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Sample records for experienced patients utilize

  1. Hospital Utilization and Characteristics of Patients Experiencing Recurrent Readmissions Within Children’s Hospitals

    PubMed Central

    Berry, Jay G.; Hall, David E.; Kuo, Dennis Z.; Cohen, Eyal; Agrawal, Rishi; Feudtner, Chris; Hall, Matt; Kueser, Jacqueline; Kaplan, William; Neff, John

    2011-01-01

    Context Early hospital readmission is emerging as an indicator of care quality. Some children with chronic illnesses may be readmitted on a recurrent basis, but there are limited data describing their rehospitalization patterns and impact. Objectives To describe the inpatient resource utilization, clinical characteristics, and admission reasons of patients recurrently readmitted to children’s hospitals. Design, Setting, and Patients Retrospective cohort analysis of 317 643 patients (n=579 504 admissions) admitted to 37 US children’s hospitals in 2003 with follow-up through 2008. Main Outcome Measure Maximum number of readmissions experienced by each child within any 365-day interval during the 5-year follow-up period. Results In the sample, 69 294 patients (21.8%) experienced at least 1 readmission within 365 days of a prior admission. Within a 365-day interval, 9237 patients (2.9%) experienced 4 or more readmissions; time between admissions was a median 37 days (interquartile range [IQR], 21–63). These patients accounted for 18.8% (109 155 admissions) of all admissions and 23.2% ($3.4 billion) of total inpatient charges for the study cohort during the entire follow-up period. Tests for trend indicated that as the number of readmissions increased from 0 to 4 or more, the prevalences increased for a complex chronic condition (from 22.3% [n=55 382/248 349] to 89.0% [n=8225/9237]; P <.001), technology assistance (from 5.3% [n = 13 163] to 52.6% [n=4859]; P <.001), public insurance use (from 40.9% [n = 101 575] to 56.3% [n=5202]; P <.001), and non-Hispanic black race (from 21.8% [n=54 140] to 34.4% [n=3181]; P <.001); and the prevalence decreased for readmissions associated with an ambulatory care–sensitive condition (from 23.1% [62 847/272 065] to 14.0% [15 282/109 155], P<.001). Of patients readmitted 4 or more times in a 365-day interval, 2633 (28.5%) were rehospitalized for a problem in the same organ system across all admissions during the interval

  2. The Experienced Utility of Expected Utility Approaches

    DTIC Science & Technology

    1980-04-01

    than one using unit weights. Similarly, goods obtained with high probability should be valued more than those obtained with low probability. Therefore...consequences are added, low or negative utility associated with one conse- quence can, in principle, be compensated for by sufficiently high utility on...calibrated probability assessor should have more true statements associated with high than with low probabilities. Specifically, XX% of the statements

  3. Knowledge utilization among experienced staff nurses.

    PubMed

    Asselin, M E

    2001-01-01

    The purpose of this descriptive exploratory study was to describe the processes staff nurses use to select and transfer new knowledge to practice. Eleven experienced staff nurses shared 29 examples in which gaining new knowledge resulted in changes in thinking or acting in a clinical situation. Findings indicated that knowledge utilization originated with the nurse who was active in selecting and using new knowledge. Nurses used multiple knowledge utilization processes primarily involving factual knowledge and instrumental utilization. Often, the decision to move knowledge to practice was based on comparison by similarity. There were no variations in utilization processes as nurses floated across units. Sources of new knowledge were primarily informal and unit based. Implications for staff development focus on developing unit-based resources and resource personnel, using innovative ways to introduce new knowledge on the unit, and providing time in formal classes for exchange of ideas on using new knowledge in practice.

  4. A patient experiencing pseudoseizures: a case report.

    PubMed

    Joseph, F; Quinlan, J

    2012-06-01

    Pseudoseizures are a relatively complex problem of unknown aetiology and prognosis. They can at times resemble genuine seizure attacks but they have no abnormal electroencephalograpic (EEG) activity. Understanding the patient's unique psychological background appears to be fundamental in managing seizure frequency. Pseudoseizures can be disruptive to a person's lifestyle, limiting their ability to function and progress in society, particularly when it comes to employment or social interaction. The case discussed involves a 59-year-old man who presents with what is believed to be seizure-related activity but through the course of clinical evaluation, this turned out to be pseudoseizures.

  5. Persistent Super-Utilization of Acute Care Services Among Subgroups of Veterans Experiencing Homelessness.

    PubMed

    Szymkowiak, Dorota; Montgomery, Ann Elizabeth; Johnson, Erin E; Manning, Todd; O'Toole, Thomas P

    2017-10-01

    Acute health care utilization often occurs among persons experiencing homelessness. However, knowing which individuals will be persistent super-utilizers of acute care is less well understood. The objective of the study was to identify those more likely to be persistent super-utilizers of acute care services. We conducted a latent class analysis of secondary data from the Veterans Health Administration Corporate Data Warehouse, and Homeless Operations Management and Evaluation System. The study sample included 16,912 veterans who experienced homelessness and met super-utilizer criteria in any quarter between July 1, 2014 and December 31, 2015. The latent class analysis included veterans' diagnoses and acute care utilization. Medical, mental health, and substance use morbidity rates were high. More than half of the sample utilized Veterans Health Administration Homeless Programs concurrently with their super-utilization of acute care. There were 7 subgroups of super-utilizers, which varied considerably on the degree to which their super-utilization persisted over time. Approximately a third of the sample met super-utilizer criteria for ≥3 quarters; this group was older and disproportionately male, non-Hispanic white, and unmarried, with lower rates of post-9/11 service and higher rates of rural residence and service-connected disability. They were much more likely to be currently homeless with more medical, mental health, and substance use morbidity. Only a subset of homeless veterans were persistent super-utilizers, suggesting the need for more targeted interventions.

  6. Physicians Experiencing Intense Emotions While Seeing Their Patients: What Happens?

    PubMed Central

    da Silva, Joana Vilela; Carvalho, Irene

    2016-01-01

    Objectives: Physicians often deal with emotions arising from both patients and themselves; however, management of intense emotions when they arise in the presence of patients is overlooked in research. The aim of this study is to inspect physicians’ intense emotions in this context, how these emotions are displayed, coping strategies used, adjustment behaviors, and the impact of the emotional reactions on the physician-patient relationship. Methods: A total of 127 physicians completed a self-report survey, built from a literature review. Participants were recruited in 3 different ways: through a snowball sampling procedure, via institutional e-mails, and in person during service meetings. Results: Fifty-two physicians (43.0%) reported experiencing intense emotions frequently. Although most physicians (88.6%) tried to control their reactions, several reported not controlling themselves. Coping strategies to deal with the emotion at the moment included behavioral and cognitive approaches. Only the type of reaction (but not the emotion’s valence, duration, relative control, or coping strategies used) seemed to affect the physician-patient relationship. Choking-up/crying, touching, smiling, and providing support were significantly associated with an immediate positive impact. Withdrawing from the situation, imposing, and defending oneself were associated with a negative impact. Some reactions also had an extended impact into future interactions. Conclusion: Experiencing intense emotions in the presence of patients was frequent among physicians, and the type of reaction affected the clinical relationship. Because many physicians reported experiencing long-lasting emotions, these may have important clinical implications for patients visiting physicians while these emotions last. Further studies are needed to clarify these results. PMID:27479947

  7. Experiencing virtual patients in clinical learning: a phenomenological study.

    PubMed

    Edelbring, Samuel; Dastmalchi, Maryam; Hult, Håkan; Lundberg, Ingrid E; Dahlgren, Lars Owe

    2011-08-01

    Computerised virtual patients (VPs) are increasingly being used in medical education. With more use of this technology, there is a need to increase the knowledge of students' experiences with VPs. The aim of the study was to elicit the nature of virtual patients in a clinical setting, taking the students' experience as a point of departure. Thirty-one students used VPs as a mandatory part of an early clinical rotation in rheumatology. Using the qualitative approach of phenomenology, we interviewed these students and then analysed data regarding their experiences of VPs as a learning activity. The result shows that students perceived VP activities in relation to actual patients, the clinical context and other learning activities. The VPs represented typical clinical cases which encouraged clinical reasoning and allowed for decision making. The students experienced the activities as integrating biomedical knowledge and clinical experience, providing structure that prepared for the unstructured clinical environment and patient encounters under unstressful conditions. However, the VPs were experienced as lacking the emotional interactivity and complexity of actual patients. Theoretical frameworks of clinical reasoning and experiential learning are suggested as foundations for further educational integration of VPs in the clinical environment. VP activities during clinical rotations provide experiences of clinical reality and allow students to solve problems actively. These features are dependent on VP technology but are also contingent on the surrounding environment.

  8. Fatigue experienced by patients receiving maintenance dialysis in hemodialysis units.

    PubMed

    Letchmi, Santhna; Das, Srijit; Halim, Hasliza; Zakariah, Farid Azizul; Hassan, Hamidah; Mat, Samsiah; Packiavathy, Ruth

    2011-03-01

    The fatigue that is observed in patients who are undergoing dialysis is usually associated with an impaired quality of life. The present cross-sectional study was conducted from January to April 2009 in three hemodialysis units in Kuala Lumpur, Malaysia. In this study, the Multidimensional Fatigue Inventory and Depression Anxiety and Stress Score 21 were used to determine the level of fatigue, depression, anxiety, and stress of patients who were undergoing dialysis. The data were obtained from a calculated sample of 116 and a total of 103 respondents participated in the study. A total of 56 (54.4%) and 47 (45.6%) respondents experienced a high level and a low level of fatigue, respectively. There was a significant relationship between the duration of treatment and the level of fatigue. The respondents who had been receiving treatment for > 2 years experienced more fatigue, compared to the respondents who had been undergoing hemodialysis for > 2 years. There was a significant difference in relation to the age of the participants regarding the level of fatigue. No significant relationship between the sex of the participants, anemia, depression, anxiety, stress, and the level of fatigue was observed. Special attention needs to be paid to both the younger and older adults who are receiving treatment. In addition, proper planning is needed for the patients regarding their daily activities in order to reduce fatigue. Nurses who work in hemodialysis units are recommended to provide exercise classes or group therapy in order to boost the energy levels among patients who are undergoing dialysis. Health professionals should provide appropriate treatment for patients who are experiencing fatigue in order to prevent any other complications that could arise.

  9. [Difficulties experienced at work by patients with multiple sclerosis].

    PubMed

    Ongagna, J C; Passadori, A; Pinelli, J; Isner-Horobeti, M E; Zaenker, C; De Seze, J

    2015-11-01

    Multiple sclerosis (MS) is a disease of the central nervous system that affects young adults at a time when they launch into the workforce. The disease often has a great impact on working life. The objective of this survey was to identify the problems faced by people with multiple sclerosis in the context of their work. To describe the difficulties experienced at work by patients with multiple sclerosis, we carried out in 2010 a regional survey including neurology and functional rehabilitation centers. Two hundred and seven MS patients of working age responded to the survey. The employment rate was 67.6%. Among difficulties expressed by patients, physical and mental fatigue appeared as the issues affecting work. For 41% of respondents, preventive measures at work could help maintain or resume employment. Problems of fatigability put forward by MS patients are elements that can predict a loss of employment. Copyright © 2015. Published by Elsevier Masson SAS.

  10. Symptoms experienced by cancer patients and barriers to symptom management.

    PubMed

    Nayak, Malathi G; George, Anice; Vidyasagar, M S; Mathew, Stanley; Nayak, Sudhakar; Nayak, Baby S; Shashidhara, Y N; Kamath, Asha

    2015-01-01

    People living with cancer experience wide variety of symptoms. If symptoms are not managed well, it may hamper an individual's ability to continue his or her activities of daily life. Treatment of symptoms relieves suffering and improves the rate of recovery as well as the quality of life. To assess the symptoms of suffering among cancer patients and to identify the perceived barriers to their symptom management. A cross-sectional study was carried out among 768 cancer patients selected by stratified sampling with a proportionate selection from each stratum. Data were collected from cancer patients by interview technique using structured validated questionnaire. Majority of the samples (30.2%) belonged to the age group of 51-60 years, most of them were diagnosed with head and neck cancer (40.1%) and 57.7% had stage III disease. The majority of the patients studied had pain (77%), tiredness (96.5%), disturbed sleep (96.4%), weight loss (63.3%), and irritability (85.7%). Most of the patients had lack of appetite (89.4%), feeling of sadness (96.6%), worry (94.5%), and feeling of nervousness (82.8%). Majority of the patients had some misconception regarding symptoms, that is, increasing pain signifies disease progression (92.7%), medicine to control pain may weaken the immune system (89.9%) and pain is inevitable for cancer patients (78.5%). Seventy-seven percent of samples reported that the anxiety or depression is expected after the diagnosis of cancer. This study provides an overview of symptoms among cancer patients and barriers experienced by them.

  11. Perception of environmental sounds by experienced cochlear implant patients

    PubMed Central

    Shafiro, Valeriy; Gygi, Brian; Cheng, Min-Yu; Vachhani, Jay; Mulvey, Megan

    2011-01-01

    Objectives Environmental sound perception serves an important ecological function by providing listeners with information about objects and events in their immediate environment. Environmental sounds such as car horns, baby cries or chirping birds can alert listeners to imminent dangers as well as contribute to one's sense of awareness and well being. Perception of environmental sounds as acoustically and semantically complex stimuli, may also involve some factors common to the processing of speech. However, very limited research has investigated the abilities of cochlear implant (CI) patients to identify common environmental sounds, despite patients' general enthusiasm about them. This project (1) investigated the ability of patients with modern-day CIs to perceive environmental sounds, (2) explored associations among speech, environmental sounds and basic auditory abilities, and (3) examined acoustic factors that might be involved in environmental sound perception. Design Seventeen experienced postlingually-deafened CI patients participated in the study. Environmental sound perception was assessed with a large-item test composed of 40 sound sources, each represented by four different tokens. The relationship between speech and environmental sound perception, and the role of working memory and some basic auditory abilities were examined based on patient performance on a battery of speech tests (HINT, CNC, and individual consonant and vowel tests), tests of basic auditory abilities (audiometric thresholds, gap detection, temporal pattern and temporal order for tones tests) and a backward digit recall test. Results The results indicated substantially reduced ability to identify common environmental sounds in CI patients (45.3%). Except for vowels, all speech test scores significantly correlated with the environmental sound test scores: r = 0.73 for HINT in quiet, r = 0.69 for HINT in noise, r = 0.70 for CNC, r = 0.64 for consonants and r = 0.48 for vowels. HINT and

  12. Perception of environmental sounds by experienced cochlear implant patients.

    PubMed

    Shafiro, Valeriy; Gygi, Brian; Cheng, Min-Yu; Vachhani, Jay; Mulvey, Megan

    2011-01-01

    Environmental sound perception serves an important ecological function by providing listeners with information about objects and events in their immediate environment. Environmental sounds such as car horns, baby cries, or chirping birds can alert listeners to imminent dangers as well as contribute to one's sense of awareness and well being. Perception of environmental sounds as acoustically and semantically complex stimuli may also involve some factors common to the processing of speech. However, very limited research has investigated the abilities of cochlear implant (CI) patients to identify common environmental sounds, despite patients' general enthusiasm about them. This project (1) investigated the ability of patients with modern-day CIs to perceive environmental sounds, (2) explored associations among speech, environmental sounds, and basic auditory abilities, and (3) examined acoustic factors that might be involved in environmental sound perception. Seventeen experienced postlingually deafened CI patients participated in the study. Environmental sound perception was assessed with a large-item test composed of 40 sound sources, each represented by four different tokens. The relationship between speech and environmental sound perception and the role of working memory and some basic auditory abilities were examined based on patient performance on a battery of speech tests (HINT, CNC, and individual consonant and vowel tests), tests of basic auditory abilities (audiometric thresholds, gap detection, temporal pattern, and temporal order for tones tests), and a backward digit recall test. The results indicated substantially reduced ability to identify common environmental sounds in CI patients (45.3%). Except for vowels, all speech test scores significantly correlated with the environmental sound test scores: r = 0.73 for HINT in quiet, r = 0.69 for HINT in noise, r = 0.70 for CNC, r = 0.64 for consonants, and r = 0.48 for vowels. HINT and CNC scores in quiet

  13. An Evaluation of the Physiological Strain Experienced by Electrical Utility Workers in North America.

    PubMed

    Meade, Robert D; Lauzon, Martin; Poirier, Martin P; Flouris, Andreas D; Kenny, Glen P

    2015-01-01

    The purpose of this study was to assess the physiological strain experienced by North American electrical utility workers during the performance of their normal work duties in heat stressed conditions. Three common job categories were monitored as they are normally performed in 32 electrical utility workers: (i) Ground Work (n = 11); (ii) Bucket Work (n = 9); and (iii) Manual Pole Work (n = 12). Worker hydration status (urine specific gravity (USG)) was measured prior to and following the work monitoring period (duration: 187 ± 104 min). Core and skin temperatures as well as heart rate were measured continuously. Physiological Strain Index (PSI) was calculated from the measurements of core temperature and heart rate. Prior to the start of the work shift, 38% of workers were euhydrated (USG < 1.020; n = 12) whereas the majority of workers were dehydrated (USG > 1.020; prevalence: 75%; p < 0.01) following work. The overall mean and peak core temperatures for all monitored workers were 37.9 ± 0.3 °C and 38.3 ± 0.5 °C, respectively. When responses were compared between job categories, greater mean and peak increases in core temperature were observed in Manual Pole Work relative to the other job categories (both p < 0.04). In fact, six workers performing Manual Pole Work achieved core temperatures in excess of 38.5 °C, while only one other worker surpassed this threshold in Bucket Work. The high levels of thermal strain were paralleled by elevated mean and peak heart rate and PSI responses, which were greater in Manual Pole Work in comparison to the other job categories (all p ≤ 0.05). Furthermore, two workers performing Manual Pole Work achieved severely elevated core temperatures reaching or exceeding 39.5 °C along with prolonged periods of near maximal heart rate responses (i.e., >90% of heart rate reserve). We report elevated levels of thermal and cardiovascular strain in electrical utility workers during work in the heat and potentially dangerous levels of

  14. Patient-aligned Care Team Engagement to Connect Veterans Experiencing Homelessness With Appropriate Health Care.

    PubMed

    Gundlapalli, Adi V; Redd, Andrew; Bolton, Daniel; Vanneman, Megan E; Carter, Marjorie E; Johnson, Erin; Samore, Matthew H; Fargo, Jamison D; O'Toole, Thomas P

    2017-09-01

    Veterans experiencing homelessness frequently use emergency and urgent care (ED). To examine the effect of a Patient-aligned Care Team (PACT) model tailored to the unique needs of Veterans experiencing homelessness (H-PACT) on frequency and type of ED visits in Veterans Health Administration (VHA) medical facilities. During a 12-month period, ED visits for 3981 homeless Veterans enrolled in (1) H-PACT at 20 VHA medical centers (enrolled) were compared with those of (2) 24,363 homeless Veterans not enrolled in H-PACT at the same sites (nonenrolled), and (3) 23,542 homeless Veterans at 12 non-H-PACT sites (usual care) using a difference-in-differences approach. The primary outcome was ED and other health care utilization and the secondary outcome was emergent (not preventable/avoidable) ED visits. H-PACT enrollees were predominantly white males with a higher baseline Charlson comorbidity index. In comparing H-PACT enrollees with usual care, there was a significant decrease in ED usage among the highest ED utilizers (difference-in-differences, -4.43; P<0.001). The decrease in ED visits were significant though less intense for H-PACT enrollees versus nonenrolled (-0.29, P<0.001). H-PACT enrollees demonstrated a significant increase in the proportion of ED care visits that were not preventable/avoidable in the 6 months after enrollment, but had stable rates of primary care, mental health, social work, and substance abuse visits over the 12 months. Primary care treatment engagement can reduce ED visits and increase appropriate use of ED services in VHA for Veterans experiencing homelessness, especially in the highest ED utilizers.

  15. Comparing the Utilization and Cost of Health Services between Veterans Experiencing Brief and Ongoing Episodes of Housing Instability.

    PubMed

    Byrne, Thomas; Nelson, Richard E; Montgomery, Ann Elizabeth; Brignone, Emily; Gundlapalli, Adi V; Fargo, Jamison D

    2017-02-01

    Housing instability is associated with costly patterns of health and behavioral health service use. However, little prior research has examined patterns of service use associated with higher costs among those experiencing ongoing housing instability. To address this gap, we compared inpatient and outpatient medical and behavioral health service utilization and costs between veterans experiencing brief and ongoing episodes of housing instability. We used data from a brief screening instrument for homelessness and housing instability that has been implemented throughout the US Department of Veterans Affairs (VA) health care system to identify a national sample of veterans experiencing housing instability. Veterans were classified as experiencing either brief or ongoing housing instability, based on two consecutive responses to the instrument, and we used a series of two-part regression models to conduct adjusted comparisons of costs between veterans experiencing brief and ongoing episodes of housing instability. Among 5794 veterans screening positive for housing instability, 4934 (85%) were experiencing brief and 860 (15%) ongoing instability. The average total annual incremental cost associated with ongoing versus brief episodes of housing instability was estimated at $7573, with the bulk of this difference found in inpatient services. Cost differences resulted more from a higher probability of service use among those experiencing ongoing episodes of housing instability than from higher costs among service users. Our findings suggest that VA programmatic efforts aimed at preventing extended episodes of housing instability could potentially result in substantial cost offsets for the VA health care system.

  16. Experiencing health care service quality: through patients' eyes.

    PubMed

    Schembri, Sharon

    2015-02-01

    The primary aim of the present study was to consider health care service quality from the patients' perspective, specifically through the patient's eyes. A narrative analysis was performed on 300 patient stories. This rigorous analysis of patient stories is designed to identify and describe health care service quality through patients' eyes in an authentic and accurate, experiential manner. The findings show that there are variant and complex ways that patients experience health care service quality. Patient stories offer an authentic view of the complex ways that patients experience health care service quality. Narrative analysis is a useful tool to identify and describe how patients experience health care service quality. Patients experience health care service quality in complex and varying ways.

  17. Suicidal patients as experienced by psychiatric nurses in inpatient care.

    PubMed

    Carlén, Pontus; Bengtsson, Anita

    2007-08-01

    Psychiatric nurses have a major influence on the lives of patients with suicidal behaviour in inpatient care. Despite this, there is a lack of knowledge about how nurses experience patients with suicidal behaviour in a deeper sense. The aim of this study was to investigate how psychiatric nurses experience patients with suicidal behaviour within an inpatient psychiatric context. Semi-structured interviews were carried out with 11 psychiatric nurses, each of whom had more than 5 years of experience caring for patients with suicidal behaviour. Data were analysed using qualitative latent content analysis. Two main themes emerged from the data analysis. These are 'labelled' and 'suffering'. In the nurses' natural attitude, they saw patients as being labelled with different conditions and/or behaviours based on objective signs. These were categorized into different groups or identities such as psychiatric diagnosis, mask wearer, screened-off, or the social, relapsing or determined patient. On reflection, however, the nurses described the patients' suffering in terms related to feelings of hopelessness, meaninglessness, and being out of control. The nurses' experiences of the patients as suffering were based on their subjective reflective experience of the patients. The study gives support to the conclusion that two main logic systems are represented in the care of patients with suicidal behaviour: technical practical and nursing perspectives. In order to ensure that these two logic systems combine, it is necessary for the psychiatric care organization to intervene to support the nurses in reflecting on their everyday work.

  18. Experiencing Virtual Patients in Clinical Learning: A Phenomenological Study

    ERIC Educational Resources Information Center

    Edelbring, Samuel; Dastmalchi, Maryam; Hult, Hakan; Lundberg, Ingrid E.; Dahlgren, Lars Owe

    2011-01-01

    Computerised virtual patients (VPs) are increasingly being used in medical education. With more use of this technology, there is a need to increase the knowledge of students' experiences with VPs. The aim of the study was to elicit the nature of virtual patients in a clinical setting, taking the students' experience as a point of departure.…

  19. Experiencing Virtual Patients in Clinical Learning: A Phenomenological Study

    ERIC Educational Resources Information Center

    Edelbring, Samuel; Dastmalchi, Maryam; Hult, Hakan; Lundberg, Ingrid E.; Dahlgren, Lars Owe

    2011-01-01

    Computerised virtual patients (VPs) are increasingly being used in medical education. With more use of this technology, there is a need to increase the knowledge of students' experiences with VPs. The aim of the study was to elicit the nature of virtual patients in a clinical setting, taking the students' experience as a point of departure.…

  20. Experiencing Madness: Mental Patients in Medieval Arabo-Islamic Medicine.

    PubMed

    Koetschet, Pauline

    2016-01-01

    This paper focuses on the mental patients in Arabo-Islamic Middle Ages. Patients suffering from mental illnesses generated a lot of interest for Arabo-Islamic physicians. The first objective of this study is to identify who were the mentally infirm and to compare the Arab physicians' typologies of mental patients to that of their Greek predecessors. The second part of this paper shifts the focus from theoretical descriptions to case histories and biographical sources, in order to understand how the physicians treated their mental patients, and to find out what was the social impact of this medical approach. Finally, because the special provision for the insane is a distinctive feature of the Islamic hospital, the third part of my paper examines whether the main purpose of these hospitals was the patients' confinement or their treatment.

  1. [Incidence of aphasia in patients experiencing an ischemic stroke].

    PubMed

    González Mc, Francisca; Lavados G, Pablo; Olavarría I, Verónica

    2017-02-01

    Sequelae after a stroke are common and may lead to disability. Aphasia - defined as an acquired language disturbance - can cause important limitations in quality of life. To describe the epidemiological features of patients who had an aphasia after a first episode of ischemic stroke and their functional outcome at six months. Review of a database of a population study on the incidence, 30-day case fatality rate, and prognosis of stroke performed in a northern Chilean city between 2000 and 2002. Aphasia was diagnosed in 28 of 142 patients in whom the disorder was sought (20%). The projected incidence rate in the city where the study was carried out is 7.06 per 100,000 inhabitants. The mean age of these 28 patients was 66 ± 20 years and 53% were women. The main risk factor for stroke was hypertension in 62%. The etiology of stroke was undetermined in 64% of these patients. Partial anterior circulation infarction was the most common stroke location in 61%. Twenty percent of patients with a first episode of ischemic stroke have aphasia.

  2. Christianity and Resilience as Experienced by Caregivers of Dementia Patients

    ERIC Educational Resources Information Center

    Lackey, Steven L.

    2014-01-01

    The purpose of this study was to examine the role and relationship of the practice of Christian beliefs and resilience in the context of dementia patient caregivers' lives. The guiding question was "What is the relational nature of the practice of Christian beliefs and resilience in the lived experiences of caregivers of dementia…

  3. Christianity and Resilience as Experienced by Caregivers of Dementia Patients

    ERIC Educational Resources Information Center

    Lackey, Steven L.

    2014-01-01

    The purpose of this study was to examine the role and relationship of the practice of Christian beliefs and resilience in the context of dementia patient caregivers' lives. The guiding question was "What is the relational nature of the practice of Christian beliefs and resilience in the lived experiences of caregivers of dementia…

  4. Stop regain: a pilot psychological intervention for bariatric patients experiencing weight regain.

    PubMed

    Himes, Susan M; Grothe, Karen B; Clark, Matthew M; Swain, James M; Collazo-Clavell, Maria L; Sarr, Michael G

    2015-05-01

    A subset of bariatric patients fails to achieve or maintain long-term successful weight loss. Psychological and behavioral factors contributing to poor long-term outcomes include decreased adherence to surgical eating guidelines, life stressors that derail weight maintenance, unhealthy eating patterns, and substance use. A 6-week pilot group behavioral intervention utilizing techniques of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) was developed to treat bariatric patients experiencing weight regain. Patients were treated at a large Midwestern academic medical center. Twenty-eight patients (93% female, 100% Caucasian) with a mean age of 53 and a mean BMI of 35.6 had regained an average of 17 kg or 37% of the weight lost after initially successful Roux-en-Y gastric bypass (RYGB). All patients completed the Structured Clinical Interview for DSM-IV-TR (SCID I) modules assessing mood and substance dependence, and completed a series of questionnaires before and after group treatment, with weekly assessment of depressive symptoms, binge eating, and alcohol use. Results were analyzed utilizing repeated measures ANOVA. Weight decreased during the intervention by an average of 1.6 ± 2.38 kg (p ≤ 0.01). Level of depressive symptoms improved for treatment completers (p ≤ 0.01). Food records indicated that grazing patterns decreased (p ≤ 0.01) and subjective binge eating episodes decreased (p ≤ 0.03). A 6-week pilot group behavioral intervention demonstrated an ability to help patients reverse their pattern of weight regain. Tailored behavioral interventions may be a useful treatment to enhance maintenance of long-term weight loss.

  5. Healthcare utilization and associated barriers experienced by wheelchair users: A pilot study.

    PubMed

    Stillman, Michael D; Bertocci, Gina; Smalley, Craig; Williams, Steve; Frost, Karen L

    2017-10-01

    More than twenty-five years after passage of the ADA, little remains known about the experiences of wheelchair users when attempting to access health care and how accessibility may influence health care utilization. To describe health care utilization among wheelchair users and characterize barriers encountered when attempting to obtain access to health care. An internet-based survey of wheelchair users was conducted. Measures included demographics, condition, socioeconomic status, health care utilization and receipt of preventive services within the past year, physical barriers encountered at outpatient facilities, and satisfaction with care. Four hundred thirty-two wheelchair users responded to the survey. Nearly all respondents (97.2%) had a primary care appointment within the past year and most reported 3-5 visits to both primary and specialty care providers. Most encountered physical barriers when accessing care (73.8% primary, 68.5% specialty). Participants received most preventive interventions at rates similar to national averages with the exception of Pap tests. Most participants remained clothed for their primary care evaluation (76.1%), and were examined seated in their wheelchair (69.7%). More than half of participants (54.1%) felt they received incomplete care, and 57% believed their physician had no more than a moderate understanding of their disability-specific medical concerns. Wheelchair users face persistent barriers to care, may receive less than thorough physical evaluations, receive fewer screenings for cervical cancer, and largely believe they receive incomplete care. Copyright © 2017 Elsevier Inc. All rights reserved.

  6. Patient-experienced burden of treatment in patients with multimorbidity - A systematic review of qualitative data.

    PubMed

    Rosbach, Michael; Andersen, John Sahl

    2017-01-01

    To synthesize existing qualitative literature on patient-experienced burden of treatment in multimorbid patients. A literature search identified available qualitative studies on the topic of burden of treatment in multimorbidity and meta-ethnography was applied as method. The authors' original findings were preserved, but also synthesized to new interpretations to investigate the concept of the burden of treatment using the Cumulative Complexity Model. Nine qualitative studies were identified. The majority of the 1367 participants from 34 different countries were multimorbid. The treatment burden components, experienced by patients, were identified for each study. The components financial burden, lack of knowledge, diet and exercise, medication burden and frequent healthcare reminding patients of their health problem were found to attract additional attention from the multimorbid patients. In studies conducted in the US and Australia the financial burden and the time and travel burden were found most straining to patients with deprived socioeconomic status. The burden of treatment was found to be a complex concept consisting of many different components and factors interacting with each other. The size of the burden was associated to the workload of demands (number of conditions, number of medications and health status), the capacity (cognitive, physical and financial resources, educational level, cultural background, age, gender and employment conditions) and the context (structure of healthcare and social support). Patients seem to use strategies such as prioritizing between treatments to diminish the workload and mobilizing and coordinating resources to improve their ability to manage the burden of treatment. They try to routinize and integrate the treatment into their daily lives, which might be a way to maintain the balance between workload and capacity. Healthcare providers need to increase the focus on minimizing multimorbid patients' burden of treatment

  7. Experienced Practitioners’ Beliefs Utilized to Create a Successful Massage Therapist Conceptual Model: a Qualitative Investigation

    PubMed Central

    Kennedy, Anne B.; Munk, Niki

    2017-01-01

    Background The massage therapy profession in the United States has grown exponentially, with 35% of the profession’s practitioners in practice for three years or less. Investigating personal and social factors with regard to the massage therapy profession could help to identify constructs needed to be successful in the field. Purpose This data-gathering exercise explores massage therapists’ perceptions on what makes a successful massage therapist that will provide guidance for future research. Success is defined as supporting oneself and practice solely through massage therapy and related, revenue-generating field activity. Participants and Setting Ten successful massage therapy practitioners from around the United States who have a minimum of five years of experience. Research Design Semistructured qualitative interviews were used in an analytic induction framework; index cards with preidentified concepts printed on them were utilized to enhance conversation. An iterative process of interview coding and analysis was used to determine themes and subthemes. Results Based on the participants input, the categories in which therapists needed to be successful were organized into four main themes: effectively establish therapeutic relationships, develop massage therapy business acumen, seek valuable learning environments and opportunities, and cultivate strong social ties and networks. The four themes operate within specific contexts (e.g., regulation and licensing requirements in the therapists’ state), which may also influence the success of the massage therapist. Conclusions The model needs to be tested to explore which constructs explain variability in success and attrition rate. Limitations and future research implications are discussed. PMID:28690704

  8. Patient affect experiencing following therapist interventions in short-term dynamic psychotherapy.

    PubMed

    Town, Joel M; Hardy, Gillian E; McCullough, Leigh; Stride, Chris

    2012-01-01

    The aim of this research was to examine the relationship between therapist interventions and patient affect responses in Short-Term Dynamic Psychotherapy (STDP). The Affect Experiencing subscale from the Achievement of Therapeutic Objectives Scale (ATOS) was adapted to measure individual immediate affect experiencing (I-AES) responses in relation to therapist interventions coded within the preceding speaking turn, using the Psychotherapy Interaction Coding (PIC) system. A hierarchical linear modelling procedure was used to assess the change in affect experiencing and the relationship between affect experiencing and therapist interventions within and across segments of therapy. Process data was taken from six STDP cases; in total 24 hours of video-taped sessions were examined. Therapist interventions were found to account for a statistically significant amount of variance in immediate affect experiencing. Higher levels of immediate affect experiencing followed the therapist's use of Confrontation, Clarification and Support compared to Questions, Self-disclosure and Information interventions. Therapist Confrontation interventions that attempted to direct pressure towards either the visceral experience of affect or a patient's defences against feelings led to the highest levels of immediate affect experiencing. The type of therapist intervention accounts for a small but significant amount of the variation observed in a patient's immediate emotional arousal. Empirical findings support clinical theory in STDP that suggests strategic verbal responses promote the achievement of this specific therapeutic objective.

  9. Relationships between life attitude profile and symptoms experienced with treatment decision evaluation in patients with cancer.

    PubMed

    Erci, Behice; Özdemir, Süreyya

    2013-01-01

    Despite many researches that have examined life attitude profile, treatment decision evaluation, and symptoms experienced in cancer populations, the relationships between life attitude profile and symptoms experienced with treatment decision evaluation are still not well understood. A thorough understanding of these relationships is critical for health care professionals to provide appropriate management to patients. The aim of this study was to determine relationships among life attitude profile, the treatment decision evaluation, and symptoms experienced in Turkish patients with cancer. A convenience sample of 199 patients with cancer at a Turkish university hospital completed a structured questionnaire including demographic characteristics and the Life Attitude Profile-Revised Scale for patients with cancer in 2007. The researchers visited the oncology clinic 5 work days every week and conducted interviews with the patients. The life attitude profile was not correlated with the treatment decision evaluation and symptoms experienced (r = 0.082, r = -026). The treatment decision evaluation showed that the patients were uncertain about their satisfaction with the treatment decision. Significant correlations were found between the treatment decision evaluation and symptoms experienced (r = 0.206; P <.01). Holistic nursing interventions can be implemented as they promote healing of the whole person processes as facilitating self-awareness, living meaningfully, and promotion connection with others and with nature and a higher power.

  10. Cost-Effectiveness of Dolutegravir in HIV-1 Treatment-Experienced (TE) Patients in France.

    PubMed

    Pialoux, Gilles; Marcelin, Anne-Geneviève; Despiégel, Nicolas; Espinas, Caroline; Cawston, Hélène; Finkielsztejn, Laurent; Laurisse, Audrey; Aubin, Céline

    2015-01-01

    To evaluate the cost-effectiveness of a new generation integrase inhibitor (INI), dolutegravir (DTG), in France, in treatment-experienced (TE) and INI-naïve HIV-infected adults with at least two classes resistance compared to raltegravir (RAL), by adapting previously published Anti-Retroviral Analysis by Monte Carlo Individual Simulation (ARAMIS) model. ARAMIS is a microsimulation Markov model with a lifetime time horizon and a monthly cycle length. Health states are defined as with or without opportunistic infection and death. In the initial cohort, efficacy and safety data were derived from a phase III study comparing DTG to RAL. Antiretroviral treatment algorithms, accounting for patient history, were based on French guidelines and experts opinion. Costs are mainly including treatment costs, routine HIV and opportunistic infection care, and death. Utilities depend on CD4+ cell count and the occurrence of opportunistic infections. The ARAMIS model indicates in the TE population that DTG compared to RAL over a life time is associated with 0.35 additional quality-adjusted life years (QALY; 10.75 versus 10.41) and additional costs of €7,266 (€390,001 versus €382,735). DTG increased costs are mainly related to a 9.1-month increase in life expectancy for DTG compared with RAL, and consequently a longer time spent on ART. The incremental cost-effectiveness ratio (ICER) for DTG compared with RAL is €21,048 per QALY gained. About 83% and 14% of total lifetime costs are associated with antiretroviral therapy and routine HIV care respectively. Univariate deterministic sensitivity analyses demonstrate the robustness of the model. DTG is cost-effective in the management of TE INI naive patients in France, from a collective perspective. These results could be explained by the superior efficacy of DTG in this population and its higher genetic barrier to resistance compared to RAL. These data need to be confirmed with longer-term real life data.

  11. The problems experienced by patients with cancer and their needs for palliative care.

    PubMed

    Osse, Bart H P; Vernooij-Dassen, Myrra J F J; Schadé, Egbert; Grol, Richard P T M

    2005-09-01

    To investigate the problems that patients experience and their met- and unmet needs for professional help. This information is necessary to tailor palliative care to patient needs. Patients (n=94) with disseminated cancer completed a validated checklist with 90 potential problems and needs for palliative care (PNPC questionnaire). On average, patients experienced 37 problems (range 0-68) and required more professional attention for eight problems (range 0-71). The five most prevalent problems were: fatigue, heavy housework, coping with the unpredictability of the future, fear of metastases, and frustrations because I can do less than before. The five issues most in need of extra attention were: informational needs, coping with the unpredictability of the future, fear of metastases, fear of physical suffering, and difficulties remembering what was told (during consultations). Younger patients experienced more social, psychological, and financial problems. Some 10% of patients expressed a multitude of problems and needs. While patients with metastasized cancer experienced a wide variety of problems, they asked for more support for only a few specific problems. Evidently, "problems" are not synonymous with unmet needs. Therefore, not only problems but also needs for care should be assessed. A structural need for support to cope with fears of suffering and loss of autonomy was found. Ten percent of patients expressed a multitude of problems and needs and might benefit either from psychological counseling or better palliative care.

  12. Enhancing patient safety in the operating theatre: from the perspective of experienced operating theatre nurses.

    PubMed

    Ingvarsdottir, Eydis; Halldorsdottir, Sigridur

    2017-09-22

    Surgical care is an extensive component of modern health care, but patient safety issues and complications of surgery have been identified as a major cause of death and disability. The aim of this study was to identify, from the perspective of experienced operating theatre nurses (OTNs), how patient safety in the operating theatre (OT) can be enhanced. In this phenomenological study, 14 individual interviews were conducted with a purposive sample of 11 participants: ten women and one man. Work experience as an OTN spanned 10-40 years. Mean experience was 16 years. The enhancement of patient safety in the OT from the perspective of the experienced OTNs is a constant endeavour of managing risks and preventing patient harm it involves respecting the vulnerability of the patient in the OT by being attentive to the patient at each moment, making contact with the patient and recognising how the patient loses all control by being anaesthetised or sedated and is, therefore totally dependent on OT staff. It also involves the OTN navigating the patient as safely as possible through the perioperative process by careful preparation, the use of protocols and checklists and taking measures to prevent complications and harm. Moreover, it involves contributing to a culture of safety by improving work conditions in the OT. Certain competencies of the OTN are essential for the enhancement of patient safety in the OT. These involve both nontechnical and technical competencies. Constantly managing risk and preventing the OT patient from harm is essential according to the experienced OTNs, who are in a key position to identify threats to patient safety and should be empowered to enhance patient safety as a constant endeavour. © 2017 Nordic College of Caring Science.

  13. Correlation between rest-activity rhythm and survival in cancer patients experiencing pain.

    PubMed

    Chang, Wen-Pei; Lin, Chia-Chin

    2014-10-01

    The purpose of this study was to investigate the influence of rest-activity rhythm on the survival of cancer patients. This study collected data related to cancer patients experiencing pain who had been hospitalized for treatment between August 2006 and October 2007. Data included the Karnofsky Performance Status Index as a representation of functional condition as well as the Brief Pain Inventory and the Pittsburgh Sleep Quality Index. Actigraphic methods were used to record the dichotomy index (I < O) of patients' rest-activity rhythms over periods of three consecutive days. Patients were closely followed until 31 July 2013. Results were analyzed using Kaplan-Meier survival analysis, log-rank testing and Cox proportional hazards regression analysis to evaluate whether alterations in the rest-activity rhythm affected the survival rate of the patients. Of the 68 hospitalized cancer patients experiencing pain at the time of admission, 51 subsequently died within the study period. A significant difference was observed in the survival curves between the regular I < O group and the disrupted I < O group (log rank = 7.942, p = 0.005). A multivariable proportional hazard model was used for analysis of overall survival, revealing that the risk of death within the study period among patients with disrupted I < O was 4.59 times higher than that of patients with regular I < O (95% CI: 1.92-10.96, p = 0.001). Among patients with poor performance status, the risk of death among patients with disrupted I < O was 8.68 times higher than that of patients with regular I < O (95% CI: 2.50-30.09, p = 0.001). Disruptions in rest-activity rhythm were negatively correlated with the survival of hospitalized cancer patients experiencing pain. Effects were particularly pronounced in cancer patients with poor performance status.

  14. Health Care Utilization in Patients with Gout

    PubMed Central

    Singh, Jasvinder A; Sarkin, A; Shieh, M; Khanna, D; Terkeltaub, R; Lee, SJ; Kavanaugh, A; Hirsch, JD

    2010-01-01

    Objective To study health care utilization patterns in patients with gout. Methods In a gout population from primary care and rheumatology clinics in three U.S. metropolitan cities, we collected data on gout-related utilization (primary care, rheumatology, urgent care, emergency room and other) in the past year. We evaluated the association of comorbidities, age, gender, gout characteristics (time since last gout attack and tophi) and gout severity ratings (mean of serum uric acid, patient-rated and physician-rated gout severity) and with emergency/urgent care and primary care utilization using regression and correlation analyses. Results Of the 296 patients who reported visiting at least one type of health practitioner for gout in the past year, percent of patients utilizing the service at least once and annual utilization rates among utilizers were: primary care physician, 60%, 3.0±3.4; nurse practitioner/physician assistant, 26%, 2.7±2.5; rheumatologist, 51%, 3.7±5.7; urgent care, 23%, 2.1±2.2; emergency room, 20%, 2.0±1.7; and hospitalization, 7%, 2.1±1.4. Higher overall gout severity was associated with greater use of each resource type and with overall gout-related utilization. Non- emergency/non-urgent care utilization (primary care physician, nurse practitioner, physician’s assistant and rheumatologist for gout) was the strongest predictor of gout-related emergency/urgent care utilization. Patients with more comorbidities had greater gout-related primary care utilization. Conclusions Overall gout severity was associated with all types of gout-related utilization. This may help to screen high utilizers for targeted behavioral and therapeutic interventions. Having a higher number of comorbid conditions was a risk factor for higher gout-related primary care utilization. PMID:20828793

  15. Sensations experienced and patients' perceptions of osteopathy in the cranial field treatment.

    PubMed

    Mulcahy, Jane; Vaughan, Brett

    2014-10-01

    Osteopathy in the cranial field is an approach used by manual and physical therapists. However, there is minimal information in the literature about patient experiences of this treatment. The present study was undertaken to explore patients' experiences of osteopathy in the cranial field. Patients completed the Patient Perception Measure-Osteopathy in the Cranial Field and identified sensations they experienced during treatment. Additional measures of anxiety, depression, Satisfaction With Life, and Meaningfulness of Daily Activity were completed. The Patient Perception Measure-Osteopathy in the Cranial Field was internally consistent (Cronbach's α = .85). The most frequently experienced sensations of osteopathy in the cranial field patients were "relaxed," "releasing," and "unwinding." Satisfaction With Life and Meaningfulness of Daily Activity were positively associated with Patient Perception Measure-Osteopathy in the Cranial Field scores. Negative associations were observed between the Patient Perception Measure-Osteopathy in the Cranial Field and depression. Psychometric properties of the Patient Perception Measure-Osteopathy in the Cranial Field require further testing. The observed associations of Satisfaction With Life and depression with patients' perceptions of osteopathy in the cranial field treatment needs to be tested in larger clinical manual therapy cohorts.

  16. Effectiveness of etravirine-based therapy for treatment-experienced HIV-infected patients.

    PubMed

    Huerta García, Gloria; Mata-Marín, José Antonio; Domínguez-Hermosillo, Juan Carlos; Chavez-García, Marcelino; Banda-Lara, Marco Issac; Nuñez-Rodríguez, Nohemi; Cruz-Herrera, Javier Enrique; Sandoval-Ramírez, Jorge Luis; Villagómez-Ruiz, Alfredo; Manjarrez-Tellez, Bulmaro; Gaytan-Martínez, Jesús Enrique

    2016-06-30

    Treatment options are limited for HIV-1-infected individuals who have received extensive previous antiretroviral therapy. ETV has shown significant clinical benefits in treatment-experienced HIV-1+ patients with antiretroviral resistance. The aim of this study was to evaluate the effectiveness of ETV plus optimized background regimen in real-life conditions in a cohort of highly HIV-1 antiretroviral-experienced patients. Retrospective cohort of treatment-experienced HIV-1-infected adults with virological failure who started therapy with an ETV-containing regimen. The effectiveness was evaluated using HIV-1 RNA viral load and changes in CD4+ cell count after 48 weeks of treatment. Forty-two patients ≥ 16 years of age were included; 74% were men, and the median age was 45 years (IQR 41-53). All participants had prior non-nucleoside reverse transcriptase inhibitor use (55% nevirapine, 83%, efavirenz, and 28% both). Baseline median HIV-1 RNA viral load was 15,598 copies/mL (IQR 2651-84,175) and CD4+ cell count was 276 cells/mL (IQR 155-436). After 48 weeks of treatment, 90.5% (95% CI 78-96) of patients had HIV-1 RNA viral load < 200 copies/mL and 76% (95% CI 61-86) had < 50 copies/mL. CD4+ cell counts increased from baseline to 48 weeks of treatment to a median of 407 cells/mL (IQR 242-579); p < 0.001. Virological outcome was associated with virological failure at baseline HIV-1 RNA viral load ≥ 100,000 copies/mL (OR 7.6; 95% CI 1.2-44.80; p = 0.025). Our study provides clinically important evidence of the effectiveness and safety of ETV in highly antiretroviral-experienced HIV-1-infected patients.

  17. Cost-Effectiveness of Dolutegravir in HIV-1 Treatment-Experienced (TE) Patients in France

    PubMed Central

    Pialoux, Gilles; Marcelin, Anne-Geneviève; Despiégel, Nicolas; Espinas, Caroline; Cawston, Hélène; Finkielsztejn, Laurent; Laurisse, Audrey; Aubin, Céline

    2015-01-01

    Objectives To evaluate the cost-effectiveness of a new generation integrase inhibitor (INI), dolutegravir (DTG), in France, in treatment-experienced (TE) and INI-naïve HIV-infected adults with at least two classes resistance compared to raltegravir (RAL), by adapting previously published Anti-Retroviral Analysis by Monte Carlo Individual Simulation (ARAMIS) model. Methods ARAMIS is a microsimulation Markov model with a lifetime time horizon and a monthly cycle length. Health states are defined as with or without opportunistic infection and death. In the initial cohort, efficacy and safety data were derived from a phase III study comparing DTG to RAL. Antiretroviral treatment algorithms, accounting for patient history, were based on French guidelines and experts opinion. Costs are mainly including treatment costs, routine HIV and opportunistic infection care, and death. Utilities depend on CD4+ cell count and the occurrence of opportunistic infections. Results The ARAMIS model indicates in the TE population that DTG compared to RAL over a life time is associated with 0.35 additional quality-adjusted life years (QALY; 10.75 versus 10.41) and additional costs of €7,266 (€390,001 versus €382,735). DTG increased costs are mainly related to a 9.1-month increase in life expectancy for DTG compared with RAL, and consequently a longer time spent on ART. The incremental cost-effectiveness ratio (ICER) for DTG compared with RAL is €21,048 per QALY gained. About 83% and 14% of total lifetime costs are associated with antiretroviral therapy and routine HIV care respectively. Univariate deterministic sensitivity analyses demonstrate the robustness of the model. Conclusion DTG is cost-effective in the management of TE INI naive patients in France, from a collective perspective. These results could be explained by the superior efficacy of DTG in this population and its higher genetic barrier to resistance compared to RAL. These data need to be confirmed with longer

  18. Utilizing Data from Cancer Patient & Survivor Studies

    Cancer.gov

    Utilizing Data from Cancer Patient & Survivor Studies and Understanding the Current State of Knowledge and Developing Future Research Priorities, a 2011 workshop sponsored by the Epidemiology and Genomics Research Program.

  19. HIV integrase variability and genetic barrier in antiretroviral naïve and experienced patients

    PubMed Central

    2011-01-01

    Background HIV-1 integrase (IN) variability in treatment naïve patients with different HIV-1 subtypes is a major issue. In fact, the effect of previous exposure to antiretrovirals other than IN inhibitors (INI) on IN variability has not been satisfactorily defined. In addition, the genetic barrier for specific INI resistance mutations remains to be calculated. Methods IN variability was analyzed and compared with reverse transcriptase (RT) and protease (PR) variability in 41 treatment naïve and 54 RT inhibitor (RTI) and protease inhibitor (PRI) experienced patients from subjects infected with subtype B and non-B strains. In addition, four HIV-2 strains were analyzed in parallel. Frequency and distribution of IN mutations were compared between HAART-naïve and RTI/PI-experienced patients; the genetic barrier for 27 amino acid positions related to INI susceptibility was calculated as well. Results Primary mutations associated with resistance to INI were not detected in patients not previously treated with this class of drug. However, some secondary mutations which have been shown to contribute to INI resistance were found. Only limited differences in codon usage distribution between patient groups were found. HIV-2 strains from INI naïve patients showed the presence of both primary and secondary resistance mutations. Conclusion Exposure to antivirals other than INI does not seem to significantly influence the emergence of mutations implicated in INI resistance. HIV-2 strain might have reduced susceptibility to INI. PMID:21453487

  20. Using the Experience of a Lifetime. NOWIS: An Employer-to-Employer Data Base of Programs Utilizing Experienced Workers.

    ERIC Educational Resources Information Center

    American Association of Retired Persons, Washington, DC. Work Force Programs Dept.

    This publication gives examples of employment programs for experienced workers taken from the National Older Workers Information System (NOWIS), a computerized system of information on more than 140 experienced worker employment programs in public and private sector organizations. (Maintained by the Business Partnerships Program of the American…

  1. Utilization of cryopreserved semen in tumor patients.

    PubMed

    Krause, W; Brake, A

    1994-01-01

    Treatment with cytotoxic drugs or with radiation in order to manage a tumor or another life-threatening disease involves a potential hazard to male fertility. In these cases cryopreservation of semen is recommended. However, the number of patients requesting the subsequent insemination of their partner is rather low. It would be of interest if patients with a high probability for desiring use of the cryodeposit for insemination could be identified. During the years 1985-1992 we performed cryopreservation in 29 patients attending our department. One year following cryopreservation the utilization of the cryodeposit was analyzed: 29 patients were not interested in further maintenance, 2 patients died, 3 patients requested use for insemination, 31 patients decided to maintain the semen further in a commercial cryobank, 17 patients had a complete restitution of spermatogenesis within the observation period. In 7 patients the interval is yet below 1 year. The different modes of utilizing the cryodeposit were analyzed in relation to the semen quality, age, status, kind of disease and primary treatment. None of these factors possibly influencing the utilization showed differences between the groups. We conclude that it is impossible to predict the probability of the use of a cryodeposit of semen based on the examined patient characteristics at the time of preservation. We plan to further on offer semen preservation to all patients requiring it in a situation of threatened fertility, bearing in mind that the relative costs of the cryopreservation are low.

  2. Gender differences among discrimination & stigma experienced by depressive patients in Pakistan.

    PubMed

    Khan, Nashi; Kausar, Rukhsana; Khalid, Adeela; Farooq, Anum

    2015-01-01

    This study aims to examine Gender Difference in the level of Discrimination and Stigma experienced by people diagnosed with Major Depressive Disorder in Pakistan. It was hypothesized that Women diagnosed with Depression are likely to be experiencing more Discrimination and Internalized Stigma in comparison to Men. This is a Cross Sectional Study. Thirty eight patients diagnosed with Major Depressive Disorder recruited from different Government Sector Hospitals of Lahore; were approached after obtaining informed consent. Discrimination and Stigma were measured through Discrimination and Stigma Scale and Internalized Stigma of Mental Illness Inventory respectively. Both Men and Women experience considerably high level of associated Stigma and Discrimination due to their Mental Illness. However, Women in comparison to Men experience significantly greater level of Internalized Stigma especially in domains of Discrimination Experience and Social Withdrawal. The findings of this study highlight the fact that people with Depression can be more benefited with psychological treatment if dealing with Stigma and Discrimination is also addressed in Intervention Plans.

  3. The importance of experienced adverse outcomes on patients' future choice of a hospital for surgery.

    PubMed

    Marang-van de Mheen, P J; Dijs-Elsinga, J; Otten, W; Versluijs, M; Smeets, H J; van der Made, W J; Vree, R; Kievit, J

    2010-12-01

    To assess whether patients who experience adverse outcomes during hospitalisation or after discharge differ in the information they would use for future choices of a hospital for surgery compared with patients without any adverse outcomes. Cross-sectional questionnaire study, including questions on (1) adverse outcome occurrence during hospitalisation and after discharge, (2) information patients would use for future hospital choice and (3) priority of information. Three hospitals in the western part of The Netherlands. All 2122 patients who underwent elective aorta reconstruction (for treatment of aneurysm), cholecystectomy, colon resection, inguinal hernia repair, oesophageal resection or thyroid surgery in the period 2005-2006, of whom 1329 (62.6%) responded. Patients who experienced postdischarge adverse outcomes intend to use more information items to choose a future hospital (on average 1.6 items more). They more often would use the item on information provision during hospitalisation (OR 2.35 (1.37 to 4.03)) and information on various quality-of-care measures, compared with patients without adverse outcomes. Patients who experienced in-hospital adverse outcomes would not use more information items but more often would use the item on mortality after surgery (OR 1.93 (1.27 to 2.94)) and extended hospital stay (OR 1.61 (1.10 to 2.36)). However, when asked for priority of information, previous treatment in that hospital is mentioned as the most important item by most patients (32%), regardless of adverse outcome occurrence, followed by hospital reputation and waiting time. Adverse outcome experience may change the information patients use (on quality of care) to choose a future hospital.

  4. Determinant Factors of the Direct Medical Costs Associated with Genotype 1 Hepatitis C Infection in Treatment-Experienced Patients.

    PubMed

    Akpo, Essè Ifèbi Hervé; Sbarigia, Urbano; Wan, George; Kleintjens, Joris

    2015-12-01

    Limited evidence is available on predictors of medical resource utilization (MRU) and related direct costs, especially in treatment-experienced patients infected with genotype 1 hepatitis C virus (HCV). This study aimed at investigating patient and treatment characteristics that predict MRU and related non-drug costs in treatment-experienced patients with chronic hepatitis C (CHC) treated with simeprevir (SMV) or telapravir (TVR) in combination with pegylated interferon and ribavirin (PegIFN/R). A total of 709 patients who completed the 72-week ATTAIN trial were included in the study. Cost data were analysed from the UK NHS perspective. Descriptive statistics and regression analyses were used to determine patterns and predictors of total MRU-related costs associated with SMV/PegIFN/R and TVR/PegIFN/R. Independent predictors for total MRU-related costs were age, region and the following interaction terms: (1) gender × F3-F4 METAVIR score × baseline viral load (BLVL), (2) body mass index (BMI) × F3-F4 METAVIR score × prior response to PegIFN/R and (3) gender × achievement of SVR at 12 weeks (SVR12) × BLVL. A F3-F4 METAVIR score was a stronger predictor of total MRU-related costs than SVR12. Predictors of adverse events included older age, female gender, low BMI, TVR/PegIFN/R and SVR12. Wilcoxon rank sum test revealed comparable total MRU-related costs between SMV/PegIFN/R and TVR/PegIFN/R. To the best of our knowledge, this study is the first to describe the relationship between commonly admitted predictors of MRU-related costs and their joint effect on total MRU-related costs in treatment-experienced patients with CHC. The identified predictors of MRU-related costs suggest that significant treatment costs can be avoided by starting treatment early before the disease progresses. Furthermore, adverse events seem to be the most important factor to take into consideration for the choice of treatment, especially when therapeutic options are associated with similar

  5. The Rules of Engagement: Perspectives on Secure Messaging From Experienced Ambulatory Patient Portal Users.

    PubMed

    Sieck, Cynthia J; Hefner, Jennifer L; Schnierle, Jeanette; Florian, Hannah; Agarwal, Aradhna; Rundell, Kristen; McAlearney, Ann Scheck

    2017-07-04

    Patient portals have shown promise in engaging individuals in self-management of chronic conditions by allowing patients to input and track health information and exchange secure electronic messages with their providers. Past studies have identified patient barriers to portal use including usability issues, low health literacy, and concerns about loss of personal contact as well as provider concerns such as increased time spent responding to messages. However, to date, studies of both patient and provider perspectives on portal use have focused on the pre-implementation or initial implementation phases and do not consider how these issues may change as patients and providers gain greater experience with portals. Our study examined the following research question: Within primary care offices with high rates of patient-portal use, what do experienced physician and patient users of the ambulatory portal perceive as the benefits and challenges of portal use in general and secure messaging in particular? This qualitative study involved 42 interviews with experienced physician and patient users of an ambulatory patient portal, Epic's MyChart. Participants were recruited from the Department of Family Medicine at a large Academic Medical Center (AMC) and included providers and their patients, who had been diagnosed with at least one chronic condition. A total of 29 patients and 13 primary care physicians participated in the interviews. All interviews were conducted by telephone and followed a semistructured interview guide. Interviews were transcribed verbatim to permit rigorous qualitative analysis. Both inductive and deductive methods were used to code and analyze the data iteratively, paying particular attention to themes involving secure messaging. Experienced portal users discussed several emergent themes related to a need for greater clarity on when and how to use the secure messaging feature. Patient concerns included worry about imposing on their physician's time

  6. The Rules of Engagement: Perspectives on Secure Messaging From Experienced Ambulatory Patient Portal Users

    PubMed Central

    Schnierle, Jeanette; Florian, Hannah; Agarwal, Aradhna; Rundell, Kristen; McAlearney, Ann Scheck

    2017-01-01

    Background Patient portals have shown promise in engaging individuals in self-management of chronic conditions by allowing patients to input and track health information and exchange secure electronic messages with their providers. Past studies have identified patient barriers to portal use including usability issues, low health literacy, and concerns about loss of personal contact as well as provider concerns such as increased time spent responding to messages. However, to date, studies of both patient and provider perspectives on portal use have focused on the pre-implementation or initial implementation phases and do not consider how these issues may change as patients and providers gain greater experience with portals. Objective Our study examined the following research question: Within primary care offices with high rates of patient-portal use, what do experienced physician and patient users of the ambulatory portal perceive as the benefits and challenges of portal use in general and secure messaging in particular? Methods This qualitative study involved 42 interviews with experienced physician and patient users of an ambulatory patient portal, Epic’s MyChart. Participants were recruited from the Department of Family Medicine at a large Academic Medical Center (AMC) and included providers and their patients, who had been diagnosed with at least one chronic condition. A total of 29 patients and 13 primary care physicians participated in the interviews. All interviews were conducted by telephone and followed a semistructured interview guide. Interviews were transcribed verbatim to permit rigorous qualitative analysis. Both inductive and deductive methods were used to code and analyze the data iteratively, paying particular attention to themes involving secure messaging. Results Experienced portal users discussed several emergent themes related to a need for greater clarity on when and how to use the secure messaging feature. Patient concerns included worry

  7. Effectiveness of tipranavir versus darunavir as a salvage therapy in HIV-1 treatment-experienced patients.

    PubMed

    Domínguez-Hermosillo, Juan Carlos; Mata-Marin, José Antonio; Herrera-González, Norma Estela; Chávez-García, Marcelino; Huerta-García, Gloria; Nuñez-Rodríguez, Nohemí; García-Gámez, José Gerardo; Jiménez-Romero, Anai; Gaytán-Martínez, Jesús Enrique

    2016-09-30

    Although both tipranavir (TPV) and darunavir (DRV) represent important options for the management of patients with multi-protease inhibitor (PI)-resistant human immunodeficiency virus (HIV), currently there are no studies comparing the effectiveness and safety of these two drugs in the Mexican population. The aim of this study was to compare the effectiveness of TPV versus DRV as a salvage therapy in HIV-1 treatment-experienced patients. This was a comparative, prospective, cohort study. Patients with HIV and triple-class drug resistance evaluated at the Hospital de Infectología "La Raza", National Medical Center, were included. All patients had the protease and retrotranscriptase genotype; resistance mutation interpretation was done using the Stanford database. A total of 35 HIV-1 triple-class drug-resistant patients were analyzed. All of them received tenofovir and raltegravir, 22 received darunavir/ritonavir (DRV/r), and 13 received tipranavir/ritonavir (TPV/r) therapies. The median baseline RNA HIV-1 viral load and CD4+ cell count were 4.34 log (interquartile range [IQR], 4.15-4.72) and 267 cells/mm3 (IQR, 177-320) for the DRV/r group, and 4.14 log (IQR, 3.51-4.85) and 445 cells/mm3 (IQR, 252-558) for the TPV/r group. At week 24 of treatment, 91% of patients receiving DRV/r and 100% of patients receiving TPV/r had an RNA HIV-1 viral load < 50 copies/mL and a CD4+ cell count of 339 cells/mm3 (IQR, 252-447) and 556 cells/mm3 (IQR, 364-659), respectively. No significant difference was observed between DRV/r and TPV/r in terms of virological suppression in HIV-1 patients who were highly experienced in antiretroviral therapy.

  8. The "Handling" of power in the physician-patient encounter: perceptions from experienced physicians.

    PubMed

    Nimmon, Laura; Stenfors-Hayes, Terese

    2016-04-18

    Modern healthcare is burgeoning with patient centered rhetoric where physicians "share power" equally in their interactions with patients. However, how physicians actually conceptualize and manage their power when interacting with patients remains unexamined in the literature. This study explored how power is perceived and exerted in the physician-patient encounter from the perspective of experienced physicians. It is necessary to examine physicians' awareness of power in the context of modern healthcare that espouses values of dialogic, egalitarian, patient centered care. Thirty physicians with a minimum five years' experience practicing medicine in the disciplines of Internal Medicine, Surgery, Pediatrics, Psychiatry and Family Medicine were recruited. The authors analyzed semi-structured interview data using LeCompte and Schensul's three stage process: Item analysis, Pattern analysis, and Structural analysis. Theoretical notions from Bourdieu's social theory served as analytic tools for achieving an understanding of physicians' perceptions of power in their interactions with patients. The analysis of data highlighted a range of descriptions and interpretations of relational power. Physicians' responses fell under three broad categories: (1) Perceptions of holding and managing power, (2) Perceptions of power as waning, and (3) Perceptions of power as non-existent or irrelevant. Although the "sharing of power" is an overarching goal of modern patient-centered healthcare, this study highlights how this concept does not fully capture the complex ways experienced physicians perceive, invoke, and redress power in the clinical encounter. Based on the insights, the authors suggest that physicians learn to enact ethical patient-centered therapeutic communication through reflective, effective, and professional use of power in clinical encounters.

  9. [The early postoperative rehabilitation of the patients presenting with cholelithiasis and experiencing psychoemotional stress].

    PubMed

    Poddubnaia, O A; Marsheva, S I

    2013-01-01

    Early postoperative rehabilitation of the patients presenting with cholelithiasis and experiencing psychoemotional stress is designed to restore the function of bile secretion, enhance their adaptive capabilities, and normalize the psychovegetative status for the purpose of preventing further progress of the disease and reducing the risk of the development of post-cholecystectomy syndrome. The inclusion of drinking mineral water, magnetic laser therapy, and UHF therapy in the combined rehabilitative treatment of such patients results in the appreciable enhancement of all functional abilities of the body manifest as the significant improvement and normalization of clinical and laboratory characteristics (elimination of clinical symptoms of the disease, improvement of general and biochemycal parameters of peripheral blood). Simultaneously, the adaptive capabilities and the psychovegetative status of the patients improved as apparent from the increased lymphocyte count, normalization of the Kerdo and Hildebrandt indices and indices of stress level, decreased psychoemotional stress, enhancement of physical functioning characteristics. Taken together, these changes account for the high effectiveness of the above procedures of early postoperative rehabilitation of the patients presenting with cholelithiasisand experiencing psychoemotional stress (94.7%).

  10. To surrender in dependence of another: the relationship with the ambulance clinicians as experienced by patients.

    PubMed

    Holmberg, Mats; Forslund, Kerstin; Wahlberg, Anna Carin; Fagerberg, Ingegerd

    2014-09-01

    Historically, the ambulance care has focused on acute transports and medical treatment, although ambulance care has also been reported as complex, encompassing more than just medical treatment and transports. Previous studies, on ambulance clinicians, have pointed out the importance of interpersonal caring activities complementary to the medical treatment. Those activities can be understood as taking part in the relationship between patients and ambulance clinicians, earlier described as essential and a core component of care. The aim of this study was to elucidate the meaning of the relationship with the ambulance clinicians as experienced by patients. Twenty ambulance patients were interviewed in the study. The interviews were transcribed verbatim and analysed with a phenomenological hermeneutical method to grasp meanings in the patients' experiences. The regional ethical committee approved the study. In the result emerged one main theme: To surrender in dependence of another. The main theme includes four themes: Being in the hands of another, Being in a caring temporary presence, Being important while involved and Being powerless while insignificant, and the themes comprise eleven subthemes. The main theme meant to have no other option than to surrender and to put their life into the hand of another. This surrender also meant to adapt to the clinicians' views even if not shared. This is experienced as excessive care. Summarised, the patients' experiences were both positive and negative and the findings provide a complex understanding of the relationship between the patient and the ambulance clinicians. Overall, the relationship embraces the whole person without reducing the patient to be a recipient of an objectified ambulance care.

  11. Perceptions of two therapeutic approaches for palliative care patients experiencing death anxiety.

    PubMed

    Sussman, Joleen Carol; Liu, William Ming

    2014-08-01

    Evidenced-based psychotherapies are not well researched for palliative care patients experiencing unrelenting anxiety about dying, even less research is focused on young adult palliative care patients with death anxiety. The aim of this study is to provide preliminary data regarding potential clients' perceptions of using evidenced based treatments with dying populations who are experiencing death anxiety. 104 college students were used as potential clients and randomly assigned to watch either a short video of a cognitive therapy (CT) session or of an acceptance and commitment therapy (ACT) session focused on treating a young adult diagnosed with an acute lymphoid leukemia expressing death anxiety. After watching the video, potential clients rated the session impact of the therapy approach using the Session Evaluation Questionnaire. No differences in ratings of session impact were found between potential clients who viewed the CT session and the ACT session. In regards to potential clients' views of session impact variables, their view of session smoothness was positively related to their post-session positivity, but inversely related to their view of session depth. Additionally, a positive correlation was found between potential clients' views of the therapist and session depth. This preliminary study suggests that palliative care patients expressing death anxiety may benefit from either ACT or CT for death anxiety, however, future research is needed to explore the usefulness of each approach. Findings of this study support the theory that ACT and CT are viewed to have a similar session impact in the palliative care population.

  12. Experienced continuity of care when patients see multiple clinicians: a qualitative metasummary.

    PubMed

    Haggerty, Jeannie L; Roberge, Danièle; Freeman, George K; Beaulieu, Christine

    2013-01-01

    Continuity of care among different clinicians refers to consistent and coherent care management and good measures are needed. We conducted a metasummary of qualitative studies of patients' experience with care to identify measurable elements that recur over a variety of contexts and health conditions as the basis for a generic measure of management continuity. From an initial list of 514 potential studies (1997-2007), 33 met our criteria of using qualitative methods and exploring patients' experiences of health care from various clinicians over time. They were coded independently. Consensus meetings minimized conceptual overlap between codes. For patients, continuity of care is experienced as security and confidence rather than seamlessness. Coordination and information transfer between professionals are assumed until proven otherwise. Care plans help clinician coordination but are rarely discerned as such by patients. Knowing what to expect and having contingency plans provides security. Information transfer includes information given to the patient, especially to support an active role in giving and receiving information, monitoring, and self-management. Having a single trusted clinician who helps navigate the system and sees the patient as a partner undergirds the experience of continuity between clinicians. Some dimensions of continuity, such as coordination and communication among clinicians, are perceived and best assessed indirectly by patients through failures and gaps (discontinuity). Patients experience continuity directly through receiving information, having confidence and security on the care pathway, and having a relationship with a trusted clinician who anchors continuity.

  13. Perceptions of family members of palliative medicine and hospice patients who experienced music therapy.

    PubMed

    Gallagher, Lisa M; Lagman, Ruth; Bates, Debbie; Edsall, Melissa; Eden, Patricia; Janaitis, Jessica; Rybicki, Lisa

    2017-06-01

    Evidence shows that music therapy aids in symptom management and improves quality of life for palliative medicine and hospice patients. The majority of previous studies have addressed patient needs, while only a few addressed the needs of family members. The primary purpose of this study was to understand family members' perceptions of music therapy experienced by a relative in palliative medicine or hospice. Patient self-reported scales and music therapist assessment of change were also investigated. Patients scored their symptoms (pain, anxiety, depression, shortness of breath, and mood) before and after music therapy sessions. One family member present during the session assessed perceived effect on the patient's pain, anxiety, depression, shortness of breath, stress level, restlessness, comfort level, mood, and quality of life. The effect on family member's stress level, quality of life, and mood and helpfulness of the music therapy session for the patient and self were studied. Recommendations about future patient participation in music therapy and qualitative comments were also solicited. Fifty family member/patient dyads participated in the study. Family member perceptions were positive, with 82% of responders indicating improvement for self and patient in stress, mood, and quality of life; 80% rating the session as extremely helpful; and 100% of 49 recommending further music therapy sessions for the patient. Patients reported statistically significant improvement in pain, depression, distress, and mood scores. Family members of patients in palliative medicine and hospice settings reported an immediate positive impact of music therapy on the patient and on themselves. More research needs to be conducted to better understand the benefits of music therapy for family members.

