of intensive follow-up versus standard models for early breast cancer patients in Iran. Materials and methods: This cross sectional study was performed with 382 patients each in the intensive and standard groups. Costs were identified and measured from a payer perspective, including direct medical outlay. To assess the effectiveness of the two follow-up models we used a decision tree along with indicators of detection of recurrence and metastasis, calculating expected costs and effectiveness for both cases; in addition, incremental cost-effectiveness ratios were determined. Results: The results of decision tree showed expected case detection rates of 0.137 and 0.018 and expected costs of US$24,494.62 and US$6,859.27, respectively, for the intensive and standard follow-up models. Tornado diagrams revealed the highest sensitivity to cost increases using the intensive follow-up model with an ICER=US$148,196.2. Conclusion: Overall, the results showed that the intensive follow-up method is not cost-effective when compared to the standard model.
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The influence of intensive lifestyle intervention on patients with isolated impaired fasting glucose: a meta-analysis. J Adv Nurs 2016; 72:2587-2597. [PMID: 27237703 DOI: 10.1111/jan.13015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2016] [Indexed: 12/31/2022]
Abstract
AIM To evaluate the effect of intensive lifestyle intervention on patients with isolated impaired fasting glucose. BACKGROUND The application of lifestyle intervention to clinical nursing can help improve outcomes of patients with impaired fasting glucose. DESIGN We performed a meta-analysis of randomized controlled trials using methods outlined in the Cochrane Handbook. METHODS We performed keyword searches of the literature databases up to September 2014 and performed manual searches of selected article reference lists. Data were extracted by the lead reviewer, cross-checked by the second reviewer, entered into RevMan5·3, and pooled and analysed using the fixed effect inverse-variance model or random effects model to determine the mean difference and calculate the weighted mean difference. The heterogeneity statistic (I2 ), overall effect (Z) and P-value were calculated. RESULTS A total of five studies were included in our analysis. Following the heterogeneity test statistic, overall effect Z score with P-value was calculated. The targets of fasting plasma glucose, weight, body mass index, triglycerides, high-density lipoprotein cholesterol and total cholesterol all showed significant differences between the intervention and control groups. CONCLUSION Lifestyle intervention can improve glycaemic control in patients with isolated impaired fasting glucose. It also reduces blood-lipid levels and promotes weight loss. Larger patient cohorts and adequate follow-up should be included in future trials.
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Protein-bound uraemic toxins, dicarbonyl stress and advanced glycation end products in conventional and extended haemodialysis and haemodiafiltration. Nephrol Dial Transplant 2015; 30:1395-402. [PMID: 25862762 DOI: 10.1093/ndt/gfv038] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/20/2015] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Protein-bound uraemic toxins (PBUT), dicarbonyl stress and advanced glycation end products (AGEs) associate with cardiovascular disease in dialysis. Intensive haemodialysis (HD) may have significant clinical benefits. The aim of this study was to evaluate the acute effects of conventional and extended HD and haemodiafiltration (HDF) on reduction ratio (RR) and total solute removal (TSR) of PBUT, dicarbonyl stress compounds and AGEs. METHODS Thirteen stable conventional HD patients randomly completed a single study of 4-h HD (HD4), 4-h HDF (HDF4), 8-h HD (HD8) and 8-h HDF (HDF8) with a 2-week interval between the study sessions. RR and TSR of PBUT [indoxyl sulphate (IS), p-cresyl sulphate (PCS), p-cresyl glucuronide, 3-carboxyl-4-methyl-5-propyl-2-furanpropionic acid (CMPF), indole-3-acetic acid (IAA) and hippuric acid] of free and protein-bound AGEs [N(ε)-(carboxymethyl)lysine (CML), N(ε)-(carboxyethyl)lysine (CEL), Nδ-(5-hydro-5-methyl-4-imidazolon-2-yl)-ornithine, pentosidine], as well as of dicarbonyl compounds [glyoxal, methylglyoxal, 3-deoxyglucosone], were determined. RESULTS Compared with HD4, HDF4 resulted in increased RR of total and/or free fractions of IAA and IS as well as increased RR of free CML and CEL. HD8 and HDF8 showed a further increase in TSR and RR of PBUT (except CMPF), as well as of dicarbonyl stress and free AGEs compared with HD4 and HDF4. Compared with HD8, HDF8 only significantly increased RR of total and free IAA and free PCS, as well as RR of free CEL. CONCLUSIONS Dialysis time extension (HD8 and HDF8) optimized TSR and RR of PBUT, dicarbonyl stress and AGEs, whereas HDF8 was superior to HD8 for only a few compounds.