  14. Subtypes of patients experiencing exacerbations of COPD and associations with outcomes.

    PubMed

    Arostegui, Inmaculada; Esteban, Cristobal; García-Gutierrez, Susana; Bare, Marisa; Fernández-de-Larrea, Nerea; Briones, Eduardo; Quintana, José M

    2014-01-01

    Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous condition characterized by occasional exacerbations. Identifying clinical subtypes among patients experiencing COPD exacerbations (ECOPD) could help better understand the pathophysiologic mechanisms involved in exacerbations, establish different strategies of treatment, and improve the process of care and patient prognosis. The objective of this study was to identify subtypes of ECOPD patients attending emergency departments using clinical variables and to validate the results using several outcomes. We evaluated data collected as part of the IRYSS-COPD prospective cohort study conducted in 16 hospitals in Spain. Variables collected from ECOPD patients attending one of the emergency departments included arterial blood gases, presence of comorbidities, previous COPD treatment, baseline severity of COPD, and previous hospitalizations for ECOPD. Patient subtypes were identified by combining results from multiple correspondence analysis and cluster analysis. Results were validated using key outcomes of ECOPD evolution. Four ECOPD subtypes were identified based on the severity of the current exacerbation and general health status (largely a function of comorbidities): subtype A (n = 934), neither high comorbidity nor severe exacerbation; subtype B (n = 682), moderate comorbidities; subtype C (n = 562), severe comorbidities related to mortality; and subtype D (n = 309), very severe process of exacerbation, significantly related to mortality and admission to an intensive care unit. Subtype D experienced the highest rate of mortality, admission to an intensive care unit and need for noninvasive mechanical ventilation, followed by subtype C. Subtypes A and B were primarily related to other serious complications. Hospitalization rate was more than 50% for all the subtypes, although significantly higher for subtypes C and D than for subtypes A and B. These results could help identify characteristics

  15. Mean HEART scores for hospitalized chest pain patients are higher in more experienced providers.

    PubMed

    Dubin, Jeff; Kiechle, Eric; Wilson, Matt; Timbol, Christian; Bhat, Rahul; Milzman, Dave

    2017-01-01

    The HEART score has been validated as a predictor of major adverse cardiac events (MACEs) in emergency department patients complaining of chest pain. Our objective was to determine the extent of physician variation in the HEART score of admitted patients stratified by years of experience. We performed a retrospective medical record review at an academic tertiary care emergency department to determine HEART score, outcome of hospitalization, and 30-day MACE. Electrocardiograms were graded by consensus between 3 physicians. We used analysis of variance to determine the difference in mean HEART scores between providers, Fisher's exact test to determine difference in MACE by duration of training, and logistic regression to determine predictors of low-risk admission (HEART score≤3). The average mean HEART score for 19 full-time physicians was 4.41 (SD 0.43). Individually, there was no difference in mean scores (P=.070), but physicians with 10-15 years of experience had significantly higher mean scores than those with 0-5 years of experience (mean HEART score 4.65 vs 3.93, P=.012). Those with 10-15 years of experience also had a significantly higher proportion of MACE in their admitted cohort (15.3%, P=.002). More experienced providers admitted higher-risk patients and were more likely to admit patients who would experience a MACE. More research is needed to determine whether adding the HEART score for clinical decision making can be used prospectively to increase sensitivity for admitting patients at high risk for MACE and to decrease admissions for chest pain in lower-risk patients by less experienced providers. Copyright © 2016 Elsevier Inc. All rights reserved.

  16. Subtypes of Patients Experiencing Exacerbations of COPD and Associations with Outcomes

    PubMed Central

    Arostegui, Inmaculada; Esteban, Cristobal; García-Gutierrez, Susana; Bare, Marisa; Fernández-de-Larrea, Nerea; Briones, Eduardo; Quintana, José M.

    2014-01-01

    Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous condition characterized by occasional exacerbations. Identifying clinical subtypes among patients experiencing COPD exacerbations (ECOPD) could help better understand the pathophysiologic mechanisms involved in exacerbations, establish different strategies of treatment, and improve the process of care and patient prognosis. The objective of this study was to identify subtypes of ECOPD patients attending emergency departments using clinical variables and to validate the results using several outcomes. We evaluated data collected as part of the IRYSS-COPD prospective cohort study conducted in 16 hospitals in Spain. Variables collected from ECOPD patients attending one of the emergency departments included arterial blood gases, presence of comorbidities, previous COPD treatment, baseline severity of COPD, and previous hospitalizations for ECOPD. Patient subtypes were identified by combining results from multiple correspondence analysis and cluster analysis. Results were validated using key outcomes of ECOPD evolution. Four ECOPD subtypes were identified based on the severity of the current exacerbation and general health status (largely a function of comorbidities): subtype A (n = 934), neither high comorbidity nor severe exacerbation; subtype B (n = 682), moderate comorbidities; subtype C (n = 562), severe comorbidities related to mortality; and subtype D (n = 309), very severe process of exacerbation, significantly related to mortality and admission to an intensive care unit. Subtype D experienced the highest rate of mortality, admission to an intensive care unit and need for noninvasive mechanical ventilation, followed by subtype C. Subtypes A and B were primarily related to other serious complications. Hospitalization rate was more than 50% for all the subtypes, although significantly higher for subtypes C and D than for subtypes A and B. These results could help identify

  17. Symptom reporting in cancer patients: the role of negative affect and experienced social stigma.

    PubMed

    Koller, M; Kussman, J; Lorenz, W; Jenkins, M; Voss, M; Arens, E; Richter, E; Rothmund, M

    1996-03-01

    Recent research suggests that patients' appraisal of somatic symptoms is more closely related to emotional variables (particularly negative affect) than to their actual health as determined by external criteria. Sixty surgical cancer patients who at the time of a routine follow-up examination filled out the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire-C30, which included a positive/negative affect scale and a scale tapping into experienced social stigma. Patients' health status was determined in two ways: the examining physician gave a global judgement on a standardized scale at the end of the examination, and an additional two external physicians later rated the patients based on the findings listed in the medical record. Patients' reports of somatic symptoms were strongly correlated with two measures of negative affect (r = 0.75 and r = 0.65, respectively) and with experienced social stigma (r = 0.51). In contrast, the correlations between reported symptoms and the examining or external physicians' ratings were considerably weaker (r = 0.31 and r = 0.19). According to a multiple linear regression with 6 predictors, negative affect was the best single predictor of symptom reporting (beta = 0.68; P < 0.001) and global quality of life (beta = 0.48; P < 0.001). Factor analysis yielded a dimension of somatopsychosocial distress that accounted for 44.1% of the variance and is comprised of reported symptoms (factor loading = 0.86), negative affect (0.90 and 0.82), experienced social stigma (0.74), and global quality of life (0.70). Physicians' ratings and positive affect constituted two additional separate factors. Cancer patients' reporting of somatic symptoms by means of a standardized quality of life questionnaire is closely related to emotional and social distress and is not equivalent to health status as determined from a clinical perspective. Researchers and practitioners have to be aware of this fact when

  18. Risk factors of anxiety and depressive symptoms in female patients experiencing intimate partner violence.

    PubMed

    Karakuła Juchnowicz, Hanna; Łukasik, Paulina; Morylowska-Topolska, Justyna; Krukow, Paweł

    2017-02-26

    The aim of the study was to find factors associated with higher severity of anxiety and depressive symptoms in female patients experiencing intimate partner violence (IPV). The study was conducted in six randomly selected primary healthcare centers in Lublin province. The HADS (Hospital Anxiety and Depression Scale) and a structured questionnaire designed by the authors were administered to a total of 350 consecutive female patients visiting a GP. Fully completed questionnaire forms were obtained from 200 women. 102 (51%) participants who confirmed experiencing IPV ultimately made up the study cohort. Sequential models were created using backward stepwise multiple regression to investigate the potential risk and the protective factors associated with higher severity of anxiety and depressive symptoms in the study group. 68% and 56% of the participants respectively had positive scores on the HADS anxiety and depression subscales. Living in a small town or in the countryside was associated with higher scores on the anxiety subscale (b = -1.18, p = 0.003), but not on the depression subscale. Chronic physical illness (b = 2.42, p = 0.013; b = 2.86, p = 0.015), being unemployed (b = 0.58, p = 0.024; b = 0.69, p = 0.008), and exposure to economic violence (b = 3.97, p < 0.001; b = 3.88, p = 0.001) were associated with higher scores on both subscales of the HADS. The fact of receiving financial support (b = 2.67, p = 0.002; b = 2.68, p = 0.003) was a protective factor against both kinds of symptoms. Exposure to physical violence was associated with higher scores on the depression subscale (b = 3.09, p = 0.005), but not on anxiety subscale. The type of violence and socioeconomic characteristics were more strongly associated with anxiety and depressive symptoms in women experiencing IPV than demographic variables.

  19. Nutritional status, symptoms experienced and general state of health in HIV-infected patients.

    PubMed

    Karlsson, A; Nordström, G

    2001-09-01

    The aim of the study was to describe HIV-infected patients with respect to nutritional status, symptoms experienced, general state of health, and relevant medical and laboratory data. An additional aim was to study the relationships between some of these variables. On admission to an acute care hospital in Sweden, 25 HIV-positive men were consecutively included in the study. Medical data, anthropometric variables such as weight, height, body mass index (BMI) and percentage weight loss were studied. The following instruments were used: the subjective global assessment (SGA) was used to determine nutritional status; the oral assessment guide (OAG) was used for subjective assessment of the oral cavity; and the numeric rating scale (NRS) was used to assess the symptoms experienced. The Health Index (HI) was used to evaluate general state of health. The results showed that more than half of the patients had suspected/severe malnutrition; between 48% and 72% complained of moderate to severe symptoms of various kinds. Two thirds felt their general state of health was rather poor or very poor. Correlations showed that the lower the BMI, the worse the nutritional status (SGA); the greater the weight loss in percent, the worse the nutritional status (SGA); and the worse the general state of health (HI), the worse the nutritional status (SGA). In conclusion, it is important that nurses have good knowledge concerning nutritional problems in order to be able to detect these conditions at an early stage and/or to endeavour to prevent them.

  20. Experienced Continuity of Care When Patients See Multiple Clinicians: A Qualitative Metasummary

    PubMed Central

    Haggerty, Jeannie L.; Roberge, Danièle; Freeman, George K.; Beaulieu, Christine

    2013-01-01

    PURPOSE Continuity of care among different clinicians refers to consistent and coherent care management and good measures are needed. We conducted a metasummary of qualitative studies of patients’ experience with care to identify measurable elements that recur over a variety of contexts and health conditions as the basis for a generic measure of management continuity. METHODS From an initial list of 514 potential studies (1997–2007), 33 met our criteria of using qualitative methods and exploring patients’ experiences of health care from various clinicians over time. They were coded independently. Consensus meetings minimized conceptual overlap between codes. RESULTS For patients, continuity of care is experienced as security and confidence rather than seamlessness. Coordination and information transfer between professionals are assumed until proven otherwise. Care plans help clinician coordination but are rarely discerned as such by patients. Knowing what to expect and having contingency plans provides security. Information transfer includes information given to the patient, especially to support an active role in giving and receiving information, monitoring, and self-management. Having a single trusted clinician who helps navigate the system and sees the patient as a partner undergirds the experience of continuity between clinicians. CONCLUSION Some dimensions of continuity, such as coordination and communication among clinicians, are perceived and best assessed indirectly by patients through failures and gaps (discontinuity). Patients experience continuity directly through receiving information, having confidence and security on the care pathway, and having a relationship with a trusted clinician who anchors continuity. PMID:23690327

  1. Absence of occult HCV infection in patients experiencing an immunodepression condition.

    PubMed

    Pisaturo, Mariantonietta; Guastafierro, Salvatore; Filippini, Pietro; Tonziello, Gilda; Sica, Antonello; Di Martino, Filomena; Sagnelli, Caterina; Ferrara, Maria Giovanna; Martini, Salvatore; Cozzolino, Domenico; Sagnelli, Evangelista; Coppola, Nicola

    2013-12-01

    The aim of our study was to evaluate the presence of occult HCV infection in two settings of patients experiencing immunosuppression: patients with Human Immunodeficiency Virus (HIV) infection and those with onco-haematological disease. Sixty consecutive HIV-positive/anti-HCV-negative/HCV RNA-negative patients (HIV group) and 32 consecutive anti-HCV/HCV RNA negative patients with an onco-haematological disease first undergoing chemotherapy (Onco-haematological group) were enrolled. HCV-RNA was sought by real time RT-PCR in plasma and Peripheral Blood Mononuclear Cell (PBMC) samples obtained at enrolment and during follow-up, in the patients in the HIV group every three months and in those in the onco-haematological group at months 1 and 3 during chemotherapy and then every three months after treatment discontinuation. No plasma or PBMC sample collected at enrolment and during the follow-up in the HIV and onco-haematological groups was HCV RNA positive. The results of this study rule out the existence of occult HCV infection in patients with strong immunosuppression due to different conditions, HIV infection and onco-haematological diseases.

  2. International normalized ratio stability in warfarin-experienced patients with nonvalvular atrial fibrillation.

    PubMed

    Nelson, Winnie W; Desai, Sunita; Damaraju, Chandrasekharrao V; Lu, Lang; Fields, Larry E; Wildgoose, Peter; Schein, Jeffery R

    2015-06-01

    Maintaining stable levels of anticoagulation using warfarin therapy is challenging. Few studies have examined the stability of the international normalized ratio (INR) in patients with nonvalvular atrial fibrillation (NVAF) who have had ≥6 months' exposure to warfarin anticoagulation for stroke prevention. Our objective was to describe INR control in NVAF patients who had been receiving warfarin for at least 6 months. Using retrospective patient data from the CoagClinic™ database, we analyzed data from NVAF patients treated with warfarin to assess the quality of INR control and possible predictors of poor INR control. Time within, above, and below the recommended INR range (2.0-3.0) was calculated for patients who had received warfarin for ≥6 months and had three or more INR values. The analysis also assessed INR patterns and resource utilization of patients with an INR >4.0. Logistic regression models were used to determine factors associated with poor INR control. Patients (n = 9433) had an average of 1.6 measurements per 30 days. Mean follow-up time was 544 days. Approximately 39% of INR values were out of range, with 23% of INR values being <2.0 and 16% being >3.0. Mean percent time with INR in therapeutic range was 67%; INR <2.0 was 19% and INR >3.0 was 14%. Patients with more than one reading of INR >4.0 (~39%) required an average of one more visit and took 3 weeks to return to an in-range INR. Male sex and age >75 years were predictive of better INR control, whereas a history of heart failure or diabetes were predictive of out-of-range INR values. However, patient characteristics did not predict the likelihood of INR >4.0. Out-of-range INR values remain frequent in patients with NVAF treated with warfarin. Exposure to high INR values was common, resulting in increased resource utilization.

  3. The Tidal Model as experienced by patients and nurses in a regional forensic unit.

    PubMed

    Cook, N R; Phillips, B N; Sadler, D

    2005-10-01

    The Tidal Model has been implemented in Rangipapa, a regional secure mental health forensic unit in New Zealand. A phenomenological study was undertaken to obtain reflective description of the nursing care experience from the perspective's of four Registered Nurses and four Special Patients. Five major themes were identified that appeared to capture the experiences of the participants. The themes show changes to the unit's unique culture and values following implementation of the model. These changes engendered a sense of hope, where nurses felt they were making a difference and patients were able to communicate in their own words their feelings of hope and optimism. Levelling was experienced as an effect emerging from individual and group processes whereby a shift in power enhanced a sense of self and connectedness in their relationships. These interpersonal transactions were noted by the special patients as being positive for their recovery. This enabled effective nurse-patient collaboration expressed simply as working together. The participants reported a feeling of humanity, so that there was a human face to a potentially objectifying forensic setting. Implications arising from this study are that the use of the model enables a synergistic interpersonal process wherein nurses are professionally satisfied and patients are validated in their experience supporting their recovery.

  4. Patient Evaluation of Emotional Comfort Experienced (PEECE): developing and testing a measurement instrument

    PubMed Central

    Lester, L; Bulsara, C; Petterson, A; Bennett, K; Allen, E; Joske, D

    2017-01-01

    Objectives The Patient Evaluation of Emotional Comfort Experienced (PEECE) is a 12-item questionnaire which measures the mental well-being state of emotional comfort in patients. The instrument was developed using previous qualitative work and published literature. Design Instrument development. Setting Acute Care Public Hospital, Western Australia. Participants Sample of 374 patients. Interventions A multidisciplinary expert panel assessed the face and content validity of the instrument and following a pilot study, the psychometric properties of the instrument were explored. Main outcome measures Exploratory and confirmatory factor analysis assessed the underlying dimensions of the PEECE instrument; Cronbach's α was used to determine the reliability; κ was used for test–retest reliability of the ordinal items. Results 2 factors were identified in the instrument and named ‘positive emotions’ and ‘perceived meaning’. A greater proportion of male patients were found to report positive emotions compared with female patients. The instrument was found to be feasible, reliable and valid for use with inpatients and outpatients. Conclusions PEECE was found to be a feasible instrument for use with inpatient and outpatients, being easily understood and completed. Further psychometric testing is recommended. PMID:28122833

  5. Stigma Experienced by Parkinson's Disease Patients: A Descriptive Review of Qualitative Studies.

    PubMed

    Maffoni, Marina; Giardini, Anna; Pierobon, Antonia; Ferrazzoli, Davide; Frazzitta, Giuseppe

    2017-01-01

    Parkinson's disease (PD) is a neurodegenerative disease characterized by motor and nonmotor symptoms. Both of them imply a negative impact on Health-Related Quality of Life. A significant one is the stigma experienced by the parkinsonian patients and their caregivers. Moreover, stigma may affect everyday life and patient's subjective and relational perception and it may lead to frustration and isolation. Aim of the present work is to qualitatively describe the stigma of PD patients stemming from literature review, in order to catch the subjective experience and the meaning of the stigma construct. Literature review was performed on PubMed database and Google Scholar (keywords: Parkinson Disease, qualitative, stigma, social problem, isolation, discrimination) and was restricted to qualitative data: 14 articles were identified to be suitable to the aim of the present overview. Results are divided into four core constructs: stigma arising from symptoms, stigma linked to relational and communication problems, social stigma arising from sharing perceptions, and caregiver's stigma. The principal relations to these constructs are deeply analyzed and described subjectively through patients' and caregiver's point of view. The qualitative research may allow a better understanding of a subjective symptom such as stigma in parkinsonian patients from an intercultural and a social point of view.

  6. Stigma Experienced by Parkinson's Disease Patients: A Descriptive Review of Qualitative Studies

    PubMed Central

    Maffoni, Marina; Pierobon, Antonia; Ferrazzoli, Davide

    2017-01-01

    Parkinson's disease (PD) is a neurodegenerative disease characterized by motor and nonmotor symptoms. Both of them imply a negative impact on Health-Related Quality of Life. A significant one is the stigma experienced by the parkinsonian patients and their caregivers. Moreover, stigma may affect everyday life and patient's subjective and relational perception and it may lead to frustration and isolation. Aim of the present work is to qualitatively describe the stigma of PD patients stemming from literature review, in order to catch the subjective experience and the meaning of the stigma construct. Literature review was performed on PubMed database and Google Scholar (keywords: Parkinson Disease, qualitative, stigma, social problem, isolation, discrimination) and was restricted to qualitative data: 14 articles were identified to be suitable to the aim of the present overview. Results are divided into four core constructs: stigma arising from symptoms, stigma linked to relational and communication problems, social stigma arising from sharing perceptions, and caregiver's stigma. The principal relations to these constructs are deeply analyzed and described subjectively through patients' and caregiver's point of view. The qualitative research may allow a better understanding of a subjective symptom such as stigma in parkinsonian patients from an intercultural and a social point of view. PMID:28243481

  7. Gender differences among discrimination & stigma experienced by depressive patients in Pakistan

    PubMed Central

    Khan, Nashi; Kausar, Rukhsana; Khalid, Adeela; Farooq, Anum

    2015-01-01

    Objective: This study aims to examine Gender Difference in the level of Discrimination and Stigma experienced by people diagnosed with Major Depressive Disorder in Pakistan. It was hypothesized that Women diagnosed with Depression are likely to be experiencing more Discrimination and Internalized Stigma in comparison to Men. Methods: This is a Cross Sectional Study. Thirty eight patients diagnosed with Major Depressive Disorder recruited from different Government Sector Hospitals of Lahore; were approached after obtaining informed consent. Discrimination and Stigma were measured through Discrimination and Stigma Scale and Internalized Stigma of Mental Illness Inventory respectively. Results: Both Men and Women experience considerably high level of associated Stigma and Discrimination due to their Mental Illness. However, Women in comparison to Men experience significantly greater level of Internalized Stigma especially in domains of Discrimination Experience and Social Withdrawal. Conclusion: The findings of this study highlight the fact that people with Depression can be more benefited with psychological treatment if dealing with Stigma and Discrimination is also addressed in Intervention Plans. PMID:26870110

  8. Medication issues experienced by patients and carers after discharge from the intensive care unit.

    PubMed

    Eijsbroek, Heleen; Howell, David C J; Smith, Felicity; Shulman, Rob

    2013-02-01

    Medication-related problems (MRPs) frequently occur at the interfaces of care settings. We examined this further because little has been published about MRPs experienced by patients/carers after discharge from the intensive care unit (ICU). Medication history data were collected before, during, and after ICU admission and by face-to-face semistructured interviews with 21 patients and 13 carers attending the ICU Follow-up Clinic (FC) of our 35-bed adult ICU. A total of 122 drugs were prescribed regularly before ICU admission, 168 on ICU discharge, 132 at hospital discharge, and 128 at the FC. Medication-related problems were identified with hypnotics/anxiolytics, antidepressants, proton pump inhibitors, and analgesics. Good follow-up was observed in all 4 cases where the antidysrhythmic agent amiodarone was initiated on ICU. Patients/carers described 20 cases of difficulty in obtaining appropriate and timely supplies and 19 of insufficient information. These results show that our incidence of MRPs after ICU discharge was encouragingly infrequent, in which we attribute it to targeted medicine reconciliation and the availability of our FC. However, MRPs were perceived to stem from inadequate communication at the interfaces of care and the lack of opportunity for patients/carers to obtain relevant information. We recommend that FC should focus on MRPs during their consultation and that further research in this area should be performed to examine our observations further. Copyright © 2013 Elsevier Inc. All rights reserved.

  9. Critical Situations in Daily Life as Experienced by Patients With Inflammatory Bowel Disease

    PubMed Central

    Hollman Frisman, Gunilla; Hjortswang, Henrik; Börjeson, Sussanne

    2016-01-01

    Crohn disease and ulcerative colitis, collectively known as inflammatory bowel disease (IBD), are chronic and have a fluctuating clinical course that impacts daily life. Daily life with a chronic disease involves thinking and worrying about the limitations that chronic disease causes. Knowledge about how patients who suffer from IBD manage critical incidents in daily life is lacking. The aim of the study was to describe how patients living with IBD experience critical incidents in daily life in relation to their disease and symptoms. Thirty adult patients were interviewed focusing on critical incidents in daily life. Data were analyzed using the critical incident technique. The study comprised 224 critical incidents and was grouped into 21 subcategories and 5 categories: losing bowel control, having a body that smells, being unable to meet own and others' expectations, not being believed or seen, and experiencing frustration due to side effects and ineffective treatment. These categories formed one main area describing the overall result “The bowels rule life.” The uncertain nature of IBD created critical incidents in which the bowel ruled life, causing patients to avoid social interaction. It also placed considerable demands on the family and sometimes had a negative effect on the afflicted person's career. PMID:26870902

  10. Nurses experience of aromatherapy use with dementia patients experiencing disturbed sleep patterns. An action research project.

    PubMed

    Johannessen, Berit

    2013-11-01

    The purpose of this study was to gain an insight into nurses' experiences of incorporating aromatherapy into the care of residents suffering from dementia, anxiety and disturbed sleep patterns. Twenty-four residents and twelve nurses from four nursing homes participated in an action research study. The use of lavender augustofolia essential oil diffused nightly was perceived as an effective care modality reducing insomnia and anxiety in this patient cohort. Nurses experienced some negative attitudes among colleagues because they considered aromatherapy as not evidence based. Nurses require greater access to evidence based use of Aromatherapy. Further research is needed to study how smell can enhance dementia care. Copyright © 2013 Elsevier Ltd. All rights reserved.

  11. A comparison of patient education practices and perceptions of novice and experienced physiotherapists in Australian physiotherapy settings.

    PubMed

    Forbes, Roma; Mandrusiak, Allison; Smith, Michelle; Russell, Trevor

    2017-04-01

    Patient education is an integral component of physiotherapy practice. Little is known about the differences in reported use and perception of patient education between experienced and novice physiotherapists. Understanding these differences has important implications for training approaches and physiotherapy practice. To compare how experienced and novice physiotherapists report frequency of patient education practices and their perceptions of the importance of these practices. A web-based purpose-designed survey was developed, piloted and administered to practicing physiotherapists through direct email. Of 305 complete responses, two subgroups were explored for comparative analysis: 'novice' (≤5years' experience, n = 52); and 'experienced' (≥11 years' experience, n = 204). The experienced group rated 14 of 15 educational items higher than the novice group in relation to frequency of use and perceived importance. Experienced physiotherapists reported a significantly higher frequency of using one-to-one discussion, personalised handouts and explicitly seeking patient understanding (p < 0.05). Novice physiotherapists perceived more barriers to patient education, particularly those related to characteristics of the patient (p < 0.05). Experienced physiotherapists report higher use of self-management education and education content that is patient-centred. Experienced therapists report a higher frequency of seeking explicit patient understanding to evaluate their teaching than novice physiotherapists and perceive fewer patient-related barriers to their practice. These findings are important when considering teaching and learning of patient education skills. Students or novice physiotherapists may benefit from strategies to facilitate patient-centred education, self-management education, evaluation approaches and strategies to manage barriers. Copyright © 2017 Elsevier Ltd. All rights reserved.

  12. Sarcopenia is a risk factor for cardiovascular events experienced by patients with critical limb ischemia.

    PubMed

    Matsubara, Yutaka; Matsumoto, Takuya; Inoue, Kentaro; Matsuda, Daisuke; Yoshiga, Ryosuke; Yoshiya, Keiji; Furuyama, Tadashi; Maehara, Yoshihiko

    2017-05-01

    Prognosis is poor for patients with critical limb ischemia (CLI), and the most frequent cause of death is cardiovascular disease. Low grip strength is a risk factor for cardiovascular events, and sarcopenia may be associated as well. Thus, we hypothesized that sarcopenia is a risk factor for cardiovascular events experienced by patients with CLI. If this is true and appropriate therapy becomes available, the prognosis of patients with CLI will improve with appropriate risk management strategies to prevent cardiovascular events. Therefore, the aim of this study was to verify this hypothesis. We studied 114 patients who underwent revascularization and computed tomography between January 2002 and December 2012 in the Department of Surgery and Sciences at Kyushu University in Japan. Sarcopenia was defined as skeletal muscle area measured by L3-level computed tomography scan <114.0 cm(2) and <89.8 cm(2) for men and women, respectively. Clinical characteristics, cardiovascular event-free survival, <2-year death, causes of death, and effective treatments for sarcopenia were investigated. We identified 53 (46.5%) patients with sarcopenia. Three-year cardiovascular event-free survival rates were 43.1% and 91.2% for patients with and without sarcopenia, respectively (P < .01). During follow-up, cardiovascular disease caused the deaths of 4 and 15 patients without and with sarcopenia (P < .01), respectively, and in particular, ischemic heart disease caused the deaths of 0 and 5 patients without or with sarcopenia (P < .05), respectively. Single antiplatelet therapy (SAPT; hazard ratio, 0.46; 95% confidence interval, 0.24-0.82; P < .01) and statin therapy (hazard ratio, 0.38; 95% confidence interval, 0.16-0.78; P < .01) were independent factors associated with improved cardiovascular event-free survival. Three-year cardiovascular event-free survival rates for patients with sarcopenia who received SAPT, dual antiplatelet therapies, and no antiplatelet therapy were 75

  13. Experiencing patient death in clinical practice: nurses' recollections of their earliest memorable patient death.

    PubMed

    Anderson, Natalie Elizabeth; Kent, Bridie; Owens, R Glynn

    2015-03-01

    Death and dying are inevitable life encounters, but a nurse's first experience with patient death may pose considerable cognitive, emotional and clinical challenges. This paper reports the findings of the second phase of a study; the first has been reported elsewhere. This phase explored the earliest memorable patient death experiences of New Zealand registered nurses. A purposeful, self-selected sub-sample of a larger study of New Zealand registered nurses, took part in individual face-to-face semi-structured interviews. Interpretative phenomenological analysis was utilised to seek to understand participants' experiences. Thematic analysis was undertaken to identify emerging themes, with participants' own words used as theme headings, where their phrases provided succinct or powerful descriptors. A diverse participant group of twenty, currently practising, New Zealand registered nurses provided rich and detailed descriptions of their earliest memorable experience with patient death. Participants from a variety of training backgrounds described patient deaths, which occurred in a range of settings - some only a few months prior, others - more than thirty years ago. Seven emergent themes, and features of more positive, or negative experiences were identified: Event Significance; Emotional Challenges; Sharing the Experience; Learning; Feeling Unprepared, Responses to Death and Finding Benefits. For participants in this study, there was considerable evidence that their earliest memorable patient death was a significant event. Furthermore, although most participants' experiences were characterised by emphatic or poignant description, there was most often a balance of challenges and rewards. Copyright © 2014 Elsevier Ltd. All rights reserved.

  14. Assessing quality of life in a clinical study on heart rehabilitation patients: how well do value sets based on given or experienced health states reflect patients' valuations?

    PubMed

    Leidl, Reiner; Schweikert, Bernd; Hahmann, Harry; Steinacker, Juergen M; Reitmeir, Peter

    2016-03-22

    Quality of life as an endpoint in a clinical study may be sensitive to the value set used to derive a single score. Focusing on patients' actual valuations in a clinical study, we compare different value sets for the EQ-5D-3L and assess how well they reproduce patients' reported results. A clinical study comparing inpatient (n = 98) and outpatient (n = 47) rehabilitation of patients after an acute coronary event is re-analyzed. Value sets include: 1. Given health states and time-trade-off valuation (GHS-TTO) rendering economic utilities; 2. Experienced health states and valuation by visual analog scale (EHS-VAS). Valuations are compared with patient-reported VAS rating. Accuracy is assessed by mean absolute error (MAE) and by Pearson's correlation ρ. External validity is tested by correlation with established MacNew global scores. Drivers of differences between value sets and VAS are analyzed using repeated measures regression. EHS-VAS had smaller MAEs and higher ρ in all patients and in the inpatient group, and correlated best with MacNew global score. Quality-adjusted survival was more accurately reflected by EHS-VAS. Younger, better educated patients reported lower VAS at admission than the EHS-based value set. EHS-based estimates were mostly able to reproduce patient-reported valuation. Economic utility measurement is conceptually different, produced results less strongly related to patients' reports, and resulted in about 20 % longer quality-adjusted survival. Decision makers should take into account the impact of choosing value sets on effectiveness results. For transferring the results of heart rehabilitation patients from another country or from another valuation method, the EHS-based value set offers a promising estimation option for those decision makers who prioritize patient-reported valuation. Yet, EHS-based estimates may not fully reflect patient-reported VAS in all situations.

  15. [Efficacy of dolutegravir in treatment-experienced patients: the SAILING and VIKING trials].

    PubMed

    Moreno, Santiago; Berenguer, Juan

    2015-03-01

    Dolutegravir is an HIV integrase inhibitor with a high genetic barrier to resistance and is active against raltegravir- and/or elvitegravir-resistant strains. The clinical development of dolutegravir for HIV infection rescue therapy is based on 3 clinical trials. In the SAILING trial, dolutegravir (5 mg once daily) in combination with 2 other antiretroviral agents was well tolerated and showed greater virological effect than raltegravir (400 mg twice daily) in the treatment of integrase inhibitor-naïve adults with virological failure infected with HIV strains with at least two-class drug resistance. The VIKING studies were designed to evaluate the efficacy of dolutegravir as rescue therapy in treatment-experienced patients infected with HIV strains with resistance mutations to raltegravir and/or elvitegravir. VIKING-1-2 was a dose-ranging phase IIb trial. VIKING-3 was a phase III trial in which dolutegravir (50 mg twice daily) formed part of an optimized regimen and proved safe and effective in this difficult-to-treat group of patients. Dolutegravir is the integrase inhibitor of choice for rescue therapy in multiresistant HIV infection, both in integrase inhibitor-naïve patients and in those previously treated with raltegravir or elvitegravir.

  16. CD4 T cell recovery is slower in patients experiencing viral load rebounds during HAART

    PubMed Central

    Scott-Algara, D; Aboulker, J-P; Durier, C; Badell, E; Marcellin, F; Prud'homme, M; Jouanne, C; Meiffredy, V; Brun-Vezinet, F; Pialoux, G; Raffi, F

    2001-01-01

    To determine whether viral load rebounds during HAART impact on CD4+ T cell recovery and immune reconstitution, we studied a prospective cohort of 355 antiretroviral naive patients enrolled to be randomized in a trial of three strategies of induction/maintenance HAART. The extent of immune reconstitution in blood through 72 weeks of antiretroviral treatment was evaluated. Lymphocyte subset markers (CD4, CD8, CD45RA, CD62L, CD16, CD19), activation markers (HLA-DR, CD38, CD25) were performed by cytometry analysis. Our results showed that plasma HIV-1 RNA was suppressed to below 500 copies per ml through week 72 in 240 patients (group 1) while the remaining 115 patients experienced at least one viral rebound (group 2). At baseline, CD4 cell count was higher and HIV-1 RNA was lower in group 1 than in group 2. Over 72 weeks, mean increase in CD4+ T cell count was 0·32 cell/mm3/day in group 1 and only 0·14 cell/mm3/day in group 2 (P < 0·0001). However, the patterns of changes in CD4+ and CD8+ T cell subsets during therapy were very similar across the two groups with only subtle and very limited differences. We conclude that permanent control of HIV replication could be necessary for faster immune reconstitution. PMID:11703374

  17. Patient-experienced burden of treatment in patients with multimorbidity – A systematic review of qualitative data

    PubMed Central

    Andersen, John Sahl

    2017-01-01

    Objective To synthesize existing qualitative literature on patient-experienced burden of treatment in multimorbid patients. Methods A literature search identified available qualitative studies on the topic of burden of treatment in multimorbidity and meta-ethnography was applied as method. The authors’ original findings were preserved, but also synthesized to new interpretations to investigate the concept of the burden of treatment using the Cumulative Complexity Model. Results Nine qualitative studies were identified. The majority of the 1367 participants from 34 different countries were multimorbid. The treatment burden components, experienced by patients, were identified for each study. The components financial burden, lack of knowledge, diet and exercise, medication burden and frequent healthcare reminding patients of their health problem were found to attract additional attention from the multimorbid patients. In studies conducted in the US and Australia the financial burden and the time and travel burden were found most straining to patients with deprived socioeconomic status. The burden of treatment was found to be a complex concept consisting of many different components and factors interacting with each other. The size of the burden was associated to the workload of demands (number of conditions, number of medications and health status), the capacity (cognitive, physical and financial resources, educational level, cultural background, age, gender and employment conditions) and the context (structure of healthcare and social support). Patients seem to use strategies such as prioritizing between treatments to diminish the workload and mobilizing and coordinating resources to improve their ability to manage the burden of treatment. They try to routinize and integrate the treatment into their daily lives, which might be a way to maintain the balance between workload and capacity. Conclusions Healthcare providers need to increase the focus on minimizing

  18. Analysis of the acoustic spectral signature of prosthetic heart valves in patients experiencing atrial fibrillation

    SciTech Connect

    Scott, D.D.; Jones, H.E.

    1994-05-06

    Prosthetic heart valves have increased the life span of many patients with life threatening heart conditions. These valves have proven extremely reliable adding years to what would have been weeks to a patient`s life. Prosthetic valves, like the heart however, can suffer from this constant work load. A small number of valves have experienced structural fractures of the outlet strut due to fatigue. To study this problem a non-intrusive method to classify valves has been developed. By extracting from an acoustic signal the opening sounds which directly contain information from the outlet strut and then developing features which are supplied to an adaptive classification scheme (neural network) the condition of the valve can be determined. The opening sound extraction process has proved to be a classification problem itself. Due to the uniqueness of each heart and the occasional irregularity of the acoustic pattern it is often questionable as to the integrity of a given signal (beat), especially one occurring during an irregular beat pattern. A common cause of these irregular patterns is a condition known as atrial fibrillation, a prevalent arrhythmia among patients with prosthetic hear valves. Atrial fibrillation is suspected when the ECG shows no obvious P-waves. The atria do not contract and relax correctly to help contribute to ventricular filling during a normal cardiac cycle. Sometimes this leads to irregular patterns in the acoustic data. This study compares normal beat patterns to irregular patterns of the same heart. By analyzing the spectral content of the beats it can be determined whether or not these irregular patterns can contribute to the classification of a heart valve or if they should be avoided. The results have shown that the opening sounds which occur during irregular beat patterns contain the same spectral information as the opening which occur during a normal beat pattern of the same heart and these beats can be used for classification.

  19. Limited benefit of antiretroviral resistance testing in treatment-experienced patients: a meta-analysis.

    PubMed

    Panidou, Ermioni T; Trikalinos, Thomas A; Ioannidis, John P A

    2004-11-05

    To estimate the effectiveness of resistance assessments based on viral sequencing (genotypic antiretroviral resistance testing, GART), phenotypic antiretroviral resistance testing (PART) or virtual PART (vPART) in the management of treatment-experienced HIV-1-infected patients. Meta-analysis of randomized controlled trials comparing treatments aided by GART, PART and vPART, and controls. The meta-analysis synthesized data on the proportion of patients with undetectable plasma viral load, the decrease in viral load, and the increase in CD4 cell count at 3 and 6 months after randomization. Ten trials were analyzed (total 2258 participants). Compared with controls, at 3 and 6 months GART increased the proportion of patients with viral load below detection by 11% [95% confidence interval (CI), 6-16], and 10% (95% CI, 5-16), respectively. The difference in viral load change was 0.27 log10 copies/ml (95% CI, 0.11-0.43) and 0.21 log10 copies/ml (95% CI, 0.09-0.34), respectively. However, no improvement was observed in the CD4 cell count at either time point: the difference in CD4 cell count -5.7 x 10(6) cells/l (95% CI, -18.8 to 7.3) and 1.2 x 10(6) cells/l (95% CI, -15.0 to 17.4), respectively, at 3 and 6 months. For PART, there was no clear evidence for any benefit versus no testing (three trials). vPART conferred a small benefit in indirect comparisons versus no testing. Evidence for benefit of antiretroviral resistance testing is sparse and limited to small short-term improvements of virologic response, mostly with GART and less with vPART. Current guidelines widely recommending the use of antiretroviral resistance testing in clinical practice are not commensurate with the available evidence.

  20. Development and pilot evaluation of a complex intervention to improve experienced continuity of care in patients with cancer.

    PubMed

    King, M; Jones, L; McCarthy, O; Rogers, M; Richardson, A; Williams, R; Tookman, A; Nazareth, I

    2009-01-27

    High experienced continuity of care in patients with cancer is associated with lower needs for care, better quality of life and better psychological outcomes. We developed and evaluated an intervention to improve experienced continuity. The intervention, consisted of (1) a 17-item patient-completed continuity assessment; (2) feedback to clinical nurse specialists and action to address the needs identified. Multidisciplinary team meetings and oncology outpatient clinics were observed, and patients and staff were interviewed. After qualitative work and reliability testing, the intervention was evaluated in a feasibility trial. Sixty-one patients provided data for analysis. No statistically significant differences were found in patients' experienced continuity between the trial arms, but important trends were seen in measures of needs for care in favour of those receiving the intervention. Feeding back findings from the continuity assessment to clinicians reduced patients' needs for care. Our results indicate that an intervention to target patients' experiences of continuity can reduce their subsequent needs for care. However, overcoming barriers to organisational change and addressing some patients' hesitation to report their continuity difficulties must be considered when implementing such an intervention. A phase III trial targeting patients with inadequate experienced continuity of care is recommended.

  1. Utilization of Communication Robot in Patient Education.

    PubMed

    Ishiguro, Keitaro; Majima, Yukie

    2016-01-01

    In Japan, the population is expected to decrease. Moreover, the proportion of elderly people living alone among the elderly population is expected to increase for both men and women. Therefore, the demand for elderly care is increasing year by year. In this paper, we aim at making environment in which elderly people can receive interactive guidance, and reducing the burden on medical staff such as caregivers and nurses. So, we design a patient education by ARCS model which classifies concepts related to learning motivation, and consider to utilize a communication robot "Pepper".

  2. From armchair to wheelchair: how patients with a locked-in syndrome integrate bodily changes in experienced identity.

    PubMed

    Nizzi, Marie-Christine; Demertzi, Athena; Gosseries, Olivia; Bruno, Marie-Aurélie; Jouen, François; Laureys, Steven

    2012-03-01

    Different sort of people are interested in personal identity. Philosophers frequently ask what it takes to remain oneself. Caregivers imagine their patients' experience. But both philosophers and caregivers think from the armchair: they can only make assumptions about what it would be like to wake up with massive bodily changes. Patients with a locked-in syndrome (LIS) suffer a full body paralysis without cognitive impairment. They can tell us what it is like. Forty-four chronic LIS patients and 20 age-matched healthy medical professionals answered a 15-items questionnaire targeting: (A) global evaluation of identity, (B) body representation and (C) experienced meaning in life. In patients, self-reported identity was correlated with B and C. Patients differed with controls in C. These results suggest that the paralyzed body remains a strong component of patients' experienced identity, that patients can adjust to objectives changes perceived as meaningful and that caregivers fail in predicting patients' experience.

  3. Perception of disease and doctor-patient relationship experienced by patients with psoriasis: a questionnaire-based study.

    PubMed

    Linder, Dennis; Dall'olio, Elena; Gisondi, Paolo; Berardesca, Enzo; Gennaro, Emilia De; Pennella, Angelo R; Giannetti, Alberto; Peserico, Andrea; Girolomoni, Giampiero

    2009-01-01

    Many studies have addressed the impact of psoriasis on quality of life, but few studies have investigated patient perception of the disease or the patient-physician relationship. As with most chronic diseases, improvement in the patient-physician relationship may be important in the proper management of patients with psoriasis. To assess how psoriasis and its treatments are subjectively experienced by patients as well as patient expectations with regard to the patient-physician relationship. A discussion agenda for 'focus group meetings' was organized by a group of sociologists, psychologists, educators, researchers, and clinicians active in the field of psychodermatology. Four meetings were held in Northern and Central Italy and participants included one moderator and either eight dermatologists or eight patients. Discussions were based on a predefined agenda and included: (i) the psychological representation of psoriasis; (ii) the hetero- and self-perception of the patient; (iii) the patient-physician relationship; and (iv) the development of an educational intervention for dermatologists in order to improve the patient-physician relationship. A questionnaire, based on the information gathered at the focus groups, was administered to 323 patients with moderate to severe chronic plaque psoriasis from 17 dermatology clinics throughout Italy. Three hundred patients completed the questionnaire. Psoriasis elicited anger, annoyance at the inconvenience of the disease, and irritation in approximately 50% of the patients, whilst 38% of patients were unable to describe their emotional state. Aspects of life that were limited by psoriasis included clothing (57%), social interactions (43%), and personal hygiene (31%). The disease was often seen by patients as incomprehensible, incurable, and uncontrollable. More than half of the patients stressed their need to be listened to by the treating physician, and their wish that the physician should use simple language and should

  4. Experienced Cognition.

    ERIC Educational Resources Information Center

    Carlson, Richard A.

    This book describes a theoretical framework, "experienced cognition," for understanding cognition at the level of conscious mental states that make up a person's stream of awareness. The central idea is a cospecification hypothesis that an experienced self and experienced objects are simultaneously specified in the information available…

  5. [Applying uncertainty theory in caring for the family of a von Willebrand disease patient experiencing first time upper gastrointestinal bleeding].

    PubMed

    Chung, Ai-Lun; Shun, Shiow-Ching; Lin, Chih-Yu

    2009-10-01

    The purpose of this report was to describe the nursing experience in helping a primary caregiver cope with uncertainty as his mother experienced upper gastrointestinal (UGI) bleeding underlying von Willebrand disease and Scleromyxedema in an Emergency Department between 10 and 18 July 2008. Mishel's Uncertainty Theory was applied to assess the caregiver's uncertainty and patient disease progression. Data were collected through clinical observation, chart review, and interviews. The caregiver's nursing problems were identified as (1) uncertainty caused by symptoms of the rare disease and the probability of recurrent bleeding in the future; (2) uncertainty caused by lack of knowledge about the disease; (3) uncertainty caused by lack of confidence in home caring issues after UGI bleeding. During the nursing period, we provided clinical information related to the disease and offered psychological support to the caregiver based on our Mishel's Uncertainty Scale assessment. Successful strategies utilized by our intervention helped the caregiver reduce level of uncertainty, increase confidence to care for his mother, and improve the quality of further home care.

  6. Disclosure and Experienced Social Support are not Related to Anxiety or Depression in a German HIV Patient Cohort

    PubMed Central

    Brokamp, Felix; Thomaidis, Thomas; Schmidt, Reinhold E.; Wiltink, Jörg; Galle, Peter R.

    2014-01-01

    Background It is unclear to which extent the rate of disclosure of the diagnosis "HIV" to the social environment and the nature of experienced responses are correlated with the current mental health status of HIV-infected patients living in Germany. Materials and Methods Eighty consecutive patients of two German HIV outpatient clinics were enrolled. Patients performed the Hospital Anxiety and Depression Scale (HADS) in its German version. Disclosure behaviour and the experienced responses after disclosing as perceived by the participants were assessed using a questionnaire. In addition, patients were asked to state whether they felt guilty for the infection on a 1-4 point Likert scale. Results Pathological results on the anxiety scale were reached by 40% of male and 73% of female patients, and on the depression scale by 30% of male and 47% of female patients, thus significantly exceeding recently assessed values in the German general population, except for depression in males. None of the HADS scale results was interrelated either with the rate of disclosure or the experienced responses. 36% of patients reported to feel guilty for the infection, which was positively correlated with results from the HADS. Limitation: The time since the single disclosure events was not assessed, and the subgroup of women was comparably small. Conclusions Despite substantial improvement in treatment, HIV-infected patients in Germany still suffer from an elevated level of anxiety and, in part, depression. However, mental health status was neither related with disclosure behaviour nor with experienced responses. We hypothesize that internal beliefs may play a more important role. PMID:25024869

  7. Effectiveness of enfuvirtide in a cohort of highly antiretroviral-experienced HIV-1-infected patients in Mexico.

    PubMed

    Huerta-García, Gloria; Chavez-García, Marcelino; Mata-Marín, José Antonio; Sandoval-Ramírez, Jorge; Domínguez-Hermosillo, Juan; Rincón-Rodríguez, Ana Lourdes; Gaytán-Martínez, Jesús

    2014-01-01

    Treatments in patients with multidrug resistance often involve the use of multiple agents with partial antiviral activity and overlapping metabolic toxicities. Enfuvirtide is therefore a welcome addition to the antiretroviral management of patients with multiclass resistant virus, given the low risk of systemic toxicities and novel mechanism of action relative to existing drug classes. The aim of this study was to evaluate the effectiveness of ENF plus optimized background regimen (OBR) in a Mexican cohort of highly HIV-1 ARV-experienced patients. Prospective cohort of treatment-experienced HIV-1-infected adults with virological failure who started therapy with an ENF-containing regimen. The effectiveness of ENF treatment was evaluated with percentages of undetectable HIV-1 RNA viral load after 24 and 48 weeks of treatment, and changes in CD4+ cell counts. Forty patients >18 years were included. After 24 weeks of treatment, 91% of patients had HIV-1 RNA viral load <400 copies/mL and 65.8% had <50 copies/mL. At week 48 of treatment, 81.4% of the patients had HIV-1 RNA <400 copies/mL and 55.5% had <50 copies/mL; in both cases p <0.0001 compared to baseline. Increase CD4+ cells were also statistically significant at weeks 24 and 48 with respect to the baseline. Pain at the site of injection was the main adverse event in 100% of patients. Our study provides clinically important evidence of the effectiveness and safety of ENF in highly ARV-experienced HIV-1-infected patients. These findings strengthen the results of previous randomized controlled trials with this agent.

  8. Effectiveness, Safety, and Costs of a Treatment Switch to Dolutegravir Plus Rilpivirine Dual Therapy in Treatment-Experienced HIV Patients.

    PubMed

    Revuelta-Herrero, José Luis; Chamorro-de-Vega, Esther; Rodríguez-González, Carmen Guadalupe; Alonso, Roberto; Herranz-Alonso, Ana; Sanjurjo-Sáez, María

    2017-08-01

    Evidence about the use of dolutegravir (DTG) and rilpivirine (RPV) as an antiretroviral therapy (ART) in treatment-experienced patients is scarce. To explore the effectiveness, safety, and costs of switching to a DTG plus RPV regimen in this population. This observational, prospective study included all treatment-experienced patients who switched to DTG plus RPV between November 2014 and July 2016. Patients were excluded if resistance mutations to integrase inhibitors or RPV were found. The effectiveness endpoint was the proportion of patients who achieved virological suppression (viral load [VL] <50 copies/mL) at week 48 (W48). Safety (incidence of adverse events leading to discontinuation and laboratory abnormalities), adherence, and costs were analyzed. A total of 35 patients were included, and 91.4% were virologically suppressed at baseline. Patients were treated with ART for a median of 14 years (interquartile range = 7-20). At W48, 91.4% of patients were virologically suppressed (95% CI = 77.0-98.2). Two of the 3 patients not suppressed at baseline achieved undetectable VL at W48, and 2 patients discontinued DTG plus RPV (intolerance and a drug-drug interaction). None of the virologically suppressed patients at baseline showed virological rebound through W48. There were no significant changes in lipid, liver, and renal profiles. The proportion of patients with an ART adherence >90% increased from 65.6% to 93.8% ( P = 0.004). The annual per-patient ART costs dropped by €665 ( P = 0.265). Switching to DTG plus RPV seems to be an effective and safe strategy. Significant improvements in patients' adherence and costs were achieved.

  9. Tenofovir has inferior efficacy in adefovir-experienced chronic hepatitis B patients compared to nucleos(t)ide-naïve patients

    PubMed Central

    Chung, Goh Eun; Cho, Eun Ju; Lee, Jeong-Hoon; Yoo, Jeong-ju; Lee, Minjong; Cho, Yuri; Lee, Dong Hyeon; Kim, Hwi Young; Yu, Su Jong; Kim, Yoon Jun; Yoon, Jung-Hwan; Zoulim, Fabien

    2017-01-01

    Background/Aims A recent study reported that entecavir had inferior efficacy in nucleos(t)ide analogue (NA)-experienced chronic hepatitis B (CHB) patients compared to NA-naïve patients. We sought to compare the efficacy of tenofovir disoproxil fumarate (TDF) in NA-experienced and NA-naïve CHB patients. Methods We retrospectively enrolled 252 consecutive patients who had a serum hepatitis B virus (HBV) DNA level greater than 2,000 IU/mL at the initiation of TDF treatment and who received TDF for at least 6 months. Complete virologic suppression (CVS) was defined as undetectable serum HBV DNA. We generated a multivariate Cox proportional-hazard model to examine predictive factors that were independently associated with time to CVS. Results The mean age of patients was 48.2 years, and the cohort included 181 NA-naïve patients and 71 NA-experienced patients. The median duration of TDF treatment was 14.4 (interquartile range, 9.5-17.8) months. A total of 167 (92.3%) of 181 NA-naïve patients achieved CVS, and 60 (84.5%) of 71 NA-exposed patients achieved CVS. Forty-nine (89.1%) of 55 patients who previously took an NA aside from adefovir and 11 (68.8%) of 16 adefovir-experienced patients achieved CVS. In multivariable analysis, previous adefovir exposure significantly influenced time to CVS (hazard ratio, 0.37; 95% confidence interval, 0.19-0.72; P=0.003), after adjusting for HBeAg positivity, baseline HBV DNA level and cirrhosis. Conclusions Tenofovir had inferior efficacy in adefovir-experienced CHB patients compared to NA-naïve patients. The response of patients with previous adefovir exposure to TDF monotherapy should be monitored closely. PMID:28190329

  10. Pharmacy-related health disparities experienced by non-english-speaking patients: impact of pharmaceutical care.

    PubMed

    Westberg, Sarah M; Sorensen, Todd D

    2005-01-01

    To identify the availability of foreign language services in pharmacies near a medical clinic serving a large immigrant population and determine whether the type of observed drug therapy problems differed between English- and non-English-speaking patients at this clinic. A community health care center in a diverse neighborhood of Minneapolis, Minnesota. 40 pharmacies near the clinic and in the surrounding Minneapolis-St. Paul area known to provide services to patients in languages in addition to English and 91 clinic patients, including 38 for whom English was not their primary language, seen for full pharmaceutical care assessments. Comprehensive drug therapy assessments were conducted for English- and non-English-speaking patients (with assistance from interpreters) in a primary care setting secondary to physician referral. Patient-specific data and the results of the pharmacist's assessment were recorded in a patient management database. Language services provided by area pharmacies, frequency of drug therapy problems in English- and non-English-speaking patients, and the status of patient's medication conditions before and after provision of pharmaceutical care. Of the six primary languages other than English (Vietnamese, Hmong, Laotian, Somali, Spanish, and Cambodian) spoken by clinic patients, written or verbal information was available for five languages in one or more area pharmacies. The clinic pharmacist completed comprehensive assessments for 91 patients via 230 patient encounters, identifying 186 drug therapy problems. Problems related to adherence were significantly more prevalent in non-English-speaking patients compared with English-speaking patients (31% versus 12%). In all 91 patients, the percentage achieving desired drug therapy outcomes improved by 24% after a pharmacist joined the team of clinic providers. Despite the availability of clinic-based interpreters and foreign language services in pharmacies, adherence-related problems are

  11. Predictors of prognosis for elderly patients with poststroke hemiplegia experiencing hip fractures.

    PubMed

    Feng, Mingli; Zhang, Jian; Shen, Huiliang; Hu, Huaijian; Cao, Li

    2009-11-01

    Hip fracture is an important cause of mortality and disability in elderly patients, particularly in those with poststroke hemiplegia, but little information is available regarding differences of general characteristics between patients with and without hemiplegia who experience hip fractures, factors predicting recovery of prefracture ambulatory status, and mortality of patients with poststroke hemiplegia with hip fractures. We retrospectively reviewed 1379 consecutive prospectively followed patients with hip fractures treated from January 2000 to May 2006. Of the 1379 patients, 101 (7.3%) had poststroke hemiplegia. All patients were followed a minimum of 1 year if they survived more than a year or until death if they died within a year after surgery (mean, 19.5 months; range, 4-49 months). According to the American Society of Anesthesiologists (ASA) rating, the patients with hemiplegia were sicker than patients without hemiplegia, more likely to have three or more comorbidities, lower cognitive ability, weaker prefracture ambulatory status, more days of hospitalization, and higher mortality rate. Gender, ASA rating, number of comorbidities, and prefracture ambulatory status predicted mortality of hip fractures in elderly patients with poststroke hemiplegia, and the ASA rating, number of comorbidities, and cognitive ability predicted recovery of prefracture ambulatory status for these patients. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

  12. [Accommodation effects of the audiovisual stimulation in the patients experiencing eyestrain with the concomitant disturbances of psychological adaptation].

    PubMed

    Shakula, A V; Emel'ianov, G A

    2014-01-01

    The present study was designed to evaluate the effectiveness of audiovisual stimulation on the state of the eye accommodation system in the patients experiencing eyes train with the concomitant disturbances of psychological. It was shown that a course of audiovisual stimulation (seeing a psychorelaxing film accompanied by a proper music) results in positive (5.9-21.9%) dynamics of the objective accommodation parameters and of the subjective status (4.5-33.2%). Taken together, these findings whole allow this method to be regarded as "relaxing preparation" in the integral complex of the measures for the preservation of the professional vision in this group of the patients.

  13. Understanding the Knowledge Gap Experienced by U.S. Safety Net Patients in Teleretinal Screening.

    PubMed

    George, Sheba M; Hayes, Erin Moran; Fish, Allison; Daskivich, Lauren Patty; Ogunyemi, Omolola I

    2016-01-01

    Safety-net patients' socioeconomic barriers interact with limited digital and health literacies to produce a "knowledge gap" that impacts the delivery of healthcare via telehealth technologies. Six focus groups (2 African- American and 4 Latino) were conducted with patients who received teleretinal screening in a U.S. urban safety-net setting. Focus groups were analyzed using a modified grounded theory methodology. Findings indicate that patients' knowledge gap is primarily produced at three points during the delivery of care: (1) exacerbation of patients' pre-existing personal barriers in the clinical setting; (2) encounters with technology during screening; and (3) lack of follow up after the visit. This knowledge gap produces confusion, potentially limiting patients' perceptions of care and their ability to manage their own care. It may be ameliorated through delivery of patient education focused on both disease pathology and specific role of telehealth technologies in disease management.

  14. Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation

    PubMed Central

    Civelek, Gul Mete; Atalay, Ayce; Turhan, Nur

    2016-01-01

    [Purpose] The aim of this study was to assess the medical complications in first-time ischemic stroke patients, to identify the factors related to occurrence of complications. [Subjects and Methods] First-time ischemic stroke patients (n=81) admitted to a tertiary level inpatient rehabilitation center during a 5 year period were included in the study. The attending physiatrist noted the presence of specific medical complications and complications that required transfer to the acute care facility from patient records. The Oxfordshire Community Stroke Project classification was used to define the clinical subtypes of the ischemic stroke patients. The Charlson comorbidity index was used to evaluate co-morbid conditions. Functional disability was assessed using the Functional Independence Measure at admission and discharge. [Results] We found that 88.9% of the patients had at least one complication. The five most common complications were urinary tract infection (48.1%), shoulder pain (37.0%), insomnia (37.0%), depression (32.1%), and musculoskeletal pain other than shoulder pain (32.1%) and 11.1% of patients were transferred to acute care facility during rehabilitation period. Functional Independence Measure scores both at admission and discharge were significantly lower in patients with at least one complication than in patients with no complications. [Conclusion] Medical complications are common among patients undergoing stroke rehabilitation. Close interdisciplinary collaboration between physiatrists and other medical specialities is necessary for optimal management. PMID:27065523

  15. Universality of physicians’ burnout syndrome as a result of experiencing difficulty in relationship with patients

    PubMed Central

    Samborska-Sablik, Anna; Drożdż, Jarosław

    2012-01-01

    The aim of our work is to present the universality of burnout syndrome among physicians worldwide and to demonstrate selected aspects of the relationship between patients and doctors as a common factor predisposing to burnout. We looked up 20 original pieces of research from the Medline database published in the last 10 years to determine the prevalence of burnout among doctors in different countries. In all quoted works a remarkable percentage of doctors of interventional and non-interventional specialties suffered burnout. Because it is the relationship with patients that constitutes a key denominator for their work, in the discussion we have exposed an important aspect of it, destructive patient games, described on the basis of transactional analysis. Since universal burnout causes a deterioration of doctors’ service, for the optimal good of the patient to survive preservation of the doctor's well-being in the patient-doctor relationship is needed everywhere. PMID:23847658

  16. Direct costs of blindness experienced by patients enrolled in managed care.

    PubMed

    Frick, Kevin D; Walt, John G; Chiang, Tina H; Doyle, John J; Stern, Lee S; Katz, Laura M; Dolgitser, Margarita; Hendlish, Sarah K

    2008-01-01

    To evaluate total and condition-related charges incurred by blind patients in a managed care population in the United States and compare total charges with those of a matched nonblind cohort. Retrospective cohort study. Patients with blindness (N = 10 796) and a 1:1 matched cohort of nonblind patients were selected from a managed care claims database. All study subjects were required to be > or =18 years old at diagnosis (blind patients) or enrollment (nonblind patients) and to have had > or =1 years of continuous follow-up. Total and pharmacy-related direct medical charges in the first year of follow-up were calculated for both blind and nonblind cohorts. Among blind patients, condition-related charges, charge per treated person, and charge breakdown by age group were calculated. For patients with follow-up extending past 1 year, total charges (both cohorts) and condition-related charges (blind cohort only) were assessed and annualized. Mean and median charges were assessed for blind and nonblind patients within each stratum of matched covariates; a multivariate linear regression assessed the statistical significance of the difference in charges between the 2 cohorts. Total health care charges in the first year of follow-up and condition-related health care charges in the first year of follow-up for blind patients. For the blind population (mean age, 52 years [standard deviation (SD), 17.5]), the total mean and median health care charges per person in the first year were $20,677 (SD, $48,835) and $6854, respectively. Total mean and median health care charges per nonblind patient in the first year were $13,321 (SD, $40,059) and $3778, respectively. Condition-related charges among blind patients were substantially lower than total charges, with mean and median charges per person of $4565 (SD, $17,472) and $371, respectively. After adjusting for covariates, blind patients had significantly higher total health care charges in the first year of follow-up than nonblind

  17. Developing and testing an electronic literacy resource for Arab patients before experiencing radiology procedures.

    PubMed

    Abuzaid, Mohamed M; Alnuaimi, Aishah M; Abdi, Asma M; Mohajer, Elika A; Mohamed, Ifrah A; Bilwani, Rawan A; Alhammadi, Shaima B

    2016-09-01

    Radiological examinations require prior preparation that patients should be informed about. Radiologists and radiologic technologists have limited time and resources to do so. Therefore, the internet is a valuable and accessible resource for patient education, but the information may not be reliable, especially that in Arabic language. This study aimed to develop online patient education resources about imaging procedures in Arabic. It also evaluated the understandability and actionability of the source materials. The study was conducted at the University of Sharjah between October 2014 and July 2015. A website containing texts and audiovisuals for 21 medical imaging procedures was created. Bilingual (Arabic and English) radiology experts evaluated the materials with automatic score calculation using the Patient Education Materials Assessment Tool. Two procedures were pilot tested by one evaluator, followed by completion of 28 evaluations by 15 selected experts. Nineteen of 21 procedures were randomly evaluated. For printable materials, the mean understandability score was 92.37 (SD=8.355) and actionability score was 92.11 (SD=13.157). For audiovisual materials, the mean understandability score was 97.63 (SD=13.157) and the percentage for all actionability scores was 100%. The minimum acceptable percentage is 70%. The high percentages scored for the online materials indicate that the evaluators were satisfied with the materials included and that the information would be easy for patients to understand and follow. The higher scores for the audiovisual materials indicate that they were considered more effective for improving patient knowledge patient knowledge.

  18. Integrative Therapy Use for Management of Side Effects and Toxicities Experienced by Pediatric Oncology Patients

    PubMed Central

    Jacobs, Shana S

    2014-01-01

    Integrative Therapies (IT), otherwise known as Complementary and Alternative Medicine, are widely used among pediatric oncology patients, despite a paucity of available evidence. This review summarizes surveys that describe the prevalence of IT use by pediatric oncology patients, both during therapy and in survivorship, as well as the modalities being used. Additionally, the evidence that exists for specific treatments that appear to be efficacious in controlling specific symptoms is described. Finally, there are recommendations for practitioners on how to best counsel patients about IT use. PMID:27417488

  19. Provision of inpatient rehabilitation and challenges experienced with participation post discharge: quantitative and qualitative inquiry of African stroke patients.

    PubMed

    Rhoda, Anthea; Cunningham, Natalie; Azaria, Simon; Urimubenshi, Gerard

    2015-09-28

    The provision of rehabilitation differs between developed and developing countries, this could impact on the outcomes of post stroke rehabilitation. The aim of this paper is to present provision of in-patient stroke rehabilitation. In addition the challenges experienced by the individuals with participation post discharge are also presented. Qualitative and quantitative research methods were used to collect data. The quantitative data was collected using a retrospective survey of stroke patients admitted to hospitals over a three- to five-year period. Quantitative data was captured on a validated data capture sheet and analysed descriptively. The qualitative data was collected using interviews from a purposively and conveniently selected sample, audio-taped and analysed thematically. The qualitative data was presented within the participation model. A total of 168 medical folders were reviewed for a South African sample, 139 for a Rwandan sample and 145 for a Tanzanian sample. The mean age ranged from 62.6 (13.78) years in the South African sample to 56.0 (17.4) in the Rwandan sample. While a total of 98 % of South African stroke patients received physiotherapy, only 39.4 % of Rwandan patients received physiotherapy. From the qualitative interviews, it became clear that the stroke patients had participation restrictions. When conceptualised within the Participation Model participation restrictions experienced by the stroke patients were a lack of accomplishment, inability to engage in previous roles and a perception of having health problems. With the exception of Rwanda, stroke patients in the countries studied are admitted to settings early post stroke allowing for implementation of effective acute interventions. The participants were experiencing challenges which included a lack of transport and the physical geographic surroundings in the rural settings not being conducive to wheelchair use. Stroke patients admitted to hospitals in certain African countries

  20. Detection of Low-Signal Pulvinar Areas Using Diffusion-Weighted Imaging in Patients with Dementia Experiencing Visual Hallucinations

    PubMed Central

    Sugiura, Mayuko; Satoh, Masayuki; Tabei, Ken-ichi; Saito, Tomoki; Mori, Mutsuki; Abe, Makiko; Kida, Hirotaka; Maeda, Masayuki; Sakuma, Hajime; Tomimoto, Hidekazu

    2016-01-01

    Background Little research has been conducted regarding the role of pulvinar nuclei in the pathogenesis of visual hallucinations due to the difficulty of assessing abnormalities in this region using conventional magnetic resonance imaging (MRI). The present study aimed to retrospectively investigate the relative abilities of diffusion-weighted imaging (DWI), fluid-attenuated inversion recovery (FLAIR), and susceptibility-weighted imaging (SWI) to visualize the pulvinar and to ascertain the relationship between pulvinar visualization and visual hallucinations. Methods A retrospective analysis of 3T MRIs from 73 patients (31 males, 42 females; mean age 73.5 ± 12.7 years) of the Memory Clinic of Mie University Hospital was conducted. Correlations between pulvinar visualization and the following were analyzed: age, sex, education, hypertension, hyperlipidemia, diabetes mellitus, Mini-Mental State Examination score, Evans index, and visual hallucinations. Results DWI detected low-signal pulvinar areas in approximately half of the patients (52.1%). Participants with pulvinar visualization were significantly older, and the pulvinar was more frequently visualized in patients who had experienced visual hallucinations compared to those who had not. No significant association was observed between whole brain atrophy and pulvinar visualization. Conclusions The results of the present study indicate that diffusion-weighted 3T MRI is the most suitable method for the detection of pulvinar nuclei in patients with dementia experiencing visual hallucinations. PMID:27790244

  1. Nonpharmacologic supportive strategies to promote quality of life in patients experiencing cancer-related fatigue: a systematic review.

    PubMed

    Wanchai, Ausanee; Armer, Jane M; Stewart, Bob R

    2011-04-01

    Cancer-related fatigue (CRF) is a distressing symptom that affects the quality of life (QOL) of patients with breast cancer and their families. The effectiveness of pharmacologic therapies alone has not been sufficient in the management of CRF; therefore, a combination of pharmacologic and nonpharmacologic approaches is justified. The purpose of this article is to critically review the literature related to nonpharmacologic supportive strategies in enhancing QOL among patients with breast cancer experiencing CRF. The results show that exercises (e.g., home-based exercise, supervised exercise), education and counseling, sleep therapy, and complementary therapy are feasible as effective nonpharmacologic supportive interventions to improve QOL in patients with breast cancer suffering from CRF. Therefore, nurses may consider these nonpharmacologic supportive strategies as adjunctive interventions to pharmacologic interventions in enhancing QOL for patients with breast cancer experiencing CRF. However, because previous studies had some methodologic limitations, such as small sample size, lack of objective measures, or predominantly Caucasian sample, future research to further explore nonpharmacologic interventions in this area is warranted.

  2. Changes Experienced in Quality of Life for Skull Base Surgical Patients: A Qualitative Case Study.

    PubMed

    de Almeida, John R; Vescan, Allan D; Witterick, Ian J; Gullane, Patrick J; Gentili, Fred; Ringash, Jolie; Thoma, Achilles; Lohfeld, Lynne

    2015-03-01

    Objective Skull base tumors are associated with quality of life (QOL) changes. A qualitative case-study approach may help better understand patients' experiences. Methods A total of 34 skull base surgery patients were selected into focus groups using a criterion-based maximum variation sampling strategy from a sampling frame of 138 patients. Eight groups were organized based on a factorial design of surgical approach (endoscopic/pen) and tumor location (anterior/central). Data were analyzed using a conceptual framework. Qualitative analysis was performed on focus group transcripts to identify major themes and determine if surgical approach or tumor location had differential effects on QOL. Concepts were quantitatively tallied from written workbooks. Results The 34 participants (19 men, 15 women; mean age: 48 years, standard deviation: 14 years) had mixed reactions to their diagnosis ranging from relief to fear. Participants reported physical and nonphysical changes in QOL with some variation in physical complaints by tumor location. Several major themes emerged from the analysis. Skull base tumors are associated with fear and frustration, loss of physical senses and self-identity, social isolation, and coping mechanisms. Conclusions Skull base surgery may impact patients' lives. Qualitative study of patient experiences can provide rich information to better understand this disease.

  3. Piloting staff education in Australia to reduce falls in older hospital patients experiencing delirium.

    PubMed

    Toye, Christine; Kitchen, Su; Hill, Andrew; Edwards, Deborah; Sin, Michelle; Maher, Sean

    2017-03-01

    This study piloted a hospital-based delirium and falls education program to investigate the impacts on staff knowledge and practice plus patient falls. On a medical ward, staff knowledge was compared before and after education sessions. Other data - collected a day before and after program implementation - addressed documentation of patients' delirium and evidence of compliance with falls risk minimization protocols. These data, and numbers of patient falls, were compared before and after program implementation. Almost all ward staff members participated in education sessions (7 doctors, 7 allied health practitioners, and 45 nurses) and knowledge was significantly improved in the 22 who completed surveys both before and after session attendance. Patients assessed as having delirium (5 before implementation, 4 afterwards) were all documented as either confused or delirious. Small changes eventuated in adherence with falls risk management protocols for confused patients and the number of falls decreased. The program merits a stronger emphasis on staff activities relating to the detection, documentation, and management of delirium to inter-professional roles and communication. Evidence of practice enhancement from program implementation should precede rigorous testing of impacts upon falls. © 2016 John Wiley & Sons Australia, Ltd.

  4. Depression and caregiver burden experienced by caregivers of Jordanian patients with stroke.

    PubMed

    Kamel, Andaleeb Abu; Bond, A Elaine; Froelicher, Erika Sivarajan

    2012-04-01

    Many stroke survivors will be cared for at home, primarily by their relatives. Providing care to a family member with a chronic disabling disease can be both emotionally and physically distressing for the caregivers. The purpose of this study was to investigate the relationship between patients' characteristics, duration of caregiving, daily caregiving time, caregiver's characteristics, caregiver depression and burden in caregivers of patients with stroke. A cross-sectional design was used with a convenience sample of 116 subjects. The Center of Epidemiologic Studies of Depression and the Caregiver Strain Index were used to identify caregiver depression and burden, respectively. Logistic regression analysis identified the influence of independent variables on caregiver depression and caregiver burden. Caregivers had high scores for depression and burden indices. Caregivers' health, receiving professional home health care and caregivers' burden were related to caregiver depression. Functional disabilities of patients with stroke and depression of caregivers were related to caregiver burden. To decrease caregiver depression and burden, nurses must provide caregivers with instructions for home management of patients with stroke. Development of specialized stroke home health services in Jordan that targets patients with stroke and their caregivers are recommended. © 2012 Blackwell Publishing Asia Pty Ltd.

  5. Changes Experienced in Quality of Life for Skull Base Surgical Patients: A Qualitative Case Study

    PubMed Central

    de Almeida, John R.; Vescan, Allan D.; Witterick, Ian J.; Gullane, Patrick J.; Gentili, Fred; Ringash, Jolie; Thoma, Achilles; Lohfeld, Lynne

    2014-01-01

    Objective Skull base tumors are associated with quality of life (QOL) changes. A qualitative case-study approach may help better understand patients' experiences. Methods A total of 34 skull base surgery patients were selected into focus groups using a criterion-based maximum variation sampling strategy from a sampling frame of 138 patients. Eight groups were organized based on a factorial design of surgical approach (endoscopic/pen) and tumor location (anterior/central). Data were analyzed using a conceptual framework. Qualitative analysis was performed on focus group transcripts to identify major themes and determine if surgical approach or tumor location had differential effects on QOL. Concepts were quantitatively tallied from written workbooks. Results The 34 participants (19 men, 15 women; mean age: 48 years, standard deviation: 14 years) had mixed reactions to their diagnosis ranging from relief to fear. Participants reported physical and nonphysical changes in QOL with some variation in physical complaints by tumor location. Several major themes emerged from the analysis. Skull base tumors are associated with fear and frustration, loss of physical senses and self-identity, social isolation, and coping mechanisms. Conclusions Skull base surgery may impact patients' lives. Qualitative study of patient experiences can provide rich information to better understand this disease. PMID:28856080

  6. More than one-third of successfully nonoperatively treated patients with complicated appendicitis experienced recurrent appendicitis: Is interval appendectomy necessary?

    PubMed

    Tanaka, Yujiro; Uchida, Hiroo; Kawashima, Hiroshi; Fujiogi, Michimasa; Suzuki, Keisuke; Takazawa, Shinya; Deie, Kyoichi; Amano, Hizuru; Iwanaka, Tadashi

    2016-12-01

    Although nonoperative treatment (non-OPT) for complicated appendicitis is performed widely, the long-term outcomes and merits of interval appendectomy (IA) need to be evaluated. Between April 2007 and December 2013, all appendicitis patients with well-circumscribed abscess or phlegmon were required to select either laparoscopic surgery (OPT) or non-OPT with optional IA on admission. Optional IA was planned at ≥3months after non-OPT. For non-OPT, intravenous injection of antibiotics was continued until the serum C-reactive protein concentration decreased to <0.5mg/dL, with occasional drainage of abscesses. Thirty-three patients chose OPT, and 55 chose non-OPT. Among non-OPT patients, 16 selected IA. The success rate of non-OPT was 98.2%. Recurrence occurred in 13 (34.2%) of the 38 non-IA group patients. Although the non-IA group patients frequently had perforated appendicitis at recurrence, they visited the hospital earlier than at the initial appendicitis and had less inflammation. Readmission rate or complications in patients undergoing IA were not different compared with those of the patients in the non-IA group, who had recurrence at ≥3months, or with those of patients in the OPT group. Although many patients experienced recurrent appendicitis after successful nonoperative treatment, IA may not be necessary after non-OPT. Prospective comparative study, level II. Copyright © 2016 Elsevier Inc. All rights reserved.

  7. [Presence of Streptococcus bovis in urine samples from patients experiencing symptoms of urinary tract].

    PubMed

    Gómez-Camarasa, Cristina; Gutiérrez Soto, Blanca; Jiménez-Guerra, Gemma; Sorlózano Puerto, Antonio; Navarro-Marí, José María; Gutiérrez-Fernández, José

    Given the relevance of proper clinical validation of Streptococcus bovis, we here consider revising its presence in urine samples in order to determine its relative frequency and the pattern of antibiotic susceptibility. The susceptibility to antibiotics of 91 isolates of S. bovis from urine samples was retrospectively reviewed over a period of 4 years (2012-2015). The mean age of patients was 55 years, 81% of whom were women and 37.4% were hospitalized patients suffering from urological diseases (61%). Susceptibility to penicillin, vancomycin and teicoplanin was 97.8%. Due to the fact that S. bovis can be infrequent in urine isolates and given its presence in patients suffering from urological diseases, further pathogenic studies, showing the true ability of this group of bacteria to produce disease, are required. Copyright © 2016 Asociación Argentina de Microbiología. Publicado por Elsevier España, S.L.U. All rights reserved.

  8. Cognitive and Affective Symptoms Experienced by Cancer Patients Receiving High-Dose Intravenous Interleukin 2 Therapy: An Integrative Literature Review.

    PubMed

    Mann, Tara K; Dail, Robin B; Bailey, Donald E

    2016-01-01

    Alterations in cognitive/affective functioning are among the most challenging adverse effects experienced by 80% of patients with metastatic melanoma and metastatic renal cell carcinoma undergoing high-dose interleukin 2 (IL-2) therapy. The purpose of this literature review is to describe what is known about IL-2-induced cognitive/affective symptoms, their prevalence, and level of severity and synthesize findings to determine areas for future research to address symptom management challenges. This review describes the IL-2 patient experience and the pathophysiology leading to these changes. An online electronic search using PubMed was performed to identify relevant literature published between 1992 and 2015. Of the original 113 articles, information was extracted from 9 articles regarding cognitive symptoms, affective symptoms, sample size, research design, reliability, and validity. Our review suggests that the trajectories, breadth, and depth of cognitive/affective symptoms have yet to be described. Despite intervention studies designed to address the psychosocial complications of IL-2, an understanding of the level of altered cognitive/affective symptoms experienced by IL-2 patients remains unclear. Our literature review reveals a lack of standardization when assessing, reporting, and managing cognitive/affective symptoms. Patients/family members have reported cognitive/affective symptoms to be the most alarming and difficult symptoms, yet these symptoms are not adequately screened for, and patients were not informed about potential changes. Assessing patients for cognitive/affective alterations is important to reduce anxiety while improving outcomes. Education about the illness trajectory (what to expect during/after treatment) can help care partners/patients set realistic shared expectations and increase coping.

  9. Stressors Experienced by Relatives of Patients in an Innovative Rehabilitation Program.

    ERIC Educational Resources Information Center

    Quine, Susan; And Others

    1993-01-01

    Conducted 450 interviews with 78 family caregivers of 37 patients with severe brain injuries in rehabilitation treatment program in acute care hospital. Found that involvement in providing treatment was stressful, because of both demands on the family and unproven efficacy of treatment. Findings suggest that family's ability to provide treatment…

  10. Anxiety and depression after failure of assisted reproductive treatment among patients experiencing infertility.

    PubMed

    Maroufizadeh, Saman; Karimi, Elaheh; Vesali, Samira; Omani Samani, Reza

    2015-09-01

    To investigate the impact of the number of previous infertility treatment failures on anxiety and depression. In a cross-sectional study, individuals (men and women, but not couples) aged at least 18 years who had a history of infertility and could read and write in Persian were enrolled at the Royan Institute, Tehran, Iran, between November 1, 2013, and February 28, 2014. Participants provided demographic and infertility information and completed the Persian version of the Hospital Anxiety and Depression Scale (HADS). Overall, 330 patients (122 men, 208 women) were included. Mean scores on the HADS anxiety and depression subscales (HADS-A and HADS-D) were 8.40±4.51 and 5.95±3.54, respectively. In multiple regression analysis, mean HADS-A scores were significantly higher for patients with one treatment failure (9.57±4.58) than for those without a history of treatment (7.79±4.13; P=0.003). HADS-D scores were significantly higher for patients with two failures (6.92±3.69) than for those with no previous treatment (5.59±3.79; P=0.019). Patients with infertility have increased depression and anxiety after infertility treatment failure. Counseling or treatment for these potential psychological effects should be considered after infertility treatment failure. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

  11. Three-year safety and efficacy of vicriviroc, a CCR5 antagonist, in HIV-1-infected treatment-experienced patients.

    PubMed

    Wilkin, Timothy J; Su, Zhaohui; Krambrink, Amy; Long, Jianmin; Greaves, Wayne; Gross, Robert; Hughes, Michael D; Flexner, Charles; Skolnik, Paul R; Coakley, Eoin; Godfrey, Catherine; Hirsch, Martin; Kuritzkes, Daniel R; Gulick, Roy M

    2010-08-01

    Vicriviroc, an investigational CCR5 antagonist, demonstrated short-term safety and antiretroviral activity. Phase 2, double-blind, randomized study of vicriviroc in treatment-experienced subjects with CCR5-using HIV-1. Vicriviroc (5, 10, or 15 mg) or placebo was added to a failing regimen with optimization of background antiretroviral medications at day 14. Subjects experiencing virologic failure and subjects completing 48 weeks were offered open-label vicriviroc. One hundred eighteen subjects were randomized. Virologic failure (<1 log10 decline in HIV-1 RNA > or =16 weeks postrandomization) occurred by week 48 in 24 of 28 (86%), 12 of 30 (40%), 8 of 30 (27%), 10 of 30 (33%) of subjects randomized to placebo, 5, 10, and 15 mg, respectively. Overall, 113 subjects received vicriviroc at randomization or after virologic failure, and 52 (46%) achieved HIV-1 RNA <50 copies per milliliter within 24 weeks. Through 3 years, 49% of those achieving suppression did not experience confirmed viral rebound. Dual or mixed-tropic HIV-1 was detected in 33 (29%). Vicriviroc resistance (progressive decrease in maximal percentage inhibition on phenotypic testing) was detected in 6 subjects. Nine subjects discontinued vicriviroc due to adverse events. Vicriviroc seems safe and demonstrates sustained virologic suppression through 3 years of follow-up. Further trials of vicriviroc will establish its clinical utility for the treatment of HIV-1 infection.

  12. Three-Year Safety and Efficacy of Vicriviroc, a CCR5 Antagonist, in HIV-1-Infected, Treatment-Experienced Patients

    PubMed Central

    Wilkin, Timothy J.; Su, Zhaohui; Krambrink, Amy; Long, Jianmin; Greaves, Wayne; Gross, Robert; Hughes, Michael D.; Flexner, Charles; Skolnik, Paul R.; Coakley, Eoin; Godfrey, Catherine; Hirsch, Martin; Kuritzkes, Daniel R.; Gulick, Roy M.

    2010-01-01

    Background Vicriviroc, an investigational CCR5 antagonist, demonstrated short-term safety and antiretroviral activity. Methods Phase 2, double-blind, randomized study of vicriviroc in treatment-experienced subjects with CCR5-using HIV-1. Vicriviroc (5, 10 or 15 mg) or placebo was added to a failing regimen with optimization of background antiretroviral medications at day 14. Subjects experiencing virologic failure and subjects completing 48 weeks were offered open-label vicriviroc. Results 118 subjects were randomized. Virologic failure (<1 log10 decline in HIV-1 RNA ≥16 weeks post-randomization) occurred by week 48 in 24/28 (86%), 12/30 (40%), 8/30 (27%), 10/30 (33%) of subjects randomized to placebo, 5, 10 and 15 mg respectively. Overall, 113 subjects received vicriviroc at randomization or after virologic failure, and 52 (46%) achieved HIV-1 RNA <50 copies/mL within 24 weeks. Through 3 years, 49% of those achieving suppression did not experience confirmed viral rebound. Dual or mixed-tropic HIV-1 was detected in 33 (29%). Vicriviroc resistance (progressive decrease in maximal percentage inhibition on phenotypic testing) was detected in 6 subjects. Nine subjects discontinued vicriviroc due to adverse events. Conclusions Vicriviroc appears safe and demonstrates sustained virologic suppression through 3 years of follow-up. Further trials of vicriviroc will establish its clinical utility for the treatment of HIV-1 infection. PMID:20672447

  13. Understanding the Knowledge Gap Experienced by U.S. Safety Net Patients in Teleretinal Screening

    PubMed Central

    George, Sheba M.; Hayes, Erin Moran; Fish, Allison; Daskivich, Lauren Patty; Ogunyemi, Omolola I.

    2016-01-01

    Safety-net patients’ socioeconomic barriers interact with limited digital and health literacies to produce a “knowledge gap” that impacts the delivery of healthcare via telehealth technologies. Six focus groups (2 African- American and 4 Latino) were conducted with patients who received teleretinal screening in a U.S. urban safety-net setting. Focus groups were analyzed using a modified grounded theory methodology. Findings indicate that patients’ knowledge gap is primarily produced at three points during the delivery of care: (1) exacerbation of patients’ pre-existing personal barriers in the clinical setting; (2) encounters with technology during screening; and (3) lack of follow up after the visit. This knowledge gap produces confusion, potentially limiting patients’ perceptions of care and their ability to manage their own care. It may be ameliorated through delivery of patient education focused on both disease pathology and specific role of telehealth technologies in disease management. PMID:28269855

  14. Barotrauma-induced pneumocephalus experienced by a high risk patient after commercial air travel.

    PubMed

    Huh, Jisoon

    2013-08-01

    A 49-year-old female with a history of several neurosurgical and otolaryngologic procedures for occipital meningioma and cerebrospinal fluid leaks was diagnosed with pneumocephalus after a one hour flight on a domestic jet airliner. Despite multiple operations, the air appeared to enter the cranium through a weak portion of the skull base due to the low atmospheric pressure in the cabin. The intracranial air was absorbed with conservative management. The patient was recommended not to fly before a definite diagnostic work up and a sealing procedure for the cerebrospinal fluid leak site had been performed. Recent advances in aviation technology have enabled many people to travel by air, including individuals with medical conditions. Low cabin pressure is not dangerous to healthy individuals; however, practicing consultant neurosurgeons should understand the cabin environment and prepare high risk patients for safe air travel.

  15. States with the least restrictive regulations experienced the largest increase in patients seen by nurse practitioners.

    PubMed

    Kuo, Yong-Fang; Loresto, Figaro L; Rounds, Linda R; Goodwin, James S

    2013-07-01

    The use of nurse practitioners (NPs) is one way to address the shortage of physician primary care providers. NP training programs and the number of practicing NPs have increased in the past two decades. However, regulations limiting their scope of practice vary greatly by state. We assessed the impact of state regulations on the increase in care provided by NPs in the United States, using a 5 percent national sample of Medicare beneficiaries. We found that between 1998 and 2010 the number of Medicare patients receiving care from NPs increased fifteenfold. By 2010 states with the least restrictive regulations of NP practice had a 2.5-fold greater likelihood of patients' receiving their primary care from NPs than did the most restrictive states. Relaxing state restrictions on NP practice should increase the use of NPs as primary care providers, which in turn would reduce the current national shortage of primary care providers.

  16. Effectiveness and Risk Factors for Virological Outcome of Raltegravir-Based Therapy for Treatment-Experienced HIV-Infected Patients.

    PubMed

    Mata-Marín, José Antonio; Smeke, Ariane Estrella Weiser; Rodriguez, Mariana Rotzinger; Chávez-García, Marcelino; Banda-Lara, Marco Isaac; Rios, Alma Minerva Pérez; Nuñez-Rodríguez, Nohemí; Domínguez-Hermosillo, Juan Carlos; Sánchez, Alberto Chaparro; Juarez-Kasusky, Irene; Herrera, Javier Enrique Cruz; Ramírez, Jorge Luis Sandoval; Gaytán-Martínez, Jesús

    2017-03-01

    We evaluated the effectiveness of a raltegravir (RAL)-containing regimen plus an optimized background regimen in HIV-1 highly treatment-experienced patients. A retrospective cohort, multicentre study was conducted. Adult (>16 years old) HIV treatment-experience patients starting therapy with a RAL-containing regimen were included. Effectiveness was evaluated as the percentage of patients with an undetectable HIV-1 RNA viral load (<50 and <200 copies/mL) after 48 weeks, and changes in CD4+ cell counts. We evaluated the risk factors associated with treatment failure. Of the 107 patients in the cohort, 86% were men, the median age was 45 years [interquartile range (IQR) 40-52] and the median number of previous regimens was six (IQR 4-7). After 48 weeks of treatment, 73% (IQR 63-80%) of patients (n = 78) had a viral load of <50 copies/mL and 85% (IQR 77-90%) (n = 91) had <200 copies/mL. In a logistic regression model, risk factors associated with a virological outcome of HIV-1 RNA of <200 copies/mL were age >40 years [odds ratio (OR) 5.61; 95% confidence interval (CI) 1.61-18.84; P = 0.006] and use of tenofovir in the regimen (OR 0.16; 95% CI 0.03-0.80; P = 0.026). In this Mexican cohort, RAL achieved high rates of virological suppression and an increase in CD4+ cell count in highly treatment-experienced patients infected with HIV-1. Age >40 years was associated with a good virological outcome, contrary to tenofovir use, which was associated with a poor virological outcome.

  17. [Clinical, microbiological and evolutionary profile of patients experiencing failures and relapses of tuberculosis in Ivory Coast].

    PubMed

    Kouamé-N'Takpé, N; Horo, K; Koné, A; N'guessan, K R; Touré, K; Kouadio, C; Assi, D; Coulibaly, I; Kouakou, A

    2015-02-01

    Multidrug-resistant tuberculosis (MDR-TB) is a major obsession for TB control. The main risk factor for MDR-TB remains a history of TB treatment especially bad conduct. The objective of this study is to describe the profile of patients in situations of failure and relapse of tuberculosis. We performed a retrospective survey of the analysis of records of patients starting TB retreatment for failure or relapse of tuberculosis. We used 193 cases with results of culture-sensitivity. The proportion of failure is 59/193 (30.6 %) and cases of relapse are 134/193 (69.4 %). The proportion of married life is 23.4 % (11/47) in chess against 41.5 % (51/123) in relapse of TB [P=0.021, OR=0.431 (0.201 to 0.927)]. Patients failing therapy have more chest pain [5.8 % (3/52) versus 0 % (0/126) with P=0.024]. The proportion of MDR-TB was 61.4 (38/59) in case of failure against 41 % (55/134) in case of relapse [P=0.002, OR=2.599 (1.378 to 4.902)]. The evolution is the same whatever the indication of reprocessing. The proportion of MDR-TB is very important in case of reprocessing failure and relapse of tuberculosis. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

  18. Viewing videotape of themselves while experiencing delirium tremens could reduce the relapse rate in alcohol-dependent patients.

    PubMed

    Mihai, Adriana; Damsa, Cristian; Allen, Michael; Baleydier, Bertrand; Lazignac, Coralie; Heinz, Andreas

    2007-02-01

    The aim of this prospective randomized controlled study was to determine whether viewing videotape of themselves while experiencing delirium tremens (DT) reduces the relapse rate in alcohol-dependent patients. Our hypothesis about the efficacy of videotapes exposure to DT is consistent with a cognitive behavior model. Sixty patients with DT and a minimum of 3 years of severe alcohol dependence [Diagnostic and Statistical Manual version IV (DSM-IV criteria] were included in this study. Patients were videotaped during the acute phase of DT and randomized into two groups: group A patients received individual exposure to their videotape and an explanation of the symptoms by a psychiatrist; and control group B patients, who were without videotape experience. Both groups received the same treatment during the acute and the maintenance phases, without aversive therapy or psychotherapy. The two groups did not differ significantly in number of drinks per day prior to admission, age, marital status, social environment, education, professional and financial status or family psychiatric history. An in-patient crisis unit for patients with alcohol dependence. All patients were observed for 6 months during monthly visits. Outcomes included relapse, drinking days per week and number of drinks per drinking day. All patients and their families signed informed consent. The patients with videotape experience had a significantly lower relapse rate after the first month (0% versus 20%), 2 months (13.33% versus 46.67%) and 3 months (26.67% versus 53.33%). Patients with videotape experience had less severe relapses and consumed fewer units of alcohol than controls. Videotape exposure in delirium tremens is an original therapeutic method which seems to be effective in reducing relapse risk in patients with alcohol dependence.

  19. Considering psychoeducation on structural dissociation for dialectical behavior therapy patients experiencing high-risk dissociative behaviors.

    PubMed

    Shabb, Olivia

    2016-01-01

    Dialectical behavioral therapy (DBT) programs, particularly for low-functioning individuals at the safety and stabilization phase of therapy, work with a variety of high-risk and often complex cases, with a curriculum consisting primarily of concrete skill acquisition and application. A significant subset of individuals in DBT programs, however, may suffer high-risk dissociative episodes in which skill application may be less available to them, contributing to further destabilization, demoralization, and thoughts of self-inefficacy in treatment. This article evaluates the potential benefits of complementing traditional DBT with psychoeducation on structural dissociation for such patients, acknowledging and addressing some of the concerns that might accompany such a consideration.

  20. Patient-reported outcome of solifenacin treatment among women experiencing urinary urgency and urgency incontinence.

    PubMed

    But, Igor; Orešković, Slavko; Bratuš, Dejan; Šprem-Goldštajn, Marina; Hlebič, Gregor

    2014-01-01

    To evaluate treatment success and tolerability of solifenacin among women with urinary urgency (UU) and urgency urinary incontinence (UUI). In a prospective, observational, multicenter pilot study in Slovenia and Croatia, 100 women with UU and UUI were enrolled between January 2011 and July 2011. Patients received 5mg of solifenacin once daily for 12 weeks and completed a 3-day bladder diary, urgency questionnaire, Urogenital Distress Inventory (UDI), and Incontinence Impact Questionnaire (IIQ). Overall, 91 women completed 12 weeks of treatment. Severity, frequency, and bother of UU significantly had decreased at weeks 4 and 12 (P<0.001). Improvement in UU led to an improvement in mean IIQ score: a reduction in UU frequency had the greatest impact (P=0.006). The mean treatment success rate was 74.2% (by visual analog score) and was closely related to the mean change in irritative UDI score (r=0.39; P<0.001). Treatment success was greatest for patient perception of intensity of urgency scale (PPIUS; P=0.003), UU bother (P=0.017), and micturition frequency (P<0.026). Dry mouth occurred in 35.2% of women at 4 weeks, and 27.7% at week 12. Solifenacin treatment was effective and well-tolerated among women with UU and UUI. All overactive bladder symptoms had improved by week 12. © 2013.

  1. HIV-1 drug resistance mutations emerging on darunavir therapy in PI-naive and -experienced patients in the UK

    PubMed Central

    El Bouzidi, Kate; White, Ellen; Mbisa, Jean L.; Sabin, Caroline A.; Phillips, Andrew N.; Mackie, Nicola; Pozniak, Anton L.; Tostevin, Anna; Pillay, Deenan; Dunn, David T.

    2016-01-01

    Background Darunavir is considered to have a high genetic barrier to resistance. Most darunavir-associated drug resistance mutations (DRMs) have been identified through correlation of baseline genotype with virological response in clinical trials. However, there is little information on DRMs that are directly selected by darunavir in clinical settings. Objectives We examined darunavir DRMs emerging in clinical practice in the UK. Patients and methods Baseline and post-exposure protease genotypes were compared for individuals in the UK Collaborative HIV Cohort Study who had received darunavir; analyses were stratified for PI history. A selection analysis was used to compare the evolution of subtype B proteases in darunavir recipients and matched PI-naive controls. Results Of 6918 people who had received darunavir, 386 had resistance tests pre- and post-exposure. Overall, 2.8% (11/386) of these participants developed emergent darunavir DRMs. The prevalence of baseline DRMs was 1.0% (2/198) among PI-naive participants and 13.8% (26/188) among PI-experienced participants. Emergent DRMs developed in 2.0% of the PI-naive group (4 mutations) and 3.7% of the PI-experienced group (12 mutations). Codon 77 was positively selected in the PI-naive darunavir cases, but not in the control group. Conclusions Our findings suggest that although emergent darunavir resistance is rare, it may be more common among PI-experienced patients than those who are PI-naive. Further investigation is required to explore whether codon 77 is a novel site involved in darunavir susceptibility. PMID:27856703

  2. Pairing virtual reality with dynamic posturography serves to differentiate between patients experiencing visual vertigo.

    PubMed

    Keshner, Emily A; Streepey, Jefferson; Dhaher, Yasin; Hain, Timothy

    2007-07-09

    To determine if increased visual dependence can be quantified through its impact on automatic postural responses, we have measured the combined effect on the latencies and magnitudes of postural response kinematics of transient optic flow in the pitch plane with platform rotations and translations. Six healthy (29-31 yrs) and 4 visually sensitive (27-57 yrs) subjects stood on a platform rotated (6 deg of dorsiflexion at 30 deg/sec) or translated (5 cm at 5 deg/sec) for 200 msec. Subjects either had eyes closed or viewed an immersive, stereo, wide field of view virtual environment (scene) moved in upward pitch for a 200 msec period for three 30 sec trials at 5 velocities. RMS values and peak velocities of head, trunk, and head with respect to trunk were calculated. EMG responses of 6 trunk and lower limb muscles were collected and latencies and magnitudes of responses determined. No effect of visual velocity was observed in EMG response latencies and magnitudes. Healthy subjects exhibited significant effects (p < 0.05) of visual field velocity on peak angular velocities of the head. Head and trunk velocities and RMS values of visually sensitive subjects were significantly larger than healthy subjects (p < 0.05), but their responses were not modulated by visual field velocity. When examined individually, patients with no history of vestibular disorder demonstrated exceedingly large head velocities; patients with a history of vestibular disorder exhibited head velocities that fell within the bandwidth of healthy subjects. Differentiation of postural kinematics in visually sensitive subjects when exposed to the combined perturbations suggests that virtual reality technology could be useful for differential diagnosis and specifically designed interventions for individuals whose chief complaint is sensitivity to visual motion.

  3. Pairing virtual reality with dynamic posturography serves to differentiate between patients experiencing visual vertigo

    PubMed Central

    Keshner, Emily A; Streepey, Jefferson; Dhaher, Yasin; Hain, Timothy

    2007-01-01

    Background To determine if increased visual dependence can be quantified through its impact on automatic postural responses, we have measured the combined effect on the latencies and magnitudes of postural response kinematics of transient optic flow in the pitch plane with platform rotations and translations. Methods Six healthy (29–31 yrs) and 4 visually sensitive (27–57 yrs) subjects stood on a platform rotated (6 deg of dorsiflexion at 30 deg/sec) or translated (5 cm at 5 deg/sec) for 200 msec. Subjects either had eyes closed or viewed an immersive, stereo, wide field of view virtual environment (scene) moved in upward pitch for a 200 msec period for three 30 sec trials at 5 velocities. RMS values and peak velocities of head, trunk, and head with respect to trunk were calculated. EMG responses of 6 trunk and lower limb muscles were collected and latencies and magnitudes of responses determined. Results No effect of visual velocity was observed in EMG response latencies and magnitudes. Healthy subjects exhibited significant effects (p < 0.05) of visual field velocity on peak angular velocities of the head. Head and trunk velocities and RMS values of visually sensitive subjects were significantly larger than healthy subjects (p < 0.05), but their responses were not modulated by visual field velocity. When examined individually, patients with no history of vestibular disorder demonstrated exceedingly large head velocities; patients with a history of vestibular disorder exhibited head velocities that fell within the bandwidth of healthy subjects. Conclusion Differentiation of postural kinematics in visually sensitive subjects when exposed to the combined perturbations suggests that virtual reality technology could be useful for differential diagnosis and specifically designed interventions for individuals whose chief complaint is sensitivity to visual motion. PMID:17620142

  4. ABT-450: a novel agent for the treatment of CHC genotype 1: focus on treatment-experienced patients.

    PubMed

    Gamal, Nesrine; Vitale, Giovanni; Andreone, Pietro

    2015-03-01

    Chronic hepatitis C (CHC) constitutes a major health concern. Hepatitis C virus eradication by antiviral treatment can markedly reduce the risk of developing cirrhosis, hepatocellular carcinoma and liver-related death. A plethora of new direct antiviral agents have been developed and are being explored in clinical trials. One of the newest members of this family is the NS3/4A protease inhibitor ABT-450. The multi-targeted approach combining ritonavir-enhanced ABT-450 with ombitasvir and dasabuvir has been evaluated for the treatment of CHC Gt1 in treatment-naïve and treatment-experienced adults. In this article, we sought to discuss the current knowledge on ABT-450-containing regimens, with special emphasis on treatment-experienced CHC Gt1 patients. This new combination was found to be potent, safe and well tolerated. Future Phase III trials with larger sample size in patients with decompensated cirrhosis, non-Gt1, end-stage renal disease and liver transplant recipients are eagerly awaited.

  5. High-utilizing Crohn's disease patients under psychosomatic therapy*

    PubMed Central

    Deter, Hans-Christian; von Wietersheim, Jörn; Jantschek, Günther; Burgdorf, Friederike; Blum, Brigitta; Keller, Wolfram

    2008-01-01

    Objective Few studies have been published on health care utilization in Crohn's disease and the influence of psychological treatment on high utilizers. Methods The present sub study of a prospective multi center investigation conducted in 87 of 488 consecutive Crohn's disease (CD) patients was designed to investigate the influence of the course of Crohn's disease on health care utilization (hospital days (HD) and sick leave days (SLD) collected by German insurance companies) and to examine the conditions of high-utilizing patients. Predictors of health care utilization should be selected. Based on a standardized somatic treatment, high health care utilizing patients of the psychotherapy and control groups should be compared before and after a one-year treatment. Results Multivariate regression analysis identified disease activity at randomization as an important predictor of the clinical course (r2 = 0.28, p < 0.01). Health care utilization correlated with duration of disease (p < 0.04), but the model was not significant (r2 = 0.15, p = 0.09). The patients' level of anxiety, depression and lack of control at randomization predicted their health-related quality of life at the end of the study (r2 = 0.51, p < 0.00001). Interestingly, steroid intake and depression (t1) predicted the combined outcome measure (clinical course, HRQL, health care utilization) of Crohn's disease at the end of the study (r2 = 0.22, p < 0.001). Among high utilizers, a significantly greater drop in HD (p < 0.03) and in mean in SLD were found in the treatment compared to the control group. Conclusion The course of Crohn's disease is influenced by psychological as well as somatic factors; especially depression seems important here. A significant drop of health care utilization demonstrates the benefit of psychological treatment in the subgroup of high-utilizing CD patients. Further studies are needed to replicate the findings of the clinical outcome in this CD subgroup. PMID:18851749

  6. An evaluation of patients' experienced usability of a diabetes mHealth system using a multi-method approach.

    PubMed

    Georgsson, Mattias; Staggers, Nancy

    2016-02-01

    mHealth systems are becoming more common to aid patients in their diabetes self-management, but recent studies indicate a need for thorough evaluation of patients' experienced usability. Current evaluations lack a multi-method design for data collection and structured methods for data analyses. The purpose of this study was to provide a feasibility test of a multi-method approach for both data collection and data analyses for patients' experienced usability of a mHealth system for diabetes type 2 self-management. A random sample of 10 users was selected from a larger clinical trial. Data collection methods included user testing with eight representative tasks and Think Aloud protocol, a semi-structured interview and a questionnaire on patients' experiences using the system. The Framework Analysis (FA) method and Usability Problem Taxonomy (UPT) were used to structure, code and analyze the results. A usability severity rating was assigned after classification. The combined methods resulted in a total of 117 problems condensed into 19 usability issues with an average severity rating of 2.47 or serious. The usability test detected 50% of the initial usability problems, followed by the post-interview at 29%. The usability test found 18 of 19 consolidated usability problems while the questionnaire uncovered one unique issue. Patients experienced most usability problems (8) in the Glucose Readings View when performing complex tasks such as adding, deleting, and exporting glucose measurements. The severity ratings were the highest for the Glucose Diary View, Glucose Readings View, and Blood Pressure View with an average severity rating of 3 (serious). Most of the issues were classified under the artifact component of the UPT and primary categories of Visualness (7) and Manipulation (6). In the UPT task component, most issues were in the primary category Task-mapping (12). Multiple data collection methods yielded a more comprehensive set of usability issues. Usability

  7. The ICU patient room: views and meanings as experienced by the next of kin: a phenomenological hermeneutical study.

    PubMed

    Olausson, Sepideh; Ekebergh, Margaretha; Lindahl, Berit

    2012-06-01

    The rooms in Intensive Care Units are considered as high-tech environments and believed to affect recovery process and wellbeing of patients. Moreover, the design and interiors affect the interplay between the patient and the next of kin. The aim of this study was to describe and interpret the meanings of the intensive care patient room as experienced by next of kin. Next of kin (n=14) from two different intensive care units participated. Data were collected through photo-voice and analysed using a phenomenological hermeneutical method. Three major themes emerged; dwelling in the room and time, becoming at home and extension of the room. The results show that the room is perceived as a lived and extended place and space. The design, interiors and furnishing in the patient room are fundamental in shaping the next of kin's experiences in the room and affect wellbeing. How intensive care patient rooms are designed, the place given to next of kin and the way they are received in the room are decisive for the support given to the loved one. Simple interventions can make the patient room a more healing environment. Copyright © 2011 Elsevier Ltd. All rights reserved.

  8. Patient Care Utility Module for DEPMEDS Hospitals

    DTIC Science & Technology

    1991-06-05

    following groups for their assistance with this project: DEPMEDS Coordinating Group COL Lowman Gober , COL Darlene Grubor, LTC Judy Jackson, LTC Mike...overall ward configurations and obtain necessary dimensions. A market survey was conducted to identify potentially useful components of patient care...usable between beds were identified in the market survey. One was Fairfield Medical Products Corp., Tampa, FL, which manufactures the MEMO (Mobile

  9. Cost-effectiveness of Newer Antiretroviral Drugs in Treatment-Experienced Patients with Multi-drug Resistant HIV Disease

    PubMed Central

    Bayoumi, Ahmed M.; Barnett, Paul G.; Joyce, Vilija R.; Griffin, Susan C.; Sun, Huiying; Bansback, Nick J.; Holodniy, Mark; Sanders, Gillian; Brown, Sheldon T.; Kyriakides, Tassos C.; Angus, Brian; Cameron, D. William; Anis, Aslam H.; Sculpher, Mark; Owens, Douglas K.

    2014-01-01

    Objective Newer antiretroviral drugs provide substantial benefits but are expensive. We determined the cost-effectiveness of using antiretroviral drugs in combination for patients with multi-drug resistant HIV disease. Design We built a cohort state-transition model representing treatment-experienced patients with low CD4 counts, high viral load levels, and multi-drug resistant virus. We estimated the effectiveness of newer drugs (those approved in 2005 or later) from published randomized trials. We estimated other parameters from a randomized trial and from the literature. The model had a lifetime time horizon and used the perspective of an ideal insurer in the United States. The interventions were combination antiretroviral therapy, consisting of two newer drugs and one conventional drug, compared to three conventional drugs. Outcome measures were life-years, quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness. Results Substituting newer antiretroviral drugs increased expected survival by 3.9 years in advanced HIV disease. The incremental cost-effectiveness ratio of newer, compared to conventional, antiretroviral drugs was $75,556/QALY gained. Sensitivity analyses showed that substituting only one newer antiretroviral drug cost $54,559 to $68,732/QALY, depending on assumptions about efficacy. Substituting three newer drugs cost $105,956 to $117,477/QALY. Cost-effectiveness ratios were higher if conventional drugs were not discontinued. Conclusions In treatment-experienced patients with advanced HIV disease, use of newer antiretroviral agents can be cost effective, given a cost-effectiveness threshold in the range of $50,000 to $75,000 per QALY gained. Newer antiretroviral agents should be used in carefully selected patients for whom less expensive options are clearly inferior. PMID:24129369

  10. Mental Trauma Experienced by Caregivers of patients with Diffuse Axonal Injury or Severe Traumatic Brain Injury

    PubMed Central

    Syed Hassan, Syed Tajuddin; Jamaludin, Husna; Abd Raman, Rosna; Mohd Riji, Haliza; Wan Fei, Khaw

    2013-01-01

    Context As with care giving and rehabilitation in chronic illnesses, the concern with traumatic brain injury (TBI), particularly with diffuse axonal injury (DAI), is that the caregivers are so overwhelmingly involved in caring and rehabilitation of the victim that in the process they become traumatized themselves. This review intends to shed light on the hidden and silent trauma sustained by the caregivers of severe brain injury survivors. Motor vehicle accident (MVA) is the highest contributor of TBI or DAI. The essence of trauma is the infliction of pain and suffering and having to bear the pain (i.e. by the TBI survivor) and the burden of having to take care and manage and rehabilitate the TBI survivor (i.e. by the TBI caregiver). Moreover many caregivers are not trained for their care giving task, thus compounding the stress of care giving and rehabilitating patients. Most research on TBI including DAI, focus on the survivors and not on the caregivers. TBI injury and its effects and impacts remain the core question of most studies, which are largely based on the quantitative approach. Evidence Acquisition Qualitative research can better assess human sufferings such as in the case of DAI trauma. While quantitative research can measure many psychometric parameters to assess some aspects of trauma conditions, qualitative research is able to fully reveal the meaning, ramification and experience of TBI trauma. Both care giving and rehabilitation are overwhelmingly demanding; hence , they may complicate the caregivers’ stress. However, some positive outcomes also exist. Results Caregivers involved in caring and rehabilitation of TBI victims may become mentally traumatized. Posttraumatic recovery of the TBI survivor can enhance the entire family’s closeness and bonding as well as improve the mental status of the caregiver. Conclusions A long-term longitudinal study encompassing integrated research is needed to fully understand the traumatic experiences of

  11. HIV-1 drug resistance mutations emerging on darunavir therapy in PI-naive and -experienced patients in the UK.

    PubMed

    El Bouzidi, Kate; White, Ellen; Mbisa, Jean L; Sabin, Caroline A; Phillips, Andrew N; Mackie, Nicola; Pozniak, Anton L; Tostevin, Anna; Pillay, Deenan; Dunn, David T

    2016-12-01

    Darunavir is considered to have a high genetic barrier to resistance. Most darunavir-associated drug resistance mutations (DRMs) have been identified through correlation of baseline genotype with virological response in clinical trials. However, there is little information on DRMs that are directly selected by darunavir in clinical settings. We examined darunavir DRMs emerging in clinical practice in the UK. Baseline and post-exposure protease genotypes were compared for individuals in the UK Collaborative HIV Cohort Study who had received darunavir; analyses were stratified for PI history. A selection analysis was used to compare the evolution of subtype B proteases in darunavir recipients and matched PI-naive controls. Of 6918 people who had received darunavir, 386 had resistance tests pre- and post-exposure. Overall, 2.8% (11/386) of these participants developed emergent darunavir DRMs. The prevalence of baseline DRMs was 1.0% (2/198) among PI-naive participants and 13.8% (26/188) among PI-experienced participants. Emergent DRMs developed in 2.0% of the PI-naive group (4 mutations) and 3.7% of the PI-experienced group (12 mutations). Codon 77 was positively selected in the PI-naive darunavir cases, but not in the control group. Our findings suggest that although emergent darunavir resistance is rare, it may be more common among PI-experienced patients than those who are PI-naive. Further investigation is required to explore whether codon 77 is a novel site involved in darunavir susceptibility. © The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.

  12. Distribution of HIV-1 Infection in Different T Lymphocyte Subsets: Antiretroviral Therapy-Naïve vs. Experienced Patients

    PubMed Central

    Perez, Raul; Gibson, Sonia; Lopez, Pablo; Koenig, Ellen; De Castro, Marisol

    2011-01-01

    Abstract Memory CD4 T cells are the primary targets of HIV-1 infection, which then subsequently spreads to other T lymphocyte subsets. Antiretroviral therapy (ART) alters the pattern of HIV-1 distribution. Blood samples were collected from ART-naïve or -experienced HIV-1 patients, and the memory and naïve subsets of CD4+ and CD8+ T lymphocytes, respectively, were isolated by cell sorting. DNA was extracted and the HIV-1 env C2/V3 region PCR amplified. Amplicons were cloned and sequenced, and genetic relatedness among different HIV-1 compartments was determined by the phylogenetic analysis of clonal sequences. The viral V3 sequence of HIV-1 in each compartment was analyzed by using webPSSM to determine CCR5 or CXCR4 coreceptor binding property of the virus. The direction of viral migration among involved compartments was determined by using the MacClade program. In ART-naïve patients, HIV-1 was generally confined to the memory CD4 T (mT4) cell compartment, even though in a few cases, naïve CD4 T (nT4) cells were also infected. When this occurred, the HIV-1 gene migrated from nT4 to mT4. In contrast, HIV-1 was detected in nT4 and mT4 as well as in the memory CD8 T (mT8) compartments of ART-experienced patients. However, no clear pattern of directional HIV-1 gene flow among the compartments could be determined because of the small sample size. All HIV-1–infected T cell compartments housed the virus that used either CCR5 or CXCR4 as the coreceptor. PMID:21054214

  13. Immune correlates of CD4 decline in HIV-infected patients experiencing virologic failure before undergoing treatment interruption

    PubMed Central

    Huang, Kenneth H; Loutfy, Mona R; Tsoukas, Christos M; Bernard, Nicole F

    2008-01-01

    Background The advantage of treatment interruptions (TIs) in salvage therapy remains controversial. Regardless, characterizations of the correlates of CD4 count fall during TI are important to identify since patients with virologic failure commonly stop antiretroviral (ARV) therapy. The objective of this study was to determine the predictive value of pre-TI proliferative capacity and cell surface markers for CD4 count change in HIV-infected patients experiencing virologic failure before undergoing TI. Methods Peripheral blood mononuclear cells (PBMCs) from 13 HIV-infected patients experiencing virologic failure at baseline time points before the TI were tested for proliferation using the 5,6-carboxyfluorescein diacetate succinimidyl ester (CFSE) dilution assay and a Gag p55 peptide pool, staphylococcus enterotoxin B (SEB), cytomegalovirus (CMV) recall antigen, and anti-CD3 antibody as stimuli. CD28 and CD57 expression on CD4+ and CD8+ T-cells was measured. Results The median changes in the CD4+ T-cell count and viral load from baseline to the TI time point corresponding to the CD4 count nadir were -44 cells/mm3 {Interquartile range (IQR) -17, -104} and +85,332 copies/mL (IQR +11,198, +283,327), respectively. CD4+ T-cell proliferation to CMV, pre-TI CD4+ T-cell count, and percent CD4+CD57+ cells correlated negatively with CD4 count change during TI (r = -0.59, p = 0.045, r = -0.61, p = 0.030 and r = -0.69, p = 0.0095, respectively; Spearman correlation). The presence of HIV-specific proliferative responses was not associated with a reduced decline in CD4 count during TI. Conclusion The use of pre-TI immune proliferative responses and cell surface markers may have predictive value for CD4 count decline during TI. PMID:18454861

  14. Clinical experience with repository corticotropin injection in patients with multiple sclerosis experiencing mood changes with intravenous methylprednisolone: a case series

    PubMed Central

    Murray, Stacey; Woo, Andrew

    2015-01-01

    The elevated prevalence of neuropsychiatric symptoms and disorders among patients with multiple sclerosis (MS) is well recognized, as are potential neuropsychiatric side effects of treatment with corticosteroids. Both methylprednisolone (MP) and repository corticotropin injection (HP Acthar® gel) have demonstrated efficacy in reducing short-term disability after exacerbations of MS. Although historical data are limited, repository corticotropin injection has not generally been associated with detrimental neuropsychiatric effects. We describe six cases of patients with relapsing-remitting MS who had previously experienced detrimental mood changes with MP treatment. Some of these patients had previous histories of mood disorders or other neuropsychiatric symptoms prior to MS diagnosis. All six patients were subsequently treated with repository corticotropin injection for MS exacerbations and each demonstrated improvements in MS symptoms. This clinical experience suggests that repository corticotropin injection should be considered as an alternative for patients who do not tolerate corticosteroids or have difficulties associated with intravenous medication. Furthermore, the rate of neuropsychiatric side effects observed in these patients was low. These observations support repository corticotropin injection as a viable alternative for the treatment of acute exacerbations of MS, particularly in patients who have a history of neuropsychiatric disorders or symptoms either independently or in response to MP treatment. In reviewing both the published data and our own clinical experience regarding potential neuropsychiatric adverse events with treatment for MS exacerbations, we hope to stimulate further research into the potential efficacy and safety of repository corticotropin injection among patients with some form of neuropsychiatric complications that must be considered when establishing a treatment plan for MS. PMID:27134674

  15. Communication challenges experienced by migrants with cancer: A comparison of migrant and English-speaking Australian-born cancer patients.

    PubMed

    Hyatt, Amelia; Lipson-Smith, Ruby; Schofield, Penelope; Gough, Karla; Sze, Ming; Aldridge, Lynley; Goldstein, David; Jefford, Michael; Bell, Melanie L; Butow, Phyllis

    2017-10-01

    Understanding the difficulties faced by different migrant groups is vital to address disparities and inform targeted health-care service delivery. Migrant oncology patients experience increased morbidity, mortality and psychological distress, with this tentatively linked to language and communication difficulties. The objective of this exploratory study was to investigate the communication barriers and challenges experienced by Arabic, Greek and Chinese (Mandarin and Cantonese) speaking oncology patients in Australia. This study employed a cross-sectional design using patient-reported outcome survey data from migrant and English-speaking Australian-born patients with cancer. Patients were recruited through oncology clinics and Australian state cancer registries. Data were collected regarding patient clinical and demographic characteristics and health-care and communication experiences. Data from the clinics and registries were combined for analysis. Significant differences were found between migrant groups in demographic characteristics, communication and health-care experiences, and information and care preferences. Chinese patients cited problems with understanding medical information, the Australian health-care system, and communicating with their health-care team. Conversely, Arabic- and Greek-speaking patients reported higher understanding of the health-care system, and less communication difficulties. Our study findings suggest that migrant groups differ from each other in their health communication expectations and requirements. Lower education and health literacy of some groups may play a role in poorer health outcomes. Public health interventions and assistance provided to migrants should be tailored to the specific needs and characteristics of that language or cultural group. Future research directions are discussed. © 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.

  16. Rifaximin treatment is associated with reduced risk of cirrhotic complications and prolonged overall survival in patients experiencing hepatic encephalopathy.

    PubMed

    Kang, S H; Lee, Y B; Lee, J-H; Nam, J Y; Chang, Y; Cho, H; Yoo, J-J; Cho, Y Y; Cho, E J; Yu, S J; Kim, M Y; Kim, Y J; Baik, S K; Yoon, J-H

    2017-08-24

    Rifaximin might decrease the risk of portal hypertension-related complications by controlling small intestinal bacterial overgrowth. To evaluate whether rifaximin was associated with the risk of death and cirrhotic complications. We conducted a retrospective study that included 1042 patients experiencing hepatic encephalopathy (HE): 421 patients without hepatocellular carcinoma (HCC; the non-HCC cohort) and 621 patients with HCC (the HCC cohort). The primary endpoint was overall survival and secondary endpoints were recurrence of HE and the development of spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS) and variceal bleeding. In the non-HCC cohort, 145 patients received rifaximin plus lactulose (the rifaximin group) and 276 patients received lactulose alone (the control group). The multivariate analysis revealed that rifaximin was significantly associated with lower risk of death (adjusted hazard ratio [aHR], 0.697; P = .024) and reduced the risk of recurrent HE (aHR, 0.452; P < .001), SBP (aHR, 0.210; P < .001) and variceal bleeding (aHR, 0.425; P = .011) but not HRS (aHR, 0.598; P = .08). In the HCC cohort, 173 patients received rifaximin plus lactulose and 448 patients received lactulose. Rifaximin was not associated with the risk of death (aHR, 1.177; P = .121). Rifaximin was associated with lower risk of SBP (aHR, 0.323; P < .001) but not with variceal bleeding (aHR, 0.660; P = .104) or recurrent HE (aHR, 0.689; P = .057). The risk of Clostridium difficile-associated diarrhoea was not different between the groups (aHR, 0.028; P = .338). In patients without HCC, rifaximin treatment was significantly associated with prolonged overall survival and reduced risks of spontaneous bacterial peritonitis, variceal bleeding and recurrent hepatic encephalopathy. © 2017 John Wiley & Sons Ltd.

  17. Personality Compensates for Impaired Quality of Life and Social Functioning in Patients With Psychotic Disorders Who Experienced Traumatic Events

    PubMed Central

    Boyette, Lindy-Lou; van Dam, Daniëlla; Meijer, Carin; Velthorst, Eva; Cahn, Wiepke; de Haan, Lieuwe; Kahn, René; de Haan, Lieuwe; van Os, Jim; Wiersma, Durk; Bruggeman, Richard; Cahn, Wiepke; Meijer, Carin; Myin-Germeys, Inez

    2014-01-01

    Background: Patients with psychotic disorders who experienced childhood trauma show more social dysfunction than patients without traumatic experiences. However, this may not hold for all patients with traumatic experiences. Little is known about the potential compensating role of Five-Factor Model personality traits within this group, despite their strong predictive value for social functioning and well-being in the general population. Methods: Our sample consisted of 195 patients with psychotic disorders (74% diagnosed with schizophrenia) and 132 controls. Cluster analyses were conducted to identify and validate distinct personality profiles. General linear model analyses were conducted to examine whether patients with different profiles differed in social functioning and quality of life (QoL), while controlling for possible confounders. Mediation models were tested to assess potential causal links. Results: In general, patients with higher levels of self-reported traumatic experiences (PT+) showed lower QoL and more social withdrawal compared with patients with lower traumatic experiences (PT−). Two clusters reflecting personality profiles were identified. PT+ with the first profile (lower neuroticism and higher extraversion, openness, agreeableness, and conscientiousness) presented higher levels of QoL and better social functioning in several areas, including less withdrawal, compared with both PT+ and PT− with the second profile. PT+ and PT− with the first personality profile did not differ in QoL and social functioning. Mediation analyses suggested that personality traits mediate the relation between traumatic experiences and QoL and social withdrawal. Conclusions: Our findings indicate that personality may “buffer” the impact of childhood traumatic experiences on functional outcome in patients with psychotic disorders. PMID:24771304

  18. Persistence to single-tablet regimen versus less-drug regimen in treatment experienced HIV-infected patients on antiretroviral therapy.

    PubMed

    Jiménez-Galán, Rocio; Cantudo Cuenca, Maria-Rosa; Robustillo-Cortés, María Aguas; Borrego Izquierdo, Y; Almeida-Gonzalez, Carmen Victoria; Morillo-Verdugo, Ramón

    2016-06-01

    Decreased antiretroviral therapy persistence is associated with increased rates of virologic failure, development of antiretroviral resistance, and increased morbidity and mortality. Different therapeutic strategies, such as single-tablet regimens (STR) and less-drug regimens (LDR), have been developed in order to simplify antiretroviral therapy (ART) and increase persistence. The primary objective was to compare antiretroviral persistence among patients receiving STRs and patients receiving LDRs. A secondary objective was to identify factors associated with non-persistence. This was a retrospective study that included treatment- experienced HIV-infected patients who received ART based on STR or LDR. Baseline patient characteristics collected included demographic information, HIV risk transmission, substance abuse during the therapy, presence of psychiatric disorder and hepatitis B or C virus infection. Kaplan-Meier analysis and Log rank was utilized to compare persistence to STR and LDR. To identify independent predictors of non-persistence we developed a multivariate Cox regression analysis. A total of 244 patients were included, 176 with STR and 68 with LDR. 60 (34.1%) patients discontinued in the STR group and 13 (19.1%) in the LDR group. The Cox regression model showed that the only variable associated with higher risk of non-persistence was the substance abuse (HR = 2.59; p = 0.005). Adverse events were the main reason for ART discontinuation in the STR group and virologic failure in the LDR group. Persistence to STR and LDR seems to be similar in pretreated HIV-infected patients. Drug abuse was the only factor identified with a higher risk of non-persistence. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.

  19. Connection Subdomain Mutations in HIV-1 Subtype-C Treatment-Experienced Patients Enhance NRTI and NNRTI Drug Resistance

    PubMed Central

    Delviks-Frankenberry, Krista A.; Lengruber, Renan B.; Santos, Andre F.; Silveira, Jussara M.; Soares, Marcelo A.; Kearney, Mary F.; Maldarelli, Frank; Pathak, Vinay K.

    2012-01-01

    Mutations in the connection subdomain (CN) and RNase H domain (RH) of HIV-1 reverse transcriptase (RT) from subtype B-infected patients enhance nucleoside and nonnucleoside RT inhibitor (NRTI and NNRTI) resistance by affecting the balance between polymerization and RNase H activity. To determine whether CN mutations in subtype C influence drug sensitivity, single genome sequencing was performed on Brazilian subtype C-infected patients failing RTI therapy. CN mutations identified were similar to subtype B, including A376S, A400T, Q334D, G335D, N348I, and A371V, and increased AZT resistance in the presence of thymidine analog mutations. CN mutations also enhanced NNRTI resistance in the presence of classical NNRTI mutations: etravirine resistance was enhanced 6- to 11-fold in the presence of L100I/K103N/Y181C. These results indicate that selection of CN mutations in treatment-experienced patients also occurs in subtype-C-infected patients and are likely to provide valuable information in predicting clinical RTI resistance. PMID:23068886

  20. Prevention preferable to treatment: 3 case reports of patients experiencing right-sided heart failure after Ebstein anomaly correction

    PubMed Central

    Luo, Ming; Lin, Jing; Qin, Zhen; Du, Lei

    2017-01-01

    Abstract Rationale: Ebstein anomaly is a common congenital heart disease that may induce severe tricuspid regurgitation and dilation of the “atrialized” portion of the right ventricle. Patients who undergo surgery to correct Ebstein anomaly are at high risk of postoperative right-sided heart failure, yet little is known about what pre-, peri-, or postoperative procedures may help reduce this risk. Patient concerns: Here, we describe 3 cases of adults with Ebstein anomaly who underwent corrective surgery and in whom right-sided heart failure occurred with severe tricuspid regurgitation detected by transesophageal echocardiography. Diagnoses: Ebstein anomaly. Intervention: Various approaches were applied to prevent right heart failure: perioperative control of atrial and ventricle arrhythmia, protection of myocardium, reduction of right-side cardiac workload after cardiopulmonary bypass, and mechanical support for right heart. Outcomes: One of the 3 patients died, another experienced kidney failure despite postoperative support on extracorporeal membrane oxygenation, and the third patient survived without complications. Lessons: Our case series suggests that surgical prognosis can be improved through aggressive preoperative treatment, vasoactive and anti-arrhythmia medications, and comprehensive measures designed to reduce myocardial injury, prevent myocardial edema, and reduce pre- and afterload on the right ventricle. PMID:28072699

  1. Issues experienced while administering care to patients with dementia in acute care hospitals: A study based on focus group interviews

    PubMed Central

    Fukuda, Risa; Shimizu, Yasuko

    2015-01-01

    Objective Dementia is a major public health problem. More and more patients with dementia are being admitted to acute care hospitals for treatment of comorbidities. Issues associated with care of patients with dementia in acute care hospitals have not been adequately clarified. This study aimed to explore the challenges nurses face in providing care to patients with dementia in acute care hospitals in Japan. Methods This was a qualitative study using focus group interviews (FGIs). The setting was six acute hospitals with surgical and medical wards in the western region of Japan. Participants were nurses in surgical and internal medicine wards, excluding intensive care units. Nurses with less than 3 years working experience, those without experience in dementia patient care in their currently assigned ward, and head nurses were excluded from participation. FGIs were used to collect data from February to December 2008. Interviews were scheduled for 1–1.5 h. The qualitative synthesis method was used for data analysis. Results In total, 50 nurses with an average experience of 9.8 years participated. Eight focus groups were formed. Issues in administering care to patients with dementia at acute care hospitals were divided into seven groups. Three of these groups, that is, problematic patient behaviors, recurrent problem, and problems affecting many people equally, interact to result in a burdensome cycle. This cycle is exacerbated by lack of nursing experience and lack of organization in hospitals. In coping with this cycle, the nurses develop protection plans for themselves and for the hospital. Conclusions The two main issues experienced by nurses while administering care to patients with dementia in acute care hospitals were as follows: (a) the various problems and difficulties faced by nurses were interactive and caused a burdensome cycle, and (b) nurses do their best to adapt to these conditions despite feeling conflicted. PMID:25716983

  2. Darunavir-based dual therapy of treatment-experienced HIV-infected patients: analysis from a national multicenter database.

    PubMed

    Sterrantino, Gaetana; Zaccarelli, Mauro; Di Biagio, Antonio; Biondi, Maria Luisa; Antinori, Andrea; Penco, Giovanni

    2015-06-01

    We assessed the virological response of dual therapy with DRV/r, plus raltegravir, maraviroc or etravirine, in virological failure patients and in virologically suppressed patients collected in the Italian Antiretroviral Resistance Database (ARCA). The primary endpoint was the percentage of patients remaining free of virological failure (confirmed >50 copies/mL or any change in the regimen). Subjects had a resistance test and at least one follow-up visit. Observation was censored at last visit under dual therapy and survival analysis and proportional hazard models were used. Sixty-seven percent of the 221 patients started DRV/r with RAL, 20.4 % with ETV, and 12.2 % with MAR; 31.2 % virological failures were observed. At survival analysis, the overall proportion of failure was 29.2 % at 1 year and 33.8 % at 2 years. The proportion of failure was lower in patients starting with undetectable vs. detectable viral load (13.3 and 25.2 % vs. 37.4 and 38.8 % at 1 and 2 years, respectively, p = 0.001 for both analyses) and in patients treated with DRV 600 BID vs. 800 QD (HR: 0.56, 95 % CI: 0.31-0.99, p < 0.05). By regimen, the adjusted proportional model showed no significant difference among the three regimens. A significant lower risk of failure was associated with higher GSS (HIV-DB HR: 0.53, 95 % CI: 0.32-0.88, p = 0.014; Rega 0.60, 0.40-0.88, p < 0.01; ANRS 0.55, 0.34-0.90, p = 0.017), while a higher risk of failure with detectable HIV-RNA (3.02, 1.70-5.72, p < 0.001). Among experienced patients, the best candidates for dual-therapy regimens including DRV/r are those with undetectable viral load and higher GSS.

  3. Issues experienced while administering care to patients with dementia in acute care hospitals: a study based on focus group interviews.

    PubMed

    Fukuda, Risa; Shimizu, Yasuko; Seto, Natsuko

    2015-01-01

    Dementia is a major public health problem. More and more patients with dementia are being admitted to acute care hospitals for treatment of comorbidities. Issues associated with care of patients with dementia in acute care hospitals have not been adequately clarified. This study aimed to explore the challenges nurses face in providing care to patients with dementia in acute care hospitals in Japan. This was a qualitative study using focus group interviews (FGIs). The setting was six acute hospitals with surgical and medical wards in the western region of Japan. Participants were nurses in surgical and internal medicine wards, excluding intensive care units. Nurses with less than 3 years working experience, those without experience in dementia patient care in their currently assigned ward, and head nurses were excluded from participation. FGIs were used to collect data from February to December 2008. Interviews were scheduled for 1-1.5 h. The qualitative synthesis method was used for data analysis. In total, 50 nurses with an average experience of 9.8 years participated. Eight focus groups were formed. Issues in administering care to patients with dementia at acute care hospitals were divided into seven groups. Three of these groups, that is, problematic patient behaviors, recurrent problem, and problems affecting many people equally, interact to result in a burdensome cycle. This cycle is exacerbated by lack of nursing experience and lack of organization in hospitals. In coping with this cycle, the nurses develop protection plans for themselves and for the hospital. The two main issues experienced by nurses while administering care to patients with dementia in acute care hospitals were as follows: (a) the various problems and difficulties faced by nurses were interactive and caused a burdensome cycle, and (b) nurses do their best to adapt to these conditions despite feeling conflicted.

  4. Urinary cytokines/chemokines pattern in patients with painful bone metastases undergoing external beam radiotherapy experiencing pain flare.

    PubMed

    Bushehri, Ahmad; Chow, Edward; Zhang, Liying; Azad, Azar; Vuong, Sherlyn; Pasetka, Mark; Zhou, Michelle; Hird, Amanda; Dennis, Kristopher; McDonald, Rachel; DeAngelis, Carlo

    2016-04-01

    External beam radiotherapy (EBRT) is a mainstay for treatment of painful bone metastases. Transient worsening of pain ("pain flare") occurs in 40% of patients. We investigated the pathophysiology of pain flare through assessment of changes in urinary cytokines/chemokines in patients receiving EBRT for painful bone metastases. Urine samples were collected from patients receiving a single 8 Gy fraction for painful bone metastases preparation, day 1 or 2 and on an additional day between days 3 to 5 post radiation. Patients completed a standardized pain and analgesic use diary daily for 10 days following radiation. Patients were deemed to have pain flare if they had a two-point increase from baseline worst pain on 0-10 scale and no decrease in analgesic intake or a 25% increase in analgesic intake with no decrease in worst pain. The Millipore Milliplex 42-Plex Cyto-kine/Chemokine Kit™ was used to measure urinary levels of a panel of cytokines/chemokines. Forty-six patients consented to the study of which 28 were evaluable (complete urine and diary data), and 83/84 urine samples were available for analysis. Pain flare was experienced by 11 patients (39%). The following cytokines/chemokines were detectable in at least 50% of the patients: EGF, fractalkine, GRO, IL-4, IL-8, interferon gamma induced protein 10 (IP-10), MCP-1, macrophage derived chemokine (MDC), PDGF-AA, sIL-2Ra, TGF-Alpha, VEGF. Comparing patients with or without pain flare EGF, fractalkine, GRO, IL-8, IP-10, MCP-1, MDC, sIL-2Ra, and TGF-alpha increased following radiation in both groups. Patients with pain flare have significant lower levels on IL-8, IP-10, and MDC over time. No specific time trend was noticed. Patients who experience pain flare appear to have a different pattern in urinary cytokine/chemokine levels than patients without pain flare. A larger study is required to confirm the possible role of cytokines/chemokines in predisposition to and/or the cause of pain flare following radiation to

  5. Suicidality and symptoms of anxiety, irritability, and agitation in patients experiencing manic episodes with depressive symptoms: a naturalistic study

    PubMed Central

    Eberhard, Jonas; Weiller, Emmanuelle

    2016-01-01

    Purpose Patients with a bipolar I disorder (BD-I) manic episode meeting the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), criteria for “with mixed features” have a high incidence of suicide attempts and of anxiety, irritability, and agitation (AIA) symptoms. The aim of this analysis was to explore the relationship between suicidality and AIA symptoms in patients with BD-I experiencing mania with depressive symptoms, using data from a previous naturalistic study. Patients and methods Psychiatrists completed an online questionnaire about their adult patients who had a current BD-I manic episode. Questions covered the DSM-5 “with mixed features” specifier, the severity of AIA symptoms, the frequency and controllability of suicidal ideation, and the number of suicide attempts. Results Of 1,035 patients with BD-I mania who were included in the analyses, 348 (33.6%) met the criteria for the DSM-5 “with mixed features” specifier (three or more depressive symptoms). These patients were further stratified according to the severity of their AIA symptoms: “mild AIA” (zero or one AIA symptom above a severity threshold; 105 patients) or “severe AIA” (all three AIA symptoms above a severity threshold; 167 patients). A greater incidence of suicidal ideation was observed in the severe AIA group (71.9%) than in the mild AIA group (47.6%). Twice as many patients had easily controlled suicidal ideation than difficult-to-control suicidal ideation in both subgroups. The mean number of suicide attempts was higher in the severe AIA group than in the mild AIA group, during the current episode (0.84 vs 0.34 attempts, respectively; P<0.05) and over the patient’s lifetime (1.56 vs 1.04 attempts, respectively). Conclusion The high risk of suicide among BD-I mania patients with depressive symptoms is further increased when they experience severe AIA symptoms. Recognizing AIA symptoms in BD-I mania could provide a means of identifying

  6. Collaboration and communication in colorectal cancer care: a qualitative study of the challenges experienced by patients and health care professionals.

    PubMed

    Kamradt, Martina; Baudendistel, Ines; Längst, Gerda; Kiel, Marion; Eckrich, Felicitas; Winkler, Eva; Szecsenyi, Joachim; Ose, Dominik

    2015-12-01

    Colorectal cancer is becoming a chronic condition. This has significant implications for the delivery of health care and implies the involvement of a range of health care professionals (HCPs) from different settings to ensure the needed quality and continuity of care. To explore the challenges that patients and HCPs experience in the course of colorectal cancer care and the perceived consequences caused by these challenges. Ten semi-structured focus groups were conducted including patients receiving treatment for colorectal cancer, representatives of patient support groups, physicians and other non-physician HCPs from different health care settings. Participants were asked to share their experiences regarding colorectal cancer care. All data were audio- and videotaped, transcribed verbatim and thematically analysed using qualitative content analysis. Patients and HCPs (total N = 47) experienced collaboration and communication as well as exchange of information between HCPs as challenging. Particularly communication and information exchange with GPs appeared to be lacking. The difficulties identified restricted a well-working coordination of care and seemed to cause inappropriate health care. Colorectal cancer care seems to require an effective, well-working collaboration and communication between the different HCPs involved ensuring the best possible care to suit patients' individual needs. However, the perceived challenges and consequences of our participants seem to restrict the delivery of the needed quality of care. Therefore, it seems crucial (i) to include all HCPs involved, especially the GP, (ii) to support an efficient and standardized exchange of health-related information and (iii) to focus on the patients' entire pathway of care. © The Author 2015. Published by Oxford University Press.

  7. Improving Patient Flow Utilizing a Collaborative Learning Model.

    PubMed

    Tibor, Laura C; Schultz, Stacy R; Cravath, Julie L; Rein, Russell R; Krecke, Karl N

    2016-01-01

    This initiative utilized a collaborative learning approach to increase knowledge and experience in process improvement and systems thinking while targeting improved patient flow in seven radiology modalities. Teams showed improvements in their project metrics and collectively streamlined the flow for 530 patients per day by improving patient lead time, wait time, and first case on-time start rates. In a post-project survey of 50 project team members, 82% stated they had more effective solutions as a result of the process improvement methodology, 84% stated they will be able to utilize the process improvement tools again in the future, and 98% would recommend participating in another project to a colleague.

  8. On-treatment mortality predictors in chronic hepatitis B patients experiencing severe acute exacerbation: a prospective observational study.

    PubMed

    Chen, Yi-Cheng; Hsu, Chao-Wei; Chang, Ming-Yang; Yeh, Chau-Ting

    2013-09-02

    Severe acute exacerbation in chronic hepatitis B could lead to mortality in some patients unless timely liver transplantation is performed. The baseline bilirubin level has been reported to be an important prognostic factor for mortality. Here we conducted a prospective observational study to examine the clinical performance of this predictor. Twenty-one consecutive chronic hepatitis B patients experiencing severe acute exacerbation were treated with either telbivudine or entecavir. The clinical characteristics at baseline and week-2 were documented and correlated with mortality. Of the 21 patients included, 9 had baseline bilirubin >10 mg/dL. Four of these 9 patients (44.4%) eventually died, whereas all other patients survived. During the initial 2-week period, the change of bilirubin was -1.2 mg/dl in the survivors, but was +8.05 mg/dl in the mortalities (P = 0.009). When this on-treatment factor was combined, 5 of the 21 patients had baseline bilirubin > 10 mg/dL plus an increase of bilirubin level at week-2. Of these 5 patients, 4 (80%) died. Thus, by combining the baseline and on-treatment bilirubin levels, a positive predictive value of 80% and a negative predictive value of 100% could be achieved. Other significant on-treatment mortality predictors (at week-2) included higher international normalized ratio of prothrombin time (2.75 vs. 1.3, P = 0.004), higher model for end-stage liver disease score (30 vs. 17, P = 0.006), lower alpha-fetoprotein level (36.3 vs. 459.6 ng/mL, P = 0.039), and more rapid deterioration of the estimated glomerular filtration rate (eGFR) (P = 0.008). Interestingly, during the course, deterioration of eGFR was statistically significant in entecavir-treated (P = 0.028), but not in telbivudine-treated patients. Additionally, the patients treated with telbivudine had significant increase in serum alpha-fetoprotein (27.9 to 191.9 ng/ml, P = 0.046) in the first 2 weeks, whereas the corresponding feature was not found in those treated

  9. Comparison of Healthcare Utilization Among Patients Treated With Alcoholism Medications

    PubMed Central

    Mark, Tami L.; Montejano, Leslie B.; Kranzler, Henry R.; Chalk, Mady; Gastfriend, David R.