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Abstract
In 2005, the Scottish Executive recommended that young people with severe mental health difficulties should be managed in the community wherever possible. This study reports on the clinical outcomes associated with the development of a Child and Adolescent Mental Health (CAMH) Intensive Treatment Service (ITS) embedded within a Tier Four CAMHS structure. Following intervention, mean CGAS ratings significantly improved by 16 points (p<0.001) and HoNOSCA Clinical Scores significantly decreased by a mean of 6.94 points (p<0.001). This trend was replicated in self-report measures, where service users reported significant clinical improvements in mental health symptoms and indicators of quality of life. A CAMHS ITS, with close links to an adolescent inpatient unit, can provide a balanced care approach where young people with severe mental health difficulties can be treated in the community, where possible, without compromising on patient safety and quality of care.
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Intensive palliative care for patients with hematological cancer dying in hospice: analysis of the level of medical care in the final week of life. Am J Hosp Palliat Care 2013; 32:221-5. [PMID: 24259405 DOI: 10.1177/1049909113512412] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dying of hematological oncology patients often take place in respective hematology ward or intensive care unit rather than hospice. With the increased attention to quality palliative care for hematology patients, concerns regarding their level of medical care at end-of-life need to be addressed. We conducted a retrospective review of consecutive hematological oncology patients who succumbed in a palliative unit between July 2012 and August 2013. The primary outcome measure was their level of medical care received, including administration of antibiotics, total parenteral nutrition, blood sampling, GCSF injection and blood products transfusion, during their last seven days of life. During the last seven days of life, 85.7 % of patients had blood sampling and 23.8% of patients received G-CSF injection. Total parenteral nutrition was administered in 14.3% of patients. One-third of patients received transfusion of packed cells and nearly half of them received transfusion of platelet concentrates. Almost 90% of patients received antibiotics during their last week of life. Collaboration between hematology and palliative care has resulted in successful transition of hematologic cancer patients into hospice unit in their terminal phase of illness. However, their level of medical care, even approaching last seven days of life, remained intensive. Proper allocation of medical resources and future research regarding optimal end-of-life care for hematology patients are warranted.
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Large reduction in volume with the intensive treatment of lymphedema: reduction of fluids? Int J Angiol 2013; 21:171-4. [PMID: 23997564 DOI: 10.1055/s-0032-1325167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
The aim of this study is to report on the intensive treatment of lymphedema of the legs demonstrating a large reduction in volume in a short period of time. The case of a 29-year-old female patient, who developed the most serious form of lymphedema, associated with verrucosities of the leg and genitalia is reported. Elephantiasis evolved after surgery and radiotherapy. The patient was treated at the Clinica Godoy in Sao Jose do Rio Preto, Brazil using an intensive course of treatment. Baseline and then daily evaluations of the leg perimeter and body weight were performed during treatment. Intensive treatment for 8 hours daily was performed on an outpatient basis using manual and mechanical (RAGodoy device, São Jose do Rio Preto, São Paulo-Brazil) lymph drainage and the continuous use of a compression garment made of a cotton-polyester textile and adjusted every 3 hours. A reduction of 31 kg was seen in 10 days (over 2 weeks); in the first few days, the patient lost 6 kg per day. Due to the excess of skin, the length of intensive treatment sessions was reduced to avoid the compression garment causing a tourniquet effect, the size of the compression stocking was only adjusted once per day and daily walks were included in the treatment program. After 1 month, the size of the leg was reduced by another 4 kg. Intensive lymphedema treatment is an option that rapidly reduces edema, and constant use of low-stretch compression maintains the result achieved and continues to reduce the swelling.
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Abstract
INTRODUCTION The management of trauma patients differs depending upon the healthcare system available. AIM To compare the pre-hospital management and outcome of polytrauma patients between two countries with differing approaches to pre-hospital management. MATERIALS AND METHODS The Scottish trauma and audit group (STAG) and the German trauma registry (GTR) databases were used to compare the management and outcome of trauma patients in Scotland and Germany. Severely injured patients (injury severity score (ISS) > 16) were analyzed for a 3 year period (2000 to 2002). Patient demographics, pre-hospital interventions, ISS, revised trauma score (RTS), time from scene of injury to arrival to the emergency department (ED), 120 day mortality and standardized mortality ratios using TRISS methodology were compared. RESULTS There were 227 patients identified from the STAG registry and 6878 patients from the GTR registry. There was a significant difference in ISS (24.9 vs. 29.8, P = 0.001, respectively). No significant difference was observed for the RTS (P = 0.2). There was a significantly higher rate of pre-hospital interventions in the German group (P < 0.001). The mean time from an injury to arrival to the ED (73 vs. 247 minutes, P = 0.001) was longer for the Scottish patients. There was no difference for an unadjusted mortality rate between the groups, but the standardized mortality ratio was significantly greater for the Scottish population (3.8 vs. 2.2, P = 0.036). CONCLUSION Despite variation in pre-hospital transfer times and interventions, no significant difference was demonstrated in RTS upon arrival, or for the unadjusted mortality rates.