    2014-01-01

    Objectives To determine in a large claims database the healthcare utilization and costs associated with treatment of alcohol dependence with medications vs no medication and across 4 US Food and Drug Administration (FDA)–approved medications. Study Design Claims database analysis. Methods Eligible adults with alcohol dependence claims (n = 27,135) were identified in a commercial database (MarketScan; Thomson Reuters Inc, Chicago, Illinois). Following propensity score–based matching and inverse probability weighting on demographic, clinical, and healthcare utilization variables, patients who had used an FDA-approved medication for alcohol dependence (n = 2977) were compared with patients who had not (n = 2977). Patients treated with oral naltrexone hydrochloride (n = 2064), oral disulfiram (n = 2076), oral acamprosate calcium (n = 5068), or extended-release injectable naltrexone (naltrexone XR) (n = 295) were also compared for 6-month utilization rates of alcoholism medication, inpatient detoxification days, alcoholism-related inpatient days, and outpatient services, as well as inpatient charges. Results Patients who received alcoholism medications had fewer inpatient detoxification days (706 vs 1163 days per 1000 patients, P <.001), alcoholism-related inpatient days (650 vs 1086 days, P <.001), and alcoholism-related emergency department visits (127 vs 171, P = .005). Among 4 medications, the use of naltrexone XR was associated with fewer inpatient detoxification days (224 days per 1000 patients) than the use of oral naltrexone (552 days, P = .001), disulfiram (403 days, P = .049), or acamprosate (525 days, P <.001). The group receiving naltrexone XR also had fewer alcoholism-related inpatient days than the groups receiving disulfiram or acamprosate. More patients in the naltrexone XR group had an outpatient substance abuse visit compared with patients in the oral alcoholism medication groups. Conclusion Patients who received an alcoholism medication had lower

  10. Healthcare Utilization of Patients With Acute Coronary Syndrome in Germany

    PubMed Central

    Hoer, Ariane; Behrendt, Susann; Schmidt, Torsten; Lottmann, Kathrin

    2013-01-01

    Background The aim of this study was to determine the health care utilization of patients with acute coronary syndrome (ACS) of one German statutory health insurance. The utilization of ambulatory services as well as of inpatient rehabilitation should be regarded. Moreover, the study should reveal the prescription of drugs for secondary prevention. Here, patients showing guideline corresponding prescriptions should be compared with patients without such prescriptions. Methods A retrospective claims data analysis of one German statutory health insurance was conducted. Health care utilization was considered in the first year after an index hospitalization due to ACS. Beneficiaries for whom an ICD-10 discharge diagnosis of ACS was reported between January 1st 2007 and December 31st 2009 were included. In order to reveal differences in health care utilization depending on the type of ACS (STEMI versus NSTEMI/UA) stratified analyses were performed. Another stratification was done for patients with and without defined drug prescriptions. Results From 45,188 patients with ACS almost three quarters were assigned to the group of NSTEMI/UA. For 8.9% of all ACS patients (18.74% STEMI, 8.89% NSTEMI/UA), inpatient post-hospital rehabilitation related to ACS was recorded. Ambulatory care related to CHD diagnosis was utilized by 77.6% of patients, more often by STEMI than by NSTEMI/UA patients. For 36.7% and 45.7% of ACS patients, a prescription of aspirin or clopidogrel was recorded, respectively, 79.4% of STEMI patients received at least one prescription for antiplatelet drugs, the corresponding proportion of NSTEMI/UA was 59.8%. A considerable part of patients without prescription dropped out within the first 90 days after the index event. Conclusions A claims data analysis of one German statutory health insurance fund showed that health care utilization of ACS patients varied depending on the ACS type. It is necessary to distinguish between STEMI and NSTEMI/UA patients when

  11. Health Care Utilization and Expenditures Associated With Remote Monitoring in Patients With Implantable Cardiac Devices.

    PubMed

    Ladapo, Joseph A; Turakhia, Mintu P; Ryan, Michael P; Mollenkopf, Sarah A; Reynolds, Matthew R

    2016-05-01

    Several randomized trials and decision analysis models have found that remote monitoring may reduce health care utilization and expenditures in patients with cardiac implantable electronic devices (CIEDs), compared with in-office monitoring. However, little is known about the generalizability of these findings to unselected populations in clinical practice. To compare health care utilization and expenditures associated with remote monitoring and in-office monitoring in patients with CIEDs, we used Truven Health MarketScan Commercial Claims and Medicare Supplemental Databases. We selected patients newly implanted with an implantable cardioverter defibrillators (ICD), cardiac resynchronization therapy defibrillator (CRT-D), or permanent pacemaker (PPM), in 2009, who had continuous health plan enrollment 2 years after implantation. Generalized linear models and propensity score matching were used to adjust for confounders and estimate differences in health care utilization and expenditures in patients with remote or in-office monitoring. We identified 1,127; 427; and 1,295 pairs of patients with a similar propensity for receiving an ICD, CRT-D, or PPM, respectively. Remotely monitored patients with ICDs experienced fewer emergency department visits resulting in discharge (p = 0.050). Remote monitoring was associated with lower health care expenditures in office visits among patients with PPMs (p = 0.025) and CRT-Ds (p = 0.006) and lower total inpatient and outpatient expenditures in patients with ICDs (p <0.0001). In conclusion, remote monitoring of patients with CIEDs may be associated with reductions in health care utilization and expenditures compared with exclusive in-office care.

  12. Utilization and Perception of Integrative Medicine Among Plastic Surgery Patients.

    PubMed

    Patel, Nirav; Pierson, Justine; Lee, Timothy; Mast, Bruce; Lee, Bernard T; Estores, Irene; Singhal, Dhruv

    2017-05-01

    Integrative medicine (IM) is currently used by 40% of Americans. Our objective is to examine the prevalence and perception of IM utilization in patients being evaluated for elective plastic surgery. In July 2014, 402 consecutive patients presenting to plastic surgery clinics at the University of Florida, Veterans Affairs (VA), and Private Practices in Gainesville, Florida were requested to complete a survey regarding utilization of and attitudes towards IM. The survey completion rate was 75.5% (n = 331). The respondents' mean age was 48.5 years, and they were primarily white (75%), married (48%), and educated with at least a college degree (58%). The respondents were distributed between the university (74%), VA (15%), and private practice (11%). There was an equal mix of reconstructive (52%) and cosmetic (48%) visits. Overall IM utilization was 80.0%. Integrative medicine use correlated with having a college degree (P = 0.0002) and being middle age (40-64 years, P < 0.005). A higher utilization rate of IM in the private sector (87.0%) compared with the university (76.1%) and VA (71.0%) was not statistically significant (P = 0.17). Similarly, higher IM utilization in cosmetic patients compared with reconstructive patients (81% vs 74%) was not statistically significant (P = 0.56). The majority of patients stated a strong belief in self-healing techniques (71%, P < 0.005), and they desired (61%) that their physician should be familiar with these techniques (P < 0.005). The IM utilization is highly prevalent among plastic surgery patients regardless of reason for visit (cosmetic versus reconstruction) or practice setting (private versus academic versus VA). Increasing awareness of IM usage and potential impact on outcomes is especially important for academic and VA plastic surgeons. Moreover, an opportunity exists to study how certain aspects of IM can positively impact plastic surgery care.

  13. Cost effectiveness of lopinavir/ritonavir compared with atazanavir plus ritonavir in antiretroviral-experienced patients in the US.

    PubMed

    Simpson, Kit N; Jones, Walter J; Rajagopalan, Rukmini; Dietz, Birgitta

    2007-01-01

    To estimate the cost effectiveness and long-term combined effects of HIV disease and antiretroviral (ARV) therapy-related risk for coronary heart disease (CHD) on quality-adjusted survival and healthcare costs for ARV-experienced patients. A previously validated Markov model was updated and supplemented with the Framingham CHD risk equation. The representative patient in the model was male, aged 37 years and had a baseline 10-year CHD risk of 4.6%. Patients started with either lopinavir/ritonavir (LPV/r) or ritonavir-boosted atazanavir (ATV+RTV) as the protease inhibitor (PI). The proportions of patients with viral suppression below 400 and 50 copies/mL, respectively, at week 48 reported in clinical trials were used to estimate the differences between these two therapies. The daily ARV costs were $US 24.60 for LPV/r capsules (2005 costs) and $US 26.54 for LPV/r tablets (2006 costs), $US 29.76 for ATV and $US 8.57 for ritonavir (2005 costs). Costs of other ARV drugs were taken from average wholesale drug reports for 2005. The cost of AIDS events was estimated from Medicaid billing databases and reflected a medical care system perspective and 2005 treatment costs. Cost-effectiveness calculations assumed a lifetime time horizon. The effects of different model assumptions were tested in a multiway sensitivity analysis by combining extreme values of parameters. The model estimated a clinical and economic advantage to using LPV/r over ATV+RTV, which varied depending upon the use of LPV/r capsules or tablets. Using LPV/r capsules was comparatively beneficial for ARV-experienced patients in quality-adjusted life-months (QALMs) of 4.6 (corrected for differences in CHD risk) compared with ATV+RTV. In addition, there were 5- and 10-year overall per-patient cost savings of $US 17,995 and $US 21,298, respectively. Estimates for the LPV/r tablet formulation approved in 2005 (assuming similar efficacy) improved cost savings over 5- and 10-year periods to $US 19,598 and $US 23

  14. Prospective assessment of patient-reported outcomes and estradiol and drug concentrations in patients experiencing toxicity from adjuvant aromatase inhibitors.

    PubMed

    Kadakia, Kunal C; Kidwell, Kelley M; Seewald, Nicholas J; Snyder, Claire F; Storniolo, Anna Maria; Otte, Julie L; Flockhart, David A; Hayes, Daniel F; Stearns, Vered; Henry, N Lynn

    2017-07-01

    Aromatase inhibitors (AI), which decrease circulating estradiol concentrations in post-menopausal women, are associated with toxicities that limit adherence. Approximately one-third of patients will tolerate a different AI after not tolerating the first. We report the effect of crossover from exemestane to letrozole or vice versa on patient-reported outcomes (PROs) and whether the success of crossover is due to lack of estrogen suppression. Post-menopausal women enrolled on a prospective trial initiating AI therapy for early-stage breast cancer were randomized to exemestane or letrozole. Those that discontinued for intolerance were offered protocol-directed crossover to the other AI after a washout period. Changes in PROs, including pain [Visual Analog Scale (VAS)] and functional status [Health Assessment Questionnaire (HAQ)], were compared after 3 months on the first versus the second AI. Estradiol and drug concentrations were measured. Eighty-three patients participated in the crossover protocol, of whom 91.3% reported improvement in symptoms prior to starting the second AI. Functional status worsened less after 3 months with the second AI (HAQ mean change AI #1: 0.2 [SD 0.41] vs. AI #2: -0.05 [SD 0.36]; p = 0.001); change in pain scores was similar between the first and second AI (VAS mean change AI #1: 0.8 [SD 2.7] vs. AI #2: -0.2 [SD 2.8]; p = 0.19). No statistical differences in estradiol or drug concentrations were found between those that continued or discontinued AI after crossover. Although all AIs act via the same mechanism, a subset of patients intolerant to one AI report improved PROs with a different one. The mechanism of this tolerance remains unknown, but does not appear to be due to non-adherence to, or insufficient estrogen suppression by, the second AI.

  15. Determinants of Emergency Medical Services Utilization Among Acute Ischemic Stroke Patients in Hubei Province in China.

    PubMed

    Yin, Xiaoxv; Yang, Tingting; Gong, Yanhong; Zhou, Yanfeng; Li, Wenzhen; Song, Xingyue; Wang, Mengdie; Hu, Bo; Lu, Zuxun

    2016-03-01

    Emergency medical services (EMS) can effectively shorten the prehospital delay for patients with acute ischemic stroke. This study aimed to investigate EMS utilization and its associated factors in patients with acute ischemic stroke in China. A cross-sectional study was conducted from October 1, 2014, to January 31, 2015, which included 2096 patients admitted for acute ischemic stroke from 66 hospitals in Hubei province in China. A multivariable stepwise logistic regression model was undertaken to identify the factors associated with EMS utilization. Of the 2096 participants, only 323 cases (15.4%) used EMS. Those acute ischemic stroke patients who previously used EMS (odds ratio [OR] =9.8), whose National Institutes of Health Stroke Scale score was ≥10 (OR=3.7), who lived in urban communities (OR=2.5), who had sudden onset of symptoms (OR=2.4), who experienced their first stroke (OR=1.8), and who recognized initial symptom as stroke (OR=1.4) were more likely to use EMS. Additionally, when acute ischemic stroke patients' stroke symptom were noticed first by others (OR=2.1), rather than by the patients, EMS was more likely to be used. A very low proportion of patients with acute ischemic stroke used the EMS in Hubei province in China. Considerable education programs are required regarding knowledge of potential symptoms and the importance of EMS for stroke. © 2016 American Heart Association, Inc.

  16. Effectiveness of Supportive Educative Learning programme on the level of strain experienced by caregivers of stroke patients in Thailand.

    PubMed

    Oupra, R; Griffiths, R; Pryor, J; Mott, S

    2010-01-01

    In Thailand, the crude death rate from stroke is 10.9/100,000 population and increasing. Unlike Western countries where community rehabilitation programmes have been established to provide services following the acute stage of stroke recovery, there is no stroke rehabilitation team in the community in Thailand. Therefore, family caregivers are the primary source for ongoing care and support. While family members accompany patients during their hospitalisation, they receive little information about how to assist their relatives, and as a result feel inadequately trained, poorly informed and dissatisfied with the support that is available after discharge. Family caregivers report that they suffer both physically and psychologically and find themselves overwhelmed with strain, experiencing burden and exhaustion. This study aimed to develop and implement a nurse-led Supportive Educative Learning programme for family caregivers (SELF) of stroke survivors in Thailand and to evaluate the effect of the SELF programme on family caregiver's strain and quality of life. This was a non-randomised comparative study with concurrent controls, using a two-group pre-test and post-test design. A total of 140 stroke survivors and 140 family caregivers were recruited; 70 patients/caregiver pair in each group. Caregivers of patients admitted to the intervention hospital following an acute stroke received the intervention, while caregivers of patients admitted to the comparison hospital received the usual care provided at the hospital. The data were collected prior to discharge of the patients and after 3 months. The family caregivers in the intervention group had a significantly better quality of life than the comparison group (GHQ-28 at discharge t = 2.82, d.f. = 138, P = 0.006; and at 3 months t = 6.80, d.f. = 135, P < 0.001) and they also reported less strain (Caregiver Strain Index at discharge t = 6.73, d.f. = 138, P < 0.001; and at 3 months t = 7.67, d.f. = 135, P < 0.001). This

  17. Demographic, Operational, and Healthcare Utilization Factors Associated with Emergency Department Patient Satisfaction.

    PubMed

    Morgan, Matthew W; Salzman, Joshua G; LeFevere, Robert C; Thomas, Avis J; Isenberger, Kurt M

    2015-07-01

    The primary aim of this study was to determine which objectively-measured patient demographics, emergency department (ED) operational characteristics, and healthcare utilization frequencies (care factors) were associated with patient satisfaction ratings obtained from phone surveys conducted by a third-party vendor for patients discharged from our ED. This is a retrospective, observational analysis of data obtained between September 2011 and August 2012 from all English- and Spanish-speaking patients discharged from our ED who were contacted by a third-party patient satisfaction vendor to complete a standardized nine-item telephone survey by a trained phone surveyor. We linked data from completed surveys to the patient's electronic medical record to abstract additional demographic, ED operational, and healthcare utilization data. We used univariate ordinal logistic regression, followed by two multivariate models, to identify significant predictors of patient satisfaction. We included 20,940 patients for analysis. The overall patient satisfaction ratings were as follows: 1=471 (2%); 2=558 (3%); 3=2,014 (10%), 4=5,347 (26%); 5=12,550 (60%). Factors associated with higher satisfaction included race/ethnicity (Non-Hispanic Black; Hispanic patients), age (patients ≥65), insurance (Medicare), mode of arrival (arrived by bus or on foot), and having a medication ordered in the ED. Patients who felt their medical condition did not improve, those treated in our ED behavioral health area, and those experiencing longer wait times had reduced satisfaction. These findings provide a basis for development and evaluation of targeted interventions that could be used to improve patient satisfaction in our ED.

  18. Feeding tube utilization in patients with salivary gland malignancies

    PubMed Central

    Chen, Diane Wenhua; Lewin, Jan S.; Xu, Li; Lai, Stephen Y.; Gunn, G. Brandon; Fuller, Clifton David; Mohamed, Abdallah S. R.; Kanwar, Aasheesh; Sturgis, Erich M.; Hutcheson, Katherine A.

    2016-01-01

    Objectives To evaluate feeding tube utilization in patients with salivary gland malignancies (SGM). Study Design Case series with planned data collection. Setting The University of Texas MD Anderson Cancer Center, Houston, TX, USA. Subjects and Methods Patients (n=287) were sampled from an epidemiologic SGM registry during a 12-year period. Feeding tube history was retrospectively reviewed. Patients with outside locoregional therapy or palliative treatment were excluded. Enteral feeding and length of dependence were analyzed as a function treatment modality and site of SGM. Results Seventy-nine of 287 patients (28%) required temporary nasogastric tube feeding (median duration: 13 days, IQR 6–21). Among those 79, 30 (10% of total cohort) required conversion to percutaneous gastrostomy (G-tube). Median G-tube duration was 4.8 months (IQR 3.7–13.1). G-tube placement was only necessary in patients receiving multimodality therapy (p<0.001), and among those, 50% with SGM arising from pharyngeal/laryngeal sites required G-tube compared to 8-to-19% of SGM arising from all other sites (p<0.01). At a median follow-up of 2.4 years, 9 (3%) of all SGM patients were G-tube dependent, but 14% (3/22) of patients with laryngeal/pharyngeal sites treated with multimodality therapy remained chronically G-tube dependent. Conclusion While almost 30% of SGM survivors require a temporary nasogastric tube, G-tube utilization is uncommon, in roughly 10% of SGM overall. G-tube utilization appears exclusive to patients treated with multimodality therapy, and chronic gastrostomy remains high (14%) in patients with minor gland cancers arising in the pharynx/larynx suggesting impetus for dysphagia prophylaxis in these higher risk subsets similar to patients treated for squamous cancers. PMID:27576681

  19. Feeding Tube Utilization in Patients with Salivary Gland Malignancies.

    PubMed

    Chen, Diane Wenhua; Lewin, Jan S; Xu, Li; Lai, Stephen Y; Gunn, G Brandon; Fuller, Clifton David; Mohamed, Abdallah S R; Kanwar, Aasheesh; Sturgis, Erich M; Hutcheson, Katherine A

    2017-01-01

    Objectives To evaluate feeding tube utilization in patients with salivary gland malignancies (SGMs). Study Design Case series with planned data collection. Setting The University of Texas MD Anderson Cancer Center, Houston, Texas, USA. Subjects and Methods Patients (N = 287) were sampled from an epidemiologic SGM registry during a 12-year period. Feeding tube history was retrospectively reviewed. Patients with outside locoregional therapy or palliative treatment were excluded. Enteral feeding and length of dependence were analyzed as a function treatment modality and site of SGM. Results Of 287 patients, 79 (28%) required temporary nasogastric tube feeding (median duration: 13 days, interquartile range: 6-21). Among those 79, 30 (10% of total cohort) required conversion to percutaneous gastrostomy tube (G-tube). Median G-tube duration was 4.8 months (interquartile range: 3.7-13.1). G-tube placement was necessary only in patients receiving multimodality therapy ( P < .001), and among those, 50% with SGMs arising from pharyngeal/laryngeal sites required G-tube, as compared with 8% to 19% of SGMs arising from all other sites ( P < .01). At a median follow-up of 2.4 years, 9 (3%) of all SGM patients were G-tube dependent, but 14% (3 of 22) with laryngeal/pharyngeal sites treated with multimodality therapy remained chronically G-tube dependent. Conclusion While almost 30% of SGM survivors require a temporary nasogastric tube, G-tube utilization is uncommon, in roughly 10% of SGM overall. G-tube utilization appears exclusive to patients treated with multimodality therapy, and chronic gastrostomy remains high (14%) in patients with minor gland cancers arising in the pharynx/larynx, suggesting impetus for dysphagia prophylaxis in these higher-risk subsets, similar to patients treated for squamous cancers.

  20. The utility of hand transplantation in hand amputee patients.

    PubMed

    Alolabi, Noor; Chuback, Jennifer; Grad, Sharon; Thoma, Achilles

    2015-01-01

    To measure the desirable health outcome, termed utility, and the expected quality-adjusted life years (QALYs) gained with hand composite tissue allotransplantation (CTA) using hand amputee patients and the general public. Using the standard gamble (SG) and time trade-off (TTO) techniques, utilities were obtained from 30 general public participants and 12 amputee patients. The health utility and net QALYs gained or lost with transplantation were computed. A sensitivity analysis was conducted to account for the effects of lifelong immunosuppression on the life expectancy of transplant recipients. Higher scores represent greater utility. Hand amputation mean health utility as measured by the SG and TTO methods, respectively, was 0.72 and 0.80 for the general public and 0.69 and 0.70 for hand amputees. In comparison, hand CTA mean health utility was 0.74 and 0.82 for the general public and 0.83 and 0.86 for amputees. Hand CTA imparted an expected gain of 0.9 QALYs (SG and TTO) in the general public and 7.0 (TTO) and 7.8 (SG) QALYs in hand amputees. A loss of at least 1.7 QALYs was demonstrated when decreasing the life expectancy in the sensitivity analysis in the hand amputee group. Hand amputee patients did not show a preference toward hand CTA with its inherent risks. With this procedure being increasingly adopted worldwide, the benefits must be carefully weighed against the risks of lifelong immunosuppressive therapy. This study does not show clear benefit to advocate hand CTA. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

  1. Safety of darunavir/ritonavir (DRV/r) in HIV-1-infected DRV/r-experienced and -naïve patients: analysis of data in the real-world setting in Italy.

    PubMed

    Antinori, Andrea; Borderi, Marco; Cauda, Roberto; Bini, Teresa; Chirianni, Antonio; Squillace, Nicola; Mancusi, Daniela; Termini, Roberta

    2014-01-01

    This descriptive, non-interventional study on HIV-1-infected patients treated with DRV/r in the usual clinical setting, with a single-arm prospective observational design, collected data on utilization of darunavir/ritonavir (DRV/r) under the conditions described in marketing authorization in usual clinical practice in Italy to evaluate efficacy and safety of DRV/r-based antiretroviral (ARV) treatment. This analysis focussed on the safety profile of DRV/r in HIV-1 infected patients. Data were analyzed from four cohorts of HIV-1-infected patients treated with DRV/r in the real-world setting, including an ARV-naïve-DRV/r-naïve cohort (Cohort 1), an ARV-experienced-DRV/r-naïve cohort (Cohort 2) and two ARV-DRV/r-experienced cohorts (Cohorts 3 and 4), one of which (Cohort 3) was from the DRV/r Early Access Program. The objective of this analysis was to examine the safety data obtained in these four cohorts in patients enrolled from June 2009 to November 2011 and observed until December 2012 or DRV/r discontinuation. Safety data from 875 patients were analyzed. DRV/r-based treatment was well tolerated, with 36.2% of patients reporting ≥1 adverse event (AE) and very few discontinuations due to study drug-related AEs (3.0% overall). The most frequent AEs were diarrhoea (2.7%), reduced bone density (2.6%) and hypercholesterolaemia (2.1%) (Table 1). Regarding metabolic parameters, levels of liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) remained stable from baseline to the last study visit (LSV) in DRV-experienced patients and decreased in DRV-naïve patients. Blood glucose concentrations remained stable in all cohorts. Serum triglyceride and cholesterol concentrations remained stable in DRV-experienced patients but increased in naïve patients, yet were still within normal range. In HIV-1-infected patients treated with DRV/r in these settings, the tolerability profile was favourable and similar to (or better than) that reported in

  2. A focus group study of enteric disease case investigation: successful techniques utilized and barriers experienced from the perspective of expert disease investigators.

    PubMed

    Ing, Stanley; Lee, Christina; Middleton, Dean; Savage, Rachel D; Moore, Stephen; Sider, Doug

    2014-12-18

    In Ontario, Canada, enteric case investigators perform a number of functions when conducting telephone interviews including providing health education, collecting data for regulatory purposes ultimately to prevent further illness, enforcement, illness source attribution and outbreak detection. Information collected must be of high quality as it may be used to inform decisions about public health actions that could have significant consequences such as excluding a person from work, recalling a food item that is deemed to be a health hazard, and/or litigations. The purpose of this study was to describe, from the perspectives of expert investigators, barriers experienced and the techniques used to overcome these barriers during investigation of enteric disease cases. Twenty eight expert enteric investigators participated in one of four focus groups via teleconference. Expert investigators were identified based on their ability to 1) consistently obtain high quality data from cases 2) achieve a high rate of completion of case investigation questionnaires, 3) identify the most likely source of the disease-causing agent, and 4) identify any possible links between cases. Qualitative data analysis was used to identify themes pertaining to successful techniques used and barriers experienced in interviewing enteric cases. Numerous barriers and strategies were identified under the following categories: case investigation preparation and case communication, establishing rapport, source identification, education to prevent disease transmission, exclusion, and linking cases. Unique challenges experienced by interviewers were how to collect accurate exposure data and educate cases in the face of misconceptions about enteric illness, as well as how to address tensions created by their enforcement role. Various strategies were used by interviewers to build rapport and to enhance the quality of data collected. To our knowledge, this is the first study to examine the perspectives of

  3. Resource utilization, costs and treatment patterns of switching and discontinuing treatment of MS patients with high relapse activity

    PubMed Central

    2013-01-01

    Background Multiple sclerosis (MS) is a chronic disease that affects mainly adults in the prime of their lives. However, few studies report the impact of high annual relapse rates on outcomes. The purpose of this study was to identify high relapse activity (HRA) in patients with MS, comparing differences in outcomes between patients with and without HRA. Methods A retrospective longitudinal study was conducted using the MarketScan® Commercial Claims and Encounters and Medicare Supplemental Database. Patients had to have at least one ICD-9 for MS (340.XX) in 2009 and one in 2008, be older than 18 years, and have continuous enrolment in the years 2009–2010. HRA was defined as having ≥2 relapses in 2009. Multivariate analyses compared all-cause and MS-specific emergency room (ER) visits, hospitalizations, and all-cause costs, excluding disease modifying therapy (DMT) costs, in 2010 between patients with and without HRA, controlling for baseline characteristics. A subgroup analysis using treatment exposure was also performed. Results 19,219 patients were included: 5.3% (n=1,017) had ≥2 relapses in 2009. Patients with HRA were more likely to have all-cause and MS-specific resource utilization than patients without HRA. Mean total all-cause non DMT costs were $12,057 higher for the HRA group. In the subgroup analysis, HRA treatment-naïve patients were more likely to start treatment, and HRA treatment-experienced patients were more likely to discontinue or switch index DMT (P<0.01). Conclusions Patients with ≥2 relapses annually have higher resource utilization and costs. The difference in cost was over twice as large in treatment-naïve patients versus treatment-experienced patients. HRA was also associated with an increased likelihood of starting DMT treatment (treatment-naïve patients), and switching or discontinuing DMT therapy (treatment-experienced patients). PMID:23565628

  4. Health Service Utilization and Poor Health Reporting in Asthma Patients.

    PubMed

    Behr, Joshua G; Diaz, Rafael; Akpinar-Elci, Muge

    2016-06-30

    The management and treatment of adult asthma has been associated with utilization of health services. First, to investigate the likelihood of health service utilization, including primary care, emergency department, and hospital stays, among persons diagnosed with an asthma condition relative to those that do not have an asthma condition. Second, to examine the likelihood of poor physical health among asthma respondents relative to those that do not have an asthma condition. Third, to demonstrate that these relationships vary with frequency of utilization. Fourth, to discuss the magnitude of differences in frequent utilization between asthma and non-asthma respondents. Data is derived from a random, stratified sampling of Hampton Roads adults, 18 years and older (n = 1678). Study participants are interviewed to identify asthma diagnosis, access to primary care, frequency of emergency department utilization, hospital admissions, and days of poor physical health. Odds-ratios establish relationships with the covariates on the outcome variable. Those with asthma are found more likely (OR 1.50, 95% CI 1.05-2.15) to report poor physical health relative to non-asthma study participants. Further, asthma respondents are found more likely (OR 4.23, 95% CI 1.56-11.69) to frequently utilize primary care that may be associated with the management of the condition and are also more likely to utilize treatment services, such as the emergency department (OR 1.87, 95% CI 1.32-2.65) and hospitalization (OR 2.21, 95% CI 1.39-3.50), associated with acute and episodic care. Further, it is a novel finding that these likelihoods increase with frequency of utilization for emergency department visits and hospital stays. Continuity in care and better management of the diseases may result in less demand for emergency department services and hospitalization. Health care systems need to recognize that asthma patients are increasingly more likely to be characterized as frequent utilizers of

  5. Antiretroviral drug resistance among antiretroviral-naïve and treatment experienced patients infected with HIV in Iran.

    PubMed

    Baesi, Kazem; Ravanshad, Mehrdad; Ghanbarisafari, Maryam; Saberfar, Esmaeil; Seyedalinaghi, Seyedahmad; Volk, Jonathan E

    2014-07-01

    Resistance to antiretroviral therapy (ART) threatens the success of programs to reduce HIV morbidity and mortality, particularly in countries with few treatment options. In the present study, genotype and phenotype data from ART-naïve and experienced hospitalized patients infected with HIV in Tehran, Iran were used to assess the prevalence and types of transmitted (TDR) and acquired drug resistance (ADR) mutations. All 30 participants naïve to ART and 62 of 70 (88.6%) participants receiving ART had detectable viral loads. Among participants receiving ART with sequencing data available (n = 62), 36 (58.1%) had at least one drug resistance mutation; the most common mutations were K103N (21.0%), M184V (19.4%), and the thymidine analogue mutations. Seven (11.3%), 27 (43.5%), and two (3.2%) of these participants had resistance to one, two, and three drug classes, respectively. High-level resistance to efavirenz (EFV) was more common among participants on EFV-based regimens than high-level lopinavir/ritonivar (LPV/r) resistance among those on LPV/r-based regimens (55.3% vs. 6.7%, P < 0.0001). Two (6.7%) antiretroviral-naïve participants had K103N mutations. These findings document an alarmingly high frequency of multiple HIV drug class resistance in Iran, confirm the presence of TDR, and highlight the need for systematic viral load monitoring and drug resistance testing, including at diagnosis. Expanded access to new antiretroviral medications from additional drug classes is needed.

  6. Development of a Clinical Competency Checklist for Care of Patients Experiencing Substance Withdrawal Delirium or Delirium: Use of a Delphi Technique and Expert Panel.

    PubMed

    Saylor, Jennifer L; Schell, Kathleen A; Mendell, Mark F; Graber, Jennifer S

    2015-06-01

    Health care providers are challenged by the presentation and management of inpatients experiencing substance withdrawal delirium (SWD) and delirium. The current Delphi study used an expert panel to develop a clinical competency checklist for nurse and physician educator use in teaching health care providers about the initial care of patients with SWD or delirium. The checklist includes categories of patient safety, history and information gathering, physical examination and assessment, treatment plan, and patient/family-centered care. Copyright 2015, SLACK Incorporated.

  7. Impact of ranolazine on clinical outcomes and healthcare resource utilization in patients with refractory angina pectoris.

    PubMed

    Ling, Hua; Packard, Kathleen A; Burns, Tammy L; Hilleman, Daniel E

    2013-12-01

    Ranolazine is a novel antianginal medication approved for the treatment of chronic angina. There are only limited data concerning the efficacy of ranolazine in reducing healthcare resource utilization in patients with refractory angina pectoris. The primary objective of this analysis was to evaluate the efficacy and safety of ranolazine in refractory angina pectoris. In addition, the impact of ranolazine on healthcare resource utilization was assessed. Consecutive patients with refractory angina pectoris treated with ranolazine at two cardiology practices in the state of Nebraska were included in this analysis. The Canadian Cardiovascular Society (CCS) angina class and frequency and type of healthcare resource consumption were determined during the 12 months prior to and the 12 months after initiation of ranolazine. A total of 150 pts (64 % men) with a mean age of 66 ± 12 years were included in this analysis. All patients had previously undergone coronary revascularization. Nitrates, β-adrenoceptor antagonists (β-blockers), and calcium antagonists (calcium channel blockers) were being used in 83, 97, and 75 % of patients, respectively. During ranolazine treatment, a significant improvement in CCS angina class was observed, with 23 patients improving by one class and no patient experiencing a deterioration in functional class (p = 0.025). A total of 53 side effects occurred in 28 (19 %) patients receiving ranolazine. Of those patients with side effects, four required dose reduction and seven required drug discontinuation. The frequency of clinic visits and emergency room visits was lower during ranolazine treatment, but the differences in frequency were not significant. The number of patients hospitalized and the number of hospitalizations were significantly lower during ranolazine therapy than in the pre-ranolazine study period (p = 0.002). Ranolazine improved the CCS angina class and reduced hospitalizations over a 12-month follow-up period in a group

  8. Utilization Patterns of Coagulation Factor Consumption for Patients with Hemophilia.

    PubMed

    Lee, Soo Ok; Yu, Su-Yeon

    2016-01-01

    Hemophilia is a serious rare disease that requires continuous management and treatment for which the medicine is costly at the annual average of 100 million KRW for an individual. The aim of this study was to investigate trends in the utilization of coagulation factor (CF) used for hemophilia treatment using the National Health Insurance database from 2010 to 2013 in Korea and compare the utilization of CF with other countries. The consumption of CF per capita (IU) in Korea was not more than other countries with similar income to Korea. However, CF usage per patient IU was higher because the prevalence rate of hemophilia in Korea was lower than in other countries while the number of serious patients was much more. Therefore, it is difficult to say that the consumption of hemophilia medicine in Korea is higher than that in other countries. The consumption and cost of hemophilia medicine in Korea is likely to increase due to the increased utilization of expensive bypassing agents and the widespread use of prophylaxis for severe hemophilia. Even during the research period, it increased slightly and other countries show a similar trend. Thus, hemophilia patient management should accompany active monitoring on the health and cost outcomes of pharmaceutical treatment in the future. This study is expected to contribute to further insight into drug policies for other countries that face similar challenges with high price pharmaceuticals.

  9. Identifying Patients at Risk of High Healthcare Utilization

    PubMed Central

    Sheets, Lincoln; Popejoy, Lori; APRN, GCNS-BC; Khalilia, Mohammed; Petroski, Greg; Parker, Jerry C.

    2016-01-01

    Objective. To develop a systematic and reproducible way to identify patients at increased risk for higher healthcare costs. Methods. Medical records were analyzed for 9,581 adults who were primary care patients in the University of Missouri Health System and who were enrolled in Medicare or Medicaid. Patients were categorized into one of four risk tiers as of October 1, 2013, and the four tiers were compared on demographic characteristics, number of healthcare episodes, and healthcare charges in the year before and the year after cohort formation. Results. The mean number of healthcare episodes and the sum of healthcare charges in the year following cohort formation were higher for patients in the higher-risk tiers. Conclusions. Retrospective information that is easily extracted from medical records can be used to create risk tiers that provide highly useful information about the prospective risk of healthcare utilization and costs. PMID:28269910

  10. Utilization of pressure-volume curves in the pediatric patient.

    PubMed

    Bone, R C; Jantzen, D; Heithold, R

    1978-04-01

    Seven patients treated with continuous mechanical ventialtion were monitored with static and dynamic pressure-volume curves. Three patients developed no pulmonary complications, and mechanical ventilation was discontinued within 96 hr. In four patients, pressure-volume curves were used as a diagnostic aid in the detection of the physiologic defect resulting from bronchoconstriction, atelectasis, loculated pleural fluid, pulmonary edema, and mucous plugging. These measurements were also utilized to evaluate the effectivess of therapeutic modalities such as treatment of bronchoconstriction with bronchodilators, mucous plugging with adequate suctioning, and drainage of loculated pleural effusion. Pressure-v-lume measurements are simple, noninvasive, and require the smae equipment used in continuous mechanical ventilation. Pressure-volume monitoring of pediatric patients with curves warrants further investigation to evaluate its value.

  11. Therapeutic approaches in the treatment of juvenile dermatomyositis in patients with recent-onset disease and in those experiencing disease flare: an international multicenter PRINTO study.

    PubMed

    Hasija, Rachana; Pistorio, Angela; Ravelli, Angelo; Demirkaya, Erkan; Khubchandani, Raju; Guseinova, Dinara; Malattia, Clara; Canhao, Helena; Harel, Liora; Foell, Dirk; Wouters, Carine; De Cunto, Carmen; Huemer, Christian; Kimura, Yukiko; Mangge, Harald; Minetti, Carlo; Nordal, Ellen Berit; Philippet, Pierre; Garozzo, Rosaria; Martini, Alberto; Ruperto, Nicolino

    2011-10-01

    To evaluate response to therapy over a 24-month period in a large prospective international cohort of patients with juvenile dermatomyositis (DM). The study included 145 patients with recent-onset juvenile DM and 130 juvenile DM patients experiencing disease flare, all of whom were <18 years old. Disease activity parameters and therapeutic approaches in 4 geographic areas were analyzed at baseline and at 6, 12, and 24 months. Response was assessed according to the Pediatric Rheumatology International Trials Organization (PRINTO) juvenile DM response criteria, and data were reported "as observed" and in the intent-to-treat (ITT) population. Patients with recent-onset juvenile DM at baseline had higher baseline disease activity and greater improvement over 24 months when compared to juvenile DM patients experiencing disease flare at baseline. Methotrexate (MTX) or high-dose corticosteroids were administered more frequently to patients with recent-onset juvenile DM, compared to juvenile DM patients experiencing disease flare, who were more likely to receive cyclosporine. Compared to patients from Western and Eastern Europe, a higher proportion of patients from South and Central America and North America received pulse steroids, and the average steroid dosage was higher in the North American and South and Central American patients. The use of MTX was similar in all 4 regions, while cyclosporin A was more frequently used in Western Europe. In the "as observed" analysis, 57.9% of the patients with recent-onset juvenile DM and 36.4% of the patients experiencing disease flare (P<0.001) reached at least a 70% response by PRINTO criteria at 6 months; these proportions had increased at month 24 to 78.4% and 51.2%, respectively (P<0.001). Corresponding results of the ITT analysis were much lower, with only one-third of the patients able to maintain the initial assigned therapy over 24 months. Patients with recent-onset juvenile DM are more likely to achieve significant

  12. Utilization of Emergent Neuroimaging for Thrombolysis-Eligible Stroke Patients.

    PubMed

    Sanossian, Nerses; Fu, Katherine A; Liebeskind, David S; Starkman, Sidney; Hamilton, Scott; Villablanca, J Pablo; Burgos, Adrian M; Conwit, Robin; Saver, Jeffrey L

    2017-01-01

    Advances in diagnostic imaging of stroke include multimodal techniques such as noninvasive angiography and perfusion imaging. We aimed to characterize trends in neuroimaging utilization among acute stroke patients. Utilization of multimodal imaging for acute stroke in the community has remained largely uncharacterized despite its increased adoption at academic medical centers. We quantified neuroimaging utilization in the emergency department (ED) for 1,700 hyperacute stroke patients presenting <2 hours after symptom onset who participated in the National Institutes of Health Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study throughout Los Angeles and Orange Counties. FAST-MAG provided no recommendation as to imaging utilization. A total of 1,700 cases were imaged a median (interquartile range [IQR]) of 92 (74-120) minutes after last known well time and 28 (19-41) minutes after ED arrival. The initial scanner used in the ED was computed tomography (CT) in a preponderance of cases (N = 1,612, 95%), with magnetic resonance imaging (MRI) in 88 cases (5%). CT angiography (CTA) was obtained in 192 (11%) and perfusion CT (CTP) in 91 (5.4%) cases. MRI imaging was universally obtained using diffusion-weighted images, 60% with MR angiography and 33% included perfusion imaging. Rates of concomitant CTA or CTP use increased in the later years of the study from 4% in 2005-2006, 2% in 2007-2008, 8% in 2009-2010, and 26% in 2011-2012 (P for trend < .001). Among acute stroke patients, noncontrast CT was the most common initial imaging strategy in clinical practice in the 2005-2012 time period, though use of concomitant CTA grew to one-quarter of cases, suggestive of an upward trend. Copyright © 2016 by the American Society of Neuroimaging.

  13. How Do Patients and Health Workers Interact around Malaria Rapid Diagnostic Testing, and How Are the Tests Experienced by Patients in Practice? A Qualitative Study in Western Uganda

    PubMed Central

    Altaras, Robin; Nuwa, Anthony; Agaba, Bosco; Streat, Elizabeth; Tibenderana, James K.; Martin, Sandrine; Strachan, Clare E.

    2016-01-01

    Background Successful scale-up in the use of malaria rapid diagnostic tests (RDTs) requires that patients accept testing and treatment based on RDT results and that healthcare providers treat according to test results. Patient-provider communication is a key component of quality care, and leads to improved patient satisfaction, higher adherence to treatment and better health outcomes. Voiced or perceived patient expectations are also known to influence treatment decision-making among healthcare providers. While there has been a growth in literature on provider practices around rapid testing for malaria, there has been little analysis of inter-personal communication around the testing process. We investigated how healthcare providers and patients interact and engage throughout the diagnostic and treatment process, and how the testing service is experienced by patients in practice. Methods This research was conducted alongside a larger study which explored determinants of provider treatment decision-making following negative RDT results in a rural district (Kibaale) in mid-western Uganda, ten months after RDT introduction. Fifty-five patients presenting with fever were observed during routine outpatient visits at 12 low-level public health facilities. Observation captured communication practices relating to test purpose, results, diagnosis and treatment. All observed patients or caregivers were immediately followed up with in-depth interview. Analysis followed the ‘framework’ approach. A summative approach was also used to analyse observation data. Results Providers failed to consistently communicate the reasons for carrying out the test, and particularly to RDT-negative patients, a diagnostic outcome or the meaning of test results, also leading to confusion over what the test can detect. Patients appeared to value testing, but were frustrated by the lack of communication on outcomes. RDT-negative patients were dissatisfied by the absence of information on an

  14. Modeling clinical progression and healthcare utilization of HIV-positive patients in British Columbia prior to death

    PubMed Central

    Cui, Zishan; Grafstein, Eric; Yip, Benita; Hogg, Robert; Montaner, Julio S.G.; Lima, Viviane Dias

    2014-01-01

    Objectives The extent in which clinical progression of HIV-positive patients leads to an increase in healthcare utilization, especially prior to their death, is unknown. Thus, we modeled trends in CD4 cell count and emergency department utilization and the likelihood of an emergency department visit leading to a transfer to acute care level facility prior to a patient’s death from non-accidental causes. Methods Eligible patients initiated HAART in British Columbia between August 1996 and June 2006 (N=457). Patients were followed until their death, which occurred on or before June 30, 2007 (period in which the emergency department visit data were available). Trends were modeled using generalized mixed effects. Results Patients experienced a significantly steep decline in CD4 cell count and a corresponding increase in the number of emergency department visits and transfers to acute level facilities in the five years prior to death. For every 6-month interval prior to death, the CD4 cell count decreased 13.22 cells/mm3, the risk of experiencing an emergency department visit increased by 9%, and among those ever admitted, the odds ratio of being transferred to an acute care level facility increased by 3%. Conclusions We showed that patients experienced a steep decline in CD4 cell count, which was associated with an increase in healthcare utilization prior to their death. These findings highlight the substantial residual avoidable burden that unsuccessfully managed HIV disease poses, even in the HAART era. Further strategies to enhance sustained and successful engagement in care are urgently needed to mitigate high healthcare utilization. PMID:24641495

  15. Health utility indexes in patients with acute coronary syndromes

    PubMed Central

    Gencer, Baris; Rodondi, Nicolas; Auer, Reto; Nanchen, David; Räber, Lorenz; Klingenberg, Roland; Pletscher, Mark; Jüni, Peter; Windecker, Stephan; Matter, Christian M; Lüscher, Thomas F; Mach, François; Perneger, Thomas V; Girardin, François R

    2016-01-01

    Background Acute coronary syndromes (ACS) have been associated with lower health utilities (HUs) compared with the general population. Given the prognostic improvements after ACS with the implementation of coronary angiography (eg, percutaneous coronary intervention (PCI)), contemporary HU values derived from patient-reported outcomes are needed. Methods We analysed data of 1882 patients with ACS 1 year after coronary angiography in a Swiss prospective cohort. We used the EuroQol five-dimensional questionnaire (EQ-5D) and visual analogue scale (VAS) to derive HU indexes. We estimated the effects of clinical factors on HU using a linear regression model and compared the observed HU with the average values of individuals of the same sex and age in the general population. Results Mean EQ-5D HU 1-year after coronary angiography for ACS was 0.82 (±0.16) and mean VAS was 0.77 (±0.18); 40.9% of participants exhibited the highest utility values. Compared with population controls, the mean EQ-5D HU was similar (expected mean 0.82, p=0.58) in patients with ACS, but the mean VAS was slightly lower (expected mean 0.79, p<0.001). Patients with ACS who are younger than 60 years had lower HU than the general population (<0.001). In patients with ACS, significant differences were found according to the gender, education and employment status, diabetes, obesity, heart failure, recurrent ischaemic or incident bleeding event and participation in cardiac rehabilitation (p<0.01). Conclusions At 1 year, patients with ACS with coronary angiography had HU indexes similar to a control population. Subgroup analyses based on patients' characteristics and further disease-specific instruments could provide better sensitivity for detecting smaller variations in health-related quality of life. PMID:27252878

  16. Efficacy of Once Daily Darunavir/Ritonavir in PI-Naïve, NNRTI-Experienced Patients in the ODIN Trial.

    PubMed

    Geretti, Anna Maria; Moeketsi, Mathe; Demasi, Ralph; van Delft, Yvon; Mohammed, Perry

    2015-01-01

    Background. An exploratory subanalysis of the ODIN trial was performed to evaluate the efficacy of darunavir/ritonavir (DRV/r) 800/100 mg OD versus 600/100 mg BID in patients who were NNRTI-experienced but PI-naïve. Methods. ODIN was a phase III, 48-week study comparing DRV/r OD versus BID in 590 treatment-experienced patients with no DRV resistance-associated mutations (RAMs) at screening. Patients received DRV/r 800/100 mg OD or DRV/r 600/100 mg BID plus ≥2 NRTIs. Of the 590 patients randomized, 272 (46%) were NNRTI-experienced but PI-naïve. Results. Overall, 272 patients received DRV/r OD (n = 135) or BID (n = 137) plus ≥2 optimised NRTIs. The mean age was 39 years; 35% were female; 27% were Black, 24% Caucasian, 26% Oriental/Asian, and 23% other races; 17% were recruited in South Africa; and 48% had non-B HIV-1 subtypes. Mean baseline plasma HIV-1 RNA load was 4.10 log10⁡ copies/mL; median CD4 cell count was 258 cells/μL. At week 48, 111/135 (82%) of DRV/r OD and 109/137 (80%) of DRV/r BID patients achieved an HIV-1 RNA load <50 copies/mL. No patient developed primary PI RAMs. Conclusion. DRV/r 800/100 mg OD in combination with ≥2 optimised NRTIs led to virological suppression <50 copies/mL in 82% of NNRTI-experienced, PI-naïve patients by week 48.

  17. Cross-resistance to elvitegravir and dolutegravir in 502 patients failing on raltegravir: a French national study of raltegravir-experienced HIV-1-infected patients.

    PubMed

    Fourati, Slim; Charpentier, Charlotte; Amiel, Corinne; Morand-Joubert, Laurence; Reigadas, Sandrine; Trabaud, Mary-Anne; Delaugerre, Constance; Nicot, Florence; Rodallec, Audrey; Maillard, Anne; Mirand, Audrey; Jeulin, Hélène; Montès, Brigitte; Barin, Francis; Bettinger, Dominique; Le Guillou-Guillemette, Hélène; Vallet, Sophie; Signori-Schmuck, Anne; Descamps, Diane; Calvez, Vincent; Flandre, Philippe; Marcelin, Anne-Genevieve

    2015-05-01

    The objectives of this study were to determine the prevalence and patterns of resistance to integrase strand transfer inhibitors (INSTIs) in patients experiencing virological failure on raltegravir-based ART and the impact on susceptibility to INSTIs (raltegravir, elvitegravir and dolutegravir). Data were collected from 502 treatment-experienced patients failing a raltegravir-containing regimen in a multicentre study. Reverse transcriptase, protease and integrase were sequenced at failure for each patient. INSTI resistance-associated mutations investigated were those included in the last ANRS genotypic algorithm (v23). Among the 502 patients, at failure, median baseline HIV-1 RNA (viral load) was 2.9 log10 copies/mL. Patients had been previously exposed to a median of five NRTIs, one NNRTI and three PIs. Seventy-one percent harboured HIV-1 subtype B and the most frequent non-B subtype was CRF02_AG (13.3%). The most frequent mutations observed were N155H/S (19.1%), Q148G/H/K/R (15.4%) and Y143C/G/H/R/S (6.7%). At failure, viruses were considered as fully susceptible to all INSTIs in 61.0% of cases, whilst 38.6% were considered as resistant to raltegravir, 34.9% to elvitegravir and 13.9% to dolutegravir. In the case of resistance to raltegravir, viruses were considered as susceptible to elvitegravir in 11% and to dolutegravir in 64% of cases. High HIV-1 viral load at failure (P < 0.001) and low genotypic sensitivity score of the associated treatment with raltegravir (P < 0.001) were associated with the presence of raltegravir-associated mutations at failure. Q148 mutations were selected more frequently in B subtypes versus non-B subtypes (P = 0.004). This study shows that a high proportion of viruses remain susceptible to dolutegravir in the case of failure on a raltegravir-containing regimen. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions

  18. The Utility of Exercise Testing in Patients with Lung Cancer.

    PubMed

    Ha, Duc; Mazzone, Peter J; Ries, Andrew L; Malhotra, Atul; Fuster, Mark

    2016-09-01

    The harm associated with lung cancer treatment include perioperative morbidity and mortality and therapy-induced toxicities in various organs, including the heart and lungs. Optimal treatment therefore entails a need for risk assessment to weigh the probabilities of benefits versus harm. Exercise testing offers an opportunity to evaluate a patient's physical fitness/exercise capacity objectively. In lung cancer, it is most often used to risk-stratify patients undergoing evaluation for lung cancer resection. In recent years, its use outside this context has been described, including in nonsurgical candidates and lung cancer survivors. In this article we review the physiology of exercise testing and lung cancer. Then, we assess the utility of exercise testing in patients with lung cancer in four contexts (preoperative evaluation for lung cancer resection, after lung cancer resection, lung cancer prognosis, and assessment of efficiency of exercise training programs) after systematically identifying original studies involving the most common forms of exercise tests in this patient population: laboratory cardiopulmonary exercise testing and simple field testing with the 6-minute walk test, shuttle walk test, and/or stair-climbing test. Lastly, we propose a conceptual framework for risk assessment of patients with lung cancer who are being considered for therapy and identify areas for further studies in this patient population.

  19. Utilization of telemedicine by heart disease patients following hospitalization.

    PubMed

    Morguet, Andreas J; Kühnelt, Paul; Kallel, Antje; Rauch, Ursula; Schultheiss, Heinz-Peter

    2008-01-01

    NYHA class III and IV chronic heart failure has been established as a potential indication for telemedical care and monitoring already. We conducted a prospective study to assess the utilization of telemedical services by cardiac patients in order to identify further indications. A total of 540 patients (mean age 59 years) with various heart diseases participated for at least 30 days in a home-based telemedicine service programme. The two primary outcome measures were the rates of symptom-driven telephone calls (A) and ECG transmissions (B) per patient-year. The total follow-up was 68,649 days, with a median of 93 days. Symptomatic patients placed 713 calls and transmitted 221 ECGs. Poisson regression analysis with subset selection yielded four significant (P < 0.05) independent positive predictors of the use of the telemedicine service: (1) recent repeat (at least one previous) percutaneous coronary intervention (A, P = 0.010; B, P = 0.001); (2) recent cardioversion for atrial fibrillation or flutter (A, P < 0.0001; B, P < 0.0001); (3) ejection fraction (A, P = 0.012; B, P > 0.05); and (4) reciprocal of age (A, P < 0.0001; B, P > 0.05). These data suggest that telemedicine may benefit patients following repeat percutaneous coronary intervention or cardioversion for atrial fibrillation. Since patients availed themselves of telemedicine service less with deteriorating ejection fraction and increasing age, individuals with chronic heart failure will need dedicated programmes, especially when they are older.

  20. A Genotypic Test for HIV-1 Tropism Combining Sanger Sequencing with Ultradeep Sequencing Predicts Virologic Response in Treatment-Experienced Patients

    PubMed Central

    Kagan, Ron M.; Johnson, Erik P.; Siaw, Martin; Biswas, Pinaki; Chapman, Douglass S.; Su, Zhaohui; Platt, Jamie L.; Pesano, Rick L.

    2012-01-01

    A tropism test is required prior to initiation of CCR5 antagonist therapy in HIV-1 infected individuals, as these agents are not effective in patients harboring CXCR4 (X4) coreceptor-using viral variants. We developed a clinical laboratory-based genotypic tropism test for detection of CCR5-using (R5) or X4 variants that utilizes triplicate population sequencing (TPS) followed by ultradeep sequencing (UDS) for samples classified as R5. Tropism was inferred using the bioinformatic algorithms geno2pheno[coreceptor] and PSSMx4r5. Virologic response as a function of tropism readout was retrospectively assessed using blinded samples from treatment-experienced subjects who received maraviroc (N = 327) in the MOTIVATE and A4001029 clinical trials. MOTIVATE patients were classified as R5 and A4001029 patients were classified as non-R5 by the original Trofile test. Virologic response was compared between the R5 and non-R5 groups determined by TPS, UDS alone, the reflex strategy and the Trofile Enhanced Sensitivity (TF-ES) test. UDS had greater sensitivity than TPS to detect minority non-R5 variants. The median log10 viral load change at week 8 was −2.4 for R5 subjects, regardless of the method used for classification; for subjects with non-R5 virus, median changes were −1.2 for TF-ES or the Reflex Test and −1.0 for UDS. The differences between R5 and non-R5 groups were highly significant in all 3 cases (p<0.0001). At week 8, the positive predictive value was 66% for TF-ES and 65% for both the Reflex test and UDS. Negative predictive values were 59% for TF-ES, 58% for the Reflex Test and 61% for UDS. In conclusion, genotypic tropism testing using UDS alone or a reflex strategy separated maraviroc responders and non-responders as well as a sensitive phenotypic test, and both assays showed improved performance compared to TPS alone. Genotypic tropism tests may provide an alternative to phenotypic testing with similar discriminating ability. PMID:23029482

  1. CT scan utilization patterns in pediatric patients with recurrent headache.

    PubMed

    DeVries, Andrea; Young, Paul C; Wall, Eric; Getchius, Thomas ScD; Li, Chia-hsuan; Whitney, John; Rosenberg, Alan

    2013-07-01

    Although unnecessary for children with headache and normal history, computed tomography (CT) scans are widely used. This study sought to determine current practice patterns of neuroimaging to diagnose pediatric headache in a variety of treatment settings and to identify factors associated with increased use of neuroimaging. This retrospective claims analysis included children (aged 3–17 years) with ≥2 medical claims for headache. The primary outcome was CT scan utilization on or after first presentation with headache in a physician’s office or emergency department (ED). Of 15 836 patients, 26% (4034 patients; mean age: 11.8 years) had ≥1 CT scan, 74% within 1 month of index diagnosis. Patients with ED visits were 4 times more likely to undergo a CT scan versus those without ED visits (P < .001 [95% confidence interval: 3.9–4.8]). However, even outside the ED, use of CT scans remained widespread. Two-thirds of patients with CT scans had no ED use.Among patients with no ED utilization, >20% received a CT scan during the study period. Evaluation by a neurologist was strongly associated with a lower likelihood of CT scan compared with other provider specialties (odds ratio: 0.37; P < .01 [95% confidence interval: 0.30–0.46]). Use of CT scans to diagnose pediatric headache remains high despite existing guidelines, low diagnostic yield, and high potential risk. Implementing quality improvement initiatives to ensure that CT scans in children are performed only when truly indicated will reduce unnecessary exposure to ionizing radiation and associated cancer risks.

  2. [Mental health service utilization among borderline personality disorder patients inpatient].

    PubMed

    Cailhol, L; Thalamas, C; Garrido, C; Birmes, P; Lapeyre-Mestre, M

    2015-04-01

    Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability and impulsivity. Several North American prospective studies support the high level of mental health care utilization in this population. There is little data in other systems of health organization, such as France. Furthermore, little is known on the variables associated with the mental health service utilization among BPD patients. The main objective was to compare the utilization of mental health care among BPD patients, to the general population and patients with another personality disorder (PD) and to describe the demographic and clinical factors associated with the group of patients who use the most health care. A multi-center (5 public and private centers), epidemiological study. Data were collected prospectively (database of an insurance fund covering 80% of the population) and viewed, retrospectively. We used the data collected during the five years previously to the inclusion. Inclusion criteria were age (18-60 years) and membership in the health insurance fund targeted. Patients on legal protection, forced hospitalization, with a chronic psychotic disorder, manic, mental retardation, or not reading French were excluded. First, four groups were composed: BPD, other PD, control groups for PD and other PD. The first two groups were recruited from a screening of inpatients including a self-administered questionnaire (Personality Disorder Questionnaire 4+). Assessment by a psychologist including the Structured Interview for DSM-IV Personality Disorders (SIDP-IV) was given straight to those who had a score above 28. This questionnaire allowed us to distinguish one group of subjects with BPD and a group with other PD (without BPD). Clinical evaluation included Axis I (MINI), Axis II (SIDP-IV), psychopathological features (YSQ-I, DSQ-40), demographic variables and therapeutic alliance (Haq-II). Matched controls (age, sex) composed the 3rd and 4th group (BPD control and

  3. Treatment utilization by gender in patients with borderline personality disorder.

    PubMed

    Goodman, Marianne; Patil, Uday; Steffel, Lauren; Avedon, Jennifer; Sasso, Scott; Triebwasser, Joseph; Stanley, Barbara

    2010-05-01

    Minimal data exist on treatment utilization by gender in borderline personality disorder (BPD). This study used an online questionnaire to investigate initial and lifetime patterns of utilization of multiple treatment modalities by patients with BPD, and parental satisfaction with treatment. Respondents were parents of probands diagnosed with BPD who completed a 100-question anonymous Internet survey. Of the 495 surveys that were analyzed, 409 pertained to female subjects with BPD and 86 to male subjects with BPD. Results for probands with BPD across gender were notable for similar high lifetime levels of use of care, including hospitalization, day programs, and halfway houses, but not similar levels of use of drug/alcohol rehabilitation services, which was greater among the male subjects with BPD. The male subjects with BPD received significantly less lifetime psychotherapy and pharmacotherapy than the female subjects with BPD, although the duration of medication and psychotherapy treatment did not differ by gender. These results highlight the need for more research to better understand what might account for these gender differences in treatment and improve strategies to provide appropriate care for male patients with BPD.

  4. Utility of Ward-Based Retinal Photography in Stroke Patients.

    PubMed

    Frost, Shaun; Brown, Michael; Stirling, Verity; Vignarajan, Janardhan; Prentice, David; Kanagasingam, Yogesan

    2017-03-01

    Improvements in acute care of stroke patients have decreased mortality, but survivors are still at increased risk of future vascular events and mitigation of this risk requires thorough assessment of the underlying factors leading to the stroke. The brain and eye share a common embryological origin and numerous similarities exist between the small vessels of the retina and brain. Recent population-based studies have demonstrated a close link between retinal vascular changes and stroke, suggesting that retinal photography could have utility in assessing underlying stroke risk factors and prognosis after stroke. Modern imaging equipment can facilitate precise measurement and monitoring of vascular features. However, use of this equipment is a challenge in the stroke ward setting as patients are frequently unable to maintain the required seated position, and pupil dilatation is often not feasible as it could potentially obscure important neurological signs of stroke progression. This small study investigated the utility of a novel handheld, nonmydriatic retinal camera in the stroke ward and explored associations between retinal vascular features and stroke risk factors. This camera circumvented the practical limitations of conducting retinal photography in the stroke ward setting. A positive correlation was found between carotid disease and both mean width of arterioles (r = .40, P = .00571) and venules (r = .30, P = .0381). The results provide further evidence that retinal vascular features are clinically informative about underlying stroke risk factors and demonstrate the utility of handheld retinal photography in the stroke ward. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

  5. Assessing the utility of testing aluminum levels in dialysis patients.

    PubMed

    Sharma, Ashish K; Toussaint, Nigel D; Pickering, Janice; Beeston, Tony; Smith, Edward R; Holt, Stephen G

    2015-04-01

    Plasma aluminum (Al) is routinely tested in many dialysis patients. Aluminum exposure may lead to acute toxicity and levels in excess of ∼2.2 μmol/L (60 μg/L) should be avoided. Historically, toxicity has been caused by excessive dialyzate Al but modern reverse osmosis (RO) water should be Al free. Nevertheless, many units continue to perform routine Al levels on dialysis patients. This single-center study retrospectively analyzed Al levels in plasma, raw water feed, and RO product between 2010 and 2013 using our database (Nephworks 6) with the aim of determining the utility of these measurements. Two thousand fifty-eight plasma Al tests in 755 patients (61.9% male, mean age 64.7 years) were reviewed showing mean ± SD of 0.41 ± 0.30 μmol/L. One hundred eleven (5.4%) tests from 61 patients had Al levels >0.74 μmol/L and 45 (73.8%) of these patients were or had been prescribed Al hydroxide (Al(OH)(3)) as a phosphate binder. Seven patients had Al concentrations >2.2 μmol/L with no source of Al identified in 1 patient. One hundred sixty-six patients taking Al(OH)(3) (78.7% of all patients on Al(OH)(3)) had levels ≤0.74 μmol/L, the odds ratio of plasma Al > 0.74 μmol/L on Al(OH)3 was 9. The cost of plasma Al assay is $A30.60; thus, costs were $A62,974.80 over the study period. Despite RO feed water Al levels as high as 48 μmol/L, Al output from the RO was almost always undetectable (<0.1 μmol/L) with dialyzate Al levels > 2.2 μmol/L only 3 times since 2010, and never in the last 3 years. Routine unselected testing of plasma Al appears unnecessary and expensive and more selective testing in dialysis patients should be considered. © 2014 International Society for Hemodialysis.

  6. Diagnostics Cost Groups and Concurrent Utilization among Patients

    PubMed Central

    Rosen, Amy K; Loveland, Susan A; Anderson, Jennifer J; Hankin, Cheryl S; Breckenridge, James N; Berlowitz, Dan R

    2002-01-01

    Objective To assess the performance of Diagnostic Cost Groups (DCGs) in explaining variation in concurrent utilization for a defined subgroup, patients with substance abuse (SA) disorders, within the Department of Veterans Affairs (VA). Data Sources A 60 percent random sample of veterans who used health care services during Fiscal Year (FY) 1997 was obtained from VA administrative databases. Patients with SA disorders (13.3 percent) were identified from primary and secondary ICD-9-CM diagnosis codes. Study Design Concurrent risk adjustment models were fitted and tested using the DCG/HCC model. Three outcome measures were defined: (1) “service days” (the sum of a patient's inpatient and outpatient visit days), (2) mental health/substance abuse (MH/SA) service days, and (3) ambulatory provider encounters. To improve model performance, we ran three DCG/HCC models with additional indicators for patients with SA disorders. Data Collection To create a single file of veterans who used health care services in FY 1997, we merged records from all VA inpatient and outpatient files. Principal Findings Adding indicators for patients with mild/moderate SA disorders did not appreciably improve the R-squares for any of the outcome measures. When indicators were added for patients with severe SA who were in the most costly category, the explanatory ability of the models was modestly improved for all three outcomes. Conclusions Modifying the DCG/HCC model with additional markers for SA modestly improved homogeneity and model prediction. Because considerable variation still remained after modeling, we conclude that health care systems should evaluate “off-the-shelf” risk adjustment systems before applying them to their own populations. PMID:12236385

  7. Utilizing Information Technologies for Lifelong Monitoring in Diabetes Patients

    PubMed Central

    Capozzi, Davide; Lanzola, Giordano

    2011-01-01

    Background Information and communication technologies have long been acknowledged to support information sharing along the whole chain of care, from the clinic to the homes of patients and their relatives. Thus they are increasingly being considered for improving the delivery of health care services also in light of clinical and technological achievements that propose new treatments requiring a tighter interaction among patients and physicians. Methods The multiagent paradigm has been utilized within an architecture for delivering telemedicine services to chronic outpatients at their domiciles and enforcing cooperation among patients, caregivers, and different members of the health care staff. The architecture sees each communication device such as a palmtop, smart phone, or personal digital assistant as a separate agent upon which different services are deployed, including telemetry, reminders, notifications, and alarms. Decoupling services from agents account for a highly configurable environment applicable to almost any context that can be customized as needed. Results The architecture has been used for designing and implementing a prototypical software infrastructure, called LifePhone, that runs on several communication devices. A basic set of services has been devised with which we were able to configure two different applications that address long-term and short-term monitoring scenarios for diabetes patients. The long-term scenario encompasses telemetry and reminder services for patients undergoing peritoneal dialysis, which is a treatment for chronic renal failure, a diabetes complication. The short-term scenario incorporates telemetry and remote alarms and is applicable for training patients to use an artificial pancreas. Conclusions Our experiments proved that an infrastructure such as LifePhone can be used successfully for bridging the interaction gap that exists among all the components of a health care delivery process, improving the quality of service

  8. [Development and Evaluation of a Self-Reflection Program for Intensive Care Unit Nurses Who Have Experienced the Death of Pediatric Patients].

    PubMed

    Kang, Hyun Ju; Bang, Kyung Sook

    2017-06-01

    This study aims to develop a self-reflection program for nurses who have experienced the death of pediatric patients in the intensive care unit and to evaluate its effectiveness. The self-reflection program was developed by means of the following four steps: establishment of the goal through investigation of an initial request, drawing up the program, preliminary research, and implementation and improvement of the program. The study employed a methodological triangulation to evaluate the effectiveness of the program. Participants were 38 nurses who had experienced the death of pediatric patients (experimental group=15, control group=23); they were recruited using convenience sampling. The self-reflection program was provided over 6 weeks (6 sessions). Data were collected from April to August, 2014 and analyzed using t-tests and content analysis. The quantitative results showed that changes in personal growth (t=-6.33, p<.001) and burnout scores (z=-2.76, p=.005) were better in the experimental group compared to the control group. The qualitative results exhibited two themes, namely "personal growth" and "professional growth", and ten sub-themes. The self-reflection program developed by this study was effective in helping nurses who had experienced the death of pediatric patients to achieve personal growth through self-reflection, and it was confirmed that the program can be applied in a realistic clinical nursing setting. Furthermore, it can be recommended as an intervention program for clinical nurses.

  9. Empower Me? Yes, Please, But in My Way: Different Patterns of Experiencing Empowerment in Patients with Chronic Conditions.

    PubMed

    Suárez Vázquez, Ana; Del Río Lanza, Ana Belén; Suárez Álvarez, Leticia; Vázquez Casielles, Rodolfo

    2016-07-19

    Empowerment is a widely used word within the realm of health care. This is especially true in the case of patients living with a chronic illness, who may be active participants and learn to manage their disease, irrespective of their desires or preferences. This article focuses on the empowering experience of patients with chronic conditions. We have built on earlier research that explains the factors that mediate communication between health care professionals and patients: patient participation, patient impact, meaning, health care professionals' information provision, health care professionals' emotional support, health care professionals' attentive listening, health care professionals' trust, and patient collaboration. We propose a new model for detecting types of patients who differ in the way they live their empowering experience. Using survey data from a sample of 181 patients of hemophilia, we found two types of patients: patients with an inner locus of empowerment and patients with an outer locus of empowerment. We conclude by discussing different strategies for fostering the sense of power in each of these types of patients.

  10. [A case of endotracheal intubation in prone position utilizing PENTAX-Airwayscope for morbidly obese patient].

    PubMed

    Suzuki, Hiroto; Nakajima, Waka; Aoyagi, Mitsuo; Takahashi, Minori; Kuzuta, Toshimichi; Osaki, Mami

    2012-04-01

    We experienced the airway management of a morbidly obese patient in prone position utilizing PENTAX-Airwayscope (AWS) which is a novel airway device for endotracheal intubation. A 29-year-old man, who was 150 kg in weight and 51.9 kg x m(-2) in body mass index, was scheduled for the discectomy for lumbar disc herniation. After the topical anesthesia with lidocaine spray, the patient lay on his stomach by himself on the table. Following the induction of general anesthesia with ketamine and dexmedetomidine in prone position, an anatomically curved blade (INTLOCK) was inserted to his oral cavity first, then the body of AWS was attached. With the patient breathing spontaneously, we successfully inserted the reinforced endotracheal tube. After the maintenance of anesthesia with continuous infusion of dexmedetomidine, ketamin and remifentanil, the patient awoke clearly without pain and endotracheal tube was removed safely in the prone position. Although the prone position is not the standard position for endotracheal intubation under general anesthesia, our technique could be performed in emergency situations.

  11. DECREASES IN VENTRICULAR VOLUME CORRELATE WITH DECREASES IN VENTRICULAR PRESSURE IN IDIOPATHIC NORMAL PRESSURE HYDROCEPHALUS PATIENTS WHO EXPERIENCED CLINICAL IMPROVEMENT AFTER IMPLANTATION WITH ADJUSTABLE VALVE SHUNTS

    PubMed Central

    McConnell, Kathleen A.; Zou, Kelly H.; Chabrerie, Alexandra V.; Bailey, Nancy Olsen; Black, Peter McL.

    2005-01-01

    OBJECTIVE: This retrospective study examined whether changes in ventricular volume correspond with changes in adjustable valve pressure settings in a cohort of patients who received shunts to treat idiopathic normal pressure hydrocephalus. We also examined whether these pressure—volume curves and other patient variables would co-occur with a positive clinical response to shunting. METHODS: We selected 51 patients diagnosed with idiopathic normal pressure hydrocephalus who had undergone implantation of a Codman Hakim programmable valve (Medos S.A., Le Locle, Switzerland). Clinical data were gathered from the patients’ records and clinical notes by an investigator blinded to patients’ ventricular volumes. Ventricular volume was measured using 3D Slicer, an image analysis and interactive visualization software package developed and maintained at the Surgical Planning Laboratory at Brigham and Women’s Hospital. RESULTS: Eighty-six percent of patients with gait disturbance at presentation showed improvement of this symptom, 70% experienced improvement in incontinence, and 69% experienced improvement in dementia. For the group showing 100% clinical improvement, the correlation coefficient of average changes in valve pressure over time (ΔP/ΔT) and average changes in ventricular volume over time (ΔV/ΔT) were high at 0.843 (P < 0.05). For the group experiencing no or only partial improvement, the correlation coefficient was 0.257 (P = 0.32), indicating no correlation between average ΔV/ΔT and average ΔP/ΔT for each patient. CONCLUSION: This was a carefully analyzed modeling study of idiopathic normal pressure hydrocephalus treatment made possible only by adjustable valve technology. With careful volumetric analysis, we found that changes in ventricular volume correlated with adjustments in valve pressure settings for those patients who improved clinically after shunting. This suggests that positive clinical responders retained parenchymal elasticity

  12. Direct Release of Test Results to Patients Increases Patient Engagement and Utilization of Care.

    PubMed

    Pillemer, Francesca; Price, Rebecca Anhang; Paone, Suzanne; Martich, G Daniel; Albert, Steve; Haidari, Leila; Updike, Glenn; Rudin, Robert; Liu, Darren; Mehrotra, Ateev

    2016-01-01

    An important focus for meaningful use criteria is to engage patients in their care by allowing them online access to their health information, including test results. There has been little evaluation of such initiatives. Using a mixed methods analysis of electronic health record data, surveys, and qualitative interviews, we examined the impact of allowing patients to view their test results via patient portal in one large health system. Quantitative data were collected for new users and all users of the patient portal. Qualitative interviews occurred with patients who had received an HbA1c or abnormal Pap result. Survey participants were active patient portal users. Our main measures were patient portal usage, factors associated with viewing test results and utilizing care, and patient and provider experiences with patient portal and direct release. Usage data show 80% of all patient portal users viewed test results during the year. Of survey respondents, 82.7% noted test results to be a very useful feature and 70% agreed that patient portal has made their provider more accessible to them. Interviewed patients reported feeling they should have direct access to test results and identified the ability to monitor results over time and prepare prior to communicating with a provider as benefits. In interviews, both patients and physicians reported instances of test results leading to unnecessary patient anxiety. Both groups noted the benefits of results released with provider interpretation. Quantitative data showed patient utilization to increase with viewing test results online, but this effect is mitigated when results are manually released by physicians. Our findings demonstrate that patient portal access to test results was highly valued by patients and appeared to increase patient engagement. However, it may lead to patient anxiety and increase rates of patient visits. We discuss how such unintended consequences can be addressed and larger implications for

  13. Direct Release of Test Results to Patients Increases Patient Engagement and Utilization of Care

    PubMed Central

    Pillemer, Francesca; Price, Rebecca Anhang; Paone, Suzanne; Martich, G. Daniel; Albert, Steve; Haidari, Leila; Updike, Glenn; Rudin, Robert; Liu, Darren; Mehrotra, Ateev

    2016-01-01

    An important focus for meaningful use criteria is to engage patients in their care by allowing them online access to their health information, including test results. There has been little evaluation of such initiatives. Using a mixed methods analysis of electronic health record data, surveys, and qualitative interviews, we examined the impact of allowing patients to view their test results via patient portal in one large health system. Quantitative data were collected for new users and all users of the patient portal. Qualitative interviews occurred with patients who had received an HbA1c or abnormal Pap result. Survey participants were active patient portal users. Our main measures were patient portal usage, factors associated with viewing test results and utilizing care, and patient and provider experiences with patient portal and direct release. Usage data show 80% of all patient portal users viewed test results during the year. Of survey respondents, 82.7% noted test results to be a very useful feature and 70% agreed that patient portal has made their provider more accessible to them. Interviewed patients reported feeling they should have direct access to test results and identified the ability to monitor results over time and prepare prior to communicating with a provider as benefits. In interviews, both patients and physicians reported instances of test results leading to unnecessary patient anxiety. Both groups noted the benefits of results released with provider interpretation. Quantitative data showed patient utilization to increase with viewing test results online, but this effect is mitigated when results are manually released by physicians. Our findings demonstrate that patient portal access to test results was highly valued by patients and appeared to increase patient engagement. However, it may lead to patient anxiety and increase rates of patient visits. We discuss how such unintended consequences can be addressed and larger implications for

  14. Barriers and facilitators to effective communication experienced by patients with malignant lymphoma at all stages after diagnosis.

    PubMed

    van Bruinessen, Inge Renske; van Weel-Baumgarten, Evelyn M; Gouw, Hans; Zijlstra, Josée M; Albada, Akke; van Dulmen, Sandra

    2013-12-01

    This study aims to gain insight into patient-perceived communication barriers and facilitators at different stages after the diagnosis of malignant lymphoma. We have detected patterns to explain when these factors influence communication predominantly. A qualitative approach was applied, derived from the context mapping framework. A total of 28 patients completed a set of assignments about their experiences with provider-patient communication during medical consultations. Subsequently, these patients and nine companions shared their experiences during a semistructured (group) interview, which was recorded on audiotape. The audiotapes and assignments were analysed with MAXQDA software. From the patients' viewpoint, communicating effectively appears to depend on their own attributes (e.g. emotions), the health care professionals' attributes (e.g. attitude) and external factors (e.g. time pressure). Three patient communication states were identified: (i) overwhelmed, passive; (ii) pro-active, self-motivated; and (iii) proficient, empowered. Patients seem to behave differently in the three communication states. This study lists patient-perceived communication barriers and facilitators and identifies three different communication states, which indicate when certain barriers and facilitators are encountered. These findings may support health care professionals to tailor the provision of support and information and remove communication barriers accordingly. Additionally, they provide input for interventions to support patients in effective communication. Copyright © 2013 John Wiley & Sons, Ltd.

  15. Health Resource Utilization and Cost for Patients with Incontinent Overactive Bladder Treated with Anticholinergics.

    PubMed

    Yehoshua, Alon; Chancellor, Michael; Vasavada, Sandip; Malone, Daniel C; Armstrong, Edward P; Joshi, Manher; Campbell, Karen; Pulicharam, Riya

    2016-04-01

    Overactive bladder (OAB) is a common medical condition with significant economic and humanistic burden. Inadequately managed OAB may exacerbate or result in comorbidities such as depression, falls, and urinary tract infections, which can further increase the burden to the health care system. Anticholinergics are often prescribed for management of OAB with urinary incontinence ("wet" OAB). However, research has shown that patient adherence and persistence to anticholinergic therapy is poor, with approximately 80% of patients ultimately failing their first prescribed anticholinergic medication within the first year. While there has been a fair amount of research on the economic burden of OAB, the real-world impact of initiating anticholinergic therapy in patients with wet OAB has not been well studied. To compare falls/fractures, anxiety/depression, health care resource utilization, and health care costs between a cohort of patients with wet OAB who initiated anticholinergic therapy and a matched cohort of patients without OAB. This study was a retrospective medical and pharmacy claims analysis. Cases were members of a primary care-based, multispecialty physician medical group located in California. Cases were eligible for inclusion if they were prescribed anticholinergic therapy between January 2008 and May 2012 based on pharmacy claims, had a diagnosis of OAB, and reported having ≥ 1 urinary incontinence episode per day. Wet OAB cases were matched to non-OAB controls in a 1:3 ratio based on sex, age, and observation time. Medical and pharmacy claims data were used to analyze patient comorbidities, as well as track health care resource utilization (HRU) and direct payer costs. After initiating anticholinergic therapy, wet OAB patients had a 46% higher adjusted risk of experiencing falls/fractures (P < 0.001) and a 33% higher adjusted risk of experiencing depression/anxiety (P = 0.022) than non-OAB patients. Wet OAB was significantly associated with increased HRU

  16. Comparison of stress experienced by family members of patients treated in hospital at home with that of those receiving traditional acute hospital care.

    PubMed

    Leff, Bruce; Burton, Lynda; Mader, Scott L; Naughton, Bruce; Burl, Jeffrey; Koehn, Debbie; Clark, Rebecca; Greenough, William B; Guido, Susan; Steinwachs, Donald; Burton, John R

    2008-01-01

    To compare differences in the stress experienced by family members of patients cared for in a physician-led substitutive Hospital at Home (HaH) and those receiving traditional acute hospital care. Survey questionnaire completed as a component of a prospective, nonrandomized clinical trial of a substitutive HaH care model. Three Medicare managed care health systems and a Veterans Affairs Medical Center. Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. Treatment in a substitutive HaH model. Fifteen-question survey questionnaire asking family members whether they experienced a potentially stressful situation and, if so, whether stress was associated with the situation while the patient received care. The mean and median number of experiences, of a possible 15, that caused stress for family members of HaH patients was significantly lower than for family members of acute care hospital patients (mean +/- standard deviation 1.7 +/- 1.8 vs 4.3 +/- 3.1, P<.001; median 1 vs 4, P<.001). HaH care was associated with lower odds of developing mean levels of family member stress (adjusted odds ratio=0.12, 95% confidence interval=0.05-0.30). HaH is associated with lower levels of family member stress than traditional acute hospital care and does not appear to shift the burden of care from hospital staff to family members.

  17. Prevalence and Evolution of Low Frequency HIV Drug Resistance Mutations Detected by Ultra Deep Sequencing in Patients Experiencing First Line Antiretroviral Therapy Failure

    PubMed Central

    Recordon-Pinson, Patricia; Reigadas, Sandrine; Bidet, Yannick; Bruyand, Mathias; Bonnet, Fabrice; Lazaro, Estibaliz; Neau, Didier; Fleury, Hervé; Dabis, François; Morlat, Philippe; Masquelier, Bernard

    2014-01-01

    Objectives Clinical relevance of low-frequency HIV-1 variants carrying drug resistance associated mutations (DRMs) is still unclear. We aimed to study the prevalence of low-frequency DRMs, detected by Ultra-Deep Sequencing (UDS) before antiretroviral therapy (ART) and at virological failure (VF), in HIV-1 infected patients experiencing VF on first-line ART. Methods Twenty-nine ART-naive patients followed up in the ANRS-CO3 Aquitaine Cohort, having initiated ART between 2000 and 2009 and experiencing VF (2 plasma viral loads (VL) >500 copies/ml or one VL >1000 copies/ml) were included. Reverse transcriptase and protease DRMs were identified using Sanger sequencing (SS) and UDS at baseline (before ART initiation) and VF. Results Additional low-frequency variants with PI-, NNRTI- and NRTI-DRMs were found by UDS at baseline and VF, significantly increasing the number of detected DRMs by 1.35 fold (p<0.0001) compared to SS. These low-frequency DRMs modified ARV susceptibility predictions to the prescribed treatment for 1 patient at baseline, in whom low-frequency DRM was found at high frequency at VF, and 6 patients at VF. DRMs found at VF were rarely detected as low-frequency DRMs prior to treatment. The rare low-frequency NNRTI- and NRTI-DRMs detected at baseline that correlated with the prescribed treatment were most often found at high-frequency at VF. Conclusion Low frequency DRMs detected before ART initiation and at VF in patients experiencing VF on first-line ART can increase the overall burden of resistance to PI, NRTI and NNRTI. PMID:24475178

  18. Follow-up intervals in patients with Cushing's disease: recommendations from a panel of experienced pituitary clinicians.

    PubMed

    Geer, Eliza B; Ayala, Alejandro; Bonert, Vivien; Carmichael, John D; Gordon, Murray B; Katznelson, Laurence; Manuylova, Ekaterina; Shafiq, Ismat; Surampudi, Vijaya; Swerdloff, Ronald S; Broder, Michael S; Cherepanov, Dasha; Eagan, Marianne; Lee, Jackie; Said, Qayyim; Neary, Maureen P; Biller, Beverly M K

    2017-08-01

    Follow-up guidelines are needed to assess quality of care and to ensure best long-term outcomes for patients with Cushing's disease (CD). The purpose of this study was to assess agreement by experts on recommended follow-up intervals for CD patients at different phases in their treatment course. The RAND/UCLA modified Delphi process was used to assess expert consensus. Eleven clinicians who regularly manage CD patients rated 79 hypothetical patient scenarios before and after ("second round") an in-person panel discussion to clarify definitions. Scenarios described CD patients at various time points after treatment. For each scenario, panelists recommended follow-up intervals in weeks. Panel consensus was assigned as follows: "agreement" if no more than two responses were outside a 2 week window around the median response; "disagreement" if more than two responses were outside a 2 week window around the median response. Recommendations were developed based on second round results. Panel agreement was 65.9% before and 88.6% after the in-person discussion. The panel recommended follow-up within 8 weeks for patients in remission on glucocorticoid replacement and within 1 year of surgery; within 4 weeks for patients with uncontrolled persistent or recurrent disease; within 8-24 weeks in post-radiotherapy patients controlled on medical therapy; and within 24 weeks in asymptomatic patients with stable plasma ACTH concentrations after bilateral adrenalectomy. With a high level of consensus using the Delphi process, panelists recommended regular follow-up in most patient scenarios for this chronic condition. These recommendations may be useful for assessment of CD care both in research and clinical practice.

  19. Enhancing the utility of prostascint SPECT scans for patient management.

    PubMed

    Noz, Marilyn E; Chung, Grace; Lee, Benjamin Y; Maguire, Gerald Q; DeWyngaert, J Keith; Doshi, Jay V; Kramer, Elissa L; Murphy-Walcott, Antoinette D; Zeleznik, Michael P; Kwak, Noeun G

    2006-04-01

    This project investigated reducing the artifact content of In-ill ProstaScint SPECT scans for use in treatment planning and management. Forty-one patients who had undergone CT or MRI scans and simultaneous Tc-99m RBC/In-111 ProstaScint SPECT scans were included. SPECT volume sets, reconstructed using Ordered Set-Expectation Maximum (OS-EM) were compared against those reconstructed with standard Filtered Back projection (FBP). Bladder activity in Tc-99m scans was suppressed within an ellipsoidal volume. Tc-99m voxel values were subtracted from the corresponding In-111 after scaling based on peak activity within the descending aorta. The SPECT volume data sets were merged with the CT or MRI scans before and after processing. Volume merging, based both on visual assessment and statistical evaluation, was not affected. Thus iterative reconstruction together with bladder suppression and blood pool subtraction may improve the interpretation and utility of ProstaScint SPECT scans for patient management.

  20. Fludarabine add-on therapy in interferon-beta-treated patients with multiple sclerosis experiencing breakthrough disease

    PubMed Central

    Greenberg, Steven J.; Zivadinov, Robert; Lee-Kwen, Peterkin; Sharma, Jitendra; Planter, Margaret; Umhauer, Margaret; Glenister, Norman; Bakshi, Rohit

    2016-01-01

    Background: Patients with relapsing–remitting multiple sclerosis (RRMS) may experience breakthrough disease despite effective interferon beta (IFNβ) therapy. Fludarabine (FLU) is a chemotherapeutic agent used in lymphoproliferative disorders that may be synergistic when combined with immunomodulatory therapy to control active multiple sclerosis (MS). Objective: The objective of this study was to explore the safety and tolerability of FLU versus monthly methylprednisolone (MP) in IFNβ-treated RRMS patients with breakthrough disease. Clinical and MRI effects of IFNβ-1a plus FLU were evaluated. Methods: Eighteen patients with breakthrough disease [⩾2 relapses over the prior year and ⩾1.0-point increase in Expanded Disability Status Scale (EDSS) score sustained for ⩾3 months] after >1 year of IFNβ therapy were enrolled in this prospective, open-label, randomized, proof-of-concept, pilot study. Patients received intravenous (IV) MP 1 g daily for 3 days and then were randomized to receive 3 monthly IV infusions of FLU 25 mg/m2 daily for 5 consecutive days (n = 10) or MP 1 g (n = 8). All patients maintained their intramuscular IFNβ-1a treatment throughout the study. Analyses explored safety signals and directional trends; this preliminary study was not powered to detect clinically meaningful differences. Results: Both combination treatments were safe and well tolerated, with all adverse events mild. Patients treated with IFNβ-1a plus FLU had similar relapse rates, EDSS scores, and MS Functional Composite scores, but significantly less acute corticosteroid use for on-study relapses and better responses on some MRI outcomes, versus patients treated with IFNβ-1a plus MP. Conclusions: Further study of FLU for breakthrough disease in patients with RRMS is warranted. PMID:27006698

  1. Simeprevir plus sofosbuvir for eight or 12 weeks in treatment-naïve and treatment-experienced hepatitis C virus genotype 4 patients with or without cirrhosis.

    PubMed

    El Raziky, M; Gamil, M; Ashour, M K; Sameea, E A; Doss, W; Hamada, Y; Van Dooren, G; DeMasi, R; Keim, S; Lonjon-Domanec, I; Hammad, R; Hashim, M S; Hassany, M; Waked, I

    2017-02-01

    The OSIRIS study investigated efficacy and safety of simeprevir plus sofosbuvir for eight or 12 weeks in hepatitis C virus (HCV) genotype 4-infected patients with METAVIR F0-F4 fibrosis. Sixty-three patients (33 treatment-naïve and 30 peg-interferon/ribavirin (Peg-IFN/RBV)-experienced) enrolled in a partly randomized, open-label, multicentre, phase IIa study. Patients with F0-F3 fibrosis were randomized (1:1) into two groups (A1 and A2), stratified according to treatment experience and METAVIR score, to receive either eight weeks (Group A1, n=20) or 12 weeks (Group A2, n=20) of treatment. Patients with compensated cirrhosis (METAVIR F4) received 12 weeks of treatment (Group B, n=23). Treatment comprised simeprevir 150 mg and sofosbuvir 400 mg daily. The primary efficacy endpoint was sustained virologic response 12 weeks after planned end of treatment (SVR12). Safety and tolerability were assessed throughout. Overall, 92% (95% CI: 82-97) of patients achieved SVR12; 75% (15/20) in Group A1 and 100% in groups A2 and B. Patients who did not achieve SVR12 (n=5) experienced viral relapse during the first 32 days following treatment and were all prior Peg-IFN/RBV null responders. The most commonly reported treatment-emergent adverse events (TEAEs) were asymptomatic lipase increase (14%), pruritus (14%), headache (13%) and hyperbilirubinaemia (11%). No patients discontinued due to TEAEs. In conclusion, simeprevir plus sofosbuvir for 12 weeks achieved a 100% SVR rate in HCV genotype 4-infected patients with or without compensated cirrhosis (ClinicalTrials.gov: NCT02278419). The AE and laboratory profile were favourable and consistent with previous data for simeprevir plus sofosbuvir in eight- and 12-week regimens.

  2. Cost-effectiveness of direct-acting antiviral regimen ombitasvir/paritaprevir/ritonavir in treatment-naïve and treatment-experienced patients infected with chronic hepatitis C virus genotype 1b in Japan.

    PubMed

    Virabhak, Suchin; Yasui, Kikuo; Yamazaki, Kiyotaka; Johnson, Scott; Mitchell, Dominic; Yuen, Cammy; Samp, Jennifer C; Igarashi, Ataru

    2016-12-01

    This study compared the cost-effectiveness of chronic hepatitis C virus (HCV) genotype 1b (GT1b) therapy ombitasvir/paritaprevir/ritonavir (OBV/PTV/r) vs daclatasvir + asunaprevir (DCV/ASV) and no treatment in patients without cirrhosis. Cost-effectiveness analyses (CEAs) that compared OBV/PTV/r against DCV/ASV and sofosbuvir/ledipasvir (SOF/LDV) in Y93H mutation-negative, GT1b patients with and without cirrhosis were also included. A health state transition model was developed to capture the natural history of HCV. A CEA over a lifetime horizon was performed from the perspective of the public healthcare payer in Japan. Costs, health utilities, and rates of disease progression were derived from published studies. Sustained virologic response (SVR) rates of OBV/PTV/r and DCV/ASV were extracted from Japanese clinical trials. Analyses were performed for treatment-naïve and -experienced patients. Alternative scenarios and input parameter uncertainty on the results were tested. OBV/PTV/r exhibited superior clinical outcomes vs comparators. For OBV/PTV/r, DCV/ASV, and no treatment, the lifetime risk of decompensated cirrhosis in treatment-naïve patients without cirrhosis was 0.4%, 1.4%, and 9.2%, and hepatocellular carcinoma was 6.5%, 11.4%, and 49.9%, respectively. Quality-adjusted life years (QALYs) were higher in treatment-naïve and -experienced patients without cirrhosis treated with OBV/PTV/r (16.41 and 16.22) vs DCV/ASV (15.83 and 15.66) or no treatment (11.34 and 11.23). In treatment-naïve and -experienced patients without cirrhosis, the incremental cost-effectiveness ratios (ICERs) of OBV/PTV/r vs DCV/ASV were JPY 1,684,751/QALY and JPY 1,836,596/QALY, respectively; OBV/PTV/r was dominant compared with no treatment. In scenario analysis, including GT1b patients with and without cirrhosis who were Y93H mutation-negative, the ICER of OBV/PTV/r vs DCV/ASV was below the Japanese willingness-to-pay threshold of JPY 5 million/QALY, while the ICER of SOF/LDV vs

  3. Patient-experienced effect of an active implementation of a disease management programme for COPD - a randomised trial.

    PubMed

    Smidth, Margrethe; Olesen, Frede; Fenger-Grøn, Morten; Vedsted, Peter

    2013-10-03

    People living with chronic disease currently account for the majority of the total healthcare costs. The Central Denmark Region implemented a disease management programme (DMP) for chronic obstructive pulmonary disease (COPD) in 2008. This presented an opportunity to examine the effect of an evidence-based, planned and proactive implementation of a DMP compared to the usual implementation strategy. We performed a block- and cluster-randomised controlled trial with two groups and an extra external control group. The primary outcome was patients' assessment of their care after using an active implementation model for a DMP for COPD measured with the Patient-Assessment-of-Chronic-Illness-Care (PACIC) instrument. At baseline, questionnaires were sent to 2,895 patients identified by an algorithm based on health registry data on lung-related contacts to the healthcare system. Patients were asked to confirm or refute their diagnosis of COPD. Of those who responded, 1,445 (72.8%) confirmed their diagnosis. PACIC data were collected at baseline and at a 12-month follow-up for 744 (51.1%) patients. Comparing the three groups after the implementation of the DMP, we found a statistically significantly higher change in the PACIC score in the intervention group than in the control groups. No statistically significant differences were found between the control and the external control groups in any of the dimensions. Reinforcing the role of general practice as coordinator for care-and self-management-support with an active implementation of a DMP for COPD made patients score higher on the PACIC instrument, which indicates a better experience of the received healthcare. NCT01228708.

  4. Patient experienced continuity of care in the psychiatric healthcare system-a study including immigrants, refugees and ethnic danes.

    PubMed

    Jensen, Natasja Koitzsch; Johansen, Katrine Schepelern; Kastrup, Marianne; Krasnik, Allan; Norredam, Marie

    2014-09-17

    The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups.

  5. Effect of airway clearance techniques in patients experiencing an acute exacerbation of chronic obstructive pulmonary disease: a systematic review.

    PubMed

    Hill, Kylie; Patman, Shane; Brooks, Dina

    2010-01-01

    Answers were sought to the following question: Are techniques, applied predominantly with the aim of clearing secretions from the airways, to patients during an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), safe and effective? A systematic review was undertaken of studies that (i) were either randomized controlled or randomized cross-over trials, (ii) recruited patients during an AECOPD, (iii) reported the results of between-group analyses and (iv) investigated the effect of techniques applied primarily with the aim of clearing secretions from the airways. Studies that examined non-invasive positive pressure ventilation (NIPPV) and early rehabilitation were excluded. Data were extracted pertaining to resting lung function, gas exchange, sputum expectoration, symptoms, NIPPV use and hospital stay. Five studies were included with a mean Physiotherapy Evidence Database (PEDro) score of 4.4 +/- 1.1 (range: 3-6). The main findings were that (i) airway clearance techniques did not improve measures of resting lung function or produce any consistent change in measures of gas exchange, (ii) the application of 5 min of continuous chest wall percussion reduced forced expiratory volume in 1 second (FEV( 1)), (iii) in people with copious secretions, mechanical vibration, and non-oscillating positive expiratory pressure (PEP) mask therapy increased sputum expectoration and (iv) in patients with hypercapnic respiratory failure, intrapulmonary percussive ventilation (IPV) and PEP mask therapy reduced the need for, and duration of, NIPPV, respectively. With the exception of continuous chest wall percussion, airway clearance techniques were safe in patients during an AECOPD. Vibration and non-oscillating PEP facilitated sputum expectoration in patients characterized by copious airway secretions. In patients with respiratory failure, techniques that apply a positive pressure to the airways may reduce either the need for, or duration of, NIPPV and hospital

  6. Patient Experienced Continuity of Care in the Psychiatric Healthcare System—A Study Including Immigrants, Refugees and Ethnic Danes

    PubMed Central

    Jensen, Natasja Koitzsch; Johansen, Katrine Schepelern; Kastrup, Marianne; Krasnik, Allan; Norredam, Marie

    2014-01-01

    Aim: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. Method: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. Results: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. Conclusions: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups. PMID:25233017

  7. Virological analysis of once-daily and twice-daily darunavir/ritonavir in the ODIN trial of treatment-experienced patients.

    PubMed

    Lathouwers, Erkki; De La Rosa, Guy; Van de Casteele, Tom; Baeten, Benny; Tomaka, Frank; De Meyer, Sandra; Picchio, Gaston

    2013-01-01

    The aim of this analysis was to characterize viral resistance in the Phase III, randomized ODIN trial, which demonstrated non-inferiority of once-daily darunavir/ritonavir (DRV/r) 800/100 mg to DRV/r 600/100 mg twice daily, each combined with an optimized background regimen in treatment-experienced patients with no DRV resistance-associated mutations (RAMs) at screening. Virological failure (VF) was defined as never achieving or losing confirmed virological suppression after week 12, with patients being classed as 'never suppressed' (never achieved HIV-1 RNA<50 copies/ml) or 'rebounders' (achieved two consecutive HIV-1 RNA<50 copies/ml but then ≥ 50 copies/ml). Phenotypes and genotypes of plasma HIV-1 viruses, using population-based sequencing and Antivirogram(®), were determined at screening/baseline and on samples from VFs with HIV-1 RNA ≥ 50 copies/ml. Mean baseline HIV-1 RNA was 4.16 log10 copies/ml and 53.9% of patients were protease inhibitor (PI)-experienced at enrolment. VF rate was similar in both arms. A similar proportion of virologically failing patients in both arms developed PI RAMs (11.7% versus 9.5%, respectively) or nucleoside reverse transcriptase inhibitor RAMs (6.7% versus 7.1%). One patient with VF (once-daily arm) developed four primary PI mutations, three of which were also DRV RAMs. This patient was also the only VF to lose susceptibility to DRV. Loss of susceptibility to other PIs (once daily 3.4%; twice daily 0%) and nucleoside reverse transcriptase inhibitors (once daily 13.6%; twice daily 9.8%) in VF patients was infrequent and comparable between treatment arms. These analyses showed once-daily DRV/r 800/100 mg was associated with similar rates of VF and emergence of resistance as DRV/r 600/100 mg twice daily in treatment-experienced patients with no DRV RAMs.

  8. A Thematic Literature Review: The Importance of Providing Spiritual Care for End-of-Life Patients Who Have Experienced Transcendence Phenomena.

    PubMed

    Broadhurst, Kathleen; Harrington, Ann

    2016-11-01

    The purpose of this review was to investigate within the literature the link between transcendent phenomena and peaceful death. The objectives were firstly to acknowledge the importance of such experiences and secondly to provide supportive spiritual care to dying patients. Information surrounding the aforementioned concepts is underreported in the literature. The following 4 key themes emerged: spiritual comfort; peaceful, calm death; spiritual transformation; and unfinished business The review established the importance of transcendence phenomena being accepted as spiritual experiences by health care professionals. Nevertheless, health care professionals were found to struggle with providing spiritual care to patients who have experienced them. Such phenomena are not uncommon and frequently result in peaceful death. Additionally, transcendence experiences of dying patients often provide comfort to the bereaved, assisting them in the grieving process. © The Author(s) 2015.

  9. Cost-effectiveness of telaprevir in combination with pegylated interferon alpha and ribavirin in treatment-experienced chronic hepatitis C genotype 1 patients.

    PubMed

    Cure, Sandrine; Bianic, Florence; Gavart, Sandra; Curtis, Steve; Lee, Seina; Dusheiko, Geoffrey

    2014-01-01

    Telaprevir (TVR,T) and boceprevir (BOC,B) are direct-acting antivirals (DAAs) used for the treatment of chronic genotype 1 hepatitis C virus (HCV) infection. This analysis evaluated the cost-effectiveness of TVR combined with pegylated interferon (Peg-IFN) alfa-2a plus ribavirin (RBV) compared with Peg-IFN alfa-2a and RBV (PR) alone or BOC plus Peg-IFN alfa-2b and RBV in treatment-experienced patients. A Markov cohort model of chronic genotype 1 HCV disease progression reflected the pathway of experienced patients retreated with DAA therapy. The population was stratified by previous response to treatment (i.e., previous relapsers, partial responders, and null responders). Sustained virologic response (SVR) rates were derived from a mixed-treatment comparison that included results from separate Phase III trials of TVR and BOC. Incremental cost per life year (LY) gained and quality-adjusted-life-year (QALY) gained were computed at lifetime, adopting the NHS perspective. Costs and health outcomes were discounted at 3.5%. Uncertainty was assessed using deterministic and probabilistic sensitivity analyses. Sub-group analyses were carried out by interleukin (IL)-28B genotype. Higher costs and improved outcomes were associated with T/PR relative to PR alone for all experienced patients (ICER of £6079). T/PR was cost-effective for each sub-group population with high SVR advantage in relapsers (ICER of £2658 vs £7593 and £20,875 for partial and null responders). T/PR remained cost-effective regardless of IL-28B sub-type. Compared to B/PR, T/PR prolonged QALYs by 0.57 and reduced lifetime costs by £13,960 for relapsers. For partial responders T/PR was less costly but less efficacious than B/PR, equating to an ICER of £128,117 per QALY gained. No head-to-head trial provides direct evidence of better efficacy of T/PR vs B/PR. T/PR is cost-effective compared with PR alone in experienced patients regardless of treatment history and IL-28B genotype. Compared to B/PR, T

  10. Use of dolutegravir in two INI-experienced patients with multiclass resistance resulted in excellent virological and immunological responses.

    PubMed

    Hofstra, Laura Marije; Nijhuis, Monique; Mudrikova, Tania; Fun, Axel; Schipper, Pauline; Schneider, Margriet; Wensing, Annemarie

    2014-01-01

    Dolutegravir is a second generation integrase inhibitor with a proposed high genetic barrier to resistance. However, in clinical trials, decreased virological response was seen in a subset of patients with prior exposure to raltegravir and multiple integrase resistance mutations. We describe two cases of HIV subtype B-infected patients starting dolutegravir after previous failure on a raltegravir-containing regimen with extensive resistance. Genotypic analysis was performed using population sequencing and 454 ultradeep sequencing of integrase at time of raltegravir exposure. Both patients were diagnosed in early 1990s and received mono- and dual therapy, followed by several cART-regimens. Due to presence of extensive resistance, the genotypic susceptibility score of these regimens never reached a score >2 and never resulted in sustained virological suppression despite good adherence. Early 2012, the clinical condition of patient 1 worsened during persistent failure of a mega-cART regimen despite excellent drug levels. Six major PI, six minor PI, seven NRTI, six NNRTI and two INI mutations plus DM-virus were detected (Table 1). Ultra-deep sequencing of integrase showed the selection of Q148R, E138K+Q148K, and N155H variants and phenotypic raltegravir resistance was demonstrated. After addition of dolutegravir and enfuvirtide to the failing regimen (zidovudine, lamivudine, tenofovir, etravirine, darunavir/ritonavir, maraviroc), viral load (VL) decreased from 244,000 to <20 cps/mL within five months, CD4-count increased (33 to 272 mm(3)) and the clinical condition improved substantially. In patient 2, similar worsening of the clinical condition was observed late 2012 during persistent failure on mega-cART. Five major PI, six minor PI, nine NRTI, seven NNRTI and one INI mutation plus DM-virus were detected. Ultra-deep sequencing showed selection of N155H, followed by Q95K and V151I variants and phenotypic raltegravir resistance was demonstrated. Dolutegravir was added

  11. Optimizing management of treatment-naïve and treatment-experienced HIV+ patients: the role of maraviroc

    PubMed Central

    Poveda, Eva; Soriano, Vincent

    2010-01-01

    Maraviroc is the first CCR5 antagonist approved for the treatment of HIV-1 infection. It specifically inhibits the replication of R5 viruses by blocking viral entry. HIV-1 tropism can be estimated accurately and predict viral response to maraviroc. Genotypic tools are increasingly replacing phenotypic assays in most places. The favorable pharmacokinetic properties and the good safety profile of maraviroc may support an earlier use of the drug in HIV-1 infection, as well as favor its consideration as part of switch strategies in patients under suppressive antiret-roviral regimens containing less-well-tolerated drugs. Moreover, a particular immune benefit of maraviroc might encourage its use as part of intensification strategies in HIV-infected patients with impaired CD4 gains despite prolonged suppression of HIV replication with antiretroviral therapy. However, the long-term consequences of using maraviroc must be carefully checked, given its particular mechanism of action, blocking a physiologic cell receptor. PMID:22096384

  12. Patella bone density is lower in knee osteoarthritis patients experiencing moderate-to-severe pain at rest.

    PubMed

    Burnett, W; Kontulainen, S; McLennan, C; Hazel, D; Talmo, C; Hunter, D; Wilson, D; Johnston, J

    2016-03-01

    To determine differences in patellar subchondral bone mineral density (BMD) between knee osteoarthritis (OA) patients with differing levels of pain at rest. The preoperative knee of 41 total knee replacement (TKR) patients was scanned using QCT and scored for pain using Western Ontario McMasters Osteoarthritis Index (WOMAC). 'Pain at rest' was defined as average pain while lying//sitting and nocturnal pain. Participants were divided into groups: 'mild-to-no pain at rest' and 'moderate-to-severe pain at rest'. We used a depth-specific CT-based mapping technique to measure patellar subchondral BMD at depths of 0-2.5 mm, 2.5-5 mm, and 5-7.5 mm from the subchondral surface. Mean lateral and medial facet BMD were compared between groups using MANCOVA. Mean adjusted BMD was lower in participants with 'moderate-to-severe pain at rest' over the total lateral facet at depths of 0-2.5 mm (10% lower, p=0.041), 2.5-5 mm (20% lower, p=0.017), and 5-7.5 mm (25% lower, p=0.004), and over the total medial facet at 2.5-5 mm (22% lower, p=0.033) and 5-7.5 mm (28% lower, p=0.016). In OA patients with 'moderate-to-severe pain at rest', depth-specific density measures demonstrated up to 28% lower lateral and medial subchondral BMD. Patients with high levels of pain at rest may have reduced amounts of native bone prior to TKR.

  13. A Comparison of Patients’ and Nurses’ Perceptions of Stimuli Experienced in an Intensive Care Unit

    DTIC Science & Technology

    1988-01-01

    adaptation to stimuli and the nurse’s role in promoting adaptation. Sister Callista Roy believes that all people are in constant interaction with their...Framework The theory used as a basis for this study was the Roy adaptation model ( Roy , 1984). The adaptation model centers on the patient’s...residual stimuli have been validated as influencing a possible response, they become contextual ( Roy , 1984). Roy (1984) identifies two subsystems, the

  14. Dolutegravir-based monotherapy or dual therapy maintains a high proportion of viral suppression even in highly experienced HIV-1-infected patients.

    PubMed

    Gubavu, Camelia; Prazuck, Thierry; Niang, Mohamadou; Buret, Jennifer; Mille, Catherine; Guinard, Jérôme; Avettand-Fènoël, Véronique; Hocqueloux, Laurent

    2016-04-01

    Dolutegravir is a powerful, well-tolerated integrase inhibitor with a high genetic barrier to resistance and may thus constitute the backbone of lightened regimens. This was a monocentric, retrospective study. HIV-1-infected patients receiving dolutegravir as monotherapy (mDGV) or dual therapy (dDGV) were systematically identified. The primary outcome was the proportion of patients who maintained undetectable (<50 copies/mL) plasma HIV RNA [plasma viral load (PVL)]. We identified 21 patients on mDGV (50 mg/day) and 31 on dDGV (50 or 100 mg/day, with atazanavir  ±  ritonavir, n = 12; rilpivirine, n = 11; maraviroc, n = 3; lamivudine, n = 3; darunavir/ritonavir, n = 1; or abacavir, n = 1). All of the patients were treatment experienced and 48% had experienced at least one virological failure. The baseline characteristics were as follows (for the mDGV/dDGV patients, respectively): 5%/29% had a history of AIDS; the median (IQR) highest PVL was 4.5 (4.3-5.5)/5.3 (4.7-5.6) log copies/mL; the median (IQR) nadir CD4+ count was 310 (280-468)/199 (134-281) cells/mm(3); 100% had undetectable PVL before the mDGV for a median (IQR) duration of 5.9 (3.5-9.9) years/81% had undetectable PVL before the dDGV for a median (IQR) duration of 3.7 (1.4-8.3) years; and the median (IQR) HIV DNA level was 2.7 (2.1-3.1)/2.9 (2.7-3) log copies/10(6) PBMCs. At the last follow-up visit, 100% and 97% of patients showed undetectable PVL following mDGV and dDGV, respectively [median (IQR) follow-up of 32 (29-45) and 50 (30-74) weeks, respectively]. In our experience, dolutegravir-based lightened regimens provided a high proportion of viral suppression, even in highly treatment-experienced patients. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy.

  15. Dolutegravir-based monotherapy or dual therapy maintains a high proportion of viral suppression even in highly experienced HIV-1-infected patients

    PubMed Central

    Gubavu, Camelia; Prazuck, Thierry; Niang, Mohamadou; Buret, Jennifer; Mille, Catherine; Guinard, Jérôme; Avettand-Fènoël, Véronique; Hocqueloux, Laurent

    2016-01-01

    Background Dolutegravir is a powerful, well-tolerated integrase inhibitor with a high genetic barrier to resistance and may thus constitute the backbone of lightened regimens. Methods This was a monocentric, retrospective study. HIV-1-infected patients receiving dolutegravir as monotherapy (mDGV) or dual therapy (dDGV) were systematically identified. The primary outcome was the proportion of patients who maintained undetectable (<50 copies/mL) plasma HIV RNA [plasma viral load (PVL)]. Results We identified 21 patients on mDGV (50 mg/day) and 31 on dDGV (50 or 100 mg/day, with atazanavir ± ritonavir, n = 12; rilpivirine, n = 11; maraviroc, n = 3; lamivudine, n = 3; darunavir/ritonavir, n = 1; or abacavir, n = 1). All of the patients were treatment experienced and 48% had experienced at least one virological failure. The baseline characteristics were as follows (for the mDGV/dDGV patients, respectively): 5%/29% had a history of AIDS; the median (IQR) highest PVL was 4.5 (4.3–5.5)/5.3 (4.7–5.6) log copies/mL; the median (IQR) nadir CD4+ count was 310 (280–468)/199 (134–281) cells/mm3; 100% had undetectable PVL before the mDGV for a median (IQR) duration of 5.9 (3.5–9.9) years/81% had undetectable PVL before the dDGV for a median (IQR) duration of 3.7 (1.4–8.3) years; and the median (IQR) HIV DNA level was 2.7 (2.1–3.1)/2.9 (2.7–3) log copies/106 PBMCs. At the last follow-up visit, 100% and 97% of patients showed undetectable PVL following mDGV and dDGV, respectively [median (IQR) follow-up of 32 (29–45) and 50 (30–74) weeks, respectively]. Conclusions In our experience, dolutegravir-based lightened regimens provided a high proportion of viral suppression, even in highly treatment-experienced patients. PMID:26712907

  16. Long-term efficacy and safety of etravirine-containing regimens in a real-life cohort of treatment-experienced HIV-1-infected patients.

    PubMed

    Allavena, Clotilde; Katlama, Christine; Cotte, Laurent; Roger, Pierre Marie; Delobel, Pierre; Cheret, Antoine; Duvivier, Claudine; Poizot-Martin, Isabelle; Hoen, Bruno; Cabie, André; Cheret, Arnaud; Lahoulou, Rima; Raffi, François; Pugliese, Pascal

    2016-01-01

    Etravirine (ETR) was approved in France in September 2008 and is used in combination with a boosted protease inhibitor (bPI) and other anti-retrovirals (ART) in HIV-infected pre-treated patients. This study aimed to report in a real-life setting the efficacy and tolerability of ETR-based regimens and factors associated with virological response. The study population included all treatment-experienced patients who initiated an ETR-based regimen between September 2008 and July 2013 from the French Dat'AIDS cohort. Analyses were performed in ART-experienced patients starting ETR after virological failure (VF) or as a maintenance therapy (MT), with or without bPI. A total of 2006 patients (VF, n = 1014 (51%); MT, n = 992 (49%)) were included. At M12, the proportion of patients with HIV RNA < 50 copies/ml was 71.7% (72.0% and 71.1% with or without bPI) in the VF group and 90.5% (85.0% and 92.3% with or without bPI) in the MT group, without significant differences regarding the use of bPI. ETR was discontinued in 8.8% of patients for adverse events in 23.9% of cases (21.5% in VF, 29.5% in MT), treatment failure in 15.2% (16.2% in VF, 7.4% in MT) or simplification in 5.4% (4.6% in VF, 7.4% in MT). In the VF group, factors associated with virological response were a longer duration of HIV infection (OR = 2.7; p < 0.001) and baseline HIV RNA < 5 log10 copies/mL (OR = 2.1; p = 0.002). This study shows that in ART-experienced patients ETR is well tolerated with a high efficacy when combined with other active drugs, even when the regimen does not include a bPI.

  17. The Successful Application of a National Peer Advisory Committee for Physicians Who Provide Salvage Regimens to Heavily Antiretroviral-Experienced Patients in Mexican Human Immunodeficiency Virus Clinics

    PubMed Central

    Calva, Juan J.; Sierra-Madero, Juan; Soto-Ramírez, Luis E.; Aguilar-Salinas, Pedro

    2014-01-01

    Background  Designing optimal antiretroviral (ARV) salvage regimens for multiclass drug-resistant, human immunodeficiency virus (HIV)-infected patients demands specific clinical skills. Our aim was to assess the virologic and immunologic effects of the treatment recommendations drafted by a peer advisory board to physicians caring for heavily ARV-experienced patients. Methods  We conducted a nationwide, HIV clinic-based, cohort study in Mexico. Adults infected with HIV were assessed for a median of 33 months (interquartile range [IQR] = 22–43 months). These patients had experienced the virologic failure of at least 2 prior ARV regimens and had detectable viremia while currently being treated; their physicians had received therapeutic advice, by a panel of experts, regarding the ARV salvage regimen. The primary endpoint was the incidence of loss of virologic response (plasma HIV-RNA levels of <200 copies per mL, followed by levels above this threshold) during the follow-up assessment using an observed-failure competing risks regression analysis. Results  A total of 611 patients were observed (median ARV therapy exposure = 10.5 years; median prior regimens = 4). The probabilities of virologic failure were 11.9%, 14.4%, 16.9%, and 19.4% at the 12-, 24-, 36-, and 48-month follow-up assessments, respectively. Of the 531 patients who achieved a confirmed plasma HIV-RNA level below 200 copies per mL, the median increase in blood CD4+ T-cell count was 162 cells per mL (IQR = 45–304 cells per mL). Conclusions  In routine practice, a high rate of patients with extensive ARV experience, who received an optimized salvage regimen recommended by a peer advisory committee, achieved a long-term sustained virologic response and immune reconstitution. PMID:25734149

  18. Scoring correction for MMPI-2 Hs scale with patients experiencing a traumatic brain injury: a test of measurement invariance.

    PubMed

    Alkemade, Nathan; Bowden, Stephen C; Salzman, Louis

    2015-02-01

    It has been suggested that MMPI-2 scoring requires removal of some items when assessing patients after a traumatic brain injury (TBI). Gass (1991. MMPI-2 interpretation and closed head injury: A correction factor. Psychological assessment, 3, 27-31) proposed a correction procedure in line with the hypothesis that MMPI-2 endorsement may be affected by symptoms of TBI. This study assessed the validity of the Gass correction procedure. A sample of patients with a TBI (n = 242), and a random subset of the MMPI-2 normative sample (n = 1,786). The correction procedure implies a failure of measurement invariance across populations. This study examined measurement invariance of one of the MMPI-2 scales (Hs) that includes TBI correction items. A four-factor model of the MMPI-2 Hs items was defined. The factor model was found to meet the criteria for partial measurement invariance. Analysis of the change in sensitivity and specificity values implied by partial measurement invariance failed to indicate significant practical impact of partial invariance. Overall, the results support continued use of all Hs items to assess psychological well-being in patients with TBI. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

  19. Incidence of utilization- and symptom-defined COPD exacerbations in hospital- and population-recruited patients

    PubMed Central

    Erdal, Marta; Johannessen, Ane; Eagan, Tomas Mikal; Bakke, Per; Gulsvik, Amund; Grønseth, Rune

    2016-01-01

    Objectives The objectives of this study were to estimate the impact of recruitment source and outcome definition on the incidence of acute exacerbations of COPD (AECOPD) and explore possible predictors of AECOPD. Patients and methods During a 1-year follow-up, we performed a baseline visit and four telephone interviews of 81 COPD patients and 132 controls recruited from a population-based survey and 205 hospital-recruited COPD patients. Both a definition based on health care utilization and a symptom-based definition of AECOPD were applied. For multivariate analyses, we chose a negative binomial regression model. Results COPD patients from the population- and hospital-based samples experienced on average 0.4 utilization-defined and 2.9 symptom-defined versus 1.0 and 5.9 annual exacerbations, respectively. The incidence rate ratios for utilization-defined AECOPD were 2.45 (95% CI 1.22–4.95), 3.43 (95% CI 1.59–7.38), and 5.67 (95% CI 2.58–12.48) with Global Initiative on Obstructive Lung Disease spirometric stages II, III, and IV, respectively. The corresponding incidence rate ratios for the symptom-based definition were 3.08 (95% CI 1.96–4.84), 3.45 (95% CI 1.92–6.18), and 4.00 (95% CI 2.09–7.66). Maintenance therapy (regular long-acting muscarinic antagonists, long-acting beta-2 agonists, inhaled corticosteroids, or theophylline) also increased the risk of AECOPD with both exacerbation definitions (incidence rate ratios 1.65 and 1.73, respectively). The risk of AECOPD was 59%–78% higher in the hospital sample than in the population sample. Conclusion If externally valid conclusions are to be made regarding incidence and predictors of AECOPD, studies should be based on general population samples or adjustments should be made on account of a likely higher incidence in other samples. Likewise, the effect of different AECOPD definitions should be taken into consideration. PMID:27621614

  20. Holistic self-care for rehabilitation experienced by thai buddhist trauma patients in areas of political and social unrest.

    PubMed

    Songwathana, Praneed; Watanasiriwanich, Wachiraya; Kitrungrote, Luppana

    2013-01-01

    This study describes the meaning and practice of holistic self-care for rehabilitation among Thai Buddhist trauma patients living in areas of political unrest where acts of terrorism occur. Eleven Thai Buddhist trauma patients were selected as specified. The data were collected by in-depth interviews between November 2011 and April 2012, and analyzed using the Van Manen method.Those interviewed described "holistic self-care for rehabilitation" as learning (1) to acquire a new life and (2) to bear the increased demands of care as a chronic disease. Health care responses fell into 3 categories: (1) improving physical self-sufficiency and rehabilitation by increasing muscle strength, pain management, and pressure sores; (2) improving psychological well-being by applying positive thinking, making an effort to live independently, and following a set of religious practices; and (3) finding harmony in life through caution and a willingness to adjust one's lifestyle. Although the participants seemed to adapt well to their new lifestyles, extensive support from health care professionals was necessary. This study promotes better understanding of the holistic health care experiences the survivors of trauma have as a result of an unstable political situation that includes aspects of social unrest and terrorism.

  1. Effects of asenapine on depressive symptoms in patients with bipolar I disorder experiencing acute manic or mixed episodes: a post hoc analysis of two 3-week clinical trials

    PubMed Central

    2011-01-01

    Background Asenapine demonstrated superiority over placebo for mania in bipolar I disorder patients experiencing acute current manic or mixed episodes in 2 randomized, placebo-and olanzapine-controlled trials. We report the results of exploratory pooled post hoc analyses from these trials evaluating asenapine's effects on depressive symptoms in patients from these trials with significant baseline depressive symptoms. Methods In the original trials (A7501004 [NCT00159744], A7501005 [NCT00159796]), 977 patients were randomized to flexible-dose sublingual asenapine (10 mg twice daily on day 1; 5 or 10 mg twice daily thereafter), placebo, or oral olanzapine 5-20 mg once daily for 3 weeks. Three populations were defined using baseline depressive symptoms: (1) Montgomery-Asberg Depression Rating Scale (MADRS) total score ≥20 (n = 132); (2) Clinical Global Impression for Bipolar Disorder-Depression (CGI-BP-D) scale severity score ≥4 (n = 170); (3) diagnosis of mixed episodes (n = 302) by investigative site screening. For each population, asenapine and olanzapine were independently compared with placebo using least squares mean change from baseline on depressive symptom measures. Results Decreases in MADRS total score were statistically greater with asenapine versus placebo at days 7 and 21 in all populations; differences between olanzapine and placebo were not significant. Decreases in CGI-BP-D score were significantly greater with asenapine versus placebo at day 7 in all categories and day 21 in population 1; CGI-BP-D score reductions were significantly greater with olanzapine versus placebo at day 21 in population 1 and day 7 in populations 2 and 3. Conclusions These post hoc analyses show that asenapine reduced depressive symptoms in bipolar I disorder patients experiencing acute manic or mixed episodes with clinically relevant depressive symptoms at baseline; olanzapine results appeared to be less consistent. Controlled studies of asenapine in patients with acute

  2. Effects of asenapine on depressive symptoms in patients with bipolar I disorder experiencing acute manic or mixed episodes: a post hoc analysis of two 3-week clinical trials.

    PubMed

    Szegedi, Armin; Zhao, Jun; van Willigenburg, Arjen; Nations, Kari R; Mackle, Mary; Panagides, John

    2011-06-20

    Asenapine demonstrated superiority over placebo for mania in bipolar I disorder patients experiencing acute current manic or mixed episodes in 2 randomized, placebo-and olanzapine-controlled trials. We report the results of exploratory pooled post hoc analyses from these trials evaluating asenapine's effects on depressive symptoms in patients from these trials with significant baseline depressive symptoms. In the original trials (A7501004 [NCT00159744], A7501005 [NCT00159796]), 977 patients were randomized to flexible-dose sublingual asenapine (10 mg twice daily on day 1; 5 or 10 mg twice daily thereafter), placebo, or oral olanzapine 5-20 mg once daily for 3 weeks. Three populations were defined using baseline depressive symptoms: (1) Montgomery-Asberg Depression Rating Scale (MADRS) total score ≥20 (n = 132); (2) Clinical Global Impression for Bipolar Disorder-Depression (CGI-BP-D) scale severity score ≥4 (n = 170); (3) diagnosis of mixed episodes (n = 302) by investigative site screening. For each population, asenapine and olanzapine were independently compared with placebo using least squares mean change from baseline on depressive symptom measures. Decreases in MADRS total score were statistically greater with asenapine versus placebo at days 7 and 21 in all populations; differences between olanzapine and placebo were not significant. Decreases in CGI-BP-D score were significantly greater with asenapine versus placebo at day 7 in all categories and day 21 in population 1; CGI-BP-D score reductions were significantly greater with olanzapine versus placebo at day 21 in population 1 and day 7 in populations 2 and 3. These post hoc analyses show that asenapine reduced depressive symptoms in bipolar I disorder patients experiencing acute manic or mixed episodes with clinically relevant depressive symptoms at baseline; olanzapine results appeared to be less consistent. Controlled studies of asenapine in patients with acute bipolar depression are necessary to

  3. Prognostic factors in patients with metastatic germ cell tumors who experienced treatment failure with cisplatin-based first-line chemotherapy.

    PubMed

    Lorch, Anja; Beyer, Jörg; Bascoul-Mollevi, Caroline; Kramar, Andrew; Einhorn, Lawrence H; Necchi, Andrea; Massard, Christophe; De Giorgi, Ugo; Fléchon, Aude; Margolin, Kim A; Lotz, Jean-Pierre; Germa Lluch, Jose Ramon; Powles, Thomas; Kollmannsberger, Christian K

    2010-11-20

    To develop a prognostic model in patients with germ cell tumors (GCT) who experience treatment failure with cisplatin-based first-line chemotherapy. Data from 1,984 patients with GCT who progressed after at least three cisplatin-based cycles and were treated with cisplatin-based conventional-dose or carboplatin-based high-dose salvage chemotherapy was retrospectively collected from 38 centers/groups worldwide. One thousand five hundred ninety-four (80%) of 1,984 eligible patients were randomly divided into a training set of 1,067 patients (67%) and a validation set of 527 patients (33%). Seminomas were set aside for posthoc analyses. Primary end point was the 2-year progression-free survival after salvage treatment. Overall, 990 patients (62%) relapsed and 604 patients (38%) remained relapse free. Histology, primary tumor location, response, and progression-free interval after first-line treatment, as well as levels of alpha fetoprotein, human chorionic gonadotrophin, and the presence of liver, bone, or brain metastases at salvage were identified as independent prognostic variables and used to build a prognostic model in the training set. Survival rates in the training and validation set were very similar. The estimated 2-year progression-free survival rates in patients not included in the training set was 75% in very low risk, 51% in low risk, 40% in intermediate risk, 26% in high risk, and only 6% in very high-risk patients. Due to missing values in individual variables, 69 patients could not reliably be classified into one of these categories. Prognostic variables are important in patients with GCT who experienced treatment failure with cisplatin-based first-line chemotherapy and can be used to construct a prognostic model to guide salvage strategies.

  4. Inpatient schema therapy for nonresponsive patients with personality pathology: Changes in symptomatic distress, schemas, schema modes, coping styles, experienced parenting styles, and mental well-being.

    PubMed

    Schaap, Grietje M; Chakhssi, Farid; Westerhof, Gerben J

    2016-12-01

    This study provides an evaluation of group schema therapy (ST) for inpatient treatment of patients with personality pathology who did not respond to previous psychotherapeutic interventions. Forty-two patients were assessed pre- and posttreatment, and 35 patients were evaluated at follow-up 6 months later. The results showed a dropout rate of 35%. Those who dropped out did not differ from those who completed treatment with regard to demographic and clinical variables; the only exception was that those who dropped out showed a lower prevalence of mood disorders. Furthermore, intention-to-treat analyses showed a significant improvement in maladaptive schemas, schema modes, maladaptive coping styles, mental well-being, and psychological distress after treatment, and these improvements were maintained at follow-up. On the other hand, there was no significant change in experienced parenting style as self-reported by patients. Changes in schemas and schema modes measured from pre- to posttreatment were predictive of general psychological distress at follow-up. Overall, these preliminary findings suggest that positive treatment results can be obtained with group ST-based inpatient treatment for patients who did not respond to previous psychotherapeutic interventions. Moreover, these findings are comparable with treatment results for patients without such a nonresponsive treatment history. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

  5. The Decline in HIV-1 Drug Resistance in Heavily Antiretroviral-Experienced Patients Is Associated with Optimized Prescriptions in a Treatment Roll-Out Program in Mexico.

    PubMed

    Calva, Juan J; Larrea, Silvana; Tapia-Maltos, Marco A; Ostrosky-Frid, Mauricio; Lara, Carolina; Aguilar-Salinas, Pedro; Rivera, Héctor; Ramírez, Juan P

    2017-07-01

    A decrease in the rate of acquired antiretroviral (ARV) drug resistance (ADR) over time has been documented in high-income settings, but data on the determinants of this phenomenon are lacking. We tested the hypothesis that in heavily ARV-experienced patients in the Mexican ARV therapy (ART) roll-out program, the drop in ADR would be associated with changes in ARV drug usage. Genotypic resistance tests obtained from 974 HIV-infected patients with virological failure and at least 2 previously failed ARV regimens from throughout the country were analyzed for the presence of nucleos(t)ide reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, and protease inhibitor (PI) resistance-associated mutations (RAMs). Patients were divided into two groups according to their first ART start date: 488 patients initiated ART before mid-2003 (group 1) and 486 after mid-2003 (group 2). The rate of RAMs, median resistance score of several sentinel ARVs, and composition of ART drugs in patient's entire treatment history were compared between both groups. Patients in group 2 were less likely to have >3 thymidine analogue-associated mutations (TAMs) and >3 PI-mRAMs [adjusted odds ratio (aOR) = 0.37; 95% confidence interval (95% CI) = 0.25-0.54; p < .001 and aOR = 0.53; 95% CI = 0.36-0.77; p = .001, respectively] and had a significantly lower resistance score for zidovudine, tenofovir, ritonavir-boosted (r)-lopinavir, r-atazanavir, and r-darunavir than group 1 patients. A significantly lower proportion of patients in group 2 used monotherapy, bitherapy, thymidine analogue-containing regimens, nonboosted PI-containing regimens, and low resistance barrier PI-containing regimens. In Mexican ARV-experienced patients, the occurrence of TAM and PI-mRAM has significantly declined over time. This can be explained by treatment optimization in the national ART roll-out program in recent years.

  6. The value of noninvasive measurement of the compensatory reserve index in monitoring and triage of patients experiencing minimal blood loss.

    PubMed

    Nadler, Roy; Convertino, Victor A; Gendler, Sami; Lending, Gadi; Lipsky, Ari M; Cardin, Sylvain; Lowenthal, Alexander; Glassberg, Elon

    2014-08-01

    Currently available triage and monitoring tools are often late to detect life-threatening clinically significant physiological aberrations and provide limited data in prioritizing bleeding patients for treatment and evacuation. The Compensatory Reserve Index (CRI) is a novel means of assessing physiologic reserve, shown to correlate with central blood volume loss under laboratory conditions. The purpose of this study was to compare the noninvasive CRI device with currently available vital signs in detecting blood loss. Study subjects were soldiers volunteering for blood donation (n = 230), and the control group was composed of soldiers who did not donate blood (n = 34). Data collected before and after blood donation were compared, receiver operator characteristic curves were generated after either donation or the appropriate time interval, and areas under the curves (AUCs) were compared. Compared with pre-blood loss, blood donation resulted in a mean reduction of systolic blood pressure by 3% (before, 123 mmHg; after, 119 mmHg; P < 0.01). The CRI demonstrated a 16% reduction (before, 0.74; after, 0.62; P < 0.01). Heart rate, diastolic blood pressure, and oxygen saturation remained unchanged. The AUC for change in CRI was 0.81, 0.56 for change in heart rate, 0.53 for change in systolic blood pressure, 0.55 and 0.58 for pulse pressure and shock index, respectively. The AUCs for detecting mild blood loss at a single measurement were 0.73 for heart rate, 0.60 for systolic blood pressure, 0.62 for diastolic blood pressure, 0.45 for pulse oximetry, and 0.84 for CRI. The CRI was better than standard indices in detecting mild blood loss. Single measurement of CRI may enable a more accurate triage, and CRI monitoring may allow for earlier detection of casualty deterioration.

  7. Spanning boundaries and creating strong patient relationships to coordinate care are strategies used by experienced chronic condition care coordinators.

    PubMed

    Ehrlich, Carolyn; Kendall, Elizabeth; Muenchberger, Heidi

    2012-08-01

    People with complex chronic conditions frequently need to navigate their own way through and around a fragmented and siloed health care system. Care coordination is a defining principle of primary care and is frequently proposed as a solution to this problem. However, care coordination requires more time and effort than primary care physicians alone have the capacity to deliver. Although registered nurses (RNs) are skilled team members who can be included in the delivery of coordinated patient care, any model of care coordination that involves RNs needs to fit within the existing health care delivery system. In this study, which used qualitative techniques based on grounded theory and included face-to-face interviews and open coding and theoretical sampling until data saturation was achieved, and which was one component of a larger action research study, we aimed to gain an understanding of the difference between usual chronic condition care and the work of chronic condition care coordination. The researchers interviewed general practitioners and RNs from various general practice sites who were actively coordinating care. Four unique processes were found to define care coordination implementation, namely: (1) moving beyond usual practice by spanning boundaries; (2) relationship-based care; (3) agreed roles and routines among relevant parties; and (4) committing to chronic condition care coordination. The findings suggested that existing professional and organisational cultures required negotiation before care coordination could be integrated into existing contexts. The challenge, however, seems to be in acknowledging and overcoming professional practice boundaries that define existing care through reflective practice and shared resourcing.

  8. Raltegravir and Abacavir/Lamivudine in Japanese Treatment-Naïve and Treatment-Experienced Patients with HIV Infection: a 48-Week Retrospective Pilot Analysis.

    PubMed

    Suzuki, Akihito; Uehara, Yuki; Saita, Mizue; Inui, Akihiro; Isonuma, Hiroshi; Naito, Toshio

    2016-01-01

    Abacavir/lamivudine (ABC/3TC) is a nucleoside reverse transcriptase inhibitor used for treating human immunodeficiency viral (HIV) infections. Hypersensitivity reactions such as skin eruptions caused by ABC are well-known, but rarely occur in Asians. Raltegravir (RAL) is an integrase strand transfer inhibitor, that is now increasingly, used for treating HIV infections because it has few adverse effects. This retrospective analysis assessed the efficacy and safety of combined ABC/3TC and RAL in both treatment-naïve and -experienced Japanese patients with HIV infections. In all 11 treatment-naïve patients (100%), virological suppression to undetectable level was achieved. Liver transaminases, renal function, and serum lipid profiles showed no exacerbations up to 48 weeks of treatment. In 12 patients who were switched from previous regimens to ABC/3TC and RAL, HIV viral load was undetectable in 11 patients (91.6%), but remained detectable in 1 patient with poor adherence. Major reasons for switching regimens to ABC/3TC and RAL were hyperlipidemia and nausea. After switching, these adverse effects improved, and no new adverse effects were observed. Despite the small number of participants in this study, the results support the combination of ABC/3TC and RAL as a possible treatment choice in Japanese individuals with HIV-infection.

  9. Brainstorming Design for Health: Helping Patients Utilize Patient-Generated Information on the Web

    PubMed Central

    Huh, Jina; Hartzler, Andrea; Munson, Sean; Anderson, Nick; Edwards, Kelly; Gore, John L.; McDonald, David; O’Leary, Jim; Parker, Andrea; Streat, Derek; Yetisgen-Yildiz, Meliha; Pratt, Wanda; Ackerman, Mark S.

    2013-01-01

    Researchers and practitioners show increasing sinterest in utilizing patient-generated information on the Web. Although the HCI and CSCW communities have provided many exciting opportunities for exploring new ideas and building broad agenda in health, few venues offer a platform for interdisciplinary and collaborative brainstorming about design challenges and opportunities in this space. The goal of this workshop is to provide participants with opportunities to interact with stakeholders from diverse backgrounds and practices—researchers, practitioners, designers, programmers, and ethnographers—and together generate tangible design outcomes that utilize patient-generated information on the Web. Through small multidisciplinary group work, we will provide participants with new collaboration opportunities, understanding of the state of the art, inspiration for future work, and ideally avenues for continuing to develop research and design ideas generated at the workshop. PMID:24499843

  10. Brainstorming Design for Health: Helping Patients Utilize Patient-Generated Information on the Web.

    PubMed

    Huh, Jina; Hartzler, Andrea; Munson, Sean; Anderson, Nick; Edwards, Kelly; Gore, John L; McDonald, David; O'Leary, Jim; Parker, Andrea; Streat, Derek; Yetisgen-Yildiz, Meliha; Pratt, Wanda; Ackerman, Mark S

    2012-01-01

    Researchers and practitioners show increasing sinterest in utilizing patient-generated information on the Web. Although the HCI and CSCW communities have provided many exciting opportunities for exploring new ideas and building broad agenda in health, few venues offer a platform for interdisciplinary and collaborative brainstorming about design challenges and opportunities in this space. The goal of this workshop is to provide participants with opportunities to interact with stakeholders from diverse backgrounds and practices-researchers, practitioners, designers, programmers, and ethnographers-and together generate tangible design outcomes that utilize patient-generated information on the Web. Through small multidisciplinary group work, we will provide participants with new collaboration opportunities, understanding of the state of the art, inspiration for future work, and ideally avenues for continuing to develop research and design ideas generated at the workshop.

  11. Clobazam-Treated Patients with Lennox Gastaut Syndrome Experienced Fewer Seizure-Related Injuries than Placebo Patients During Trail OV-1012

    DTIC Science & Technology

    2016-08-19

    reasonable sample size6; however, simply counting seizures may not be as clinically meaningful as evaluating the conse- quences that such trial end points...provides a clinically meaningful benefit, a reduced likelihood of experiencing seizure-related injuries. KEYWORDS: Clobazam, Lennox-Gastaut syndrome, Drop...used in clinical trials to evalu- ate an active drug against placebo are useful in demon- strating efficacy, but it is often unclear whether these

  12. Evolution of HIV-1 tropism at quasispecies level after 5 years of combination antiretroviral therapy in patients always suppressed or experiencing episodes of virological failure.

    PubMed

    Rozera, Gabriella; Abbate, Isabella; Giombini, Emanuela; Castagna, Antonella; De Luca, Andrea; Ceccherini-Silberstein, Francesca; Cozzi Lepri, Alessandro; Cassola, Giovanni; Torti, Carlo; d'Arminio Monforte, Antonella; Ippolito, Giuseppe; Capobianchi, Maria R

    2014-11-01

    Tropism evolution of HIV-1 quasispecies was analysed by ultra-deep pyrosequencing (UDPS) in patients on first-line combination antiretroviral therapy (cART) always suppressed or experiencing virological failure episodes. Among ICONA patients, two groups of 20 patients on cART for ≥5 years, matched for baseline viraemia and therapy duration, were analysed [Group I, patients always suppressed; and Group II, patients experiencing episode(s) of virological failure]. Viral tropism was assessed by V3 UDPS on plasma RNA before therapy (T0) and on peripheral blood mononuclear cell proviral DNA before-after therapy (T0-T1), using geno2pheno false positive rate (FPR) (threshold for X4: 5.75). For each sample, quasispecies tropism was assigned according to X4 variant frequency: R5, <0.3% X4; minority X4, 0.3%-19.9% X4; and X4, ≥20% X4. An R5-X4 switch was defined as a change from R5/minority X4 in plasma/proviral genomes at T0 to X4 in provirus at T1. At baseline, mean FPR and %X4 of viral RNA were positively correlated with those of proviral DNA. After therapy, proviral DNA load significantly decreased in Group I; mean FPR of proviral quasispecies significantly decreased and %X4 increased in Group II. An R5-X4 switch was observed in five patients (two in Group I and three in Group II), all harbouring minority X4 variants at T0. UDPS analysis reveals that the tropism switch is not an 'on-off' phenomenon, but may result from a profound re-shaping of viral quasispecies, even under suppressive cART. However, episodes of virological failure seem to prevent reduction of proviral DNA and to accelerate viral evolution, as suggested by decreased FPR and increased %X4 at T1 in Group II patients. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

  13. Positive symptoms in first-episode psychosis patients experiencing low maternal care and stressful life events: a pilot study to explore the role of the COMT gene.

    PubMed

    Ira, Elisa; De Santi, Katia; Lasalvia, Antonio; Bonetto, Chiara; Zanatta, Gioia; Cristofalo, Doriana; Bertani, Mariaelena; Bissoli, Sarah Saviana; Riolo, Rossana; Gardellin, Francesco; Morandin, Idana; Ramon, Luana; Tansella, Michele; Ruggeri, Mirella; Tosato, Sarah

    2014-09-01

    COMT Val(158)Met moderates the effect of stress on psychotic symptoms. Exposure to stress is also associated with mesolimbic dopamine release in individuals experiencing low maternal care. We therefore test the hypothesis that recent stressful life events are associated with more severe positive symptoms (associated with mesolimbic dopamine release) in first-episode psychosis (FEP) patients who experienced low maternal care during childhood. We hypothesized that COMT Val(158)Met moderates this association. A total of 149 FEP patients recruited within the Psychosis Incident Cohort Outcome Study (PICOS) participated in the present study. Maternal care was assessed by the Parental Bonding Instrument (PBI), stressful life events were collected by the List of Events Scale and positive symptoms were assessed by the Positive and Negative Syndrome Scale (PANSS). We found that low maternal care and recent stressful life events were associated with higher level of positive symptoms at the onset (analysis of variance [ANOVA], p = 0.012), and that patients who were also homozygotes for the COMT Val(158) allele had the highest level of positive symptoms (ANOVA, p = 0.024). Low maternal care and severe stressful life events may contribute to a symptomatology characterized by more severe positive symptoms at the onset, possibly due to an increased mesolimbic dopamine release. Homozygosity for the COMT Val(158) allele seems to confer a biological predisposition to the stress-related hyperactivity of the mesolimbic dopaminergic system. The data imply that the mesolimbic dopaminergic system is involved in the mediation/modulation of the effect of stressful events on the vulnerability for psychosis.

  14. Health-related quality of life and tolerability in treatment-experienced HIV-1-infected patients on tipranavir versus comparator regimens.

    PubMed

    Huang, I-Chan; Wu, Albert W; Finnern, Henrik W; Thijs, Herbert; Gathe, Joseph C; Fairclough, Diane L

    2008-01-01

    Antiretroviral therapy including tipranavir boosted with ritonavir (TPV/r) has shown superior viral suppression and immunological response compared with comparator ritonavir-boosted protease inhibitor (CPI/r) regimens in treatment-experienced HIV-1-infected patients. This study assesses the influence of adverse events (AEs) on health-related quality of life (HRQOL) and change in HRQOL in patients treated with TPV/r versus CPI/r regimens. Changes in HRQOL over 48 weeks were assessed using Medical Outcomes Study HIV Health Survey (MOS-HIV) data combined from two randomized, open-label, Phase III studies (RESIST-1 and RESIST-2). Generalized estimating equations (GEE) were used to compare physical health and mental health summary scores and 10 subscale scores, and to compare scores of patients with and without AEs. To compare AE incidences in the two treatment groups, AEs were exposure-adjusted. There were 984 patients in the HRQOL analysis. AE occurrence and severity resulted in significantly lower MOS-HIV scores across both treatment arms (P<0.05). Overall incidence of AEs was higher in the CPI/r versus TPV/r group (562.8 versus 514.4 per 100 patient-exposure years); treatment-related AEs were more frequent in the TPV/r group (75.0 versus 56.6 per 100 patient-exposure years). HRQOL was maintained in patients on TPV/r over 48 weeks of treatment across all summary and subscale scores. Compared with CPI/r, TPV/r was associated with a significant but small (SD<0.2) improvement in pain scores (+4.8 points; P<0.05). HRQOL was maintained across both summary and all subscale scores from baseline to 48 weeks in the TPV/r and CPI/r treatment arms, despite the incidence of treatment-related AEs.