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Abstract
Acute liver failure (ALF) is a condition of acute hepatic emergency where rapid deterioration of hepatocyte function leads to hepatic encephalopathy, coagulopathy, cerebral edema (CE), infection and multi-organ dysfunction syndrome resulting in a high mortality rate. Urgent liver transplantation is the standard of care for most of these patients in Western countries. However, in India, access to liver transplantation is severely limited and, hence, the management is largely based on intensive medical care. With earlier recognition of disease, better understanding of pathophysiology and improved intensive care, ALF patients have shown a significant improvement in spontaneous survival. An evidence base for practice for supportive care is still lacking; however, intensive organ support as well as control of infection and CE are likely to be key to the successful outcome in this acute and potentially reversible condition without any sequel. A structured approach to decision making about intensive care is important in each case. Unlike in Western countries where acetamenophen is the most common cause of ALF, the role of a specific agent, such as N-acetylcysteine, is limited in India. Ammonia-lowering therapy is still in an evolving phase. The current review highlights the important medical management issues in patients with ALF in general as well as the management of major complications associated with ALF. We performed a MEDLINE search using combinations of the key words such as acute liver failure, intensive treatment of acute liver failure and fulminant hepatic failure. We reviewed the relevant publications with regard to intensive care of patients with ALF.
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Purge- and intensive-purge decontamination of dental units contaminated with biofilm. GMS KRANKENHAUSHYGIENE INTERDISZIPLINAR 2012; 7:Doc11. [PMID: 22558045 PMCID: PMC3334959 DOI: 10.3205/dgkh000195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Introduction: During hygienic-microbiological monitoring of the water quality in dental units, the total bacterial colony count was found to exceed the limits for drinking water quality; in addition, mold contamination was detected. The presumed cause was irregular decontamination of the units through purging and intensive decontamination. Methods: To decontaminate the units, the manufacturer’s recommended program for cleaning and intensive decontamination was intensified by shortened intervals over a 2-week period. For Sirona units, instead of once a day, the automatic purge program was run every morning and evening for 20 min each time, and instead of once a month, intensive decontamination was performed every two weeks; this schedule has been maintained since then. For KaVo units, cleaning with the hydroclean function was carried out for 2.5 min every morning and evening. The automatic intensive decontamination was run daily instead of weekly. A maintenance log book was introduced, in which decontamination/cleaning was confirmed by the operator’s signature. Results: Within 5 weeks, all previously contaminated units were decontaminated. Discussion: By shortening the cleaning and intensive decontamination intervals in a 2-week period with subsequent control that the recommended maintenance intervals were kept, it was possible to guarantee drinking-water quality in the dental units of both manufacturers.
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Abstract
Intensive insulin therapy (IIT) for hyperglycemia in critically ill patients has become a standard practice. Target levels for glycemia have fluctuated since 2000, as evidence initially indicated that tight glycemic control to so-called normoglycemia (80-110 mg/dl) leads to the lowest morbidity and mortality without hypoglycemic complications. Subsequent studies have demonstrated minimal clinical benefit combined with greater hypoglycemic morbidity and mortality with tight glycemic control in this population. The consensus glycemic targets were then liberalized to the mid 100s (mg/dl). Handheld POC blood glucose (BG) monitors have migrated from the outpatient setting to the hospital environment because they save time and money for managing critically ill patients who require IIT. These devices are less accurate than hospital-grade POC blood analyzers or central laboratory analyzers. Three questions must be answered to understand the role of IIT for defined populations of critically ill patients: (1) How safe is IIT, with various glycemic targets, from the risk of hypoglycemia? (2) How tightly must BG be controlled for this approach to be effective? (3) What role does the accuracy of BG measurements play in affecting the safety of this method? For each state of impaired glucose regulation seen in the hospital, such as hyperglycemia, hypoglycemia, or glucose variability, the benefits, risks, and goals of treatment, including IIT, might differ. With improved accuracy of BG monitors, IIT might be rendered even more intensive than at present, because patients will be less likely to receive inadvertent overdosages of insulin. Greater doses of insulin, but with dosing based on more accurate glucose levels, might result in less hypoglycemia, less hyperglycemia, and less glycemic variability.