  15. Treatment patterns, health state, and health care resource utilization of patients with radioactive iodine refractory differentiated thyroid cancer

    PubMed Central

    Gianoukakis, Andrew G; Flores, Natalia M; Pelletier, Corey L; Forsythe, Anna; Wolfe, Gregory R; Taylor, Matthew H

    2016-01-01

    Background Patients with differentiated thyroid cancer (DTC) often respond well to treatment but some become refractory to radioactive iodine (RAI) treatment, and treatment options are limited. Despite the humanistic and economic burden RAI refractory disease imposes on patients, published research concerning treatment patterns and health care resource utilization is sparse. Methods Data were collected from an online retrospective chart review study in the US and five European Union (EU) countries (France, Germany, Italy, Spain, and UK) with physicians recruited from an online panel. Physicians (N=211) provided demographics, disease history, treatment information, and health care resource utilization for one to four of their patients with radioactive iodine refractory differentiated thyroid cancer (RR-DTC). Results The majority of the patients with RR-DTC (N=623) were female (56%), and their mean age was 58.2 years. In this sample, 63.2% had papillary thyroid cancer and 57.0% were in Stage IV when deemed RAI refractory. Patients with RR-DTC experienced regional recurrence in the thyroid bed/central neck area (25.3%) and had distant metastatic disease (53.6%). At the time data were collected, 50.7% were receiving systemic treatment. Of those, 78.5% were on first-line treatment and 62.7% were receiving multikinase inhibitors. Regional differences for prescribed treatments were observed; the US was more likely to have patients receiving multikinase inhibitors (79.2%) compared with UK (41.2%) and Italy (17.1%). Additional details regarding treatment patterns and resource utilization are discussed. Conclusion The current study aimed to obtain a greater understanding of RR-DTC treatment globally. These results can assist in the development and implementation of treatment guidelines and ultimately enhance the care of patients with RR-DTC. PMID:27313476

  16. Utilizing the PCICS Nursing Guidelines in Managing the CICU Patient.

    PubMed

    Justice, Lindsey; Ellis, Misty; St George-Hyslop, Cecilia; Donnellan, Amy; Trauth, Amiee; Drouillard, Brenda; Watt, Claire; Callow, Louise

    2015-10-01

    The Pediatric Cardiac Intensive Care Society (PCICS) Nursing Guidelines were developed to provide an evidence-based resource for bedside cardiac intensive care unit nursing care. Guideline topics include postoperative care, hemodynamic monitoring, arrhythmia management, and nutrition. These evidence-based care guidelines were presented at the 10th International Meeting of PCICS and have been utilized in the preparation of this article. They can be accessed at http://www.pcics.org/resources/pediatric-neonatal/. Utilization of these guidelines in practice is illustrated for single ventricle stage 1 palliation, Fontan operation, truncus arteriosus, and atrioventricular septal defect. © The Author(s) 2015.

  17. Analysis of the mdr-1 Gene in Patients Co-Infected with Onchocerca volvulus and Loa loa Who Experienced a Post-Ivermectin Serious Adverse Event

    PubMed Central

    Bourguinat, Catherine; Kamgno, Joseph; Boussinesq, Michel; Mackenzie, Charles D.; Prichard, Roger K.; Geary, Timothy G.

    2010-01-01

    Ivermectin (IVM) is exceptionally safe in humans, and is used for mass treatment of onchocerciasis and lymphatic filariasis. However, cases of encephalopathy, sometimes fatal, have been reported in a small number of individuals who harbored large numbers of Loa loa microfilariae (mf). A loss-of-function mutation in the mdr-1 gene in some dog breeds and in mice leads to accumulation of the drug in the brain, causing coma and death. This hypothesis was tested in four individuals from Cameroon who experienced a post-IVM serious adverse event (SAE) and in nine non-SAE matched controls. No loss-of-function mutation was detected in mdr-1 in any subject. However, haplotypes, associated with altered drug disposition, were present as homozygotes in two of the SAE patients (50%), but absent as homozygotes in the controls (0%). An association of high Loa mf load and a genetic predisposition to altered IVM distribution could be involved in IVM SAEs. PMID:20595473

  18. Dual therapy with darunavir/r plus etravirine is safe and effective as switching therapy in antiretroviral experienced HIV-patients. The BITER Study.

    PubMed

    Portilla, Joaquín; Arazo, Piedad; Crusells, Josefa; Pérez-Martínez, Laura; Martínez-Madrid, Onofre; Boix, Vicente; Moreno, Javier; Navarro, Vicente; Rubio, Teresa; Reus, Sergio; Galera, Carlos; Bernal, Enrique; Jover, Francisco; Amador, Concepcion; Baño, David; Merino, Esperanza; Saiz-de-la-Hoya, Pablo

    2014-01-01

    Switching therapy studies are usually designed as second-line antiretroviral treatment (ART) in patients without previous virologic failures. Combined ART (cART) with DRV/r and ETR has a good pharmacokinetic profile, high genetic barrier and has been proved as rescue therapy. The aim of our study was to analyze efficacy and safety of therapy with DRV/r plus ETR in treatment experienced HIV-patients with previous therapeutic failures that need to switch ART. We present results at first 24 weeks. Multicentre retrospective observational study. adult HIV-patients on ART with HIV-VL <1000 cop/mL who started their ART with DRV/r (600/100 bid or 800/100 qd)+ETR by adverse events, non-adherence, tolerability or prevention of future complications. Patients with acute AIDS events, HBV, pregnancy, drug addiction or previous selected mutations to DRV or ETR were excluded. Ninety-nine patients were included, mean age: 47 years (r: 22-79); 70% men, 40.4% previous AIDS event and 39.3% HCV. Ninety-one patients had received ≥3 cART regimens and 45≥5, 75 patients had HIV-VL <50 cop/mL and 24 low-level viremia (LLV): 297.5±261.4 cop/mL, CD4+ 568±279 cells/µL. ART before switching: NRTI+PI/r (33%), NNRTI (17%), PI/r+NNRTI (23%), PI/r+INI (13%), other (14%). Main reason to switching was: toxicity/intolerance 50 patients (renal 32%, gastrointestinal: 14%, hyperlipidaemia 10%; osteopenia/osteoporosis: 6%); improving adherence 26 patients; prevention of complications 19 patients. Nine subjects withdrew ART during follow-up because: intolerance or new toxicity three; non-adherence two; simplification to DRV/r monotherapy two; persistence of previous toxicity one; virologic failure one. At week 24, among patients who continued with DRV/r+ETR (n=90): 81 (89%) had VL<50 cop/mL, in those with with HIV-VL<50 at baseline (67/90), 94% persisted with <50 cop., and in those with LLV (24/90), 61% (n=14) achieved a VL<50 cop. We didn't observe any significant difference in lab parameters

  19. Dual therapy with darunavir/r plus etravirine is safe and effective as switching therapy in antiretroviral experienced HIV-patients. The BITER Study

    PubMed Central

    Portilla, Joaquín; Arazo, Piedad; Crusells, Josefa; Pérez-Martínez, Laura; Martínez-Madrid, Onofre; Boix, Vicente; Moreno, Javier; Navarro, Vicente; Rubio, Teresa; Reus, Sergio; Galera, Carlos; Bernal, Enrique; Jover, Francisco; Amador, Concepcion; Baño, David; Merino, Esperanza; Saiz-de-la-Hoya, Pablo

    2014-01-01

    Introduction Switching therapy studies are usually designed as second-line antiretroviral treatment (ART) in patients without previous virologic failures. Combined ART (cART) with DRV/r and ETR has a good pharmacokinetic profile, high genetic barrier and has been proved as rescue therapy. The aim of our study was to analyze efficacy and safety of therapy with DRV/r plus ETR in treatment experienced HIV-patients with previous therapeutic failures that need to switch ART. We present results at first 24 weeks. Methods Multicentre retrospective observational study. Inclusion criteria: adult HIV-patients on ART with HIV-VL <1000 cop/mL who started their ART with DRV/r (600/100 bid or 800/100 qd)+ETR by adverse events, non-adherence, tolerability or prevention of future complications. Patients with acute AIDS events, HBV, pregnancy, drug addiction or previous selected mutations to DRV or ETR were excluded. Results Ninety-nine patients were included, mean age: 47 years (r: 22–79); 70% men, 40.4% previous AIDS event and 39.3% HCV. Ninety-one patients had received ≥3 cART regimens and 45≥5, 75 patients had HIV-VL <50 cop/mL and 24 low-level viremia (LLV): 297.5±261.4 cop/mL, CD4+ 568±279 cells/µL. ART before switching: NRTI+PI/r (33%), NNRTI (17%), PI/r+NNRTI (23%), PI/r+INI (13%), other (14%). Main reason to switching was: toxicity/intolerance 50 patients (renal 32%, gastrointestinal: 14%, hyperlipidaemia 10%; osteopenia/osteoporosis: 6%); improving adherence 26 patients; prevention of complications 19 patients. Nine subjects withdrew ART during follow-up because: intolerance or new toxicity three; non-adherence two; simplification to DRV/r monotherapy two; persistence of previous toxicity one; virologic failure one. At week 24, among patients who continued with DRV/r+ETR (n=90): 81 (89%) had VL<50 cop/mL, in those with with HIV-VL<50 at baseline (67/90), 94% persisted with <50 cop., and in those with LLV (24/90), 61% (n=14) achieved a VL<50 cop. We didn't observe

  20. Searching for existential security: a prospective qualitative study on the influence of mindfulness therapy on experienced stress and coping strategies among patients with somatoform disorders.

    PubMed

    Lind, Annemette Bondo; Delmar, Charlotte; Nielsen, Klaus

    2014-12-01

    The aim was to explore how mindfulness group therapy for somatoform disorders influenced the patients' stress experiences, coping strategies and contextual psychosocial processes. A longitudinal pre- and post-treatment design, using 22 semi-structured individual pre- and post-treatment interviews. Data-analysis was based on a thematic methodology. Pre-treatment patients were struggling in an existential crisis, feeling existentially insecure about their social identity, the causes, consequences and management of their illness; experiencing difficulties identifying and expressing stress-related cognitions, emotions and feelings, and low bodily and emotional self-contact; often leading to avoidant coping, making these individuals highly stress-vulnerable. Post-treatment, the overall change was conceptualized as increased existential security, defined by patients being more self-confident; more clarified with their social identity, the nature, management and future prospects of their illness; generally using more flexible coping strategies to reduce their daily stress experiences. Four related subthemes were identified contributing to increased existential security: 1) more secure illness perceptions - feeling existentially recognized as "really" ill, 2) enhanced relaxation ability - using mindfulness techniques, 3) increased awareness - connecting differently to mind and body 4) improved ability to identify and express needs and feelings of distress - more active communicating. Patients suggested that mindfulness therapy could be expanded with more time for group-discussions followed by additional individual therapy. Generally, treatment positively influenced the patients' illness perceptions, stress-experiences, body- and self-awareness, coping strategies, self-image, social identity and social functioning. However, patients identified potentials for treatment improvements, and they needed further treatment to fully recover. Copyright © 2014 Elsevier Inc. All

  1. Physical functioning in patients with ankylosing spondylitis: comparing approaches of experienced ability with self-reported and objectively measured physical activity.

    PubMed

    van Genderen, Simon; van den Borne, Carlie; Geusens, Piet; van der Linden, Sjef; Boonen, Annelies; Plasqui, Guy

    2014-04-01

    Physical functioning can be assessed by different approaches that are characterized by increasing levels of individual appraisal. There is insufficient insight into which approach is the most informative in patients with ankylosing spondylitis (AS) compared with control subjects. The objective of this study was to compare patients with AS and control subjects regarding 3 approaches of functioning: experienced ability to perform activities (Bath Ankylosing Spondylitis Functional Index [BASFI]), self-reported amount of physical activity (PA) (Baecke questionnaire), and the objectively measured amount of PA (triaxial accelerometer). This case-control study included 24 AS patients and 24 control subjects (matched for age, gender, and body mass index). Subjects completed the BASFI and Baecke questionnaire and wore a triaxial accelerometer. Subjects also completed other self-reported measures on disease activity (Bath AS Disease Activity Index), fatigue (Multidimensional Fatigue Inventory), and overall health (EuroQol visual analog scale). Both groups included 14 men (58%), and the mean age was 48 years. Patients scored significantly worse on the BASFI (3.9 vs 0.2) than their healthy peers, whereas PA assessed by Baecke and the accelerometer did not differ between groups. Correlations between approaches of physical functioning were low to moderate. Bath Ankylosing Spondylitis Functional Index was associated with disease activity (r = 0.49) and physical fatigue (0.73) and Baecke with physical and activity related fatigue (r = 0.54 and r = 0.54), but total PA assessed by accelerometer was not associated with any of these experience-based health outcomes. Different approaches of the concept physical functioning in patients with AS provide different information. Compared with matched control subjects, patients with AS report more difficulties but report and objectively perform the same amount of PA.

  2. Clinical utility and patient consideration in the use of lenalidomide for multiple myeloma in Chinese patients

    PubMed Central

    Wang, Jing; Guo, Hongfeng; Zhou, Xin

    2015-01-01

    Multiple myeloma (MM) is an incurable hematologic malignancy caused by the autonomous growth of malignant plasma cells. In the last decade, the introduction of novel targeted agents such as thalidomide, bortezomib, and lenalidomide has dramatically improved the clinical outcome of MM patients in both the frontline and recurrent settings. Lenalidomide is a synthetic derivative of thalidomide, which has been shown to significantly improve overall survival, time to progression, and overall response rates in patients with MM. The China Food and Drug Administration approved the use of lenalidomide in patients with MM in 2013. In a Phase II trial, lenalidomide plus low-dose dexamethasone was associated with a high response rate and acceptable safety profile in heavily pretreated Chinese patients with relapsed/refractory MM, including those with renal impairment and IgD subtype. However, lenalidomide will remain as a second-line antimyeloma drug in the near future because of its high price and the policy of health insurance reimbursement in People’s Republic of China. In this review, we summarize the clinical utility and patient considerations in the use of lenalidomide for MM in Chinese patients. Further studies with larger sample sizes are required to investigate the better quality, longer duration, and more clinically meaningful outcomes of lenalidomide in the treatment of MM in Chinese patients. PMID:26082645

  3. Predominance of Hepatitis B Virus Genotype A Among Treated HIV Infected Patients Experiencing High Hepatitis B Virus Drug Resistance in Nairobi, Kenya.

    PubMed

    Mabeya, Sepha Nyatichi; Ngugi, Caroline; Lihana, Raphael Wekesa; Khamadi, Samoel Ashimosi; Nyamache, Anthony Kebira

    2017-09-01

    Hepatitis B virus (HBV)-HIV coinfections are becoming common with information on HBV genetic diversity and drug resistance still remaining elusive. To evaluate the HBV genetic diversity and drug resistance-associated mutations among drug-experienced HIV patients, the genetic analysis of the partial HBV-pol-reverse trancriptase gene was successfully sequenced from 13 samples. Analysis of the sequences showed that all (11) the sequences belonged to genotype A. Nucleos(t)ide drug resistance mutations were found in 6 patients. Five subjects had rtV173L, rtL180M, and rtM204V and one with rtL180M and rtM204V major mutations. HBV genotype A remains the most predominant genotype circulating in Nairobi city with detected high level of HBV drug resistance to lamivudine, telbivudine, and emtricitabine. The detected circulating HBV genotype A in Nairobi reflects its possible spread in the population with its origin being within the country. We suggest that patients should not be on lamivudine monotherapy. These individuals should be managed on combination of tenofovir plus lamivudine or emtricitabine therapy to prevent the emergence of HBV drug resistant variants alongside a continuous surveillance monitoring of drug resistance and HBV genotypes.

  4. A Preliminary Study of Psychiatric, Familial, and Medical Characteristics of High Utilizing Sickle Cell Disease Patients

    PubMed Central

    Carroll, C. Patrick; Haywood, Carlton; Hoot, Michelle R.; Lanzkron, Sophie

    2012-01-01

    Objectives To identify demographic, medical, and psychosocial characteristics that distinguished sickle cell disease patients who were frequent utilizers of urgent or emergent care resources from low-utilizing patients. Methods Patients at a large urban comprehensive sickle cell disease treatment center were recruited from clinic or during urgent care visits. Participants who were high utilizers, defined as having more than 4 acute or emergency care visits in the prior 12 months, were compared to patients with more typical utilization patterns on lifetime complications of SCD, family background, psychiatric history, occupational function, coping, depressive symptoms, and personality. Results High utilizers were nearly a decade younger on average; despite this they had a similar lifetime history of SCD complications. High utilizing patients' parents appeared to have greater educational achievement overall. High utilizers reported a nearly three-fold greater prevalence of psychiatric illness in family members than low utilizers. On other measures; including coping strategies, social support, and personality; the two groups were comparable. Discussion The study strengthens emerging evidence that disease severity, familial factors related to greater parental education, and psychiatric illness are important factors in high care utilization in patients with sickle cell disease. PMID:23246997

  5. Role of integrative pharmacokinetic and pharmacodynamic optimization strategy in the management of Parkinson"s disease patients experiencing motor fluctuations with levodopa.

    PubMed

    Okereke, Chukwuemeka S

    2002-01-01

    Parkinson's disease is a progressively debilitating motor neuron disease that affects the dopaminergic neurons within the nigral-striatal and surrounding pathways and which is characterized clinically by rigidity, resting tremor and bradykinesia with or without postural imbalance. Levodopa is the "gold standard" for the treatment and management of Parkinson's disease worldwide. However, following prolonged use of the drug, the "honey-moon" which was once enjoyed by patients on levodopa begins to wane. The clinical as well as the socio-economic costs associated with such failure in response to levodopa is enormous. Various approaches in the management of Parkinson's disease patients experiencing motor fluctuations with levodopa treatment have been suggested and include both pharmacologic and non-pharmacologic strategies involving invasive surgical intervention. Currently, the non-pharmacological approach, which is invasive, remains to be fully perfected and is associated with high morbidity and mortality. The use of the non-invasive, pharmacological approach is currently the most widely accepted approach but would require a review of all possible drug regimens used. This entails evaluating the pharmacokinetics and pharmacodynamic actions of the drug regimens used and possibly, dosage form and route of administration of the drugs. The use of levodopa formulated for transdermal or intranasal administration might help improve the ease of use and compliance. Controversy abounds as to the role of plasma pharmacokinetics of levodopa in the management of Parkinson's patients, vis a vis its dynamics at the central nerve terminal and its receptor site. However, it is worthy of mention that an integrated optimal pharmacological approach involving the peripheral, and central pharmacokinetics of levodopa as well as its central pharmacodynamics would ensure better treatment and management of this disease. In addition, the choice of alternate formulations and routes of

  6. Effectiveness, safety, durability and immune recovery in a retrospective, multicentre, observational cohort of ART-experienced, HIV-1-infected patients receiving maraviroc.

    PubMed

    Dentone, C; Sterrantino, G; Signori, A; Cenderello, G; Guerra, M; De Leo, P; Bartolacci, V; Mantia, E; Orofino, G; Giacomini, M; Bruzzone, B; Francisci, D; Di Biagio, A

    2017-10-01

    The aim of this retrospective, multicentre, observational study was to assess the durability, safety, immune recovery and effectiveness on viral suppression of antiretroviral therapy (ART) in a maraviroc (MVC)-based cohort. We collected clinical, demographical, immunological and virological parameters of adult HIV patients who were infected by CCR5-tropic virus and started an ART regimen containing MVC from 2005 to 2012. We created a longitudinal mixed model to assess the change over time of data. We enrolled 126 drug-experienced patients; the median duration of MVC treatment was 25 months. The probability of stopping ART at one year was 13.3%, and at three years was 27.3%. Statistically significant changes were observed for CD4+ cell count increase ( p < 0.001), HIV-RNA decrease ( p < 0.001) and total cholesterol decrease ( p = 0.005). Ninety-four patients (79.7%) had CD4 ≥ 200 cells/mm(3) at baseline while nine of them reached this threshold at nine months (7.6%), 17 (13%) after nine months and six (5%) remained below 200 cells/mm(3) at the end of the study. Overall, 114 patients (90.5%) achieved an HIV-RNA ≤ 50 cp/ml. A majority of patients maintained CD4 cell counts of ≥ 200 cells/mm(3) and achieved an undetectable HIV viral load within three months. MVC-containing regimens are safe and appear to be a feasible therapeutic option for ART.

  7. Engaging Terminally Ill Patients in End of Life Talk: How Experienced Palliative Medicine Doctors Navigate the Dilemma of Promoting Discussions about Dying

    PubMed Central

    Parry, Ruth; Land, Victoria; Faull, Christina; Feathers, Luke; Seymour, Jane

    2016-01-01

    Objective To examine how palliative medicine doctors engage patients in end-of-life (hereon, EoL) talk. To examine whether the practice of “eliciting and responding to cues”, which has been widely advocated in the EoL care literature, promotes EoL talk. Design Conversation analysis of video- and audio-recorded consultations. Participants Unselected terminally ill patients and their companions in consultation with experienced palliative medicine doctors. Setting Outpatient clinic, day therapy clinic, and inpatient unit of a single English hospice. Results Doctors most commonly promoted EoL talk through open elaboration solicitations; these created opportunities for patients to introduce–then later further articulate–EoL considerations in such a way that doctors did not overtly ask about EoL matters. Importantly, the wording of elaboration solicitations avoided assuming that patients had EoL concerns. If a patient responded to open elaboration solicitations without introducing EoL considerations, doctors sometimes pursued EoL talk by switching to a less participatory and more presumptive type of solicitation, which suggested the patient might have EoL concerns. These more overt solicitations were used only later in consultations, which indicates that doctors give precedence to patients volunteering EoL considerations, and offer them opportunities to take the lead in initiating EoL talk. There is evidence that doctors treat elaboration of patients’ talk as a resource for engaging them in EoL conversations. However, there are limitations associated with labelling that talk as “cues” as is common in EoL communication contexts. We examine these limitations and propose “possible EoL considerations” as a descriptively more accurate term. Conclusions Through communicating–via open elaboration solicitations–in ways that create opportunities for patients to volunteer EoL considerations, doctors navigate a core dilemma in promoting EoL talk: giving

  8. Osteoporosis medication adherence: Physician perceptions vs. patients' utilization.

    PubMed Central

    Curtis, Jeffrey R.; Cai, Qian; Wade, Sally W.; Stolshek, Bradley S.; Adams, John L.; Balasubramanian, Akhila; Viswanathan, Hema N.; Kallich, Joel D.

    2013-01-01

    Few data are available on physician perceptions of osteoporosis medication adherence. This study compared physician-estimated medication adherence with adherence calculated from their patients' pharmacy claims. Women aged ≥45 years, with an osteoporosis-related pharmacy claim between January 1, 2005 and August 31, 2008, and continuous coverage for ≥12 months before and after first (index) claim, were identified from a commercial health plan population. Prescribing physicians treating ≥5 of these patients were invited to complete a survey on their perception of medication adherence and factors affecting adherence in their patients. Pharmacy claims-based medication possession ratio (MPR) was calculated for the 12-month post-index period for each patient. Physicians who overestimated the percentage of adherent (MPR ≥0.8) patients by ≥10 points were considered “optimistic”. Logistic regression assessed physician characteristics associated with optimistic perception of adherence. A total of 376 (17.2%) physicians responded to the survey; 62.0% were male, 58.2% were aged 45 to 60 years, 55.3% had ≥20 years of practice, and 35.4% practiced in an academic setting. Participating physicians prescribed osteoporosis medications for 2748 patients with claims data (mean [SD] age of 62.0 [10.6] years). On average, physicians estimated 67.2% of their patients to be adherent; however, only 40% of patients were actually adherent based on pharmacy data. Optimistic physicians (73.4%) estimated 71.9% of patients to be adherent while only 32.2% of their patients were adherent based on claims data. Physicians in academic settings were more likely to be optimistic than community-based physicians (odds ratio 1.69, 95% CI: 1.01, 2.85). Overestimation of medication adherence may impede physicians' ability to provide high quality care for their osteoporosis patients. PMID:23502042

  9. HIV-1 Drug-Resistance Surveillance among Treatment-Experienced and -Naïve Patients after the Implementation of Antiretroviral Therapy in Ghana

    PubMed Central

    Ishikawa, Koichi; Brandful, James A. M.; Ofori, Sampson B.; Yamaoka, Shoji; Ampofo, William K.; Sugiura, Wataru

    2013-01-01

    Background Limited HIV-1 drug-resistance surveillance has been carried out in Ghana since the implementation of antiretroviral therapy (ART). This study sought to provide data on the profile of HIV-1 drug resistance in ART-experienced and newly diagnosed individuals in Ghana. Methods Samples were collected from 101 HIV-1-infected patients (32 ART-experienced cases with virological failure and 69 newly diagnosed ART-naïve cases, including 11 children), in Koforidua, Eastern region of Ghana, from February 2009 to January 2010. The pol gene sequences were analyzed by in-house HIV-1 drug-resistance testing. Results The most prevalent HIV-1 subtype was CRF02_AG (66.3%, 67/101) followed by unique recombinant forms (25.7%, 26/101). Among 31 ART-experienced adults, 22 (71.0%) possessed at least one drug-resistance mutation, and 14 (45.2%) had two-class-resistance to nucleoside and non-nucleoside reverse-transcriptase inhibitors used in their first ART regimen. Importantly, the number of accumulated mutations clearly correlated with the duration of ART. The most prevalent mutation was lamivudine-resistance M184V (n = 12, 38.7%) followed by efavirenz/nevirapine-resistance K103N (n = 9, 29.0%), and zidovudine/stavudine-resistance T215Y/F (n = 6, 19.4%). Within the viral protease, the major nelfinavir-resistance mutation L90M was found in one case. No transmitted HIV-1 drug-resistance mutation was found in 59 ART-naïve adults, but K103N and G190S mutations were observed in one ART-naïve child. Conclusions Despite expanding accessibility to ART in Eastern Ghana, the prevalence of transmitted HIV-1 drug resistance presently appears to be low. As ART provision with limited options is scaled up nationwide in Ghana, careful monitoring of transmitted HIV-1 drug resistance is necessary. PMID:23977189

  10. Dolutegravir in Antiretroviral-Experienced Patients With Raltegravir- and/or Elvitegravir-Resistant HIV-1: 24-Week Results of the Phase III VIKING-3 Study

    PubMed Central

    Castagna, Antonella; Maggiolo, Franco; Penco, Giovanni; Wright, David; Mills, Anthony; Grossberg, Robert; Molina, Jean-Michel; Chas, Julie; Durant, Jacques; Moreno, Santiago; Doroana, Manuela; Ait-Khaled, Mounir; Huang, Jenny; Min, Sherene; Song, Ivy; Vavro, Cindy; Nichols, Garrett; Yeo, Jane M.; Aberg, J.; Akil, B.; Arribas, J. R.; Baril, J.-G.; Blanco Arévalo, J. L.; Blanco Quintana, F.; Blick, G.; Boix Martínez, V.; Bouchaud, O.; Branco, T.; Bredeek, U. F.; Castro Iglesias, M.; Clumeck, N.; Conway, B.; DeJesus, E.; Delassus, J.-L.; De Truchis, P.; Di Perri, G.; Di Pietro, M.; Duggan, J.; Duvivier, C.; Elion, R.; Eron, J.; Fish, D.; Gathe, J.; Haubrich, R.; Henderson, H.; Hicks, C.; Hocqueloux, L.; Hodder, S.; Hsiao, C.-B.; Katlama, C.; Kozal, M.; Kumar, P.; Lalla-Reddy, S.; Lazzarin, A.; Leoncini, F.; Llibre, J. M.; Mansinho, K.; Morlat, P.; Mounzer, K.; Murphy, M.; Newman, C.; Nguyen, T.; Nseir, B.; Philibert, P.; Pialoux, G.; Poizot-Martin, I.; Ramgopal, M.; Richmond, G.; Salmon Ceron, D.; Sax, P.; Scarsella, A.; Sension, M.; Shalit, P.; Sighinolfi, L.; Sloan, L.; Small, C.; Stein, D.; Tashima, K.; Tebas, P.; Torti, C.; Tribble, M.; Troisvallets, D.; Tsoukas, C.; Viciana Fernández, P.; Ward, D.; Wheeler, D.; Wilkin, T.; Yeni, G.-P.; Louise Martin-Carpenter, J.; Uhlenbrauck, Gina

    2014-01-01

    Background. The pilot phase IIb VIKING study suggested that dolutegravir (DTG), a human immunodeficiency virus (HIV) integrase inhibitor (INI), would be efficacious in INI-resistant patients at the 50 mg twice daily (BID) dose. Methods. VIKING-3 is a single-arm, open-label phase III study in which therapy-experienced adults with INI-resistant virus received DTG 50 mg BID while continuing their failing regimen (without raltegravir or elvitegravir) through day 7, after which the regimen was optimized with ≥1 fully active drug and DTG continued. The primary efficacy endpoints were the mean change from baseline in plasma HIV-1 RNA at day 8 and the proportion of subjects with HIV-1 RNA <50 c/mL at week 24. Results. Mean change in HIV-1 RNA at day 8 was −1.43 log10 c/mL, and 69% of subjects achieved <50 c/mL at week 24. Multivariate analyses demonstrated a strong association between baseline DTG susceptibility and response. Response was most reduced in subjects with Q148 + ≥2 resistance-associated mutations. DTG 50 mg BID had a low (3%) discontinuation rate due to adverse events, similar to INI-naive subjects receiving DTG 50 mg once daily. Conclusions. DTG 50 mg BID–based therapy was effective in this highly treatment-experienced population with INI-resistant virus. Clinical Trials Registration. www.clinicaltrials.gov (NCT01328041) and http://www.gsk-clinicalstudywww.gsk-clinicalstudyregister.com (112574). PMID:24446523

  11. Utility of Periodontal exploration in patients with Fibromyalgia

    PubMed Central

    Santos-García, Rocío; Sánchez-Domínguez, Benito; Cordero, Mario D.; Rios-Santos, José V.; Jaramillo-Santos, María R.; Climent, Mariano H.

    2012-01-01

    Objetive: Fibromyalgia (FM) is a chronic pain syndrome with unknown etiology, which affects predominantly women. Mitochondrial alteration could have a role in the pathophysilogical mechanisms of inflammatory conditions as FM and periodontitis. The aim of the present study was assay the relationship between both diseases and mitochondrial dysfunction. Patient and Methods: We study the presence of periodontitis in twelve patients diagnosed of FM and mitochondrial dysfunction described. The diagnosis of FM was established according to ACR criteria and clinical symptoms were evaluated using the Fibromyalgia Impact Questionnaire (FIQ) and Beck Depression Inventory (BDI). Results: Only one patients of twelve included and agreed to participate in the study were diagnosed with periodontitis. Conclusions: Pending studies with larger numbers of patients, we can conclude that mitochondrial dysfunction in FM is a itself event not related with periodontitis. Periodontitis could be considered a exclusion criterion in all studies about mitochondrial dysfunction in patients. Key words:Peridontitis, fibromyalgia, mitocondrial dysfunction, oxidative stress. PMID:24558523

  12. Utilizing patient satisfaction surveys to prepare for Medicaid managed care.

    PubMed

    Fields, T T; Gomez, P S

    2001-02-01

    To prepare for Medicaid managed care, a community health center incorporated the business principle of continuous quality improvement, often used in the private sector to improve customer service, into its planning process. The initial endeavor was to create a patient satisfaction survey that was appropriate for the uniqueness of the community. The survey, taken monthly, resulted in both staff and patients making active improvements in the clinic environment. Staff showed more enthusiasm, and patients were more assertive in their attitudes toward the clinic. The empowerment of the patient to take ownership in the clinic will be coupled with the next step of the formalized plan, that of educating patients on the steps necessary to ensure that their Medicaid managed care facility will be the local community health center.

  13. Demographics, clinical characteristics, health resource utilization and cost of chronic thromboembolic pulmonary hypertension patients: retrospective results from six European countries.

    PubMed

    Schweikert, Bernd; Pittrow, David; Vizza, Carmine Dario; Pepke-Zaba, Joanna; Hoeper, Marius M; Gabriel, Anja; Berg, Jenny; Sikirica, Mirko

    2014-06-09

    Chronic Thromboembolic Pulmonary Hypertension (CTEPH) results from incomplete resolution of a pulmonary embolus, leading to pulmonary hypertension and progressive right heart failure and death. We aimed to describe the demographics, treatment patterns, health resource utilization and related costs of patients with CTEPH. In specialized PH centres across six European countries, medical charts of CTEPH patients on PH medication were retrospectively extracted (chart review between 2006 and 2009). Resource utilization was valued using country-specific unit costs. Descriptive statistical analyses were performed. Twenty-one hospitals documented 119 consecutive CTEPH patients over an average of 25.4 months. Patients were inoperable (83.9%) or persistent after surgery (16.0%) with mean age 67.5 ± 12.3 years, 61% were female. The average 6-minute walking distance was 298 ± 120 meters, and NYHA class II/III/IV was 27/59/14%. At baseline, 59.7% patients received endothelin receptor antagonist, 34.4% phosphodiesterase-5 inhibitors, and 5.8% prostacyclin. Adding a second PH medication was the most common regimen change. CTEPH patients experienced 1.8 ± 2.2 hospitalizations per year accounting for 14.8 ± 26.1 days in hospital. Patients paid on average 2.8 office visits per year to their general practitioner and 1.3 visits to a specialist. Unadjusted annual mortality rate was 6.0%. Annual cost of PH specific medication was the predominant economic factor averaging € 36,768 per year. Costs for hospitalizations (€ 4,496) and concomitant medications (€ 2,510) were substantially lower. Other health care resource items only accounted for marginal additional costs. CTEPH patients are characterised by substantial morbidity and mortality. Health care utilisation, predominantly due to off-label use of PH drugs, is significant.

  14. Utility of emergency cranial computed tomography in patients without trauma.

    PubMed

    Narayanan, Vignesh; Keniston, Angela; Albert, Richard K

    2012-09-01

    The objectives of this study were to determine, in patients admitted to the hospital from the emergency department (ED) without evidence of trauma, 1) the prevalence of clinically important abnormalities on cranial computed tomography (CCT) and 2) the frequency of emergent therapeutic interventions required because of these abnormalities. The authors retrospectively reviewed the records of all patients from 2007 between the ages of 18 and 89 years who had CCT as part of their ED evaluations prior to hospitalization. Patients with any indication of trauma were excluded, as were those who had a lumbar puncture (LP). Chief complaint, results of the ED neurologic examination, tomogram findings, and whether patients had emergent interventions were recorded. Patients presenting with altered mental status (AMS) were analyzed separately. Of the 766 patients meeting inclusion criteria, 83 (11%) had focal neurologic findings, and 61 (8%) had clinically important abnormalities on computed tomography. Emergent interventions occurred in only 12 (1.6%), 11 (92%) of whom had focal neurologic findings. In the subgroup of 287 patients with AMS as their presenting problem, 14 (4.9%) had focal findings, six (2%) had clinically important abnormalities on tomography, and only two (0.7%) required emergent interventions, both of whom had focal findings. Patients presenting with AMS were less likely to have positive findings on tomography (odds ratio [OR] = 0.16, 95% confidence interval [CI] = 0.07 to 0.39). Patients presenting with motor weakness or speech abnormalities, or who were unresponsive, were more likely to have positive findings on tomography (OR = 4.7, 95% CI = 2.6 to 8.6; OR = 4.4, 95% CI = 1.5 to 2.7; and OR = 3.3, 95% CI = 1.6 to 7.1, respectively). Of patients without evidence of trauma who receive CCT in the ED, the prevalence of focal neurologic findings and clinically important abnormalities on tomography is low, the need for emergent intervention is very low, and the

  15. Emotions related to participation restrictions as experienced by patients with early rheumatoid arthritis: a qualitative interview study (the Swedish TIRA project).

    PubMed

    Östlund, Gunnel; Björk, Mathilda; Thyberg, Ingrid; Thyberg, Mikael; Valtersson, Eva; Stenström, Birgitta; Sverker, Annette

    2014-01-01

    Psychological distress is a well-known complication in rheumatoid arthritis (RA), but knowledge regarding emotions and their relationship to participation restrictions is scarce. The objective of the study was to explore emotions related to participation restrictions by patients with early RA. In this study, 48 patients with early RA, aged 20-63 years, were interviewed about participation restrictions using the critical incident technique. Information from transcribed interviews was converted into dilemmas and linked to International Classification of Functioning, Disability, and Health (ICF) participation codes. The emotions described were condensed and categorized. Hopelessness and sadness were described when trying to perform daily activities such as getting up in the mornings and getting dressed, or not being able to perform duties at work. Sadness was experienced in relation to not being able to continue leisure activities or care for children. Examples of fear descriptions were found in relation to deteriorating health and fumble fear, which made the individual withdraw from activities as a result of mistrusting the body. Anger and irritation were described in relation to domestic and employed work but also in social relations where the individual felt unable to continue valued activities. Shame or embarrassment was described when participation restrictions became visible in public. Feelings of grief, aggressiveness, fear, and shame are emotions closely related to participation restrictions in everyday life in early RA. Emotions related to disability need to be addressed both in clinical settings in order to optimize rehabilitative multi-professional interventions and in research to achieve further knowledge.

  16. Improving Therapeutic Odyssey: Preemptive Pharmacogenomics Utility in Patient Care.

    PubMed

    Lazaridis, K N

    2017-01-01

    Pharmacogenomics, studying genetic variation related to drug response, was established decades ago. Today, performing clinical pharmacogenomics testing has increased, creating great potential to improve patient care. Yet widespread implementation of pharmacogenomics in practice is currently limited, resulting in the "therapeutic odyssey" of patients. Preemptive clinical pharmacogenomics testing prior to the time of prescribing is now emerging as an option that could tailor the pharmacotherapy of patients by increasing drug effectiveness while reducing adverse drug reaction risk. © 2016 American Society for Clinical Pharmacology and Therapeutics.

  17. Utilizing a disease management approach to improve ESRD patient outcomes.

    PubMed

    Anand, Shaan; Nissenson, Allen R

    2002-01-01

    In this era of processes and systems to improve quality, disease management is one methodology to improve care delivery and outcomes for patients with chronic kidney disease (CKD). In most disease management systems a senior renal nurse coordinates all aspects of the patient's care and ensures that the prescribed and necessary care is delivered for both CKD-related and comorbid conditions. The nurse also continually monitors outcomes on quality indicators and key performance measures. These outcome data are then aggregated and analyzed, are compared with local and national benchmarks, and drive the continuous quality improvement (CQI) process. Such a system attempts to centralize the currently fragmented care delivery system, continually improve patient outcomes, and conserve scarce economic resources. Early data suggest a disease management approach may improve both the morbidity and mortality of CKD patients.

  18. Utility of Periodontal exploration in patients with Fibromyalgia.

    PubMed

    Santos-García, Rocío; Sánchez-Domínguez, Benito; Cordero, Mario D; Rios-Santos, José V; Jaramillo-Santos, María R; Climent, Mariano H; Bullon, Pedro

    2012-02-01

    [corrected] Fibromyalgia (FM) is a chronic pain syndrome with unknown etiology, which affects predominantly women. Mitochondrial alteration could have a role in the pathophysilogical mechanisms of inflammatory conditions as FM and periodontitis. The aim of the present study was assay the relationship between both diseases and mitochondrial dysfunction. We study the presence of periodontitis in twelve patients diagnosed of FM and mitochondrial dysfunction described. The diagnosis of FM was established according to ACR criteria and clinical symptoms were evaluated using the Fibromyalgia Impact Questionnaire (FIQ) and Beck Depression Inventory (BDI). Only one patients of twelve included and agreed to participate in the study were diagnosed with periodontitis. Pending studies with larger numbers of patients, we can conclude that mitochondrial dysfunction in FM is a itself event not related with periodontitis. Periodontitis could be considered a exclusion criterion in all studies about mitochondrial dysfunction in patients. Key words:Peridontitis, fibromyalgia, mitocondrial dysfunction, oxidative stress.

  19. Interferon γ-induced protein 10 kinetics in treatment-naive versus treatment-experienced patients receiving interferon-free therapy for hepatitis C virus infection: implications for the innate immune response.

    PubMed

    Lin, Jennifer C; Habersetzer, François; Rodriguez-Torres, Maribel; Afdhal, Nezam; Lawitz, Eric J; Paulson, Matthew S; Zhu, Yanni; Subramanian, Gangadharan Mani; McHutchison, John G; Sulkowski, Mark; Wyles, David L; Schooley, Robert T

    2014-12-15

    We measured interferon γ-induced protein 10 (IP-10) levels in 428 patients at baseline, week 1, and week 2 of all-oral treatment for hepatitis C virus (HCV) infection. An increased baseline IP-10 level was associated with a T allele in the IL28B gene, an increased alanine aminotransferase level in treatment-naive but not experienced patients, and an increased body mass index. At week 1, the mean decline in plasma IP-10 levels was the same in treatment-naive and treatment-experienced patients (-49%), whereas during week 2 the mean decline in IP-10 levels in treatment-naive patients (-14%) was significantly larger than in treatment-experienced patients (-2%; P = .0176). IP-10 thus may be a surrogate marker of the rate of intracellular viral replication complex decay.

  20. Cervical spine computed tomography utilization in pediatric trauma patients.

    PubMed

    Adelgais, Kathleen M; Browne, Lorin; Holsti, Maija; Metzger, Ryan R; Murphy, Shannon Cox; Dudley, Nanette

    2014-02-01

    Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs). Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression. 5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p<0.05) and more frequent ICU admissions (44.3% vs. 26.1% p<0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI=8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI=25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT. Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED. © 2014 Elsevier Inc. All rights reserved.

  1. Saskatchewan: improving patient, nursing and organizational outcomes utilizing formal nurse-patient ratios.

    PubMed

    Rozdilsky, Janlyn; Alecxe, Amber

    2012-03-01

    The issue of nurse-to-patient ratios has been of significant interest to nurses in Saskatchewan. A commitment to a nurse-to-patient pilot project was articulated in a letter of understanding in the 2005 to 2008 contract between the Saskatchewan Union of Nurses (SUN) and the Saskatchewan Association of Health Organizations. The SUN, the Saskatoon Health Region and the Saskatchewan Ministry of Health formed a partnership to engage in the pilot project, which lasted from November 2008 to March 2011. The project involved the creation of a flexible, dynamic and real-time staffing tool to inform day-to-day nurse staffing decisions on a hospital unit and was based on an adaptation of Curley's Synergy Model. A medical unit at St. Paul's Hospital in Saskatoon was selected for implementation, and all front-line nursing staff as well as unit nursing leaders were involved. A project working group adapted the Synergy-based Patient Scoring Tool (PST), which had been utilized for a recent project in British Columbia, to its own patient population. In April 2010, nurses began assessing each patient on every shift with the goal of determining the most suitable care provider. Patient assignment became based on the holistic assessment of patient needs according to the PST results rather than "geography" (for example, one nurse assigned to a multi-bed unit regardless of the acuity/capability of patients in the unit). Whenever possible, staffing on the unit was increased according to tool calculations.Positive impacts in patient outcomes began to be noted during the final data collection period for the project – nosocomial infection rates showed improvement, and the number of falls per patient-days decreased. As well, patient needs were made more visible through use of the PST, which created non-threatening opportunities for dialogue related to legislated scopes of practice. While longer timelines and larger sample size are needed to measure impacts on retention and recruitment of

  2. Utility of patch testing for patients with drug eruption.

    PubMed

    Ohtoshi, S; Kitami, Y; Sueki, H; Nakada, T

    2014-04-01

    Patch testing is less dangerous than oral provocation testing for identification of the causative drug for patients with drug eruption; however, its usefulness for such identification is controversial. To clarify the rates of positive patch testing for patients with drug eruption, classified by causative drugs and clinical features. We analysed results during the period 1990-2010 for 444 patients (151 men, 293 women; mean ± SD age 49.9 ± 18.6 years) who were tested for drug eruption. In the patient group, there were 309 people (69.1%) with maculopapular eruption and 31 (6.9%) with severe drug eruption. The test materials were applied to the back and left for 2 days under occlusion, then results were assessed by the International Contact Dermatitis Research Group (ICDRG) scoring system 3 days after application. Reactions of + to +++ were regarded as positive. Of the 444 patients, 100 (22.4%) had a positive patch test result to a suspected drug. Positive rates were 23.6% and 20.0% for maculopapular eruption and fixed drug eruption, respectively. The class of materials to which most patients reacted positively was contrast medium (n = 53; 41.1%), followed by drugs acting on the central nervous system (n = 18; 28.6%). In the latter group, 16 of the 18 patients were positive to antiepileptics. Positive rates depend on the causative drug rather than the clinical features of the drug eruption. Patch testing is useful when contrast medium or antiepileptics are suspected to be the causative drugs. However, standardization of patch test materials and method of reading is needed, as well as guidelines regarding when testing should be performed. Although patch testing for drug eruption has significant potential, it requires further validation. © 2014 The Authors. Clinical and Experimental Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.

  3. Factors associated with mortality among persistently viraemic triple-antiretroviral-class-experienced patients receiving antiretroviral therapy in the HIV Outpatient Study (HOPS).

    PubMed

    Palella, Frank J; Armon, Carl; Buchacz, Kate; Chmiel, Joan S; Novak, Richard M; D'Aquila, Richard T; Brooks, John T

    2014-10-01

    Identifying factors associated with mortality for HIV-infected patients with persistent viraemia despite antiretroviral (ARV) therapy may inform diagnostic and treatment strategies. We analysed data from viraemic triple-ARV-class-experienced HIV Outpatient Study patients seen during 1 January 1999 to 31 December 2012 who, despite treatment that included ARVs from three major drug classes [nucleoside analogue reverse transcriptase inhibitors, non-nucleoside analogue reverse transcriptase inhibitors and protease inhibitors (PIs)], had plasma HIV RNA levels [viral load (VL)] >1000 copies/mL ['triple ARV class failure' (TCF)]. The baseline was defined as the date of meeting the TCF criteria during 1999-2008. We identified factors associated with mortality using Cox regression. Of 597 patients who met the TCF criteria (median follow-up after baseline 4.9 years), 115 (19.3%) died. Baseline factors associated with mortality were age per 10 years [hazard ratio (HR) 1.61, 95% CI 1.28-2.02], risk of HIV from use of injection drugs (HR 1.81, 95% CI 1.10-2.98), CD4+ T cell count <200 cells/mm(3) (HR 3.68, 95% CI 2.41-5.62), VL ≥5.0 log10 copies/mL (HR 2.91, 95% CI 1.88-4.49) and receiving a first combination ARV therapy regimen that was PI-based (HR 2.44, 95% CI 1.47-4.06); receiving a novel ARV agent during follow-up (HR 0.45, 95% CI 0.22-0.93) was protective. Genotypic resistance testing results were available for 274 (45.9%) of the TCF patients, of whom 47 (17.2%) died. In this group, factors associated with death were increasing age (HR 1.94, 95% CI 1.36-2.78, per 10 year increment), risk of HIV from use of injection drugs (HR 2.71, 95% CI 1.37-5.39), baseline VL ≥5.0 log10 copies/mL (HR 5.35, 95% CI 2.82-10.1) and receiving PI-based first combination ARV therapy regimen (HR 3.20, 95% CI 1.25-8.17). No HIV mutations or combinations of mutations were significantly associated with survival. Factors significantly associated with mortality risk among TCF patients who

  4. The Impact of Experiencing Adverse Drug Reactions on the Patient's Quality of Life: A Retrospective Cross-Sectional Study in the Netherlands.

    PubMed

    Rolfes, Leàn; van Hunsel, Florence; Taxis, Katja; van Puijenbroek, Eugène

    2016-08-01

    There is little information as to what extent adverse drug reactions (ADRs) influence patients' health-related quality of life (HR-QOL). From a pharmacovigilance perspective, capturing and making the best use of this information remains a challenge. The Netherlands Pharmacovigilance Centre Lareb received about 1800 reports after the packaging of the drug Thyrax(®) (levothyroxine; Aspen Pharma Trading Limited, Dublin, Ireland) changed from a brown glass bottle to a blister package in the Netherlands. The objective of this study was to explore the impact of ADRs on HR-QOL in patients who reported a possible ADR to Lareb in relation to the change in the packaging of the drug Thyrax(®). A secondary objective was to explore factors correlated with change in HR-QOL. Patients who reported an ADR in relation to the Thyrax(®) packaging change were included in this study. A web-based adapted version of the COOP/WONCA questionnaire was sent to explore the HR-QOL before versus during the ADR, expressed on a 5-point scale from no impact (1) to high impact (5). Multivariable linear regression analysis was used to identify factors correlated with change in HR-QOL. Overall, 1167 patients returned the questionnaire (71.2 % response rate). The difference in HR-QOL was -0.8 for physical, -1.2 for mental, -1.4 for daily activities, -1.3 for social, and -1.3 for overall health status (p < 0.001 for each domain). Age, sex, educational level of the patient, and absence from work due to an ADR were correlated with at least one domain, while severity of the ADR was found to be correlated with all domains of HR-QOL. Patients who reported possible ADRs after the Thyrax(®) packaging change experienced a significant decrease in HR-QOL. This impact was highest for the domains 'daily activities', 'overall health status', and 'mental health' and lowest for 'physical fitness'.

  5. Utility of colour Doppler sonography in patients with Graves' disease.

    PubMed

    Kumar, K V S Hari; Vamsikrishna, P; Verma, A; Muthukrishnan, J; Rayudu, B Ramasubba; Modi, K D

    2009-12-01

    Assessment of thyroid blood flow gives valuable information about underlying functional status. Colour Flow Doppler Sonography (CFDS) is a powerful tool which displays tissue blood flow and vascularity. Colour Flow Doppler Sonography of the thyroid gland in different subsets of patients with Graves' disease was studied to define its role in initial diagnosis and management. Eighty consecutive patients with Graves' disease (both treated and untreated) presented to hospital between August 2007 and February 2008. All patients were evaluated with CFDS of the thyroid for size, vascularity and peak systolic velocity (PSV) of the Inferior Thyroid Artery (ITA). Pertechnate scan and thyroidal autoantibody levels were done in selected cases. The patients were divided into Untreated Graves' disease (n = 31), Graves' disease on treatment but hyperthyroid (n = 26) and euthyroid Graves' disease on therapy (n = 23). Mann-Whitney U-test was used for statistical analysis and a p-value of less than 0.05 was considered significant. Thyroid blood flow, as assessed by PSV of ITA, was significantly higher in untreated Graves' disease than in Graves disease on treatment but hyperthyroid and euthyroid Graves respectively (61.5 +/- 19.5 versus 42.9 +/- 24.7 versus 32.2 +/- 12.9 cm/s, p < 0.05). Parenchymal vascularity of the thyroid gland was higher in hyperthyroid patients than in euthyroid patients irrespective of therapy. In both groups on therapy, the dose of carbimazole correlated with the vascularity of the gland (r = 0.492 versus 0.564, p < 0.05). Colour Flow Doppler Sonography parameters correlated significantly with pertechnate scan results giving comparable sensitivity and specificity. Assessment of thyroid blood flow by CFDS is an effective marker in the initial diagnosis of Graves' disease. Vascularity of the gland can predict long term disease course while on medical therapy.

  6. Bone grafts utilized in dentistry: an analysis of patients' preferences.

    PubMed

    Fernández, Ramón Fuentes; Bucchi, Cristina; Navarro, Pablo; Beltrán, Víctor; Borie, Eduardo

    2015-10-20

    Many procedures currently require the use of bone grafts to replace or recover bone volume that has been resorbed. However, the patient's opinion and preferences must be taken into account before implementing any treatment. Researchers have focused primarily on assessing the effectiveness of bone grafts rather than on patients' perceptions. Thus, the aim of this study was to explore patients' opinions regarding the different types of bone grafts used in dental treatments. One hundred patients were randomly chosen participated in the study. A standardized survey of 10 questions was used to investigate their opinions regarding the different types of bone grafts used in dental treatments. Descriptive statistics were calculated for the different variables, and absolute frequencies and percentages were used as summary measures. A value of p <0.05 was selected as the threshold for statistical significance. The highest rate of refusal was observed for allografts and xenografts. The grafts with the lowest rates of refusal were autologous grafts (3 %) and alloplastics (2 %). No significant differences were found between the various types of bone grafts in the sociodemographic variables or the refusal/acceptance variable. Similarly, no significant relations were observed between a specific religious affiliation and the acceptance/refusal rates of the various types of graft. Allografts and xenografts elicited the highest refusal rates among the surveyed patients, and autologous bone and alloplastics were the most accepted bone grafts. Moreover, no differences were found in the sociodemographic variables or religious affiliations in terms of the acceptance/refusal rates of the different bone grafts.

  7. Triple therapy in treatment-experienced patients with HCV-cirrhosis in a multicentre cohort of the French Early Access Programme (ANRS CO20-CUPIC) - NCT01514890.

    PubMed

    Hézode, Christophe; Fontaine, Hélène; Dorival, Céline; Larrey, Dominique; Zoulim, Fabien; Canva, Valérie; de Ledinghen, Victor; Poynard, Thierry; Samuel, Didier; Bourlière, Marc; Zarski, Jean-Pierre; Raabe, Jean-Jacques; Alric, Laurent; Marcellin, Patrick; Riachi, Ghassan; Bernard, Pierre-Henri; Loustaud-Ratti, Véronique; Métivier, Sophie; Tran, Albert; Serfaty, Lawrence; Abergel, Armand; Causse, Xavier; Di Martino, Vincent; Guyader, Dominique; Lucidarme, Damien; Grando-Lemaire, Véronique; Hillon, Patrick; Feray, Cyrille; Dao, Thong; Cacoub, Patrice; Rosa, Isabelle; Attali, Pierre; Petrov-Sanchez, Ventzislava; Barthe, Yoann; Pawlotsky, Jean-Michel; Pol, Stanislas; Carrat, Fabrice; Bronowicki, Jean-Pierre

    2013-09-01

    In phase III trials, the safety profile of triple therapy (pegylated interferon/ribavirin with boceprevir or telaprevir) seems to be similar in HCV treatment-experienced cirrhotic and non-cirrhotic patients, but few cirrhotics were included. We report the week 16 safety and efficacy analysis in a cohort of compensated cirrhotics treated in the French Early Access Programme. 674 genotype 1 patients, prospectively included, received 48 weeks of triple therapy. The analysis is restricted to 497 patients reaching week 16. A high incidence of serious adverse events (40.0%), and of death and severe complications (severe infection or hepatic decompensation) (6.4%), and a difficult management of anaemia (erythropoietin and transfusion use in 50.7% and 12.1%) were observed. Independent predictors of anaemia < 8 g/dl or blood transfusion were: female gender (OR 2.19, 95% CI 1.11-4.33, p=0.024), no lead-in phase (OR 2.25, 95% CI 1.15-4.39, p=0.018), age ≥ 65 years (OR 3.04, 95% CI 1.54-6.02, p=0.0014), haemoglobin level (≤ 12 g/dl for females, ≤ 13 g/dl for males) (OR 5.30, 95% CI 2.49-11.5, p=0.0001). Death or severe complications were related to platelets count ≤ 100,000/mm(3) (OR 3.11, 95% CI 1.30-7.41, p=0.0105) and albumin <35 g/dl (OR 6.33, 95% CI 2.66-15.07, p=0.0001), with a risk of 44.1% in patients with both. However, the on-treatment virological response was high. The safety profile was poor and patients with platelet count ≤ 100,000/mm(3) and serum albumin <35 g/L should not be treated with the triple therapy. Copyright © 2013. Published by Elsevier B.V.

  8. Assessment of Maraviroc Exposure–Response Relationship at 48 Weeks in Treatment-Experienced HIV-1–Infected Patients in the MOTIVATE Studies

    PubMed Central

    Jacqmin, P; Wade, J R; Weatherley, B; Snoeck, E; Marshall, S; McFadyen, L

    2013-01-01

    Efficacy exposure–response relationships of the CCR5 antagonist maraviroc were evaluated across two phase III clinical trials. This post-hoc analysis used 48-week efficacy data from 841 treatment-experienced patients infected with CCR5-tropic human immunodeficiency virus type 1 (HIV-1), identified by the enhanced sensitivity Trofile assay. Probability of treatment success (viral RNA <50 copies/ml) was modeled using generalized additive logistic regression, testing exposure, clinical, and virologic variables. Prognostic factors for treatment success (in decreasing order of Akaike information criterion (AIC) change) were: maraviroc treatment, high-weighted overall susceptibility to background treatment, absence of an undetectable maraviroc concentration, high baseline CD4 count (BCD4), low viral load (VL), race (other than black), absence of non-R5 baseline tropism (BTRP), and absence of fosamprenavir (FPV). No concentration–response relationship was found with treatment (maraviroc vs. placebo) and presence/absence of undetectable maraviroc concentration (adherence marker) in the model. The maraviroc doses studied (300 or 150 mg with potent CYP3A4 inhibitors once (q.d.)/twice daily (b.i.d.)) deliver concentrations near the top of the concentration–response curve. PMID:23945605

  9. Standardization of surface electromyography utilized to evaluate patients with dysphagia.

    PubMed

    Vaiman, Michael

    2007-06-06

    Patients suspected of having swallowing disorders, could highly benefit from simple diagnostic screening before being referred to specialist evaluations. We introduce surface electromyography (sEMG) to carry out rapid assessment of such patients and propose suggestions for standardizing sEMGs in order to identify abnormal deglutition. Specifics steps for establishing standards for applying the technique for screening purposes (e.g., evaluation of specific muscles), the requirements for diagnostic sEMG equipment, the sEMG technique itself, and defining the tests suitable for assessing deglutition (e.g., saliva, normal, and excessive swallows and uninterrupted drinking of water) are presented in detail. A previously described normative database for single swallowing and drinking and standard approach to analysis was compared to data on the duration and electric activity of muscles involved in deglutition and with sEMG recordings in order to estimate stages of a swallow. SEMG of swallowing is a simple and reliable method for screening and preliminary differentiation among dysphagia and odynophagia of various origins. This noninvasive radiation-free examination has a low level of discomfort, and is simple, timesaving and inexpensive to perform. With standardization of the technique and an established normative database, sEMG can serve as a reliable screening method for optimal patient management.

  10. Standardization of surface electromyography utilized to evaluate patients with dysphagia

    PubMed Central

    Vaiman, Michael

    2007-01-01

    Backgorund Patients suspected of having swallowing disorders, could highly benefit from simple diagnostic screening before being referred to specialist evaluations. We introduce surface electromyography (sEMG) to carry out rapid assessment of such patients and propose suggestions for standardizing sEMGs in order to identify abnormal deglutition. Methods Specifics steps for establishing standards for applying the technique for screening purposes (e.g., evaluation of specific muscles), the requirements for diagnostic sEMG equipment, the sEMG technique itself, and defining the tests suitable for assessing deglutition (e.g., saliva, normal, and excessive swallows and uninterrupted drinking of water) are presented in detail. A previously described normative database for single swallowing and drinking and standard approach to analysis was compared to data on the duration and electric activity of muscles involved in deglutition and with sEMG recordings in order to estimate stages of a swallow. Conclusion SEMG of swallowing is a simple and reliable method for screening and preliminary differentiation among dysphagia and odynophagia of various origins. This noninvasive radiation-free examination has a low level of discomfort, and is simple, timesaving and inexpensive to perform. With standardization of the technique and an established normative database, sEMG can serve as a reliable screening method for optimal patient management. PMID:17553152

  11. Patient utilization of cognitive-behavioral therapy for OCD.

    PubMed

    Mancebo, Maria C; Eisen, Jane L; Sibrava, Nicholas J; Dyck, Ingrid R; Rasmussen, Steven A

    2011-09-01

    The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate "dose" of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy. Copyright © 2011. Published by Elsevier Ltd.

  12. Postacute Stroke Rehabilitation Utilization: Are There Differences between Rural-Urban Patients and Taxonomies?

    ERIC Educational Resources Information Center

    Jia, Huanguang; Cowper, Diane C.; Tang, Yuhong; Litt, Eric; Wilson, Lauren

    2012-01-01

    Purpose: To assess the association between Veterans Affairs (VA) stroke patients' poststroke rehabilitation utilization and their residential settings by using 2 common rural-urban taxonomies. Methods: This retrospective study included all VA stroke inpatients in 2001 and 2002. Rehabilitation utilization referred to rehabilitation therapy received…

  13. Postacute Stroke Rehabilitation Utilization: Are There Differences between Rural-Urban Patients and Taxonomies?

    ERIC Educational Resources Information Center

    Jia, Huanguang; Cowper, Diane C.; Tang, Yuhong; Litt, Eric; Wilson, Lauren

    2012-01-01

    Purpose: To assess the association between Veterans Affairs (VA) stroke patients' poststroke rehabilitation utilization and their residential settings by using 2 common rural-urban taxonomies. Methods: This retrospective study included all VA stroke inpatients in 2001 and 2002. Rehabilitation utilization referred to rehabilitation therapy received…

  14. The death of patients with terminal cancer: the distress experienced by their children and medical professionals who provide the children with support care.

    PubMed

    Otani, Hiroyuki; Ozawa, Miwa; Morita, Tatsuya; Kawami, Ayako; Sharma, Sahana; Shiraishi, Keiko; Oshima, Akira

    2016-02-04

    Few studies have been conducted on the experiences of children of terminally ill patients or hospital-based medical professionals supporting such children. This study explored distress among individuals whose parents died of cancer in childhood and among hospital-based medical professionals supporting such children. A qualitative study. The sample was 12 adults whose parents had died of cancer in childhood and 20 hospital-based medical professionals supporting children of patients' with terminal cancer. In-depth interviews were conducted, focusing on the distress experienced by the participants. The data were analysed thematically. Among adults whose parents died of cancer in childhood, we identified themes related to the period before death (eg, concealing the parent's illness), the time of death (eg, alienation due to isolation from the parent), soon after death (eg, fear and shock evoked by the bizarre circumstances, regrets regarding the relationship with the deceased parent before death), several years thereafter (ie, distinctive reflection during adolescence, prompted by the parent's absence) and the present time (ie, unresolved feelings regarding losing the parent). We identified seven themes among the medical professionals (eg, lack of knowledge/experience with children, the family's attempts to shield the child from the reality of death, estrangement from the family once they leave the hospital). An important finding of the study is that the participants' grief reaction to their parents' deaths during childhood was prolonged. Moreover, hospital medical professionals may find it difficult to directly support affected children. Comprehensive support involving organisations (eg, local communities) may be necessary for children who have lost a parent. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

  15. Relationship between health-related quality of life measures and high HIV viral load in HIV-infected triple-class-experienced patients.

    PubMed

    Bucciardini, Raffaella; Pugliese, Katherina; Weimer, Liliana; Digregorio, Massimiliano; Fragola, Vincenzo; Mancini, Mariagrazia; Maroccia, Zaira; Ladisa, Nicoletta; Francisci, Daniela; Bellagamba, Rita; Degli Antoni, Anna; Guaraldi, Giovanni; Cirioni, Oscar; Ortu, Francesco; Parruti, Giustino; Mannazzu, Marco; Libertone, Raffaella; Donnini, Stefania; Floridia, Marco

    2014-01-01

    Health-related quality of life (HRQoL) has been recognized as a central measure of the overall health status in HIV patients. With the availability of different highly effective drug combinations, maximizing quality-adjusted survival has become a major target of HIV treatment. Although the association of HIV RNA and CD4 cell count with clinical HIV progression has been well established, the relation between these markers and HRQoL measures is still unclear. This cross-sectional study investigated the relationship linking HIV RNA and CD4 to HRQoL measures in 181 triple-class-experienced patients with advanced HIV disease. The instrument used was the ISSQoL, a self-administered and HIV-specific HRQoL questionnaire. Data showed no correlation between HRQoL measures and CD4 counts. Higher HIV RNA levels were, however, associated with poor HRQoL scores in 3 out of 9 scales of social functioning, depression and anxiety, and satisfaction with quality of life. In multivariable analyses, only the satisfaction with quality of life mean score remained significantly lower for the HIV RNA ≯100,000 copies/mL group compared to the HIV RNA 50 to 10,000 copies/mL group. Although other determinants of HRQoL in people with HIV should also be considered, this finding suggests a negative impact of high viral load on perceived HRQoL that adds to other described determinants of lower quality of life in people with HIV, such as lower social support and self-reported symptoms.

  16. Factors associated with program utilization of radiation therapy treatment for VHA and medicare dually enrolled patients.

    PubMed

    French, Dustin D; Bradham, Douglas D; Campbell, Robert R; Haggstrom, David A; Myers, Laura J; Chumbler, Neale R; Hagan, Michael P

    2012-08-01

    We examine how distance to a Veterans Health Administration (VHA) facility, patient hometown classification (e.g., small rural town), and service-connected disability are associated with veterans' utilization of radiation therapy services across the VHA and Medicare. In 2008, 45,914 dually-enrolled veteran patients received radiation therapy. Over 3-quarters (35,513) of the patients received radiation therapy from the Medicare program. Younger age, male gender, shorter distance to a VHA facility, and VHA priority or disability status increased the odds of utilizing the VHA. However, veterans residing in urban areas were less likely to utilize the VHA. Urban dwelling patients' utilization of Medicare instead of the VHA suggests a complex decision that incorporates geographic access to VHA services, financial implications of veteran priority status, and the potential availability of multiple sources of radiation therapy in competitive urban markets.

  17. Accelerated partial breast irradiation utilizing brachytherapy: patient selection and workflow

    PubMed Central

    Wobb, Jessica; Manyam, Bindu; Khan, Atif; Vicini, Frank

    2016-01-01

    Accelerated partial breast irradiation (APBI) represents an evolving technique that is a standard of care option in appropriately selected woman following breast conserving surgery. While multiple techniques now exist to deliver APBI, interstitial brachytherapy represents the technique used in several randomized trials (National Institute of Oncology, GEC-ESTRO). More recently, many centers have adopted applicator-based brachytherapy to deliver APBI due to the technical complexities of interstitial brachytherapy. The purpose of this article is to review methods to evaluate and select patients for APBI, as well as to define potential workflow mechanisms that allow for the safe and effective delivery of APBI. Multiple consensus statements have been developed to guide clinicians on determining appropriate candidates for APBI. However, recent studies have demonstrated that these guidelines fail to stratify patients according to the risk of local recurrence, and updated guidelines are expected in the years to come. Critical elements of workflow to ensure safe and effective delivery of APBI include a multidisciplinary approach and evaluation, optimization of target coverage and adherence to normal tissue guideline constraints, and proper quality assurance methods. PMID:26985202

  18. Health care utilization of patients with multiple chronic diseases in The Netherlands: Differences and underlying factors.

    PubMed

    Hopman, Petra; Heins, Marianne J; Rijken, Mieke; Schellevis, François G

    2015-04-01

    To examine health care utilization of people with multiple chronic diseases in The Netherlands compared to people with one chronic disease, and to identify different subgroups of multimorbid patients based on differences in health care utilization. All patients diagnosed with one or more chronic diseases in 2008-2009 (N=17,443) were selected from the nationwide NIVEL Primary Care Database, and data on their GP contacts were included. Data on hospital admissions (from the Dutch Hospital Data database) and household size and income (from the Integral Household Incomes database 2010) were added. Chi-square-tests and multivariate regression analyses were performed to test for differences between multimorbid patients and patients with one chronic disease, and between subgroups of multimorbid patients derived from cluster analysis. Multimorbid patients (40% of the total sample) had more GP contacts, prescribed medications, and hospital admissions (all p<.0001) than patients with one chronic disease. The largest cluster of multimorbid patients (80%) was characterized by a relatively low level of health care utilization. Two smaller clusters comprised patients with a (very) high level of health care utilization - these people were mainly older, more often female, had a lower income, a smaller household size, and suffered from more chronic diseases. Among the vast majority of multimorbid patients health care utilization is only slightly higher compared to patients with one chronic disease. Extensive health care utilization among people with multimorbidity seems to be related to patient characteristics as well as illness characteristics. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

  19. Resource utilization patterns in patients with acquired immunodeficiency syndrome (AIDS).

    PubMed

    Okello, D O

    1994-12-01

    A survey in 1991 of resource use patterns and factors affecting the cost of care for the acquired immunodeficiency syndrome (AIDS) in Mulago Hospital, Kampala, Uganda, revealed that drugs constitute 97% of the mean cost of care of affected individuals in the outpatient and 37% in hospitalized patients. The cost of drugs per treatment episode was Ug.Sh.5785.00 in the outpatient and Ug.Sh.8309.00 for inpatients. (The exchange rate for 1991 was US$ = Ug.Sh.910.00). Analysis of an attempt to provide essential drugs for the growing number of AIDS subjects shows that drugs alone could consume the entire health budget of the Ministry of Health in Uganda. There is therefore need to critically consider options to control the high cost for drugs in AIDS care.

  20. Mandibular reconstruction in irradiated patients utilizing myosseous-cutaneous flaps

    SciTech Connect

    Pearlman, N.W.; Albin, R.E.; O'Donnell, R.S.

    1983-10-01

    Myosseous-cutaneous flaps were used for mandibular reconstruction in 16 irradiated patients. Three of six sternomastoid-clavicle flaps failed (all in conjunction with a neck dissection), as did one of 10 pectoralis major-anterior-fifth rib flaps. One trapezius-scapular flap was used and it succeeded. We found the blood supply of the sternomastoid-clavicle flap too tenuous for use in conjunction with a neck dissection. The trapezius-scapular flap had too short an arc of rotation to be used for defects other than those in the horizontal ramus. In addition, this flap required a change of position and created an undesirable functional deformity. The pectoralis major-fifth rib flap, in contrast, could be used for a variety of defects, in conjunction with a neck dissection, and did not require a change of position during operation. We found it to be the most versatile and dependable of the flaps employed in this series.

  1. Comparative study of extrapolative factors linked with oxidative injury and anti-inflammatory status in chronic kidney disease patients experiencing cardiovascular distress

    PubMed Central

    Rasool, Mahmood; Ashraf, Muhammad Abdul Basit; Malik, Arif; Waquar, Sulayman; Khan, Shahida Aziz; Qazi, Mahmood Husain; Ahmad, Waseem; Asif, Muhammad; Khan, Sami Ullah; Zaheer, Ahmad; Qaisrani, Muther Mansoor; Khan, Abdul Rehman; Iqbal, Aamir; Raza, Amir; Iram, Saima; Kamran, Kashif; Iqbal, Asim; Mustafa, Mohammad Zahid; Choudhry, Hani; Zamzami, Mazin A.; Abdulaal, Wesam H.; Jamal, Mohammad Sarwar

    2017-01-01

    Background Chronic kidney disease (CKD) is a group of heterogeneous abnormalities affecting the function and structure of the kidney and mostly further proceeds to cardiovascular damage prior to end stage renal disease (ESRD). The oxidative insult and inflammatory mediators have some undefined role in CKD and cardiovascular complications. It is therefore, aimed at to pin point the predictive factors in the development of cardiovascular disorder in patients with chronic kidney disease. Methods Fifty patients of CKD experiencing cardiovascular distress and twenty normal individuals having same age and sex acted as control during these observations. Blood samples (Each 5 ml) were drawn and subjected to centrifugation for 10–15 minutes to separate the serum at 4000-5000rpm. The levels of MDA, GSH, SOD, CAT, VIT C, VIT E, IL-1, TNF-alpha, nitric oxide (NO) and advanced oxidation protein products (AOPPs) were estimated and analyzed. Results The nitric oxide levels in the CKD patients decreased significantly (13.26±1.25 ng/ml) compared to controls (42.15±5.26 ng/ml). The serum vitamin E and C levels in these patients recorded 2.15±0.25 μg/ml and 0.97±0.09 μg/ml respectively as against their assigned controls which read 6.35±1.22 μg/ml and 3.29±0.25 μg/ml. Furthermore, a significantly higher level of Malondialdehyde (MDA) as1.25±0.07 nmol/ml was observed in CKD patients viz-a-viz relevant control. However, the serum SOD, catalase (CAT) and GSH levels in the same patients registered a significant decline as evident from respective figures 0.07±0.002 μg/dl, 1.22±0.012 μmol/mol, and 3.25±1.05 μg/dl. The control for these was observed as0.99±0.06 μg/dl, 3.19±0.05 μmol/mol, and 8.64±0.03 μg/dL. On the other hand, the IL-1 levels in the CKD patients found quite higher (402.5±18.26 pg/ml). This clearly points to substantial increase in oxidative insult and reduced NO levels leading to the renal and cardiovascular damage. Conclusion Observations support

  2. Trends in CT Utilization for Pediatric Fall Patients in US Emergency Departments.

    PubMed

    Shahi, Varun; Brinjikji, Waleed; Cloft, Harry J; Thomas, Kristen B; Kallmes, David F

    2015-07-01

    Falls are a common cause of emergency department (ED) visits in the United States. We evaluated trends in computed tomography (CT) utilization for pediatric fall victims in the United States from 2001 to 2010. Using the National Hospital Ambulatory Medical Care Survey from 2001 to 2010, we identified all visits of pediatric (aged <18 years) patients presenting to EDs after falls. This database surveys approximately 500 EDs per year for 4 weeks providing national estimates on ED resource utilization and outcomes. We studied trends in CT utilization and proportion of visits with life-threatening conditions after falls. We also studied the association between CT utilization rates and demographic characteristics and admission status. A total of 9763 unweighted observations for a total of 32,432,686 pediatric fall patients were seen in US EDs from 2001 to 2010. The proportion of pediatric fall patients receiving CT increased from 5.3% in 2001 to a peak of 16.6% in 2009 and decreased to 11.3% in 2010, whereas the proportion of pediatric fall patients with life-threatening conditions fluctuated between 1.2% and 3.3% during this period. In multivariate logistic regression analysis, each increasing year was independently associated with CT utilization (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.14-1.16). Patients aged 0-1 years had higher odds of CT utilization than patients aged 13-17 years (OR, 2.27; 95% CI, 2.26-2.27). There was a twofold increase in CT utilization among pediatric fall visits from 2001 to 2010. When controlling for demographic and clinical variables, increasing year was independently associated with CT utilization. These findings suggest that CT may be overutilized among pediatric fall patients. Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.

  3. Symptomatic Avascular Necrosis: An Understudied Risk Factor for Acute Care Utilization by Patients with SCD.

    PubMed

    Yu, Tiffany; Campbell, Timothy; Ciuffetelli, Isabella; Haywood, Carlton; Carroll, Christopher Patrick; Resar, Linda; Strouse, John J; Lanzkron, Sophie

    2016-09-01

    Sickle cell disease (SCD) is associated with high healthcare utilization rates and poor outcomes in a subset of patients, although the underlying factors that predict this phenotype are poorly understood. Prior studies suggest that comorbid avascular necrosis (AVN) contributes to high healthcare utilization. We sought to clarify whether AVN independently predicts acute care utilization in adults with SCD and to identify characteristics of those with AVN that predict higher utilization. We reviewed the medical records of 87 patients with SCD with symptomatic AVN and compared acute care utilization and clinical characteristics with 87 sex- and age-matched patients with SCD without symptomatic AVN. Patients with ≥2 years of follow-up were included. Outcomes were compared using bivariate analysis and multivariate regression. Our study included 1381 follow-up years, with a median of 7 years per patient. The AVN cohort had greater median rates of urgent care visits (3.2/year vs 1.3/year; P = 0.0155), admissions (1.3/year vs 0.4/year; P = 0.0002), and admission days (5.1 days/year vs 1.8 days/year; P = 0.0007). History of high utilization (odds ratio [OR] 4.28; P = 0.001), acute chest syndrome (OR 3.12; P = 0.005), pneumonia (OR 3.20; P = 0.023), hydroxyurea therapy (OR 2.23; P = 0.0136), and long-term transfusion (OR 2.33; P = 0.014) were associated with AVN. In a median regression model, AVN, acute chest syndrome, and pneumonia were independently associated with greater urgent care visits and admissions. Symptomatic AVN was found to be an independent risk factor for acute care utilization in patients with SCD. Because this is a potentially modifiable factor, further studies are urgently needed to determine whether AVN prevention/early treatment interventions will alter utilization and improve outcomes for patients with SCD.

  4. Prosthodontics and the patient. Part 2: Need becoming demand, demand becoming utilization.

    PubMed

    Narby, Birger; Kronström, Mats; Söderfeldt, Björn; Palmqvist, Sigvard

    2007-01-01

    Patients' oral health needs are estimated through dialogue and professional assessment. The concepts of need and demand are vital to studies of dental care and oral health. Need does not always lead to demand for treatment or to utilization, depending on the gatekeeping processes between need and demand and between demand and utilization. Demand must be accepted with the understanding that there is no objective need and that demand depends on the patient's opinion. In accordance with this, the need for prosthodontic treatment is highly individual and is not automatically related to oral health status, making need and demand difficult to measure in that respect. Therefore, sociodental factors should be included and evaluated in studies of need and demand for utilization of prosthodontic care. This theoretical and analytic paper focuses on the gatekeeping processes between need and demand and between demand and utilization of prosthodontic care. The concept of gatekeeping refers to the social and psychologic processes that transform need into demand and demand into utilization. It implies that they are complex processes that can render great differences between demand and actual utilization. It is not possible to estimate a patient's needs for prosthodontic care, since there is no objective need. Demand and utilization are factors that play an important role in the gatekeeping process. These factors are dependent on the patient's opinion, which is influenced by numerous factors.

  5. Health professionals responding to men for safety (HERMES): feasibility of a general practice training intervention to improve the response to male patients who have experienced or perpetrated domestic violence and abuse.

    PubMed

    Williamson, Emma; Jones, Sue K; Ferrari, Giulia; Debbonaire, Thangam; Feder, Gene; Hester, Marianne

    2015-05-01

    To evaluate a training intervention for general practice-based doctors and nurses in terms of the identification, documentation, and referral of male patients experiencing or perpetrating domestic violence and abuse (DVA) in four general practices in the south west of England. Research suggests that male victims and perpetrators of DVA present to primary care clinicians to seek support for their experiences. We know that the response of primary care clinicians to women patients experiencing DVA improves from training and the establishment of referral pathways to specialist DVA services. The intervention consisted of a 2-h practice-based training. Outcome measures included: a pre-post, self-reported survey of staff practice; disclosures of DVA as documented in medical records pre-post (six months) intervention; semi-structured interviews with clinicians; and practice-level contact data collected by DVA specialist agencies. Results show a significant increase in clinicians' self-reported preparedness to meet the needs of male patients experiencing or perpetrating DVA. There was a small increase in male patients identified within the medical records (6 pre- to 17 post-intervention) but only five of those patients made contact with a specialist DVA agency identified within the referral pathway. The training increased clinicians' confidence in responding to male patients affected by DVA. The increase in recorded identification of DVA male patients experiencing or perpetrating DVA was small and contact of those patients with a specialist DVA support service was negligible. We need to better understand male help seeking in relation to DVA, further develop interventions to increase identification of male patients experiencing or perpetrating DVA behaviours, and facilitate access to support services.

  6. Medical utilization of kiosks in the delivery of patient education: a systematic review.

    PubMed

    Yvonne Chan, Yu-Feng; Nagurka, Roxanne; Bentley, Suzanne; Ordonez, Edgardo; Sproule, William

    2014-01-01

    The utilization of kiosks has previously been shown to be effective for collecting information, delivering educational modules, and providing access to health information. We discuss a review of current literature for the utilization of kiosks for the delivery of patient education. The criteria for inclusion in this literature review were: (1) study discusses the utilization of kiosks for patient health education; (2) study discusses the use of touch screens for patient health information; (3) published in English. Our review includes searches via MEDLINE databases and Google Scholar for the years 1996-2014. Overall, 167 articles were screened for final eligibility, and after discarding duplicates and non-eligible studies with abstract. Full-text review of 28 articles was included in the final analysis. The review of available literature demonstrates the effectiveness of touch screen kiosks to educate patients and to improve healthcare, both at a performance and cost advantage over other modes of patient education.

  7. Medical Utilization of Kiosks in the Delivery of Patient Education: A Systematic Review

    PubMed Central

    Yvonne Chan, Yu-Feng; Nagurka, Roxanne; Bentley, Suzanne; Ordonez, Edgardo; Sproule, William

    2014-01-01

    Background: The utilization of kiosks has previously been shown to be effective for collecting information, delivering educational modules, and providing access to health information. We discuss a review of current literature for the utilization of kiosks for the delivery of patient education. Methods: The criteria for inclusion in this literature review were: (1) study discusses the utilization of kiosks for patient health education; (2) study discusses the use of touch screens for patient health information; (3) published in English. Our review includes searches via MEDLINE databases and Google Scholar for the years 1996-2014. Results: Overall, 167 articles were screened for final eligibility, and after discarding duplicates and non-eligible studies with abstract. Full-text review of 28 articles was included in the final analysis. Conclusion: The review of available literature demonstrates the effectiveness of touch screen kiosks to educate patients and to improve healthcare, both at a performance and cost advantage over other modes of patient education. PMID:25097831

  8. The clinical utility of lurasidone in schizophrenia: patient considerations.

    PubMed

    Harvey, Philip D

    2015-01-01

    Lurasidone is a novel antipsychotic agent approved for the treatment of schizophrenia in a number of countries including the United Kingdom, other European countries, the United States, and Canada. In addition to full antagonist activity at the dopamine D2 (Ki, 1 nM) and serotonin 5-HT2A (Ki, 0.5 nM) receptors, the pharmacodynamic profile of lurasidone is notable for its high affinity for serotonin 5-HT7 receptors (0.5 nM) and its partial agonist activity at 5-HT1A receptors (Ki, 6.4 nM). Long-term treatment of schizophrenia with lurasidone has been shown to reduce the risk of relapse in patients with schizophrenia. Lurasidone appears to be associated with minimal effects on body weight, and low risk for clinically meaningful alterations in glucose, lipids, or electrocardiography parameters. Evidence from two randomized trials also suggests improvement in functional capacity and cognitive functioning in people with schizophrenia. A significant evidence base supports the use of lurasidone as a promising agent for the treatment of schizophrenia.

  9. Mammography utilization: patient characteristics and breast cancer stage at diagnosis.

    PubMed

    Onitilo, Adedayo A; Engel, Jessica M; Liang, Hong; Stankowski, Rachel V; Miskowiak, Douglas A; Broton, Michael; Doi, Suhail A

    2013-11-01

    Missed mammograms represent missed opportunities for earlier breast cancer diagnosis. The purposes of this study were to identify patient characteristics associated with missed mammograms and to examine the association between missed mammograms and breast cancer stage at diagnosis. Mammography frequency and cancer stage were retrospectively examined in 1368 cases of primary breast cancer diagnosed at our clinic from 2002 to 2008. Regardless of age (median, 62.7 years), 1428 women who underwent mammography were more likely to have early-stage (stage 0-II) breast cancer at diagnosis than were those who did not undergo mammography (p < 0.001). Similarly, the number of mammographic examinations in the 5 years before diagnosis was inversely related to stage: 57.3% (94/164) of late-stage cancers were diagnosed in women missing their last five annual mammograms. In a multivariate analysis, family history of breast cancer was most predictive of undergoing mammography (odds ratio, 3.492; 95% CI, 2.616-4.662; p < 0.0001) followed by number of medical encounters (odds ratio, 1.022; 95% CI, 1.017-1.027; p < 0.0001). Time to travel to the nearest mammography center was also predictive of missing mammograms: Each additional minute of travel time decreased the odds of undergoing at least one mammographic examination in the 5 years before cancer diagnosis (odds ratio, 0.990; 95% CI, 0.986-0.993; p < 0.0001). Missing a mammogram, even in the year before a breast cancer diagnosis, increases the chance of a cancer diagnosis at a later stage. Interventions to encourage use of mammography may be of particular benefit to women most likely to miss mammograms, including those with no family history of breast cancer, fewer encounters with the health care system, and greater travel distance to the mammography center.

  10. Patient-reported utilities in bilateral visual impairment from amblyopia and age-related macular degeneration.

    PubMed

    van de Graaf, Elizabeth S; Despriet, Dominiek D G; Klaver, Caroline C W; Simonsz, Huibert J

    2016-05-17

    Utility of visual impairment caused by amblyopia is important for the cost-effectiveness of screening for amblyopia (lazy eye, prevalence 3-3.5 %). We previously measured decrease of utility in 35-year-old persons with unilateral persistent amblyopia. The current observational case-control study aimed to measure loss of utility in patients with amblyopia with recent decrease of vision in their better eye. As these patients are rare, the sample was supplemented by patients with bilateral age-related macular degeneration with similar decrease of vision. From our out-patient department, two groups of patients with recent deterioration to bilateral visual acuity less than Snellen 0.5 (bilateral visual impairment, BVI) were recruited, with either persistent amblyopia and age-related macular degeneration (AMB + AMD), or with bilateral age-related macular degeneration (BAMD). To measure utility, the time trade-off method and the standard gamble method were applied through interviews. Correlations were sought between utility values and visual acuity, age and Visual Function Questionnaire-25 scores. Seventeen AMB + AMD patients (mean age 72.9 years), and 63 BAMD patients (mean age 79.6 years) were included in the study. Among AMB + AMD, 80 % were willing to trade lifetime in exchange for cure. The overall mean time trade-off utility was 0.925. Among BAMD, 75 % were willing to trade, utility was 0.917. Among AMB + AMD, 38 % accepted risk of death in exchange for cure, overall mean standard gamble utility was 0.999. Among BAMD, 49 % accepted risk of death, utility was 0.998. Utility was not related to visual acuity but it was to age (p = 0.02). Elderly patients with BVI, caused by persistent amblyopia and age-related macular degeneration (AMD) or by bilateral AMD, had an approximately 8 % loss of TTO utility. Notably, the 8 % loss in elderly with BVI differs little from the 3.7 % loss we found previously in 35-year-old persons with unilateral

  11. A multicenter, primary-care-based, open-label study to assess the success of converting opioid-experienced patients with chronic moderate-to-severe pain to morphine sulfate and naltrexone hydrochloride extended-release capsules using a standardized conversion guide

    PubMed Central

    Setnik, Beatrice; Roland, Carl L; Sommerville, Kenneth W; Pixton, Glenn C; Berke, Robert; Calkins, Anne; Goli, Veeraindar

    2015-01-01

    Objective To evaluate the conversion of opioid-experienced patients with chronic moderate-to-severe pain to extended-release morphine sulfate with sequestered naltrexone hydrochloride (MSN) using a standardized conversion guide. Methods This open-label, single-arm study was conducted in 157 primary care centers in the United States. A total of 684 opioid-experienced adults with chronic moderate-to-severe pain were converted to oral administration of MSN from transdermal fentanyl and oral formulations of hydrocodone, hydromorphone, methadone, oxycodone, oxymorphone, and other morphine products using a standardized conversion guide. The primary endpoint was the percentage of patients achieving a stable MSN dose within a 6-week titration phase. Secondary endpoints included duration of time to stable dose, number of titration steps, safety and efficacy measures, and investigator assessment of conversion guide utility. Results Of the 684 patients, 51.3% were converted to a stable dose of MSN (95% confidence interval: 47.5%, 55.1%). The mean (standard deviation) number of days to stable dose was 20 (8.94), and number of titration steps to stable dose was 2.4 (1.37). The majority of adverse events were mild/moderate and consistent with opioid therapy. Mean pain scores at stable dose decreased from baseline. Investigators were generally satisfied with the conversion guide and, in 94% of cases, reported they would use it again. Conclusion Conversion to MSN treatment using the standardized MSN conversion guide was an attainable goal in approximately half of the population of opioid-experienced patients with chronic moderate-to-severe pain. Investigators found the guide to be a useful tool to assist conversion of opioid-experienced patients to MSN. PMID:26185466

  12. Utilization and likelihood of radiologic diagnostic imaging in patients with implantable cardiac defibrillators.

    PubMed

    Nazarian, Saman; Reynolds, Matthew R; Ryan, Michael P; Wolff, Steven D; Mollenkopf, Sarah A; Turakhia, Mintu P

    2016-01-01

    To examine imaging utilization in a matched cohort of patients with and without implantable cardioverter defibrillators (ICD) and to project magnetic resonance imaging (MRI) utilization over a 10-year period. The Truven Health MarketScan Commercial claims and Medicare Supplemental health insurance claims data were used to identify patients with continuous health plan enrollment in 2009-2012. Patients with ICDs were identified using ICD-9 and CPT codes, and matched to patients with the same demographic and comorbidity profile, but no record of device implantation. Diagnostic imaging utilization was compared across the matched cohorts, in total, by imaging categories, and in subpopulations of stroke, back pain, and joint pain. MRI use in the nonimplant group over the 4-year period was extrapolated out to 10 years for ICD-indicated patients. A cohort of 18,770 matched patients were identified; average age 65.5 ± 13.38 and 21.9% female. ICD patients had significantly less MRI imaging (0.23 0.70 SD vs. 0.00 0.08 SD, P < 0.0001) than nonimplant patients. Among patients with records of stroke/transient ischemic attack (TIA) (ICD 5%, nonimplant 4%) and accompanying diagnostic imaging, 44% of nonimplant patients underwent MRI vs. 1% of ICD patients (P < 0.0001). Forecast models estimated that 53% to 64% of ICD-eligible patients may require an MRI within 10 years. MRI utilization is lower in ICD patients compared to nonimplant patients, yet the burden of incident stroke/TIA, back, and joint pain suggests an unmet need for MR-conditional devices. © 2015 The Authors Journal of Magnetic Resonance Imaging published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.

  13. Utilization and likelihood of radiologic diagnostic imaging in patients with implantable cardiac defibrillators

    PubMed Central

    Reynolds, Matthew R.; Ryan, Michael P.; Wolff, Steven D.; Mollenkopf, Sarah A.; Turakhia, Mintu P.

    2015-01-01

    Purpose To examine imaging utilization in a matched cohort of patients with and without implantable cardioverter defibrillators (ICD) and to project magnetic resonance imaging (MRI) utilization over a 10‐year period. Materials and Methods The Truven Health MarketScan Commercial claims and Medicare Supplemental health insurance claims data were used to identify patients with continuous health plan enrollment in 2009–2012. Patients with ICDs were identified using ICD‐9 and CPT codes, and matched to patients with the same demographic and comorbidity profile, but no record of device implantation. Diagnostic imaging utilization was compared across the matched cohorts, in total, by imaging categories, and in subpopulations of stroke, back pain, and joint pain. MRI use in the nonimplant group over the 4‐year period was extrapolated out to 10 years for ICD‐indicated patients. Results A cohort of 18,770 matched patients were identified; average age 65.5 ± 13.38 and 21.9% female. ICD patients had significantly less MRI imaging (0.23 0.70 SD vs. 0.00 0.08 SD, P < 0.0001) than nonimplant patients. Among patients with records of stroke/transient ischemic attack (TIA) (ICD 5%, nonimplant 4%) and accompanying diagnostic imaging, 44% of nonimplant patients underwent MRI vs. 1% of ICD patients (P < 0.0001). Forecast models estimated that 53% to 64% of ICD‐eligible patients may require an MRI within 10 years. Conclusion MRI utilization is lower in ICD patients compared to nonimplant patients, yet the burden of incident stroke/TIA, back, and joint pain suggests an unmet need for MR‐conditional devices. J. MAGN. RESON. IMAGING 2016;43:115–127. PMID:26118943

  14. Changes in Treatment Patterns and Incremental Health Care Utilization Due to P2Y12-Associated Complications in Patients with Acute Coronary Syndrome.

    PubMed

    Vyas, Ami; Bash, Lori D; Patel, Mehul D; Simpson, Ross J

    2017-09-01

    P2Y12 antiplatelet therapy (APT) is highly efficacious in reducing the incidence of ischemic events in patients with acute coronary syndrome (ACS); however, it is associated with several adverse complications. Data on P2Y12-associated complications and adherence to APT are sparse. To describe the characteristics, frequency of P2Y12-associated complications, adherence and persistence to P2Y12 APT, and health care utilization among ACS patients on P2Y12 APT. This retrospective observational study of the MarketScan Commercial Claims and Encounters Database identified patients aged ≥ 18 years who were discharged from an ACS hospitalization in 2012-2014 and initiated P2Y12 APT (ticagrelor, prasugrel, or clopidogrel). The proportion of patients within each treatment group who experienced P2Y12-associated complications within 1 year and who were adherent to APT were determined. Frequencies of all-cause health care utilization (i.e., hospitalization, length of stay, emergency room [ER] visits, outpatient visits, cardiac events, and transfusions) were evaluated for each treatment group. Poisson regressions were conducted to evaluate the association between nonad-herence with P2Y12 APT and health care utilization, after adjusting for demographics (age and gender), health insurance type, and comorbidities. Among 11,629 ACS patients, most were male; 44.6% had hypertension; 20.6% had diabetes; and 53.4% had hyperlipidemia. Clopidogrel use was common (62.6%), with ticagrelor use less common (9.0%). Among all groups, approximately one third experienced P2Y12-associated complications. One-year adherence to APT was suboptimal (68% overall), with 73.3% adherence among prasugrel users, followed by 71.4% adherence among ticagrelor users and 65.6% adherence among clopidogrel users. Switching was most common with ticagrelor users. Inpatient hospitalizations, cardiac events, and transfusions were more common in clopidogrel users compared with prasugrel and ticagrelor users. Nonadherent

  15. Obstructive sleep apnea is associated with higher healthcare utilization in elderly patients

    PubMed Central

    Diaz, Karla; Faverio, Paola; Hospenthal, Angela; Restrepo, Marcos I.; Amuan, Megan E.; Pugh, Mary Jo V.

    2014-01-01

    BACKGROUND: Obstructive sleep apnea (OSA) is an important cause of morbidity in the elderly population. Limited data are available regarding the healthcare utilization and predisposing conditions related to OSA in the elderly. Our aim was to evaluate the healthcare utilization and the conditions associated with new and chronic diagnosis of OSA in a large cohort of elderly patients in the Veterans Health Administration (VHA). MATERIALS AND METHODS: This retrospective cohort study used inpatient and outpatient VHA data to identify the individuals diagnosed with OSA using ICD-9 codes during the fiscal years 2003-2005. Primary outcomes were emergency department (ED) visits and hospitalizations. Multivariable logistic regression analysis was performed to identify the demographic and clinical characteristics associated with new and chronic diagnosis of OSA. RESULTS: Of 1,867,876 elderly veterans having 2 years of care, 82,178 (4.4%) were diagnosed with OSA. Individuals with OSA were younger and more likely to have chronic diseases than those without OSA. Individuals with chronic OSA were more likely to have diagnoses of congestive heart failure (CHF), pulmonary circulation disorders, COPD, and obesity and less likely to have diagnoses of hypertension, osteoarthritis, and stroke than individuals with newly diagnosed OSA. The proportion of patients with new OSA diagnosis who required at least one ED visit was higher than the proportion of chronic OSA and no OSA patients (37%, 32%, and 15%, respectively; P-value <0.05). The proportion of new OSA patients who required at least one hospitalization was also higher than the proportion of chronic OSA and no OSA patients (24%, 17%, and 7%, respectively; P-value <0.05). CONCLUSION: Patients with OSA had a higher incidence of healthcare utilization compared to patients without OSA. New OSA patients had a higher rate of healthcare utilization in the year of diagnosis compared to chronic patients and patients without OSA. Early OSA

  16. Expected and Experienced Pain Levels in Electromyography

    PubMed Central

    YALINAY DİKMEN, Pınar; ILGAZ AYDINLAR, Elif; KARLIKAYA, Geysu

    2013-01-01

    Introduction The aim of the present study was to assess pain using a visual analogue scale (VAS) in patients awaiting an EMG procedure (i.e., expected VAS) and after an EMG procedure (i.e., experienced VAS). Methods Expected and experienced pain in response to nerve conduction studies (NCS) and needle EMG were assessed in 108 patients (61 females, 47 males; mean age 43.2±11.6) using a VAS. Results No significant correlations were noted between the expected or the experienced VAS in response to EMG and demographic features of the patients. The expected VAS was significantly higher than the experienced VAS in response to needle EMG (p=0.005). The highest VAS level was noted in the expected VAS in response to needle EMG (4.7±2.2). The lowest VAS level was noted in the experienced VAS in response to NCS (3.6±2.5). Conclusion The present study demonstrated that neither the expected nor the experienced pain associated with EMG exceeded a moderate level. Interestingly, we found that expected pain levels in response to needle EMG were significantly higher than experienced pain levels. Therefore, it may be possible to increase compliance if patients are provided with this information before undergoing electrophysiological procedures.

  17. Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients

    PubMed Central

    Holden, Timothy R.; Smith, Maureen A.; Bartels, Christie M.; Campbell, Toby C.; Yu, Menggang

    2015-01-01

    Abstract Background: Rehospitalizations are prevalent and associated with decreased quality of life. Although hospice has been advocated to reduce rehospitalizations, it is not known how area-level hospice utilization patterns affect rehospitalization risk. Objectives: The study objective was to examine the association between hospice enrollment, local hospice utilization patterns, and 30-day rehospitalization in Medicare patients. Methods: With a retrospective cohort design, 1,997,506 hospitalizations were assessed between 2005 and 2009 from a 5% national sample of Medicare beneficiaries. Local hospice utilization was defined using tertiles representing the percentage of all deaths occurring in hospice within each Hospital Service Area (HSA). Cox proportional hazard models were used to assess the relationship between 30-day rehospitalization, hospice enrollment, and local hospice utilization, adjusting for patient sociodemographics, medical history, and hospital characteristics. Results: Rates of patients dying in hospice were 27% in the lowest hospice utilization tertile, 41% in the middle tertile, and 53% in the highest tertile. Patients enrolled in hospice had lower rates of 30-day rehospitalization than those not enrolled (2.2% versus 18.8%; adjusted hazard ratio [HR], 0.12; 95% confidence interval [CI], 0.118–0.131). Patients residing in areas of low hospice utilization were at greater rehospitalization risk than those residing in areas of high utilization (19.1% versus 17.5%; HR, 1.05; 95% CI, 1.04–1.06), which persisted beyond that accounted for by individual hospice enrollment. Conclusions: Area-level hospice utilization is inversely proportional to rehospitalization rates. This relationship is not fully explained by direct hospice enrollment, and may reflect a spillover effect of the benefits of hospice extending to nonenrollees. PMID:25879990

  18. HIV type 1 integrase polymorphisms in treatment-naive and treatment-experienced HIV type 1-infected patients in Thailand where HIV type 1 subtype A/E predominates.

    PubMed

    Phuphuakrat, Angsana; Pasomsub, Ekawat; Kiertiburanakul, Sasisopin; Chantratita, Wasun; Sungkanuparph, Somnuek

    2012-08-01

    Integrase inhibitor (INI) is a novel antiretroviral drug recommended for both treatment-naive and treatment-experienced HIV-1-infected patients. Limited data are available on INI resistance in Thailand, where HIV-1 subtype A/E predominates. We aimed to investigate INI resistance-associated mutations (RAMs) among treatment-naive patients and patients who experienced treatment failure with NNRTI-based or PI-based antiretroviral therapy (ART) in Thailand. One hundred and eight plasma samples of 58 treatment-naive and 50 treatment-experienced HIV-1-infected individuals were collected. The HIV-1 integrase coding region was sequenced. Polymorphisms were compared between subtype A/E and B circulating in Thailand and between treatment-naive and treatment-experienced groups. Resulting amino acids were interpreted for drug resistance according to Stanford algorithms. Ninety-seven samples were HIV-1 subtype A/E, 10 were subtype B, and one was subtype C. Age, gender, and CD4 cell counts were similar between treatment-naive and treatment-experienced groups, while the treatment-failure group showed a statistically significant longer awareness time of HIV-1 infection and lower viral load than the treatment-naive group. Major INI-RAM was not found in this study, but some minor INI-RAMs, such asV54I, L68I, L74M, T97A, and S230N, were found. Comparing INI-RAMs between subtype A/E and B, the prevalence of V54I and V72I was higher in subtype B than subtype E, while V201I was found in all sequences of subtype A/E. In subtype A/E, integrase polymorphisms were not different between treatment-naive and treatment-experienced groups. However, the number of amino acid substitutions was significantly higher in the treatment-experienced group (p=0.009). One NNRTI-based ART-treated patient was found to have potential low-level INI-RAMs. INI-RAMs are rare in both treatment-naive and treatment-experienced patients in Thailand. This suggested that INI should be active in patients who are naive to

  19. Do visual analogue scale (VAS) derived standard gamble (SG) utilities agree with Health Utilities Index utilities? A comparison of patient and community preferences for health status in rheumatoid arthritis patients

    PubMed Central

    Rashidi, Amir Adel; Anis, Aslam H; Marra, Carlo A

    2006-01-01

    Background Assessment of Health Related Quality of Life (HRQL) has become increasingly important and various direct and indirect methods and instruments have been devised to measure it. In direct methods such as Visual Analog Scale (VAS) and Standard Gamble (SG), respondent both assesses and values health states therefore the final score reflects patient's preferences. In indirect methods such as multi-attribute health status classification systems, the patient provides the assessment of a health state and then a multi-attribute utility function is used for evaluation of the health state. Because these functions have been estimated using valuations of general population, the final score reflects community's preferences. The objective of this study is to assess the agreement between community preferences derived from the Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3) systems, and patient preferences. Methods Visual analog scale (VAS) and HUI scores were obtained from a sample of 320 rheumatoid arthritis patients. VAS scores were adjusted for end-aversion bias and transformed to standard gamble (SG) utility scores using 8 different power conversion formulas reported in other studies. Individual level agreement between SG utilities and HUI2 and HUI3 utilities was assessed using the intraclass correlation coefficient (ICC). Group level agreement was assessed by comparing group means using the paired t-test. Results After examining all 8 different SG estimates, the ICC (95% confidence interval) between SG and HUI2 utilities ranged from 0.45 (0.36 to 0.54) to 0.55 (0.47 to 0.62). The ICC between SG and HUI3 utilities ranged from 0.45 (0.35 to 0.53) to 0.57 (0.49 to 0.64). The mean differences between SG and HUI2 utilities ranged from 0.10 (0.08 to 0.12) to 0.22 (0.20 to 0.24). The mean differences between SG and HUI3 utilities ranged from 0.18 (0.16 to 0.2) to 0.28 (0.26 to 0.3). Conclusion At the individual level, patient and community preferences show moderate

  20. Combining entacapone with levodopa/DDCI improves clinical status and quality of life in Parkinson's Disease (PD) patients experiencing wearing-off, regardless of the dosing frequency: results of a large multicentre open-label study.

    PubMed

    Onofrj, M; Thomas, A; Vingerhoets, F; Martin, W; Giménez-Roldán, S; Azulay, J-P; Bernhard, G; Schmidt, W; Markabi, S

    2004-08-01

    The efficacy of entacapone and its impact on patient quality of life (QOL) was investigated in an open-label study of 899 patients with idiopathic Parkinson's Disease (PD) experiencing wearing-off fluctuations. Patients were divided into 3 groups (3, 4 or 5 doses daily) based on their current levodopa dosage frequency. Patients received 200 mg entacapone with each levodopa/dopa-decarboxylase inhibitor (DDCI) dose, while continuing their same levodopa/DDCI dosage regimen for 4 weeks. Primary efficacy measure was the Investigators' Clinical Global Impression of Change (CGIC). Patient QoL was assessed using the validated 8-item Parkinson's Disease Questionnaire (PDQ-8). Investigators' CGIC revealed that 76.5% of entacapone treated patients experienced an improvement in global status after 4 weeks. Treatment with entacapone was also associated with improvement in patient QoL, with a mean reduction (improvement) in PDQ-8 score of 1.8 from baseline. This study confirms and extends the results of earlier studies demonstrating that, independent of dosing frequency, completing levodopa/DDCI therapy with entacapone provides clinically relevant improvements in global status and QoL in PD patients experiencing wearing-off on their current levodopa dosing frequency.

  1. Rehabilitation of a fearful dental patient with oral sedation: utilizing the incremental oral administration technique.

    PubMed

    Feck, Anthony S; Goodchild, Jason H

    2005-01-01

    The treatment of fearful or anxious patients presents a myriad of problems for the dentist. In-office sedation using oral (enteral) medications is an effective means of increasing patient tolerance of invasive dental procedures. The incremental oral administration technique is a protocol that can be utilized to treat fearful or anxious patients. A case is presented in which this technique was used as an adjunct to the rehabilitation of a debilitated mouth.

  2. Preoperative narcotic utilization: accuracy of patient self-reporting and its association with postoperative narcotic consumption.

    PubMed

    Ahn, Junyoung; Bohl, Daniel D; Tabaraee, Ehsan; Aboushaala, Khaled; Elboghdady, Islam M; Singh, Kern

    2016-01-01

    Little is known about the accuracy of reporting of preoperative narcotic utilization in spinal surgery. As such, the purpose of this study is to compare postoperative narcotic consumption between preoperative narcotic utilizers who do and do not accurately self-report preoperative utilization. Patients who underwent anterior cervical discectomy and fusion, minimally invasive lumbar discectomy, or minimally invasive transforaminal lumbar interbody fusion procedures between 2013 and 2014 were prospectively identified. The accuracy of self-reporting preoperative narcotic consumption was determined utilizing the Illinois Prescription Monitoring Program. Total inpatient narcotic consumption during postoperative Days 0 and 1 was compared according to the demographics and preoperative narcotic reporting accuracy. Similarly, the proportion of patients who continued to be dependent on narcotic medications at each postoperative visit was compared according to the demographics and preoperative narcotic reporting accuracy. A total of 195 patients met the inclusion criteria. Of these, 25% did not use narcotics preoperatively, while 47% and 28% did do so with accurate and inaccurate reporting, respectively. Patients who used narcotics preoperatively were more likely to demonstrate elevated inpatient narcotic consumption (adjusted RR 5.3; 95% CI 1.4-20.1; p = 0.013). However, such patients were no more or less likely to be dependent on narcotic medications at the first (p = 0.618) or second (p = 0.798) postoperative visit. Among patients who used narcotics preoperatively, no differences were demonstrated in terms of inpatient narcotic consumption (p = 0.182) or narcotic dependence following the first (p = 0.982) or second (p = 0.866) postoperative visit according to the self-reported accuracy of preoperative narcotic utilization. The only preoperative factors that were independently associated with elevated inpatient narcotic consumption were workers' compensation status and

  3. Long-term efficacy and safety of Raltegravir combined with optimized background therapy in treatment-experienced patients with drug-resistant HIV infection: week 96 results of the BENCHMRK 1 and 2 Phase III trials.

    PubMed

    Steigbigel, Roy T; Cooper, David A; Teppler, Hedy; Eron, Joseph J; Gatell, Jose M; Kumar, Princy N; Rockstroh, Jurgen K; Schechter, Mauro; Katlama, Christine; Markowitz, Martin; Yeni, Patrick; Loutfy, Mona R; Lazzarin, Adriano; Lennox, Jeffrey L; Clotet, Bonaventura; Zhao, Jing; Wan, Hong; Rhodes, Rand R; Strohmaier, Kim M; Barnard, Richard J; Isaacs, Robin D; Nguyen, Bach-Yen T

    2010-02-15

    BENCHMRK-1 and -2 are ongoing double-blind phase III studies of raltegravir in patients experiencing failure of antiretroviral therapy with triple-class drug-resistant human immunodeficiency virus infection. At week 96 (combined data), raltegravir (400 mg twice daily) plus optimized background therapy was generally well tolerated, with superior and durable antiretroviral and immunological efficacy, compared with optimized background therapy alone.

  4. Health care utilization in patients with gout: a prospective multicenter cohort study.

    PubMed

    Singh, Jasvinder A; Bharat, Aseem; Khanna, Dinesh; Aquino-Beaton, Cleopatra; Persselin, Jay E; Duffy, Erin; Elashoff, David; Khanna, Puja P

    2017-05-31

    All published studies of health care utilization in gout have been cross-sectional to date, and most used a patient-reported diagnosis of gout. Our objective was to assess health care utilization and its predictors in patients with physician-confirmed gout in a prospective cohort study. In a multi-center prospective cohort study of U.S. veterans with rheumatologist-confirmed gout (N = 186; two centers), we assessed patient self-reported overall and gout-specific health care utilization with the Gout Assessment Questionnaire (GAQ) every 3-months for a 9-month period. Comparisons were made using the student's t test or the chi-square, Wilcoxon rank sum test or Fisher exact test, as appropriate. Mixed effects Poisson regression was used to assess potential correlates of gout-related health care utilization. Mean age was 64.6 years, 98% were men, 13% Hispanic or Latino, 32% were African-American, 6% did not graduate high school, mean serum urate was 8.3 and mean Deyo-Charlson score was 3.1. During the past year, mean gout-related visits were as follows: rheumatologist, 1.5; primary care physician, 2 visits; ≥1 inpatient visits, 7%; ≥1 ER visits, 26%; and urgent care/walk-in visit, 33%. In longitudinal analyses, African-American race and gout flares in the last 3 months were associated with significantly higher rate ratio of gout-related outpatient visits. African-American race and lack of college education were associated with significantly higher rate ratio for gout-related urgent visits and overnight stays. African-American race and recent gout flares were associated with higher outpatient utilization and African-American race and no college education with higher urgent or inpatient utilization. Future studies should examine whether modifiable predictors of utilization can be targeted to reduce healthcare utilization in patients with gout.

  5. Identification of Genotypic Changes in Human Immunodeficiency Virus Protease That Correlate with Reduced Susceptibility to the Protease Inhibitor Lopinavir among Viral Isolates from Protease Inhibitor-Experienced Patients

    PubMed Central

    Kempf, Dale J.; Isaacson, Jeffrey D.; King, Martin S.; Brun, Scott C.; Xu, Yi; Real, Kathryn; Bernstein, Barry M.; Japour, Anthony J.; Sun, Eugene; Rode, Richard A.

    2001-01-01

    The association of genotypic changes in human immunodeficiency virus (HIV) protease with reduced in vitro susceptibility to the new protease inhibitor lopinavir (previously ABT-378) was explored using a panel of viral isolates from subjects failing therapy with other protease inhibitors. Two statistical tests showed that specific mutations at 11 amino acid positions in protease (L10F/I/R/V, K20M/R, L24I, M46I/L, F53L, I54L/T/V, L63P, A71I/L/T/V, V82A/F/T, I84V, and L90M) were associated with reduced susceptibility. Mutations at positions 82, 54, 10, 63, 71, and 84 were most closely associated with relatively modest (4- and 10-fold) changes in phenotype, while the K20M/R and F53L mutations, in conjunction with multiple other mutations, were associated with >20- and >40-fold-reduced susceptibility, respectively. The median 50% inhibitory concentrations (IC50) of lopinavir against isolates with 0 to 3, 4 or 5, 6 or 7, and 8 to 10 of the above 11 mutations were 0.8-, 2.7-, 13.5-, and 44.0-fold higher, respectively, than the IC50 against wild-type HIV. On average, the IC50 of lopinavir increased by 1.74-fold per mutation in isolates containing three or more mutations. Each of the 16 viruses that displayed a >20-fold change in susceptibility contained mutations at residues 10, 54, 63, and 82 and/or 84, along with a median of three mutations at residues 20, 24, 46, 53, 71, and 90. The number of protease mutations from the 11 identified in these analyses (the lopinavir mutation score) may be useful for the interpretation of HIV genotypic resistance testing with respect to lopinavir-ritonavir (Kaletra) regimens and may provide insight into the genetic barrier to resistance to lopinavir-ritonavir in both antiretroviral therapy-naive and protease inhibitor-experienced patients. PMID:11462018

  6. Tolerability and Healthcare Utilization in Maintenance Hemodialysis Patients Undergoing Treatment for Tuberculosis-Related Conditions.

    PubMed

    Hamadah, Abdurrahman M; Beaulieu, Lynn M; Wilson, John W; Aksamit, Timothy R; Gregoire, James R; Williams, Amy W; Dillon, John J; Albright, Robert C; Onuigbo, Macaulay; Iyer, Venkateshwaran K; Hickson, LaTonya J

    2016-01-01

    The incidence of tuberculosis (TB) in end-stage renal disease is significantly higher than that in the general population. Among those with kidney dysfunction, anti-TB treatment is associated with increased side effects, but the effect on healthcare utilization is unknown. Methods/Aim: To assess patient-reported symptoms, adverse effects and describe changes in healthcare utilization patterns during treatment for TB, we conducted a case series (n = 12) of patients receiving maintenance hemodialysis (HD) from Mayo Clinic Dialysis Services and concurrent drug therapy for TB from January 2002 through May 2014. Healthcare utilization (hospitalizations and emergency department (ED) visits independent of hospital admission) was compared before and during treatment. Patients were treated for latent (n = 7) or active (n = 5) TB. The majority of patients with latent disease were treated with isoniazid (n = 5, 71%), while active-disease patients received a 4-drug regimen. Adverse effects were reported in 83% of patients. Compared to measurements prior to drug initiation, serum albumin and dialysis weights were similar at 3 months. Commonly reported anti-TB drug toxicities were described. More than half (58%) of the patients were hospitalized at least once. No ED or hospital admissions occurred in the period prior to drug therapy, but healthcare utilization increased during treatment in the latent disease group (hospitalization rate per person-month: pre 0 vs. post 1). Among HD patients, anti-TB therapy is associated with frequently reported symptoms and increased healthcare utilization. Among this subset, patients receiving treatment for latent disease may be those with greatest increase in healthcare use. Careful monitoring and early complication detection may help optimize medication adherence and minimize hospitalizations. © 2016 S. Karger AG, Basel.

  7. How well do General EMS 911 dispatch protocols predict ED resource utilization for pediatric patients?

    PubMed

    Fessler, Stephanie J; Simon, Harold K; Yancey, Arthur H; Colman, Michael; Hirsh, Daniel A

    2014-03-01

    The use of Emergency Medical Services (EMS) for low-acuity pediatric problems is well documented. Attempts have been made to curb potentially unnecessary transports, including using EMS dispatch protocols, shown to predict acuity and needs of adults. However, there are limited data about this in children. The primary objective of this study is to determine the pediatric emergency department (PED) resource utilization (surrogate of acuity level) for pediatric patients categorized as "low-acuity" by initial EMS protocols. Records of all pediatric patients classified as "low acuity" and transported to a PED in winter and summer of 2010 were reviewed. Details of the PED visit were recorded. Patients were categorized and compared based on chief complaint group. Resource utilization was defined as requiring any prescription medications, labs, procedures, consults, admission or transfer. "Under-triage" was defined as a "low-acuity" EMS transport subsequently requiring emergent interventions. Of the 876 eligible cases, 801 were included; 392/801 had no resource utilization while 409 of 801 had resource utilization. Most (737/801) were discharged to home; however, 64/801 were admitted, including 1 of 801 requiring emergent intervention (under-triage rate 0.12%). Gastroenterology and trauma groups had a significant increase in resource utilization, while infectious disease and ear-nose-throat groups had decreased resource utilization. While this EMS system did not well predict overall resource utilization, it safely identified most low-acuity patients, with a low under-triage rate. This study identifies subgroups of patients that could be managed without emergent transport and can be used to further refine current protocols or establish secondary triage systems. © 2013.

  8. Quality of life and health care utilization in patients with chronic respiratory diseases.

    PubMed

    Kurpas, D; Mroczek, B; Sitko, Z; Helicka, D; Kuchar, E

    2015-01-01

    High quality of life (QoL) may reduce the costs of medical care of chronically ill patients due to lower health care utilization. The purpose of this study was to establish the influence of the QoL of primary care patients with chronic respiratory diseases on the level of health care utilization and the predictors of hospitalization. The study group consisted of 594 adult patients with chronic respiratory diseases of the mean age 59.8±14.9 years. The highest QoL was observed in the social relationship domain and the lowest in the physical domain. Low QoL was associated with a low level of health care utilization among patients with chronic respiratory diseases. Most patients were hospitalized during the past 3 years. In a group of patients with chronic respiratory diseases, chances for hospitalization were: higher among patients with low QoL and health satisfaction, low QoL levels in the physical and social relationship domains, high QoL levels in the psychological domain, those with higher education, residents of rural areas, patients using frequent consultations over the phone, and those with at least an average index of services.

  9. Health state utilities and quality of life in patients with hepatitis B

    PubMed Central

    Woo, Gloria; Tomlinson, George; Yim, Colina; Lilly, Les; Therapondos, George; Wong, David KH; Ungar, Wendy; Einarson, Thomas R; Sherman, Morris; Heathcote, E Jenny; Krahn, Murray

    2012-01-01

    BACKGROUND: The effect of chronic hepatitis B (CHB) infection on health-related quality of life (HRQoL) and health state utilities has not been well characterized. OBJECTIVE: To measure utility scores and HRQoL across disease states associated with CHB infection. METHODS: Patients attending four tertiary care clinics for CHB were approached between July 2007 and March 2009. Respondents completed version 2 of the Short-Form 36 Health Survey, the EQ5D, a visual analogue scale, the Health Utilities Index Mark 3, standard gamble, and demographics and risk factor surveys in English, Cantonese or Mandarin. Charts were reviewed to determine disease stage and comorbidities. RESULTS: A total of 433 patients were studied: 294 had no cirrhosis; 79 had compensated cirrhosis; seven had decompensated cirrhosis; 23 had hepatocellular carcinoma; and 30 had received a liver transplant. The mean standard gamble utilities for these disease states were 0.89, 0.87, 0.82, 0.84 and 0.86, respectively. HRQoL scores in noncirrhotic patients were similar to those of the general population. Scores of patients with compensated cirrhosis were not significantly lower; however, patients with decompensated cirrhosis and hepatocellular carcinoma had significantly lower HRQoL scores compared with noncirrhotic patients (P<0.05). Similar scores were observed among patients on and off oral antiviral treatment. Post-liver transplant patients had a higher HRQoL than patients with decompensated cirrhosis. Age, number of comorbidities and relationship status were significantly associated with HRQoL scores. CONCLUSIONS: HRQoL in CHB patients is only impaired in the later stages of liver disease. Neither CHB infection nor antiviral treatment is associated with a lower quality of life. PMID:22803020

  10. Costs and utilization of hemophilia A and B patients with and without inhibitors.

    PubMed

    Armstrong, Edward P; Malone, Daniel C; Krishnan, Sangeeta; Wessler, Maj Jacob

    2014-11-01

    To evaluate the health system costs among patients with hemophilia A and B with and without inhibitors over 5 years. This was a retrospective, observational study utilizing medical and pharmacy electronic medical records and administrative encounters/claims data tracking US patients between 2006-2011. Patients with diagnosis codes for hemophilia A and B were identified. Patients with inhibitors were characterized by utilization of bypassing agents activated prothrombin complex concentrate or factor VIIa on two or more distinct dates. Severity was classified as mild, moderate, or severe based on laboratory tests of clotting factor. There were 160 hemophilia A patients and 54 hemophilia B patients identified. From this group, seven were designated as patients with inhibitors (five with hemophilia A and two with hemophilia B). Hemophilia A patients without inhibitors reported 65 (41.9%) as being severe, 19 (12.3%) as moderate, and 71 (45.8%) as mild. Hemophilia B patients without inhibitors reported nine (17.3%) had severe, 13 (25.0%) had moderate, and 30 (57.7%) had mild hemophilia. All patients with inhibitors had been hospitalized in the previous 5 years compared to 64 (41.3%) with hemophilia A without inhibitors and 22 (42.3%) with hemophilia B without inhibitors. The median aggregate cost per year (including factor and health resource use) was $325,780 for patients with inhibitors compared to $98,334 for hemophilia A patients without inhibitors and $23,265 for hemophilia B patients without inhibitors. The results suggest that, while the frequency of inhibitors within the hemophilia cohort was low, there was a higher frequency of hospitalizations, and the associated median aggregate costs per year were 3-fold higher than those patients without inhibitors. In contrast, hemophilia B patients experience less severe disease and account for lower aggregate yearly costs compared to either patients with hemophilia A or patients with inhibitors.

  11. Determining utility values in patients with anterior cruciate ligament tears using clinical scoring systems

    PubMed Central

    2011-01-01

    Background Several instruments and clinical scoring systems have been established to evaluate patients with ligamentous knee injuries. A comparison of individual articles in the literature is challenging, not only because of heterogeneity in methodology, but also due to the variety of the scoring systems used to document clinical outcomes. There is limited information about the correlation between used scores and quality of life with no information being available on the impact of each score on the utility values. The aim of this study was to compare the most commonly used scores for evaluating patients with anterior cruciate ligament (ACL) injuries, and to establish corresponding utility values. These values will be used for the interpretation and comparison of outcome results in the currently available literature for different treatment options. Methods Four hypothetical vignettes were defined, based on different levels of activities after rupture of the ACL to simulate typical situations seen in daily practice. A questionnaire, including the Health Utility Index (HUI) for utility values, the IKDC subjective score, the Lysholm and the Tegner score, was created and 25 orthopedic surgeons were asked to fill the questionnaire for each hypothetical patient as proxies for all patients they had treated and who would fit in that hypothetical vignette. Results The utility value as an indicator for quality of life increased with the level of activity. Having discomforts already during normal activities of daily living was rated with a mean utility value of 0.37 ± 0.19, half of that of a situation where mild sport activity was possible without discomfort (0.78 ± 0.11). All investigated scores were able to distinguish clearly (p < 0.05) between the hypothetical vignettes. However, the utility values correlated best with the IKDC subjective score (r = 0.86, p < 0.001) followed by the Lysholm score (r = 0.77, p < 0.001) and the Tegner score (r = 0.77, p < 0

  12. A multi-component patient-handling intervention improves attitudes and behaviors for safe patient handling and reduces aggression experienced by nursing staff: A controlled before-after study.

    PubMed

    Risør, Bettina Wulff; Casper, Sven Dalgas; Andersen, Lars Louis; Sørensen, Jan

    2017-04-01

    This study evaluated an intervention for patient-handling equipment aimed to improve nursing staffs' use of patient handling equipment and improve their general health, reduce musculoskeletal problems, aggressive episodes, days of absence and work-related accidents. As a controlled before-after study, questionnaire data were collected at baseline and 12-month follow-up among nursing staff at intervention and control wards at two hospitals. At 12-month follow-up, the intervention group had more positive attitudes towards patient-handling equipment and increased use of specific patient-handling equipment. In addition, a lower proportion of nursing staff in the intervention group had experienced physically aggressive episodes. No significant change was observed in general health status, musculoskeletal problems, days of absence or work-related accidents. The intervention resulted in more positive attitudes and behaviours for safe patient-handling and less physically aggressive episodes. However, this did not translate into improved health of the staff during the 12-month study period.

  13. Patterns of vasopressor utilization during the resuscitation of massively transfused trauma patients.

    PubMed

    Barmparas, Galinos; Dhillon, Navpreet K; Smith, Eric Jt; Mason, Russell; Melo, Nicolas; Thomsen, Gretchen M; Margulies, Daniel R; Ley, Eric J

    2017-09-27

    The use of vasopressors (VP) in the resuscitation of massively transfused trauma patients might be considered a marker of inadequate resuscitation. We sought to characterize the utilization of VP in patients receiving massive transfusion and examine the association of their use with mortality. Trauma patients admitted from January 2011 to October 2016 receiving massive transfusion, defined as 3 units of pRBC within the first hour from admission, were selected for analysis. Demographics, admission vital signs and labs, use of VP, surgical interventions and outcomes were collected. Standard statistical tools were utilized. Over the 5-year study period, 120 trauma patients met inclusion criteria. The median age was 39 years with 77% being male and 41% sustaining a penetrating injury. Patients who received VP [VP (+)] were more likely to have a lower admission GCS (median 4.5 vs. 14.0, p <0.01) and less likely to have a penetrating injury (31% vs. 54%, p=0.02). The overall mortality was 49% and significantly higher in the VP (+) cohort (60% vs. 34%, AHR: 9.9, adjusted p=0.03). Mortality increased in a stepwise fashion with increasing number of VP utilized, starting at 34% for no VP, to 78% for 3 VP, and 100% for 5 or more. The majority of deaths in the VP (-) group (88%) occurred within one day from admission. For the VP (+) group, 57% of deaths occurred within one day, with the remaining 43% occurring at a later time. In the era of massive transfusion protocols, vasopressors are commonly utilized in exsanguinating trauma patients and their use is associated with a higher mortality risk. Deaths in patients receiving vasopressors are more likely to occur later compared to those in patients who do not receive vasopressors. Further research to characterize the role of these agents in the resuscitation of trauma patients is required. Copyright © 2017 Elsevier Ltd. All rights reserved.

  14. Healthcare utilization in patients with esophageal cancer in a high risk area in northeast of Iran.

    PubMed

    Roshandel, Gholamreza; Majdzadeh, Reza; Keshtkar, Abbasali; Aramesh, Kiarash; Sedaghat, Seyed Mehdi; Semnani, Shahryar

    2011-01-01

    Golestan, a province located north of Persian Gulf in northeastern part of Iran is a well known area for high risk of esophageal cancer (EC) in the world. There is no information about healthcare utilization in populations residing in the area. This study was conducted to assess utilization of healthcare and its associated factors among esophageal cancer patients in this region as well as to address ethical implication of this utilization. All new cases of EC in Golestan province during year of 2007 were recruited. Seven diagnostic and five therapeutic services were used to assess diagnostic utilization index (DUI), and therapeutic utilization index (TUI), respectively. Multivariate regression analysis was used to assess the relationship between variables and DUI or TUI. P-value of less than 0.05 was considered as statistically significant. Tow hundred twenty three, patients were enrolled with mean (Standard Deviation) age of 64.3 (12.5) years with 57.8% male. We observed that occupation (P<0.01), ethnicity (P<0.01) and sex (P=0.03) were strongly associated with DUI. Insurance coverage (P<0.01), place of residency (P<0.01), and occupation (P=0.01) were associated with TUI. We concluded that several factors contribute to disparity in healthcare utilization in the studied population.

  15. Successful Re-administration of Low-dose of Methimazole (MMI) in Graves' Disease Patients Who Experienced Allergic Cutaneous Reactions to MMI at Initial Treatment and Had Received Long-term Propylthiouracil (PTU)

    PubMed Central

    Kubota, Sumihisa

    2016-01-01

    Objective When patients with Graves' disease show severe allergic cutaneous reactions, physicians often suggest that they undergo radioiodine therapy instead of receiving propylthiouracil (PTU), another antithyroid drug, because anti-neutrophil cytoplasmic antibody (ANCA)-related vasculitis can occur with PTU, especially with long-term use. However, some patients refuse radioiodine therapy and chose PTU. Sometimes PTU treatment may be prolonged. Since the frequency of adverse effects of methimazole (MMI) is dose-related, there is a possibility that we can re-administer a low dose without adverse effects to patients well-controlled with PTU who once experienced an allergic reaction to MMI. Methods I prospectively re-administered a low dose of MMI to patients who previously experienced an allergic reaction to MMI at initial treatment. The dose of re-administered MMI ranged from 5 mg twice a week to 5 mg daily. Patients Nine patients with Graves' disease who developed urticaria at initial treatment with MMI and had been treated with PTU for 6 to 21 years were recruited. Results Eight of the 9 patients were successfully controlled with MMI without allergic cutaneous reactions. Only one patient felt itchiness 2 days after switching to MMI. However, skin change was not observed. Conclusion If the patients show allergic cutaneous reactions as a side effect of MMI at the initial treatment for Graves' disease, then there is a strong possibility that such patients can tolerate a low dose of MMI without adverse effects after the disease activity has subsided. PMID:27853063

  16. Patient preferences and the measurement of utilities in the evaluation of dental technologies.

    PubMed

    Birch, S; Ismail, A I

    2002-07-01

    Advances in life sciences that are predicted in the 21st century will present many challenges for health professionals and policy-makers. The major questions will be how to allocate resources to pay for costs of new technologies and who will best benefit from advances in new diagnostic and treatment methods. We review in this paper the concept of utility and how it can be applied and expanded to provide data to help health professionals make decisions that are preferred by patients and the public at large. Utility is a measure of people's well-being or preferences for outcomes. The measurement of utilities of a new diagnostic technology, for example, can be carried out with the use of simple methods that do not incorporate all of the uncertainties and potential outcomes associated with providing the test, or with more complex methods that can incorporate most uncertainties. This review describes and critiques the different measurement methods of utilities.

  17. Utilization of Physical Therapy Intervention Among Patients With Plantar Fasciitis in the United States.

    PubMed

    Fraser, John J; Glaviano, Neal R; Hertel, Jay

    2017-02-01

    Study Design Retrospective observational study. Background Plantar fasciitis is responsible for 1 million ambulatory patient care visits annually in the United States. Few studies have investigated practice patterns in the treatment of patients with plantar fasciitis. Objective To assess physical therapist utilization and employment of manual therapy and supervised rehabilitation in the treatment of patients with plantar fasciitis. Methods A retrospective review of the PearlDiver patient record database was used to evaluate physical therapist utilization and use of manual therapy and supervised rehabilitation in patients with plantar fasciitis between 2007 and 2011. An International Classification of Diseases code (728.71) was used to identify plantar fasciitis, and Current Procedural Terminology codes were used to identify evaluations (97001), manual therapy (97140), and rehabilitation services (97110, 97530, 97112). Results A total of 819 963 unique patients diagnosed with plantar fasciitis accounted for 5 739 737 visits from 2007 to 2011, comprising 2.7% of all patients in the database. Only 7.1% (95% confidence interval: 7.0%, 7.1%) of patients received a physical therapist evaluation. Of the 57 800 patients evaluated by a physical therapist (59.8% female), 50 382 (87.2% ± 0.4%) received manual therapy, with significant increases in utilization per annum. A large proportion (89.5% ± 0.4%) received rehabilitation following physical therapist evaluation. Conclusion Despite plantar fasciitis being a frequently occurring musculoskeletal condition, a small proportion of patients with plantar fasciitis were seen by physical therapists. Most patients who were evaluated by a physical therapist received manual therapy and a course of supervised rehabilitation as part of their plan of care. Level of Evidence Treatment, level 2a. J Orthop Sports Phys Ther 2017;47(2):49-55. doi:10.2519/jospt.2017.6999.

  18. Healthcare Resource Utilization and Patient-Reported Outcomes Following Elective Surgery for Intradural Extramedullary Spinal Tumors.

    PubMed

    Chotai, Silky; Zuckerman, Scott L; Parker, Scott L; Wick, Joseph B; Stonko, David P; Hale, Andrew T; McGirt, Matthew J; Cheng, Joseph S; Devin, Clinton J

    2017-10-01

    Healthcare resource utilization and patient-reported outcomes (PROs) for intradural extramedullary (IDEM) spine tumors are not well reported. To analyze the PROs, costs, and resource utilization 1 year following surgical resection of IDEM tumors. Patients undergoing elective spine surgery for IDEM tumors and enrolled in a single-center, prospective, longitudinal registry were analyzed. Baseline and postoperative 1-year PROs were recorded. One-year spine-related direct and indirect healthcare resource utilization was assessed. One-year resource use was multiplied by unit costs based on Medicare national payment amounts (direct cost). Patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). A total of 38 IDEM tumor patients were included in this analysis. There was significant improvement in quality of life (EuroQol-5D), disability (Oswestry and Neck Disability Indices), pain (Numeric rating scale pain scores for back/neck pain and leg/arm pain), and general physical and mental health (Short-form-12 health survey, physical and mental component scores) in both groups 1 year after surgery (P < .0001). Eighty-seven percent (n = 33) of patients were satisfied with surgery. The 1-year postdischarge resource utilization including healthcare visits, medication, and diagnostic cost was $4111 ± $3596. The mean total direct cost was $23 717 ± $7412 and indirect cost was $5544 ± $4336, resulting in total 1-year cost $29 177 ± $9314. Surgical resection of the IDEM provides improvement in patient-reported quality of life, disability, pain, general health, and satisfaction at 1 year following surgery. Furthermore, we report the granular costs of surgical resection and healthcare resource utilization in this population.

  19. Acute Care Utilization by Patients After Graduation of Their Resident Primary Care Physicians.

    PubMed

    Solomon, Sonja R; Gooding, Holly C; Reyes Nieva, Harry; Linder, Jeffrey A

    2015-11-01

    The disruption in provider continuity caused by medical resident graduation may result in adverse patient outcomes. Our aim was to investigate whether resident graduation was associated with increased acute care utilization by residents' primary care patients. This was a retrospective cohort study of patients cared for by junior and senior residents finishing the academic year in 2010, 2011 and 2012. We compared rates of clinic visits, emergency department (ED) visits, and hospitalizations between transitioning patients whose residents were graduating and non-transitioning patients whose residents were not graduating. Our study population comprised 90 residents, 4018 unique patients, and 5988 resident-patient dyads that transitioned (n = 3136) or did not transition (n = 2852). For transitioning patients, the clinic visit rate per 100 patients in the 4 months before and after graduation was 129 and 102, respectively; for non-transitioning patients, the clinic visit rate was 119 and 94, respectively (difference-in-differences, +2 per 100 patients; p = 0.12). For transitioning patients, the ED visit rate per 100 patients before and after graduation was 29 and 26, respectively; for non-transitioning patients, the ED visit rate was 28 and 25, respectively (difference-in-differences, 0; p = 0.49). For transitioning patients, the hospitalization rate per 100 patients before and after graduation was 14 and 13, respectively; for non-transitioning patients, the hospitalization rate was 15 and 12, respectively (difference-in-differences, -2; p = 0.20). In multivariable modeling there was no increased risk for transitioning patients for clinic visits (adjusted rate ratio [aRR], 1.03; 95 % confidence interval [CI], 0.97 to 1.10), ED visits (aRR, 1.05; 95 % CI, 0.92 to 1.20), or hospitalizations (aRR, 1.04; 95 % CI, 0.83 to 1.31). Acute care utilization by residents' patients did not increase or decrease after graduation. Acute care utilization was high

  20. Simeprevir in combination with sofosbuvir in treatment-naïve and -experienced patients with hepatitis C virus genotype 4 infection: a Phase III, open-label, single-arm study (PLUTO).

    PubMed

    Buti, M; Calleja, J L; Lens, S; Diago, M; Ortega, E; Crespo, J; Planas, R; Romero-Gómez, M; Rodríguez, F G; Pascasio, J M; Fevery, B; Kurland, D; Corbett, C; Kalmeijer, R; Jessner, W

    2017-02-01

    Hepatitis C virus (HCV) infection is a leading cause of liver cirrhosis and subsequent hepatocellular carcinoma. HCV genotype 4 is found widely in the Middle East, Egypt and Africa, and has also spread into Europe. There are limited data available regarding the use of direct-acting antiviral agents in HCV genotype 4-infected patients with cirrhosis. To evaluate in the phase III, open-label, single-arm PLUTO study the efficacy and safety of 12 weeks of simeprevir (HCV NS3/4A protease inhibitor) plus sofosbuvir (HCV nucleotide-analogue NS5B polymerase inhibitor) in treatment-naïve and (peg)interferon ± ribavirin-experienced HCV genotype 4-infected patients, with or without compensated cirrhosis. Adult patients with chronic HCV genotype 4 infection received simeprevir 150 mg once-daily and sofosbuvir 400 mg once-daily for 12 weeks. The primary efficacy endpoint was sustained virologic response 12 weeks after the end of treatment (SVR12). Safety was also assessed. Forty patients received treatment; the majority were male (73%) and treatment-experienced (68%). Overall, 7/40 (18%) patients had compensated cirrhosis. All patients achieved SVR12 [100% (Clopper-Pearson 95% confidence interval: 91-100%)]. Adverse events, all Grade 1 or 2, were reported in 20/40 (50%) patients. No serious adverse events were reported and no patients discontinued study treatment. Grade 3 treatment-emergent laboratory abnormalities were noted in 2/40 (5%) patients. Treatment with simeprevir plus sofosbuvir for 12 weeks resulted in SVR12 rates of 100% in treatment-naïve and -experienced patients with HCV genotype 4 infection with or without compensated cirrhosis, and was well tolerated. [NCT02250807]. © 2016 John Wiley & Sons Ltd.

  1. Lack of Utility of Nasopharyngeal Swabs for Diagnosis of Burkholderia pseudomallei Pneumonia in Paediatric Patients

    PubMed Central

    Turner, Claudia; Suy, Kuong; Soeng, Sona; Day, Nicholas P. J.; Turner, Paul

    2016-01-01

    Diagnosis of Burkholderia pseudomallei pneumonia in children is challenging. We investigated the utility of nasopharyngeal swabs taken from 194 paediatric patients on admission with radiologically proven pneumonia. Melioidosis was proven in 0.5% of samples tested and only in a third of those known to be bacteraemic with B. pseudomallei. It appears unlikely that culture of nasopharyngeal secretions is helpful to confirm B. pseudomallei pneumonia in paediatric patients. PMID:26874977

  2. Medical resource utilization and costs among Australian patients with genotype 1 chronic hepatitis C: results of a retrospective observational study.

    PubMed

    McElroy, Heather J; Roberts, Stuart K; Thompson, Alex J; Angus, Peter W; McKenna, Sarah Jane; Warren, Emma; Musgrave, Sharon

    2017-01-01

    To evaluate medical resource utilization (MRU) and associated costs among Australian patients with genotype 1 chronic hepatitis C (GT1 CHC), including both untreated patients and those receiving treatment with first-generation protease inhibitor-based regimens (telaprevir, boceprevir with pegylated interferon and ribavirin). Medical records were reviewed for a stratified random sample of GT1 CHC patients first attending two liver clinics between 2011-2013 (principal population; PP), supplemented by all GT1 CHC patients attending one transplant clinic in the same period (transplant population; TP). CHC-related MRU and associated costs are reported for the PP by treatment status (treated/not treated) stratified by baseline fibrosis grade; and for the TP for the pre-transplant, year of transplant and post-transplant periods. A total 1636 patients were screened and 590 patients (36.1%) were included. Comprehensive MRU data were collected for 276 PP patients (F0-1 n = 59, F2 n = 58, F3 n = 53, F4 n = 106; mean follow-up = 17.3 months). Thirty-eight (13.8%) were treatment-experienced prior to enrolment; 55 (19.9%) received triple therapy during the study. Data were collected for 112 TP patients (mean follow-up = 29.9 months), 33 (29.5%) received a transplant during the study, and 51 (45.5%) beforehand. The annual direct medical costs, excluding drug costs, were higher among treated PP vs untreated PP (AU$: $1,954 vs $1,202); and year of transplant TP vs pre-/post-transplant TP (AU$: pre-transplant $32,407, transplant $155,138, post-transplant $7,358). To aid interpretation of results, note that only patients with GT1 CHC who are actively managed are included, and MRU data were collected specifically from liver outpatient clinics. That said, movement of patients between hospitals is rare, and any uncaptured MRU is expected to be minimal. CHC-related MRU increases substantially with disease severity. These real-world MRU data for GT1 CHC will be

  3. Sex/Gender-Based Pharmacology and Statin Utilization Amongst Elderly Patients with Diabetes.

    PubMed

    Farahani, Pendar; Johnson, Ana; Whitehead, Marlo; Rohland, Susan

    2015-12-04

    The purpose of this study was to explore the ten-year trends in utilization of bioequivalent doses of statin amongst elderly patients with diabetes according to sex/gender in Ontario, Canada. A cohort of patients with diabetes (>65 years) was constructed using the Ontario Diabetes Database Statin utilization data (2003-2012) was obtained from the Ontario Drug Benefit Program for both women and men. Bioequivalent doses for statins were calculated according to the dosing conversion factor in therapeutic interchange programs in clinical practice. Utilization pattern of high potency (Atorvastatin and Rosuvastatin) vs. low potency statins (Simvastatin, Lovastatin, Fluvastatin, Pravastatin) were also analyzed. The average bioequivalent Simvastatin utilization in 2003 was 29.22 mg/day for women and 30.35 mg/day for men. By 2008, this gap in dosing was higher for both women and men and by 2013 it had increased to 47.75 mg/day for women and 52.98 mg/day for men. For average number of day supply per year, there was no significant trend of changes over the 10-year period, although the use of high potency statins increased significantly (P<0.001) for both women and men. No differences were seen for sex/gender; either for the 10-year period or for each year. There has been significant increase in bioequivalent statin utilization amongst elderly patients with diabetes in Ontario; for both men and women. In a publicly-funded healthcare system such as Ontario, there were no sex/gender differences in the utilization of high potency statin (Atorvastatin and Rosuvastatin) amongst elderly patient with diabetes.

  4. Utilization of health resources in South Asian, Chinese and white patients with diabetes mellitus.

    PubMed

    Yang, Jiao; Nijjar, Aman; Quan, Hude; Shah, Baiju R; Rabi, Doreen; Ignaszewski, Andrew; Khan, Nadia A

    2014-07-01

    We sought to determine whether there are differences in health resource utilization among South Asian (SA), Chinese and White patients with newly diagnosed diabetes mellitus. We used province-wide administrative data from British Columbia, Canada (1997-2006) to determine proportion of patients with ≥2 visits/year for all outpatient and family physician (FP) visits, proportion of patients with at least one annual visit to specialists, ophthalmology/optometry and hospital admissions by ethnic group. There were 9529 South Asian, 14,084 Chinese and 143,630 White patients with newly diagnosed diabetes in the study. Over 90% of each of the ethnic groups visited their FP ≥2 visits/year. Chinese patients were less likely to visit FP, ophthalmology/optometrists and specialists compared to White patients. SA patients had fewer ophthalmology/optometry visits compared to White populations. White patients had higher rates of hospitalization. Although all groups had high proportion of patients with appropriate frequency of FP visits, other aspects of health care utilization varied significantly by ethnicity. Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

  5. Utilization of emergency medical service increases chance of thrombolytic therapy in patients with acute ischemic stroke.

    PubMed

    Hsieh, Ming-Ju; Tang, Sung-Chun; Chiang, Wen-Chu; Huang, Kuang-Yu; Chang, Anna Marie; Ko, Patrick Chow-In; Tsai, Li-Kai; Jeng, Jiann-Shing; Ma, Matthew Huei-Ming

    2014-11-01

    To determine whether utilization of emergency medical service (EMS) can increase use and expedite delivery of the thrombolytic therapy in acute ischemic stroke patients. We analyzed consecutive patients presenting to the emergency department (ED) with an ischemic stroke within 72 hours of symptom onset from a prospective stroke registry. Variables associated with early ED arrival (within 3 hours of stroke onset) and administration of intravenous thrombolytic therapy were analyzed. From January 1, 2010 to July 31, 2011, there were 1081 patients (62.3% men, age 69.6 ± 13 years) included in this study. Among them, 289 (26.7%) arrived in the ED within 3 hours, and 88 (8.1%) received thrombolytic therapy. Patients who arrived at the ED by EMS (n = 279, 25.8%) were independently associated with earlier ED arrival (adjusted odds ratio = 3.68, 95% confidence interval = 2.54-5.33), and higher chance of receiving thrombolytic therapy (adjusted odds ratio = 3.89, 95% confidence interval = 1.86-8.17). Furthermore, utilization of EMS significantly decreased onset-to-needle time by 26 minutes in patients receiving thrombolytic therapy. Utilization of EMS can not only help acute ischemic stroke patients in early presentation to ED, but also effectively facilitate thrombolytic therapy and shorten the onset-to-needle time. Copyright © 2013. Published by Elsevier B.V.