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Temporal trends in the treatment of pediatric type 1 diabetes and impact on acute outcomes. J Pediatr 2007; 150:279-85. [PMID: 17307546 PMCID: PMC1857326 DOI: 10.1016/j.jpeds.2006.12.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Revised: 10/24/2006] [Accepted: 12/06/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate temporal trends in pediatric type 1 diabetes (T1DM) management and resultant effects on outcomes. STUDY DESIGN Two pediatric T1DM cohorts were followed prospectively for 2 years and compared; Cohort 1 (N = 299) was enrolled in 1997 and Cohort 2 (N = 152) was enrolled in 2002. In both cohorts, eligible participants were identified and sequentially approached at regularly scheduled clinic visits until the target number of participants was reached. Main outcome measures were hemoglobin A1c (A1c), body mass index Z score (Z-BMI), and incidence rate (IR; per 100 patient-years) of hypoglycemia, hospitalizations, and emergency room (ER) visits. RESULTS At baseline, Cohort 2 monitored blood glucose more frequently than Cohort 1 (> or = 4 times/day: 72% vs 39%, P < .001) and was prescribed more intensive therapy than Cohort 1 (> or = 3 injections/day or pump: 85% vs 65%, P < .001). A1c was lower in Cohort 2 than Cohort 1 at baseline (8.4% vs 8.7%, P = .03) and study's end (8.7% vs 9.0%, P = .04). The cohorts did not differ in Z-BMI (0.83 vs 0.79, P = .57) or IR of hospitalizations (11.2 vs 12.9, P = .38). Cohort 2 had lower IR of total severe hypoglycemic events (29.4 vs 55.4, P < .001) and ER visits (22.0 vs 29.3, P = .02). CONCLUSIONS T1DM management intensified during the 5 years between cohorts and was accompanied by improved A1c and stable Z-BMI. Along with improved control, IR of severe hypoglycemia and ER visits decreased by almost 50% and 25%, respectively.
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Paediatric intensive care: out of commission. Crit Care 2002; 6:387-8. [PMID: 12398772 PMCID: PMC137322 DOI: 10.1186/cc1543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Problems with commissioning paediatric intensive care stem both from difficulties in recruitment and retention of nurses, and from incoherent or nonexistent national audit. Pyramidal career structures and patterns of remuneration that concentrate on administrative responsibility over clinical skills underlie the former, whereas poor audit conceals variations in both service quality and demand. Epidemiologically superior data are required if we are to solve commissioning problems. We need to know what happened to every child from a defined population receiving intensive care and whether a lack of resources means that some children are denied intensive care.
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A prospective, randomized 5-year follow-up study of functional restoration in chronic low back pain patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 1998; 7:111-9. [PMID: 9629934 PMCID: PMC3611221 DOI: 10.1007/s005860050040] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A functional restoration (FR) program, dealing with a combination of intensive physical and ergonomic training, psychological pain management, and patient education, was tested in two randomized, parallel group studies. In one of these patients following the FR program were compared with a non-treated control group (project A), and in the other with patients on two less intensive treatment programs (project B). A total of 238 chronic low back pain patients participated in the two studies, 106 entering project A and 132 project B. Patients from the two projects were comparable except that the patients in project A were recruited from all over the country, whereas patients in project B all were living in and around Copenhagen. Thirteen patients never started any treatment, and 20 patients (9%) dropped out during the treatment period. Of the 207 who completed treatment, 89% returned a mailed questionnaire 5 years later. This was the case for 55% of the drop-outs. The questions referred to work situation, pain level, activities of daily living, days of sick leave, contact with health care professionals, physical activity, use of medication, and a subjective overall assessment. The results show that in project A the treated group reported significantly fewer contacts with the health care system and significantly fewer days of sick leave over the 5-year follow-up period compared to the control group. In all other parameters, including work ability, there was no statistically significant difference between the two groups. In project B, patients treated in the FR program did significantly better in most measured parameters, except in leg pain, use of pain medication and sport activity, where no significant differences were found between groups. The overall result shows a positive long-term effect of the FR program, but it also shows the necessity of testing a given treatment in different projects and designs, among other things due to statistical variations.
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