  6. Does cognitive decline decrease health utility value in older adult patients with cancer?

    PubMed

    Akechi, Tatsuo; Aiki, Sayo; Sugano, Koji; Uchida, Megumi; Yamada, Atsuro; Komatsu, Hirokazu; Ishida, Takashi; Kusumoto, Shigeru; Iida, Shinsuke; Okuyama, Toru

    2017-05-01

    Cognitive decline is common among older adults with cancer. The present study aimed to investigate the impact of cognitive decline on health utility value in older adults suffering from cancer. Consecutive patients aged 65 years or older with a primary diagnosis of malignant lymphoma or multiple myeloma were recruited. Patients were asked to complete the EuroQoL-5 (EQ-5D) scale to measure health utility and the Mini-Mental State Examination to assess cognitive decline. The potential impact of cognitive decline was investigated with univariate analysis. A multivariate regression analysis was conducted to control for potential confounding factors. Complete data were obtained from 87 patients, 29% of whom had cognitive decline. The mean ± SE EQ-5D score for patients with cognitive decline was significantly lower than that for those without cognitive decline (0.67 ± 0.04 vs 0.79 ± 0.03, t = 2.38, P = 0.02). However, multiple regression analysis showed that cognitive decline was not significantly associated with EQ-5D scores. Female sex and lower performance scores (worse physical condition) were significantly associated with EQ-5D scores. Cognitive decline may be involved in decreased health utility value in older adult patients with cancer. However, this effect does not seem to be independent, and the patient's physical condition may be a relevant confounding factor. © 2016 The Authors. Psychogeriatrics © 2016 Japanese Psychogeriatric Society.

  7. Do older patients utilize excess health care resources after liver transplantation?

    PubMed

    Shankar, Neil; AlBasheer, Mamoun; Marotta, Paul; Wall, William; McAlister, Vivian; Chandok, Natasha

    2011-01-01

    Liver transplantation is a highly effective treatment for end-stage liver disease. However, there is debate over the practice of liver transplantation in older recipients (age ≥ 60 years) given the relative shortage of donor grafts, worse post-transplantation survival, and concern that that older patients may utilize excess resources postoperatively, thus threatening the economic feasibility of the procedure. To determine if patients ≥ 60 years of age utilize more health resources following liver transplantation compared with younger patients. Consecutive adult patients who underwent primary liver transplantation (n = 208) at a single center were studied over a 2.5-year period. Data were collected on clinico-demographic characteristics and resource utilization. Descriptive statistics, including means, standard deviations, or frequencies were obtained for baseline variables. Patients were stratified into 2 groups: age ≥ 60 years (n = 51) and < 60 years (n = 157). The Chi-Square Test, Mantel-Haenszel Test, 2-sample test and odds ratios were calculated to ascertain associations between age and resource utilization parameters. Regression analyses were adjusted for model for end-stage liver disease score, location before surgery, diabetes mellitus, donor age, cold ischemia time, albumin, and diagnosis of hepatitis C. Recipients ≥ 60 years of age have similar lengths of hospitalization, re-operative rates, need for consultative services and readmission rates following liver transplantation, but have longer lengths of stay in the intensive care (hazard ratio 1.97, p = 0.03). Overall, liver transplant recipients ≥ 60 years of age utilize comparable resources following LT vs. younger recipients. Our findings have implications on cost-containment policies for liver transplantation.

  8. Utilization of psychotropic drugs by patients consulting for sleeping disorders in homeopathic and conventional primary care settings: the EPI3 cohort study.

    PubMed

    Grimaldi-Bensouda, Lamiae; Abenhaim, Lucien; Massol, Jacques; Guillemot, Didier; Avouac, Bernard; Duru, Gerard; Lert, France; Magnier, Anne-Marie; Rossignol, Michel; Rouillon, Frederic; Begaud, Bernard

    2015-07-01

    Utilization of sedative hypnotic drugs for sleeping disorders (SD) raises concerns, particularly among older people. This study compared utilization of conventional psychotropic drugs for SD among patients seeking care from general practitioners (GPs) who strictly prescribe conventional medications (GP-CM), regularly prescribe homeopathy in a mixed practice (GP-Mx), or are certified homeopathic GPs (GP-Ho). This was a French population-based cohort study of GPs and their patients consulting for SD, informed through the Pittsburgh sleep quality index (PSQI) questionnaire. Information on psychotropic drugs utilization was obtained from a standardized telephone interview at inclusion, one, three and 12 months. 346 patients consulting for SD were included. Patients in the GP-Ho group experienced more often severe SD (41.3%) than patients in the GP-CM group (24.3%). Adjusted multivariate analyses showed that patients who chose to be managed by GP-Ho were less likely to use psychotropic drugs over 12 months as opposed to the GP-CM group, with Odds ratio (OR) = 0.25; 95% confidence interval (CI): 0.14 to 0.42. Patients in the GP-Mx group also used less psychotropic drugs but the result was not statistically significant (OR = 0.67; 95% CI: 0.39-1.16). Rates of clinical improvement of the SD did not differ between groups. Patients with SD who chose to consult GPs certified in homeopathy consumed less psychotropic drugs and had a similar evolution of their condition to patients treated with conventional medical management. This result may translate in a net advantage with reduction of adverse events related to psychotropic drugs. Copyright © 2015 The Faculty of Homeopathy. Published by Elsevier Ltd. All rights reserved.

  9. The potential utility of iodinated contrast media (ICM) skin testing in patients with ICM hypersensitivity.

    PubMed

    Ahn, Young-Hwan; Koh, Young-Il; Kim, Joo-Hee; Ban, Ga-Young; Lee, Yeon-Kyung; Hong, Ga-Na; Jin, U-Ram; Choi, Byung-Joo; Shin, Yoo-Seob; Park, Hae-Sim; Ye, Young-Min

    2015-03-01

    Both immediate and delayed hypersensitivity reactions to iodinated contrast media (ICM) are relatively common. However, there are few data to determine the clinical utility of immunologic evaluation of ICM. To evaluate the utility of ICM skin testing in patients with ICM hypersensitivity, 23 patients (17 immediate and 6 delayed reactions) were enrolled from 3 university hospitals in Korea. With 6 commonly used ICM including iopromide, iohexol, ioversol, iomeprol, iopamidol and iodixanol, skin prick (SPT), intradermal (IDT) and patch tests were performed. Of 10 patients with anaphylaxis, 3 (30.0%) and 6 (60.0%) were positive respectively on SPTs and IDTs with the culprit ICM. Three of 6 patients with urticaria showed positive IDTs. In total, 11 (64.7%) had positive on either SPT or IDT. Three of 6 patients with delayed rashes had positive response to patch test and/or delayed IDT. Among 5 patients (3 anaphylaxis, 1 urticaria and 1 delayed rash) taken subsequent radiological examinations, 3 patients administered safe alternatives according to the results of skin testing had no adverse reaction. However, anaphylaxis developed in the other 2 patients administered the culprit ICM again. With 64.7% (11/17) and 50% (3/6) of the sensitivities of corresponding allergic skin tests with culprit ICM for immediate and delayed hypersensitivity reactions, the present study suggests that skin tests is useful for the diagnosis of ICM hypersensitivity and for selecting safe ICM and preventing a recurrence of anaphylaxis caused by the same ICM.

  10. Utility and safety of procalcitonin in an antimicrobial stewardship program (ASP) in patients with malignancies.

    PubMed

    Liew, Y X; Lee, W; Cai, Y Y; Teo, J; Tang, S S-L; Ong, R W-Q; Lim, C L-L; Lingegowda, P B; Kwa, A L-H; Chlebicki, M P

    2012-11-01

    As data on procalcitonin utility in antibiotics discontinuation [under an antimicrobial stewardship program (ASP)] in patients with malignancies are lacking, we aimed to evaluate the utility of procalcitonin in an ASP in patients with malignancies. We conducted a retrospective review of the ASP database of all patients with malignancies in whom at least one procalcitonin level was taken and our ASP had recommended changes in carbapenem regimen, from January to December 2011. We compared clinical outcomes between two groups of patients: patients whose physicians accepted and those whose physicians rejected ASP interventions. There were 749 carbapenem cases reviewed. Ninety-nine were suggested to either de-escalate, discontinue antibiotics, or narrow the spectrum of empiric treatment, based on procalcitonin trends. While there was no statistical difference in the mortality within 30 days post-ASP intervention (accepted: 8/65 patients vs. rejected: 9/34 patients; p = 0.076), the median duration of carbapenem therapy was significantly shorter (5 vs. 7 days; p = 0.002). Procalcitonin use safely facilitates decisions on antibiotics discontinuation and de-escalation in patients with malignancies in the ASP.

  11. Matching prosthetics order records in VA National Prosthetics Patient Database to healthcare utilization databases.

    PubMed

    Smith, Mark W; Su, Pon; Phibbs, Ciaran S

    2010-01-01

    The National Prosthetics Patient Database (NPPD) is the national Department of Veterans Affairs (VA) dataset that records characteristics of individual prosthetic and assistive devices. It remains unknown how well NPPD records can be matched to encounter records for the same individuals in major VA utilization databases. We compared the count of prosthetics records in the NPPD with the count of prosthetics-related procedures for the same individuals recorded in major VA utilization databases. We then attempted to match the NPPD records to the utilization records by person and date. In general, 40% to 60% of the NPPD records could be matched to outpatient utilization records within a 14-day window around the NPPD dataset entry date. Match rates for inpatient data were lower: 10% to 16% within a 14-day window. The NPPD will be particularly important for studies of certain veteran groups, such as those with spinal cord injury or blast-related polytraumatic injury. Health services researchers should use both the NPPD and utilization databases to develop a full understanding of prosthetics use by individual patients.

  12. Cost-effectiveness analysis of dolutegravir plus backbone compared with raltegravir plus backbone, darunavir+ritonavir plus backbone and efavirenz/tenofovir/emtricitabine in treatment naïve and experienced HIV-positive patients.

    PubMed

    Restelli, Umberto; Rizzardini, Giuliano; Antinori, Andrea; Lazzarin, Adriano; Bonfanti, Marzia; Bonfanti, Paolo; Croce, Davide

    2017-01-01

    In January 2014, the European Medicines Agency issued a marketing authorization for dolutegravir (DTG), a second-generation integrase strand transfer inhibitor for HIV treatment. The study aimed at determining the incremental cost-effectiveness ratio (ICER) of the use of DTG+backbone compared with raltegravir (RAL)+backbone, darunavir (DRV)+ritonavir(r)+backbone and efavirenz/tenofovir/emtricitabine (EFV/TDF/FTC) in HIV-positive treatment-naïve patients and compared with RAL+backbone in treatment-experienced patients, from the Italian National Health Service's point of view. A published Monte Carlo Individual Simulation Model (ARAMIS-DTG model) was used to perform the analysis. Patients pass through mutually exclusive health states (defined in terms of diagnosis of HIV with or without opportunistic infections [OIs] and cardiovascular disease [CVD]) and successive lines of therapy. The model considers costs (2014) and quality of life per monthly cycle in a lifetime horizon. Costs and quality-adjusted life years (QALYs) are dependent on OI, CVD, AIDS events, adverse events and antiretroviral therapies. In treatment-naïve patients, DTG dominates RAL; compared with DRV/r, the ICER obtained is of 38,586 €/QALY (6,170 €/QALY in patients with high viral load) and over EFV/TDF/FTC, DTG generates an ICER of 33,664 €/QALY. In treatment-experienced patients, DTG compared to RAL leads to an ICER of 12,074 €/QALY. The use of DTG+backbone may be cost effective in treatment-naïve and treatment-experienced patients compared with RAL+backbone and in treatment-naïve patients compared with DRV/r+backbone and EFV/TDF/FTC considering a threshold of 40,000 €/QALY.

  13. Health utility of patients with Crohn's disease and ulcerative colitis: a systematic review and meta-analysis.

    PubMed

    Malinowski, Krzysztof Piotr; Kawalec, Paweł

    2016-08-01

    The aim of this systematic review was to collect and summarize the current data on the utilities of patients with Crohn's disease (CD) and ulcerative colitis (UC). A meta-analysis of the obtained utilities was performed using a random-effects model and meta-regression by the disease type and severity. A bootstrap analysis was performed as it does not require assumption on distribution of the data. The highest utility among patients with CD and UC was observed when the diseases were in remission. The meta-regression analysis showed that both disease severity and an instrument/method/questionnaire used to obtain utilities were significant predictors of utility. Utility was the lowest for severe disease and the highest for disease in remission, the association was more notable in patients with CD compared with UC. Expert commentary: The issue of patients' utility is important for healthcare decision makers but it has not been fully investigated and requires further study.

  14. Utilization and acceptance of virtual patients in veterinary basic sciences - the vetVIP-project.

    PubMed

    Kleinsorgen, Christin; Kankofer, Marta; Gradzki, Zbigniew; Mandoki, Mira; Bartha, Tibor; von Köckritz-Blickwede, Maren; Naim, Hassan Y; Beyerbach, Martin; Tipold, Andrea; Ehlers, Jan P

    2017-01-01

    Context: In medical and veterinary medical education the use of problem-based and cased-based learning has steadily increased over time. At veterinary faculties, this development has mainly been evident in the clinical phase of the veterinary education. Therefore, a consortium of teachers of biochemistry and physiology together with technical and didactical experts launched the EU-funded project "vetVIP", to create and implement veterinary virtual patients and problems for basic science instruction. In this study the implementation and utilization of virtual patients occurred at the veterinary faculties in Budapest, Hannover and Lublin. Methods: This report describes the investigation of the utilization and acceptance of students studying veterinary basic sciences using optional online learning material concurrently to regular biochemistry and physiology didactic instruction. The reaction of students towards this offer of clinical case-based learning in basic sciences was analysed using quantitative and qualitative data. Quantitative data were collected automatically within the chosen software-system CASUS as user-log-files. Responses regarding the quality of the virtual patients were obtained using an online questionnaire. Furthermore, subjective evaluation by authors was performed using a focus group discussion and an online questionnaire. Results: Implementation as well as usage and acceptance varied between the three participating locations. High approval was documented in Hannover and Lublin based upon the high proportion of voluntary students (>70%) using optional virtual patients. However, in Budapest the participation rate was below 1%. Due to utilization, students seem to prefer virtual patients and problems created in their native language and developed at their own university. In addition, the statement that assessment drives learning was supported by the observation that peak utilization was just prior to summative examinations. Conclusion: Veterinary

  15. Physical therapy services utilization and length of stay for obese patients following traumatic leg fracture.

    PubMed

    Slayton, Stephanie; Williams, D S Blaise; Newman, Glen

    2012-01-01

    Obesity is an increasing epidemic that can complicate the treatment of simple injuries and can increase health care costs. The purpose of the present study was to determine whether obesity is a factor in the utilization of inpatient physical therapy services and length of stay following a traumatic lower leg fracture. A retrospective study of patients admitted to the hospital in 2005 and 2006 with a primary discharge diagnosis of lower leg or ankle fracture was conducted. Inclusion criteria were age > or = 18 years, only 1 involved lower extremity, and nonweight-bearing on the affected extremity per physician orders. Patients were excluded from the study if they had a fibular fracture only, pathological fractures, multiple trauma, severe cardiac or vascular comorbidities, or cognitive impairments. Data were compiled into 3 categories on the basis of body mass index (BMI): < 30, 30-35, > 35. Physical therapy services were measured in 15-minute units of time. These data were analyzed by within-group and between-group comparisons and with regression analysis. A total of 181 patients with a primary discharge diagnosis of distal lower extremity or ankle fracture were included in the study. Patients with a BMI >35 used more physical therapy services (mean services, 9.8 units) than did patients with a BMI of 30-35 (mean services, 6.2 units) or a BMI <30 (mean services, 5.6 units) (P = .001). Length of stay was also highest among patients with a BMI >35. Factors other than BMI may be associated with length of stay and physical therapy use and may confound the association. Previous studies have shown that there is an increase in health care utilization among the bariatric population. The present study demonstrates similar findings for physical therapy services. Increased length of stay and physical therapy utilization among the bariatric population also result in increased staff utilization and equipment costs.

  16. Utilization and acceptance of virtual patients in veterinary basic sciences – the vetVIP-project

    PubMed Central

    Kleinsorgen, Christin; Kankofer, Marta; Gradzki, Zbigniew; Mandoki, Mira; Bartha, Tibor; von Köckritz-Blickwede, Maren; Naim, Hassan Y.; Beyerbach, Martin; Tipold, Andrea; Ehlers, Jan P.

    2017-01-01

    Context: In medical and veterinary medical education the use of problem-based and cased-based learning has steadily increased over time. At veterinary faculties, this development has mainly been evident in the clinical phase of the veterinary education. Therefore, a consortium of teachers of biochemistry and physiology together with technical and didactical experts launched the EU-funded project “vetVIP”, to create and implement veterinary virtual patients and problems for basic science instruction. In this study the implementation and utilization of virtual patients occurred at the veterinary faculties in Budapest, Hannover and Lublin. Methods: This report describes the investigation of the utilization and acceptance of students studying veterinary basic sciences using optional online learning material concurrently to regular biochemistry and physiology didactic instruction. The reaction of students towards this offer of clinical case-based learning in basic sciences was analysed using quantitative and qualitative data. Quantitative data were collected automatically within the chosen software-system CASUS as user-log-files. Responses regarding the quality of the virtual patients were obtained using an online questionnaire. Furthermore, subjective evaluation by authors was performed using a focus group discussion and an online questionnaire. Results: Implementation as well as usage and acceptance varied between the three participating locations. High approval was documented in Hannover and Lublin based upon the high proportion of voluntary students (>70%) using optional virtual patients. However, in Budapest the participation rate was below 1%. Due to utilization, students seem to prefer virtual patients and problems created in their native language and developed at their own university. In addition, the statement that assessment drives learning was supported by the observation that peak utilization was just prior to summative examinations. Conclusion

  17. Effect of laparoscopic surgery on health care utilization and costs in patients who undergo colectomy.

    PubMed

    Crawshaw, Benjamin P; Chien, Hung-Lun; Augestad, Knut M; Delaney, Conor P

    2015-05-01

    Laparoscopic colectomy is safe and effective in the treatment of many colorectal diseases. However, the effect of increasing use of laparoscopy on overall health care utilization and costs, especially in the long term, has not been thoroughly investigated. To evaluate the effect of laparoscopic vs open colectomy on short- and long-term health care utilization and costs. Retrospective multivariate regression analysis of national health insurance claims data was used to evaluate health care utilization and costs up to 1 year following elective colectomy. Data were obtained from the Truven Health Analytics MarketScan Commercial Claims and Encounters database. Patients aged 18 to 64 years who underwent elective laparoscopic or open colectomy from January 1, 2010, through December 31, 2010, were included. Patients with complex diagnoses that require increased non-surgery-related health care utilization, including malignant neoplasm, inflammatory bowel disease, human immunodeficiency virus, transplantation, and pregnancy, were excluded. Of 25 481 patients who underwent colectomy, 4160 were included in the study. Healthcare utilization, including office, hospital outpatient, and emergency department visits and inpatient services 90 and 365 days after the index procedure; total health care costs; and estimated days off from work owing to health care utilization. Of 25 481 patients who underwent colectomy, 4160 were included in the study (laparoscopic, 45.6%; open, 54.4%). The mean (SD) net and total payments were lower for laparoscopy ($23 064 [$14 558] and $24 196 [$14 507] vs $29 753 [$21 421] and $31 606 [$23 586]). In the first 90 days after surgery, an open approach was significantly associated with a 1.26-fold increase in health care costs (estimated, $1715; 95% CI, $338-$2853), increased use of heath care services, and more estimated days off from work (2.78 days; 95% CI, 1.93-3.59). Similar trends were found in the full postoperative year, with

  18. Effects of music therapy on self- and experienced stigma in patients on an acute care psychiatric unit: a randomized three group effectiveness study.

    PubMed

    Silverman, Michael J

    2013-10-01

    Stigma is a major social barrier that can restrict access to and willingness to seek psychiatric care. Psychiatric consumers may use secrecy and withdrawal in an attempt to cope with stigma. The purpose of this study was to determine the effects of music therapy on self- and experienced stigma in acute care psychiatric inpatients using a randomized design with wait-list control. Participants (N=83) were randomly assigned by cluster to one of three single-session group-based conditions: music therapy, education, or wait-list control. Participants in the music therapy and education conditions completed only posttests while participants in the wait-list control condition completed only pretests. The music therapy condition was a group songwriting intervention wherein participants composed lyrics for "the stigma blues." Results indicated significant differences in measures of discrimination (experienced stigma), disclosure (self-stigma), and total stigma between participants in the music therapy condition and participants in the wait-list control condition. From the results of this randomized controlled investigation, music therapy may be an engaging and effective psychosocial technique to treat stigma. Limitations, suggestions for future research, and implications for clinical practice and psychiatric music therapy research are provided. © 2013.

  19. Evidence-Based Utilization of Non-Invasive Ventilation and Patient Outcomes.

    PubMed

    Mehta, Anuj B; Douglas, Ivor S; Walkey, Allan J

    2017-05-25

    Strong evidence supports use of non-invasive ventilation (NIV) for patients with respiratory distress from chronic obstructive pulmonary disease and heart failure (strong evidence conditions). Despite unclear benefits of NIV for other causes of acute respiratory failure, utilization for conditions with weaker evidence is increasing despite evidence demonstrating higher mortality for patients who suffer NIV failure (progression from NIV to invasive mechanical ventilation (IMV)) compared to being treated initially with IMV. Determine the association of hospital variation in evidence-based utilization of NIV with patient outcomes. Using the California State Inpatient Database 2011, we identified adult patients who received NIV. Patients were considered to have a strong evidence condition for NIV if they had an acute exacerbation of chronic obstructive pulmonary disease or heart failure. We used multivariable hierarchical logistic regression to determine the association between hospital rates of NIV use for strong evidence conditions and patient risk of NIV failure (need for invasive mechanical ventilation after NIV). Among 22,706 hospitalizations with NIV as the initial ventilatory strategy, 6,820 (30.0%) had strong evidence conditions. Patients with strong evidence conditions had lower risk of NIV failure than patients with weak evidence conditions (8.1% vs 18.2%, p<0.0001). Regardless of underlying diagnosis, patients admitted to hospitals with greater use of NIV for strong evidence conditions had lower risk of NIV failure (Quartile 4 vs Quartile 1 aOR=0.62, 95% CI 0.49-0.80). Even patients without a strong evidence condition benefited from admission to hospitals that used NIV more often for patients with strong evidence conditions (Quartile 4 vs Quartile 1 aOR for NIV failure = 0.68, 95% CI 0.52-0.88). Most patients who received NIV did not have conditions with strong supporting evidence for its use with wide institutional variation in patient selection for NIV

  20. Advanced Imaging Utilization Trends in Privately Insured Patients From 2007 to 2013.

    PubMed

    Horný, Michal; Burgess, James F; Cohen, Alan B

    2015-12-01

    The aim of the study was to investigate whether the increase in utilization of advanced diagnostic imaging for privately insured patients in 2011 was the beginning of a new trend in imaging utilization growth, or an isolated deviation from the declining trend that began in 2008. We extracted outpatient and inpatient CT, diagnostic ultrasound, MRI, and PET procedures from databases, for the years 2007 to 2013. This study extended previous work, covering 2012 to 2013, using the same methodology. For every year of the study period, we calculated the following: number of procedures per person-year covered by private health insurance; proportion of office and emergency visits that resulted in an imaging session; average payments per procedure; and total payments per person-year covered by private health insurance. Outpatient utilization of CT and PET decreased in both 2012 and 2013; outpatient utilization of MRI mildly increased in 2012, but then decreased in 2013. Outpatient utilization of diagnostic ultrasound showed a very different pattern, increasing throughout the study period. Inpatient utilization of all imaging modalities except PET decreased in both 2012 and 2013. Adjusted payments for all imaging modalities increased in 2012, and then dropped substantially in 2013, except the adjusted payments for diagnostic ultrasound that increased in 2013 again. The trend of increasing utilization of advanced diagnostic imaging seems to be over for some, but not all, imaging modalities. A combination of policy (eg, breast density notification laws), technologic advancement, and wider access seems to be responsible for at least part of an increasing utilization of diagnostic ultrasound. Copyright © 2015 American College of Radiology. All rights reserved.

  1. ED Utilization by Uninsured and Medicaid Patients after Availability of Telephone Triage.

    PubMed

    Howell, Tim

    2016-03-01

    For emergency departments experiencing crowding and a high percentage of patients leaving without being seen, a telephone triage service can provide other care options for low-acuity patients. A nonexperimental pre- and postintervention comparative design was used to measure ED visit volumes from Medicaid and uninsured patients presenting with a low-acuity health care problem. Visit volumes for the 12 months before and 12 months after the initiation of telephone triage were compared. The overall low-acuity visit volume increased in the first 12 months of telephone triage availability. However, the proportion of low-acuity Medicaid and uninsured patients seeking ED care decreased. For the first 12 months of operation, telephone triage received 10,055 calls. Sixty percent of the calls (N = 6086) were from uninsured and Medicaid patients. More than 43% of the calls resulted in a self-care decision. A telephone triage service may help decrease ED crowding by communicating other care options to patients with low-acuity health problems. Copyright © 2016 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.

  2. US Hemophilia Treatment Center population trends 1990-2010: patient diagnoses, demographics, health services utilization.

    PubMed

    Baker, J R; Riske, B; Drake, J H; Forsberg, A D; Atwood, R; Voutsis, M; Shearer, R

    2013-01-01

    For several decades, US government agencies have partially supported regional networks of Hemophilia Treatment Centers (HTC). HTC multidisciplinary teams provide comprehensive and coordinated diagnosis, treatment, prevention, education, outreach and surveillance services to improve the health of people with genetic bleeding disorders. However, national data are scarce on HTC-patient population trends and services. The aim of the study was to examine national trends over the past 20 years in patient diagnoses, demographics and health services utilization among the Health Resources and Services Administration (HRSA) and Centers for Disease Control and Prevention (CDC)-supported HTC network. Diagnoses, demographics and health services utilization data from 1990 to 2010 were aggregated from all HTCs using the Hemophilia Data Set (HDS). From 1990 to 2010, the HTC population grew 90% from 17 177 to 32 612. HTC patients with von Willebrand's disease increased by 148%, females by 346%, Hispanic patients by 236% and African Americans by 104%. Four thousand and seventy-five deaths were reported. From 2002 to 2010, annual comprehensive evaluations grew 38%, and persons with severe haemophilia on a home intravenous therapy programme rose 37%. In 2010, 46% of patients were less than 18 years vs. 24% for the general US population. The Hemophilia Data Set documents the growth and diversity of the US Hemophilia Treatment Center Network's patient population and services. Despite disproportionate deaths due to HIV, the HTC patient base grew faster than the general US population. The HDS is a vital national public health registry for this rare-disorder population.

  3. Utilization of sperm banking and barriers to its use in testicular cancer patients.

    PubMed

    Sonnenburg, D W; Brames, M J; Case-Eads, S; Einhorn, L H

    2015-09-01

    Testicular cancer is the most common carcinoma in 20- to 40-year-old men. Eighty percent of patients with metastases achieve disease-free status with chemotherapy with or without surgical resection. Standard first-line chemotherapy is bleomycin, etoposide, and cisplatin (BEP) for three to four courses or etoposide and cisplatin (EP) for four courses. Forty percent of patients receiving chemotherapy will have permanently reduced sperm counts impairing future fertility. Sperm banking is an effective method of maintaining fertility. This retrospective study was performed to assess utilization and results from sperm banking, as well as the barriers to its use. Patients 18 and older who had received chemotherapy were given a five-item questionnaire on follow-up visit. This questionnaire included a mix of quantitative and qualitative questions. Two hundred patients enrolled in the study, and all 200 completed the questionnaire. Of the two hundred, 139 (70 %) patients chose not to bank sperm; 71 (51 %) of those were not interested, 25 (18 %) declined due to desire to start chemotherapy, 24 (17 %) were not offered, 12 (9 %) declined due to cost, and 7 (5 %) answered "other." The average age at cancer diagnosis of patients who banked sperm was 28.4 as opposed to 32.6 for patients who did not (p = 0.003). The percentage of patients that had children before their diagnosis was 21 % in the sperm banking group, and 50 % in the group that did not (p = 0.0002). Sixty-one (30 %) chose to bank sperm; 11 of 61 patients (18 %) utilized the banked sperm; 9 of 11 (82 %) patients that utilized were successful; and 3 of 9 (33 %) successes resulted in multiple gestations. Sperm banking provides the opportunity for paternity in testicular cancer patients with reduced sperm counts following treatment. However, the majority of these patients chose not to bank sperm or were not offered the opportunity. A range of factors such as time, emotional state, patient age, disease stage, prior

  4. Healthcare resource utilization among haemophilia A patients in the United States.

    PubMed

    Valentino, L A; Pipe, S W; Tarantino, M D; Ye, X; Xiong, Y; Luo, M P

    2012-05-01

    Advances in therapy have improved life expectancy and quality of life of patients with haemophilia A. Due to the chronic and complex management of this disease, particularly, the development of inhibitors, little is known about their health resource utilization in the real-life setting over time. The aim was to assess the distribution and trend of healthcare resource utilization among US haemophilia A patients with and without inhibitors. The MarketScan® Database, was queried to identify individuals with ≥1 year continuous enrolment, two medical diagnoses of haemophilia A and claims for factor VIII or bypassing agent (to infer inhibitor status) during 2001-2007. Haemophilia-related cost was estimated from inpatient, outpatient and pharmacy claims. Annual cost differences were assessed by age and over a 4-year period for those with continuous enrolment. Among 51 million covered lives, 1044 haemophilia patients were identified, of whom 981 (94%; mean age = 21.2 years) did not have an inhibitor. The median haemophilia-related cost for these patients was $63,935 per patient per year. When normalized by weight, annual cost was stable (no statistically significant differences) among 312 non-inhibitor patients (mean age = 21.8 years) with 4-year continuous data. While there was a wide distribution of haemophilia-related cost among the 63 individuals with an inhibitor (mean age = 15.4 years), only 0.6% of the total haemophilia patients had costs exceeding $1 million per patient per year. This study indicated that most haemophilia A patients were inhibitor-free with relatively stable annual costs over time. There was a wide distribution of haemophilia-related cost for inhibitor patients, while the proportion of patients who incurred extreme high cost was low.

  5. Maximizing patient safety utilizing effective patient identification and image labeling practices.

    PubMed

    Aloisio, John J

    2008-01-01

    Proper patient identification in the radiology setting is increasingly being recognized as a widespread safety issue. This article discusses the corrective action taken when a mislabeled portable image contributed to a patient's demise. Annual bedside portable exams at North Shore University Hospital exceed 60,000 procedures. Managing workload of this volume is extremely difficult and requires effective patient identification policies and procedures to ensure patient safety. Developing a safety culture across the radiology department is a critical component of patient safety. Staff education and ongoing re-enforcement of safety principles are fundamental elements to a successful program.

  6. Impact of Consultation on Hospital Outcomes and Resource Utilization for Patients with Acute Congestive Heart Failure.

    PubMed

    Varga, Zoltan; Sabzwari, Syed Ali Rafay; Abusaada, Khalid

    2017-07-01

    Consultation is an important tool for acquiring subspecialty support when managing patients with acute congestive heart failure (CHF). The effect of consultation on hospital outcomes and resource utilization in CHF is unknown. The objectives of our study were to determine the effect of consultation on outcomes in CHF and to evaluate factors affecting the frequency of consultation. Our study was a retrospective cohort study of patients admitted to Florida Hospital Orlando for CHF between January 1, 2011 and December 31, 2013. Data on demographics, number of consultations, length of stay (LOS), readmissions within 30 days, cost of care, and mortality were compared according to the number of consultations. For statistical analysis, analysis of variance, the χ(2) test, and multivariate linear regression analysis were used. Risk-adjusted outcomes were reported as observed/expected. A total of 1554 patients were included; 103 (6.6%) patients received no consultation; 482 (31%) received 1; 365 (23.5%) received 2; 229 (14%) received 3; and 375 (24%) received ≥4. Teaching service, age, and African American race were associated with decreased consultation (P < 0.001 for all) and high case-mix index was associated with increased consultation (P < 0.001). Adjusted LOS and costs increased with an increased number of consultations (P < 0.001 for both). There was no difference in adjusted mortality or 30-day readmission rate based on the number of consultations (P = 0.35 and 0.98, respectively). Increased consultation with patients with CHF is associated with increased costs and LOS without improved mortality or readmission rate. Decreased utilization of consultations by the teaching service suggests that there is an opportunity to decrease utilization of healthcare resources by streamlining the utilization of consultations.

  7. Re-analysis of survival data of cancer patients utilizing additive homeopathy.

    PubMed

    Gleiss, Andreas; Frass, Michael; Gaertner, Katharina

    2016-08-01

    In this short communication we present a re-analysis of homeopathic patient data in comparison to control patient data from the same Outpatient´s Unit "Homeopathy in malignant diseases" of the Medical University of Vienna. In this analysis we took account of a probable immortal time bias. For patients suffering from advanced stages of cancer and surviving the first 6 or 12 months after diagnosis, respectively, the results show that utilizing homeopathy gives a statistically significant (p<0.001) advantage over control patients regarding survival time. In conclusion, bearing in mind all limitations, the results of this retrospective study suggest that patients with advanced stages of cancer might benefit from additional homeopathic treatment until a survival time of up to 12 months after diagnosis. Copyright © 2016 Elsevier Ltd. All rights reserved.

  8. Does primary stroke center certification change ED diagnosis, utilization, and disposition of patients with acute stroke?

    PubMed

    Ballard, Dustin W; Reed, Mary E; Huang, Jie; Kramer, Barbara J; Hsu, John; Chettipally, Uli

    2012-09-01

    We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification. A retrospective cohort study of 30,461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification-using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages. There were 15,687 precertification ED visits and 11,040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival. Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival. Copyright © 2012 Elsevier Inc. All rights reserved.

  9. Outpatient follow-up does not prevent emergency department utilization by trauma patients.

    PubMed

    Dalton, Michael K; Fox, Nicole M; Porter, John M; Hazelton, Joshua P

    2017-10-01

    Although most trauma centers have a regularly scheduled trauma clinic, research demonstrates that trauma patients do not consistently attend follow-up appointments and often use the emergency department (ED) for outpatient care. A retrospective review of outpatient follow-up of adult patients admitted to the trauma service (January 2014-December 2014) at an urban level I trauma center was conducted (n = 2134). A total of 219 patients (10%) were evaluated in trauma clinic after discharge from the hospital. Twenty-one percent of patients seen in trauma clinic visited the ED within 30 d compared with 12% of those not seen in clinic (P < 0.001). A total of 104 patients were readmitted within 30 d of discharge; no difference existed in the rate of hospital readmission between patients seen in clinic and those not seen in clinic (P = 0.25). Stepwise logistic regression showed that clinic follow-up was not a significant predictor of decreased ED utilization (adjusted odds ratio [OR] 1.16 [95% confidence interval 0.78-1.72], P = 0.461) and also showed that while ED use was a significant predictor of readmission (adjusted OR 216 [93-500], P < 0.001), clinic visits were not (adjusted OR 0.74 [0.33-1.69], P = 0.48). Outpatient follow-up in the trauma clinic does not decrease ED utilization or hospital readmissions indicating that interventions aimed at improving access to a conventional outpatient clinic will not impact ED utilization rates. Further study is necessary to determine the best system for providing clinically appropriate and cost-effective outpatient follow-up for trauma patients. Copyright © 2017 Elsevier Inc. All rights reserved.

  10. Utility of Allergy Testing in Patients with Chronic Laryngopharyngeal Symptoms: Is It Allergic Laryngitis?

    PubMed

    Brook, Christopher D; Platt, Michael P; Reese, Stephen; Noordzij, J Pieter

    2016-01-01

    To determine the utility of allergy evaluation in patients with chronic refractory laryngeal symptoms. Case series with chart review. Tertiary academic medical center. All patients who underwent in vitro allergy testing at a single institution from 2006 to 2010, for a total of 998 patients. Charts of patients who underwent in vitro allergy testing were identified. The charts were reviewed for the primary indication for allergy testing, as categorized into rhinitis complaints, chronic sinusitis, otitis media, and refractory laryngeal symptoms (globus, cough, throat clearing, increased secretions, and hoarseness). Results of allergy tests and comorbid conditions were analyzed and compared among groups. The positive yield of allergy testing in patients with primary laryngeal indications was 51.8%, 63.3% for rhinitis, 60.9% for sinusitis, and 33.3% for otitis media. The odds ratio of having a positive test was not statistically different for patients with laryngeal symptoms, rhinitis, or sinusitis. Patients with chronic laryngeal symptoms and positive allergy testing were most often sensitized to dust mites (63%) and least often sensitized to molds (1.3%). Allergy testing in patients with chronic laryngeal symptoms yields positive results in equivalent proportion to patients with other common presenting symptoms. Dust mites sensitization is the most common sensitization in patients with allergic laryngitis. © American Academy of Otolaryngology-Head and Neck Surgery Foundation 2015.

  11. Resource Utilization and Costs of Care prior to ART Initiation for Pediatric Patients in Zambia.

    PubMed

    Iyer, Hari S; Scott, Callie A; Lembela Bwalya, Deophine; Meyer-Rath, Gesine; Moyo, Crispin; Bolton Moore, Carolyn; Larson, Bruce A; Rosen, Sydney

    2014-01-01

    Objective. We estimated time to initiation, outpatient resource use, and costs of outpatient care during the 6 months prior to ART initiation for HIV-infected pediatric patients in Zambia. Methods. We enrolled 1,102 children who initiated ART at <15 years of age between 2006 and 2011 at 5 study sites. Of these, 832 initiated ART ≤6 months after first presenting to care at the study sites. Data on time in care and resources utilized during the 6 months prior to ART initiation were extracted from patient medical records. Costs were estimated from the provider's perspective and are reported in 2011 USD. Results. For the patients who initiated ART ≤6 months after presenting to care, median age at presentation to care was 3.9 years; median CD4 percentage was 13%. Median time to ART initiation was 26 days. Patients made, on average, 2.38 clinic visits prior to ART initiation and received 0.81 CD4 tests, 0.74 full blood count tests, and 0.49 blood chemistry tests. The mean cost of pre-ART care was $20 per patient. Conclusions. Zambian pediatric patients initiating ART ≤6 months after presenting to care do so quickly, utilize fewer resources than mandated by national guidelines, and accrue low costs.

  12. Healthcare utilization of patients with epilepsy in Yuma County, Arizona: do disparities exist?

    PubMed

    Sim, Yeeck; Nokes, Brandon; Byreddy, Seenu; Chong, Jenny; Coull, Bruce M; Labiner, David M

    2014-02-01

    The aim of this study was to describe the disparities in healthcare utilization and costs between Hispanic and non-Hispanic patients with seizures or epilepsy. We reviewed the insurance status and healthcare resource utilization data from 2005 to 2008 for all patients with seizures and epilepsy seen at the Yuma Regional Medical Center (YRMC). Charges for medical services provided to Hispanic patients with epilepsy between the ages of 18 and 49 were significantly less than those for non-Hispanic patients with epilepsy (Hispanic: $3167.63 versus non-Hispanic: $5154.36, P<0.001). Taking into account the differences in insurance status, setting of care, and total number of procedures, we still saw a significant difference in charges between the two groups at the outpatient settings. These data differ from currently available data on national and Eastern US Hispanic patients with epilepsy, suggesting that patients in this border community are somehow different from Hispanics elsewhere in the US. © 2013.

  13. Resource Utilization and Costs of Care prior to ART Initiation for Pediatric Patients in Zambia

    PubMed Central

    Iyer, Hari S.; Scott, Callie A.; Lembela Bwalya, Deophine; Meyer-Rath, Gesine; Moyo, Crispin; Bolton Moore, Carolyn; Larson, Bruce A.

    2014-01-01

    Objective. We estimated time to initiation, outpatient resource use, and costs of outpatient care during the 6 months prior to ART initiation for HIV-infected pediatric patients in Zambia. Methods. We enrolled 1,102 children who initiated ART at <15 years of age between 2006 and 2011 at 5 study sites. Of these, 832 initiated ART ≤6 months after first presenting to care at the study sites. Data on time in care and resources utilized during the 6 months prior to ART initiation were extracted from patient medical records. Costs were estimated from the provider's perspective and are reported in 2011 USD. Results. For the patients who initiated ART ≤6 months after presenting to care, median age at presentation to care was 3.9 years; median CD4 percentage was 13%. Median time to ART initiation was 26 days. Patients made, on average, 2.38 clinic visits prior to ART initiation and received 0.81 CD4 tests, 0.74 full blood count tests, and 0.49 blood chemistry tests. The mean cost of pre-ART care was $20 per patient. Conclusions. Zambian pediatric patients initiating ART ≤6 months after presenting to care do so quickly, utilize fewer resources than mandated by national guidelines, and accrue low costs. PMID:24711925

  14. Hospitalist utilization and hospital performance on 6 publicly reported patient outcomes.

    PubMed

    Goodrich, Kate; Krumholz, Harlan M; Conway, Patrick H; Lindenauer, Peter; Auerbach, Andrew D

    2012-01-01

    The increase in hospitalist-provided inpatient care may be accompanied by an expectation of improvement on patient outcomes. To date, the association between utilization of hospitalists and the publicly reported patient outcomes is unknown. Assess the relationship between hospitalist utilization and performance on 6 publicly reported patient outcomes. Cross-sectional study. Representatives of 598 hospitals in the United States with direct knowledge of inpatient service models. Survey of hospital personnel with knowledge of hospitalist use and hospitalist programs. Six publicly reported quality outcome measures across 3 medical conditions: acute myocardial infarction (AMI), congestive heart failure (HF), and pneumonia. Using multivariable regression models, we assessed the relationship between presence of hospitalists and performance on each outcome measure; we further assessed the relationship between the percentage of patients admitted by hospitalists and each outcome measure. Of 598 respondents, 429 (72%) reported the use of hospitalist services. In the comparison of hospitals with and without hospitalists, there was no statistically significant difference on any of the mortality or readmissions measures with the exception of the risk-stratified readmission rate for heart failure. For hospitals that used hospitalists, there was no significant change in any of the outcome measures with increasing percentage of patients admitted by hospitalists. The presence of hospitalists is not an independent predictor of performance on publicly reported mortality and readmissions measures for AMI, HF, or pneumonia. It is likely that broader system or organizational interventions are required to improve performance on patient outcomes. Copyright © 2012 Society of Hospital Medicine.

  15. Breast Density Legislation: Discussion of Patient Utilization and Subsequent Direct Financial Ramifications for Insurance Providers.

    PubMed

    Sobotka, John; Hinrichs, Clay

    2015-10-01

    Now that New Jersey has become the 14th state in the United States to enact legislation regarding dense breast screening, its patients are eligible to receive screening breast sonography coverage from their insurance carriers. This law is intended to improve breast cancer detection in patients with dense breasts and create awareness of unique issues that come with dense breast tissue, while reinforcing already present efforts to reduce the incidence of and morbidity related to the diagnosis of breast cancer. The aim of this study was to examine data from months preceding the effective date of this legislation in a community hospital setting and compare these data with data from months immediately after, and 6 months after, its enactment to present patient participation data and estimate the legislation's direct financial ramifications. Detractors of this type of legislation worry about overburdening the health care system with an influx of patients. Although there is a lack of present studies confirming this suspicion in other states with dense breast legislation, this study confirms a large increase in patient utilization after enactment, showing a minimum relative increase of 176.90% and a maximum relative increase of 335.56% in patient utilization of screening breast sonography. The investigators further include an estimation of an increased direct cost for insurers of $4,910,899.18 to $9,848,897.96 for a given month.

  16. Identifying patient, community and program specific barriers to free specialty care utilization by uninsured patients in East Baltimore.

    PubMed

    Handy, Catherine; Ma, Sai; Block, Lauren; de la Torre, Desiree; Langley, Anne; Cook, Barbara

    2013-05-01

    Uninsured individuals face multiple barriers to accessing specialty care. The Access Partnership (TAP) offers free specialty care and care coordination to qualified uninsured patients at an urban academic medical center for a small program entry fee (waived for financial hardship). In the program's first year, 104 eligible patients (31%) did not enroll. To understand why, we investigated demographic, referral, personal, and program-specific factors. After adjusting for age, gender, and ZIP code, diagnostic and therapeutic referrals were more likely to be completed than ancillary referrals (OR=8.56, p=.001; OR 3.53, p=.03). There was no difference between pain related and ancillary referrals (OR=2.80, p=.139). Eighteen patients were surveyed and reported program and patient-specific barriers. While removing costs is necessary to improve access to specialty care for underserved patients, it is insufficient. Improving communication from program coordinators and enrollment strategies may help to improve utilization of free care programs by the uninsured.

  17. Comparative inpatient resource utilization for patients undergoing endoscopic or microscopic transsphenoidal surgery for pituitary lesions.

    PubMed

    Little, Andrew S; Chapple, Kristina; Jahnke, Heidi; White, William L

    2014-07-01

    OBJECT.: An increasingly important measure in the health care field is utilization of hospital resources, particularly in the context of emerging surgical techniques. Despite the recent widespread adoption of the endoscopic transsphenoidal approach for pituitary lesion surgery, the health care resources utilized with this approach have not been compared with those utilized with the traditional microscopic approach. The purpose of this study was to determine the drivers of resource utilization by comparing hospital charges for patients with pituitary tumors who had undergone either endoscopic or microscopic transsphenoidal surgery. A complete accounting of all hospital charges for 166 patients prospectively enrolled in a surgical quality-of-life study at a single pituitary center during October 2011-June 2013 was undertaken. Patients were assigned to surgical technique group according to surgeon preference and then managed according to a standard postoperative institutional set of orders. Individual line-item charges were assigned to categories (such as pharmacy, imaging, surgical, laboratory, room, pathology, and recovery unit), and univariate and multivariate statistical analyses were conducted. Of the 166 patients, 99 underwent microscopic surgery and 67 underwent endoscopic surgery. Baseline demographic descriptors and tumor characteristics did not differ significantly. Mean total hospital charges were $74,703 ± $15,142 and $72,311 ± $16,576 for microscopic and endoscopic surgery patients, respectively (p = 0.33). Furthermore, other than for pathology, charge categories did not differ significantly between groups. A 2-step multivariate regression model revealed that length of stay was the most influential variable, followed by a diagnosis of Cushing's disease, and then by endoscopic surgical technique. The model accounts for 42% of the variance in hospital charges. Study findings suggest that adoption of the endoscopic transsphenoidal technique for pituitary

  18. Prognostic Utility of a Modified HEART Score in Chest Pain Patients in the Emergency Department.

    PubMed

    McCord, James; Cabrera, Rafael; Lindahl, Bertil; Giannitsis, Evangelos; Evans, Kaleigh; Nowak, Richard; Frisoli, Tiberio; Body, Richard; Christ, Michael; deFilippi, Christopher R; Christenson, Robert H; Jacobsen, Gordon; Alquezar, Aitor; Panteghini, Mauro; Melki, Dina; Plebani, Mario; Verschuren, Franck; French, John; Bendig, Garnet; Weiser, Silvia; Mueller, Christian

    2017-02-01

    The TRAPID-AMI trial study (High-Sensitivity Troponin-T Assay for Rapid Rule-Out of Acute Myocardial Infarction) evaluated high-sensitivity cardiac troponin-T (hs-cTnT) in a 1-hour acute myocardial infarction (AMI) exclusion algorithm. Our study objective was to evaluate the prognostic utility of a modified HEART score (m-HS) within this trial. Twelve centers evaluated 1282 patients in the emergency department for possible AMI from 2011 to 2013. Measurements of hs-cTnT (99th percentile, 14 ng/L) were performed at 0, 1, 2, and 4 to 14 hours. Evaluation for major adverse cardiac events (MACEs) occurred at 30 days (death or AMI). Low-risk patients had an m-HS≤3 and had either hs-cTnT<14 ng/L over serial testing or had AMI excluded by the 1-hour protocol. By the 1-hour protocol, 777 (60%) patients had an AMI excluded. Of those 777 patients, 515 (66.3%) patients had an m-HS≤3, with 1 (0.2%) patient having a MACE, and 262 (33.7%) patients had an m-HS≥4, with 6 (2.3%) patients having MACEs (P=0.007). Over 4 to 14 hours, 661 patients had a hs-cTnT<14 ng/L. Of those 661 patients, 413 (62.5%) patients had an m-HS≤3, with 1 (0.2%) patient having a MACE, and 248 (37.5%) patients had an m-HS≥4, with 5 (2.0%) patients having MACEs (P=0.03). Serial testing of hs-cTnT over 1 hour along with application of an m-HS identified a low-risk population that might be able to be directly discharged from the emergency department. © 2017 American Heart Association, Inc.

  19. Understanding the digital divide in the clinical setting: the technology knowledge gap experienced by US safety net patients during teleretinal screening.

    PubMed

    George, Sheba; Moran, Erin; Fish, Allison; Ogunyemi, Lola

    2013-01-01

    Differential access to everyday technology and healthcare amongst safety net patients is associated with low technological and health literacies, respectively. These low rates of literacy produce a complex patient "knowledge gap" that influences the effectiveness of telehealth technologies. To understand this "knowledge gap", six focus groups (2 African-American and 4 Latino) were conducted with patients who received teleretinal screenings in U.S. urban safety-net settings. Findings indicate that patients' "knowledge gap" is primarily produced at three points: (1) when patients' preexisting personal barriers to care became exacerbated in the clinical setting; (2) through encounters with technology during screening; and (3) in doctor-patient follow-up. This "knowledge gap" can produce confusion and fear, potentially affecting patients' confidence in quality of care and limiting their disease management ability. In rethinking the digital divide to include the consequences of this knowledge gap faced by patients in the clinical setting, we suggest that patient education focus on both their disease and specific telehealth technologies deployed in care delivery.

  20. Socioeconomic factors associated with visual impairment and ophthalmic care utilization in patients with type II diabetes.

    PubMed

    Hwang, Jongnam; Rudnisky, Christopher; Bowen, Sarah; Johnson, Jeffrey A

    2015-04-01

    To examine the association between socioeconomic factors and ophthalmic care services/visual impairment among patients with diabetes. Data from the Survey on Living with Chronic Disease in Canada (SLCDC)-Diabetes Component 2011 were used. A cross-sectional, nationally representative sample of patients with diabetes weighted to represent the civilian, noninstitutionalized Canadian population with self-reported type II diabetes. Socioeconomic factors were classified into predictive factors, need, and non-need factors. Factors associated with the ophthalmic care utilization and visual impairment were assessed using logistic regression models, weighted for the SLCDC sampling strategy. Among all patients with type II diabetes, factors associated with increased eye screening were: (i) discussion of diabetic complications with health professionals (odds ratio [OR] 2.02, 95% CI 1.28-3.19); (ii) having private insurance (OR 3.23, 95% CI 2.21-4.73); and (iii) duration of diabetes longer than 10 years (OR 1.53, 95% CI 1.04-2.25). Among asymptomatic patients (those who reported having no visual impairment), patients with lower income had 40% decreased odds of having eye screening services compared with those with higher income (OR 0.60, 95% CI 0.37-0.98). Among all patients with type II diabetes, visual impairment was more likely in females (OR 1.53, 95% CI 1.12-2.09), older patients (OR 18.12, 95% CI 6.63-49.51), and those with poor self-rated health (OR 3.10, 95% CI 1.62-5.96). Our study found that interactions between health professionals and patients, as well as having private health insurance, were the main factors associated with ophthalmic resource utilization, whereas age, sex, duration of diabetes, and self-rated health were associated with visual impairment in patients with type II diabetes. Copyright © 2015 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.

  1. Utilizing Actionable Data Analytics to Support Patient Navigation Enrollment and Retention Within Federally Qualified Health Centers.

    PubMed

    Robinson, Melody M; Stone, Gregory; Tokarz, Stephanie; Wortham, Benjamin

    Emergency departments (EDs) have become the primary source of care for increasing number of patients, leading to treatment of nonemergent cases, which divert resources from true emergency situations and represent poor cost-effectiveness for treating such cases. There is evidence that suggests that patient navigation (PN) integrated into the ED and other case management techniques can help reduce the number of primary care-related ED visits and these navigation programs are more cost-effective than the ED visits themselves. The Greater New Orleans Community Health Connection Primary Care Capacity Project Quality Improvement Initiative (GNOPQii) is a pilot project aimed at improving the efficiency of PN for patients who have had avoidable ED encounters or inpatient readmissions through applied data and technology program. Partnering Federally Qualified Health Centers were equipped with actionable ED utilization data to integrate with their own patient clinical data to track patient ED activity. The pilot design also included the use of patient navigators to address the nonclinical cultural and behavioral barriers to care. As part of the overall evaluation, comparisons of data utilization and PN services pre- and post-GNOPQii were conducted. A total of 337 referrals were made, and 145 patients were enrolled into the GNOPQii pilot program. The direct services needed the most by patients were transportation and medication resources. Of those who enrolled (N = 145), 63 patients graduated, meaning program compliance and 90 days without visits to the ED, resulting in a 43% success rate. If an estimated $1898 savings for every nonemergency ED encounter replaced by an office-based encounter is applied to our results, the GNOPQii program contributed to a minimum of $119 574.00 savings even if only 1 deterred ED visit per graduate is assumed. Future research is needed to systematically test the efficacy of GNOPQii in reducing nonemergent ED visits.

  2. Association between resource utilization and patient satisfaction at a tertiary care medical center.

    PubMed

    Biondi, Eric A; Hall, Matthew; Leonard, Michael S; Pirraglia, Paul A; Alverson, Brian K

    2016-11-01

    The Centers for Medicare and Medicaid Services has emphasized patient satisfaction as a means by which hospitals should be compared and as a component of financial reimbursement. We sought to identify whether resource utilization is associated with patient satisfaction ratings. This was a retrospective, cohort study over a 27-month period from January 2012 to April 2014 of adult respondents (n = 10,007) to the Hospital Consumer Assessment of Healthcare Providers and Systems survey at a tertiary care medical center. For each returned survey, we developed a resource intensity score related to the corresponding hospitalization. We calculated a raw satisfaction rating (RSR) for each returned survey. Multivariable logistic regression was used to determine the association between resource intensity and top decile RSRs, using those with the lowest resource intensity as the reference group. Adjusting for age, gender, insurance payer, severity of illness, and clinical service, patients in higher resource intensity groups were more likely to assign top decile RSRs than the lowest resource intensity group ("moderate" [adjusted odds ratio {aOR}: 1.42, 95% confidence interval {CI}: 1.11-1.83], "major" [aOR: 1.56, 95% CI: 1.22-2.01], and "extreme" [aOR: 2.29, 95% CI: 1.8-2.92]). Resource utilization may be positively associated with patient satisfaction. These data suggest that hospitals with higher per-patient expenditures may receive higher ratings, which could result in hospitals with higher per-patient resource utilization appearing more attractive to healthcare consumers. Journal of Hospital Medicine 2016;11:785-791. © 2016 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.

  3. Left Ventricular Assist Devices Impact Hospital Resource Utilization Without Affecting Patient Mortality in Gastrointestinal Bleeding.

    PubMed

    Li, Feng; Hinton, Alice; Chen, Alan; Mehta, Nishaki K; Eldika, Samer; Zhang, Cheng; Hussan, Hisham; Conwell, Darwin L; Krishna, Somashekar G

    2017-01-01

    Left ventricular assist devices (LVADs) are being utilized for management of end-stage heart failure and require systemic anticoagulation. Gastrointestinal bleeding (GIB) is one of the most common adverse events following LVAD implantation. To investigate the impact of continuous-flow (CF) LVAD implants on outcomes of patients admitted with GIB. This is a cross-sectional study utilizing the Nationwide Inpatient Sample in the CF-LVAD era from 2010 to 2012. All adult admissions with a primary diagnosis of GIB were included. Among hospitalizations with GIB, patients with (cases) and without (controls) CF-LVAD implants were compared using univariate and multivariate analyses. The main outcome measurements were in-hospital mortality, length of stay, and hospitalization costs. Among 1,002,299 hospitalizations for GIB, 1112 (0.11%) patients had CF-LVADs. Bleeding angiodysplasia accounted for a majority of GIB in CF-LVAD patients (35.4% of 1112). Multivariate analysis adjusting for demographic, hospital and etiological differences, site of GIB, and patient comorbidities revealed that CF-LVADs were not adversely associated with mortality in GIB (OR 0.53, 95% CI 0.07-4.15). However, CF-LVADs independently accounted for prolonged hospitalization (3.5 days, 95% CI 2.6-4.6) and higher hospital charges ($37,032, 95% CI $7991-$66,074). In patients admitted with GIB, CF-LVAD implantation accounts for higher healthcare utilization, but is not adversely associated with mortality despite therapeutic anticoagulation, increased comorbidities, and comparatively delayed endoscopy. These findings are relevant as CF-LVADs are the dominant type of LVAD and are associated with increased risk of GIB compared to their predecessors.

  4. Resource utilization before and during infliximab therapy in patients with inflammatory bowel disease.

    PubMed

    Waters, Heidi C; Vanderpoel, Julie E; Nejadnik, Bijan; McKenzie, R Scott; Lunacsek, Orsolya E; Lennert, Barbara J; Goff, John; Augustyn, Damian H

    2012-01-01

    Although Remicade (infliximab) is costly relative to non-biologic therapy, its impact on healthcare resource utilization and mucosal healing may make it a cost-effective option. This study aimed to compare gastrointestinal (GI)-related healthcare resource utilization and severity of mucosal damage before and during infliximab therapy in Crohn's disease (CD) or ulcerative colitis (UC) patients. A retrospective chart review was conducted at 14 gastroenterology practices from across the country, which varied in practice sizes and types. Patients were aged ≥18 years, diagnosed with CD or UC, and had an infliximab index date between January 1, 2005 and September 30, 2007. GI-related utilization 12 months before and 12 months after the index date was compared. Endoscopic disease severity was categorized based on blinded review of abstracted reports. Results from 268 patients indicated significantly lower rates of surgery (29.7% to 9.9%, p < 0.0001, CD; 24.4% to 12.8%, p = 0.042, UC) and colonoscopy (54.4% to 17.6%, p < 0.0001, CD; 50.0% to 22.1%, p = 0.0007, UC) during infliximab therapy. The rates of hospitalizations in UC (15.1% to 3.5%, p = 0.0124) and radiology assessments in CD (23.1% to 10.4%, p = 0.006) also decreased. Based on severity data from 183 procedures, greater proportions of patients had normal or mild ratings during infliximab treatment compared with pre-treatment. This retrospective descriptive study is limited by the type and quantity of information available in patient charts from 14 gastroenterology clinics during the first year of infliximab treatment. In addition, the number of patients with pre-treatment and post-treatment disease severity information was too small to make comparisons among disease severity groups. Further information about the severity of disease and the extent of mucosal healing could be helpful in determining the effect of therapy on resource utilization in future research. GI-related resource

  5. A phase IIIb study of ledipasvir/sofosbuvir fixed-dose combination tablet in treatment-naïve and treatment-experienced Korean patients chronically infected with genotype 1 hepatitis C virus.

    PubMed

    Lim, Young-Suk; Ahn, Sang Hoon; Lee, Kwan Sik; Paik, Seung Woon; Lee, Youn-Jae; Jeong, Sook-Hyang; Kim, Ju-Hyun; Yoon, Seung Kew; Yim, Hyung Joon; Tak, Won Young; Han, Sang-Young; Yang, Jenny C; Mo, Hongmei; Garrison, Kimberly L; Gao, Bing; Knox, Steven J; Pang, Phillip S; Kim, Yoon Jun; Byun, Kwan-Soo; Kim, Young Seok; Heo, Jeong; Han, Kwang-Hyub

    2016-11-01

    The standard-of-care regimen for chronic hepatitis C virus (HCV) infection in Korea, pegylated-interferon-alpha plus ribavirin, is poorly tolerated. Ledipasvir/sofosbuvir is a two-drug, fixed-dose combination tablet approved in the USA, European Union, and Japan for chronic genotype 1 HCV infection. This single-arm, phase IIIb study (NCT02021656) investigated the efficacy and safety of ledipasvir/sofosbuvir fixed-dose combination tablet for 12 weeks in treatment-naïve and treatment-experienced Korean patients chronically infected with genotype 1 HCV with or without compensated cirrhosis. The proportion of patients with sustained virologic response 12 weeks after treatment discontinuation (SVR12) was 99 % (92/93), with rates of 100 % (46/46) and 98 % (46/47) in treatment-naïve and treatment-experienced patients, respectively. There were no on-treatment failures. One patient relapsed after the end of treatment. The most common treatment-emergent adverse events were headache (8 %, 7/93) and fatigue (6 %, 6/93). There were no grade 3 or 4 adverse events, seven grade 3 laboratory abnormalities, and one premature discontinuation of study treatment (due to nonserious mouth ulceration). None of the three reported serious adverse events were related to treatment. These data suggest that 12 weeks of ledipasvir/sofosbuvir is effective and well tolerated in treatment-naïve and treatment-experienced Korean patients with chronic genotype 1 HCV infection.

  6. Virologic Response to Tipranavir-Ritonavir or Darunavir-Ritonavir Based Regimens in Antiretroviral Therapy Experienced HIV-1 Patients: A Meta-Analysis and Meta-Regression of Randomized Controlled Clinical Trials

    PubMed Central

    Berhan, Asres; Berhan, Yifru

    2013-01-01

    Background The development of tipranavir and darunavir, second generation non-peptidic HIV protease inhibitors, with marked improved resistance profiles, has opened a new perspective on the treatment of antiretroviral therapy (ART) experienced HIV patients with poor viral load control. The aim of this study was to determine the virologic response in ART experienced patients to tipranavir-ritonavir and darunavir-ritonavir based regimens. Methods and Findings A computer based literature search was conducted in the databases of HINARI (Health InterNetwork Access to Research Initiative), Medline and Cochrane library. Meta-analysis was performed by including randomized controlled studies that were conducted in ART experienced patients with plasma viral load above 1,000 copies HIV RNA/ml. The odds ratios and 95% confidence intervals (CI) for viral loads of <50 copies and <400 copies HIV RNA/ml at the end of the intervention were determined by the random effects model. Meta-regression, sensitivity analysis and funnel plots were done. The number of HIV-1 patients who were on either a tipranavir-ritonavir or darunavir-ritonavir based regimen and achieved viral load less than 50 copies HIV RNA/ml was significantly higher (overall OR = 3.4; 95% CI, 2.61– 4.52) than the number of HIV-1 patients who were on investigator selected boosted comparator HIV-1 protease inhibitors (CPIs-ritonavir). Similarly, the number of patients with viral load less than 400 copies HIV RNA/ml was significantly higher in either the tipranavir-ritonavir or darunavir-ritonavir based regimen treated group (overall OR = 3.0; 95% CI, 2.15 – 4.11). Meta-regression showed that the viral load reduction was independent of baseline viral load, baseline CD4 count and duration of tipranavir-ritonavir or darunavir-ritonavir based regimen. Conclusions Tipranavir and darunavir based regimens were more effective in patients who were ART experienced and had poor viral load control. Further studies are

  7. Lack of clinical utility of urine gram stain for suspected urinary tract infection in pediatric patients.

    PubMed

    Cantey, Joseph B; Gaviria-Agudelo, Claudia; McElvania TeKippe, Erin; Doern, Christopher D

    2015-04-01

    Urinary tract infection (UTI) is one of the most common infections in children. Urine culture remains the gold standard for diagnosis, but the utility of urine Gram stain relative to urinalysis (UA) is unclear. We reviewed 312 pediatric patients with suspected UTI who had urine culture, UA, and urine Gram stain performed from a single urine specimen. UA was considered positive if ≥10 leukocytes per oil immersion field were seen or if either nitrates or leukocyte esterase testing was positive. Urine Gram stain was considered positive if any organisms were seen. Sensitivity, specificity, and positive and negative predictive values were calculated using urine culture as the gold standard. Thirty-seven (12%) patients had a culture-proven UTI. Compared to urine Gram stain, UA had equal sensitivity (97.3% versus 97.5%) and higher specificity (85% versus 74%). Empirical therapy was prescribed before the Gram stain result was known in 40 (49%) patients and after in 42 (51%) patients. The antibiotics chosen did not differ between the two groups (P=0.81), nor did they differ for patients with Gram-negative rods on urine Gram stain compared to those with Gram-positive cocci (P=0.67). From these data, we conclude that UA has excellent negative predictive value that is not enhanced by urine Gram stain and that antibiotic selection did not vary based on the urine Gram stain result. In conclusion, the clinical utility of urine Gram stain does not warrant the time or cost it requires.

  8. Dialysis Facility and Patient Characteristics Associated with Utilization of Home Dialysis

    PubMed Central

    Walker, David R.; Inglese, Gary W.; Sloand, James A.

    2010-01-01

    Background and objectives: Nonmedical factors influencing utilization of home dialysis at the facility level are poorly quantified. Home dialysis is comparably effective and safe but less expensive to society and Medicare than in-center hemodialysis. Elimination of modifiable practice variation unrelated to medical factors could contribute to improvements in patient outcomes and use of scarce resources. Design, setting, participants, & measurements: Prevalent dialysis patient data by facility were collected from the 2007 ESRD Network’s annual reports. Facility characteristic data were collected from Medicare’s Dialysis Facility Compare file. A multivariate regression model was used to evaluate associations between the use of home dialysis and facility characteristics. Results: The utilization of home dialysis was positively associated with facility size, percent patients employed full- or part-time, younger population, and years a facility was Medicare certified. Variables negatively associated include an increased number of hemodialysis patients per hemodialysis station, chain association, rural location, more densely populated zip code, a late dialysis work shift, and greater percent of black patients within a zip code. Conclusions: Improved understanding of factors affecting the frequency of use of home dialysis may help explain practice variations across the United States that result in an imbalanced use of medical resources within the ESRD population. In turn, this may improve the delivery of healthcare and extend the ability of an increasingly overburdened medical financing system to survive. PMID:20634324

  9. Clinical characteristics and healthcare utilization of patients with multicentric Castleman disease.

    PubMed

    Casper, Corey; Teltsch, Dana Y; Robinson, Don; Desrosiers, Marie-Pierre; Rotella, Philip; Dispenzieri, Angela; Qi, Ming; Habermann, Thomas; Reynolds, Matthew W

    2015-01-01

    Multicentric Castleman disease (MCD) is a rare lymphoproliferative disease. Little is known about how patient clinical features and healthcare utilization varies by human immunodeficiency virus (HIV) status and disease subtype. Data of MCD patients identified between 2000 and 2009 were collected from medical records at two United States treatment centres. Clinical, demographic, and biochemical characteristics, drug therapies and medical utilization were descriptively reported by HIV status and cell histology, and statistically compared with the Fisher's Exact and Kruskal-Wallis tests. Patients (n = 59) had a pathologically and clinically confirmed MCD diagnosis: plasmacytic (42%), hyaline vascular (29%) and mixed (15%); 10% had HIV infection. In the first year after diagnosis, MCD patients on average saw a healthcare provider more than six times, were hospitalized at least once and underwent frequent radiological and laboratory testing. Rituximab was the most commonly used drug therapy, followed by corticosteroids and conventional chemotherapy. One- and 2-year survival was excellent in HIV-negative patients (100% and 97%, respectively) but inferior for HIV-positive cases (67% and 67%, respectively). Heterogeneous treatment decisions were observed in this MCD study; HIV status was the only distinguishing clinical criteria associated with pharmacotherapies. Additional research is necessary to guide treatment of this rare lymphoproliferative disorder. © 2014 John Wiley & Sons Ltd.

  10. Neuroleptic drug utilization in out-patients--a prescription database study.

    PubMed Central

    Rosholm, J U; Hansen, L J; Hallas, J; Gram, L F

    1993-01-01

    1 A prescription database study was conducted to describe the out-patient utilization of neuroleptics in the Odense area (207,000 inhabitants) during a period of 1 year. 2 Neuroleptic drug use is widespread, the period prevalence being 2.45% of the population. 3 The prevalence increases with increasing age. Fifteen percent of the population aged 90 years or more received neuroleptic drugs in spite of the many warnings against side effects in the elderly. 4 Estimated daily doses of neuroleptics were considerably lower than the Defined Daily Dose, probably as a reflection of many neuroleptics being prescribed to non-psychotic patients, in whom lower doses are used. 5 For perphenazine, a comparison of estimated daily doses from this study with doses from patients whose treatment had been adjusted by plasma concentration monitoring showed that generally much lower doses were used by patients included in this study. PMID:12959276

  11. Defense Mechanisms and Utilization in Cancer Patients Undergoing Radiation Therapy: A Pilot Study.

    PubMed

    Porcerelli, John H; Cramer, Phebe; Porcerelli, Daniel J; Arterbery, V Elayne

    2017-06-01

    A group of 49 patients who had been diagnosed with cancer during the preceding year and who were receiving radiation therapy were assessed for their use of defense mechanisms, as well as for their level of psychological distress. In addition, their utilization of medical services was determined. It was predicted that the use of services that were under the patients' control-namely, requesting extra outpatient visits and making trips to the emergency department-would be related to the patients' use of defense mechanisms, whereas a treatment option not under the patients' control-overnight hospitalization based on physicians' assessment of condition-would not be related to defense use. The findings confirmed the hypotheses. Outpatient visits were strongly predicted by defense use, whereas hospitalization was determined by psychological distress. However, emergency department visits were determined by both defense use and psychological distress. In addition, an interaction between defense and distress was found to predict hospitalization.

  12. Dual Therapy Treatment Strategies for the Management of Patients Infected with HIV: A Systematic Review of Current Evidence in ARV-Naive or ARV-Experienced, Virologically Suppressed Patients.

    PubMed

    Baril, Jean-Guy; Angel, Jonathan B; Gill, M John; Gathe, Joseph; Cahn, Pedro; van Wyk, Jean; Walmsley, Sharon

    2016-01-01

    We reviewed the current literature regarding antiretroviral (ARV)-sparing therapy strategies to determine whether these novel regimens can be considered appropriate alternatives to standard regimens for the initial treatment of ARV-naive patients or as switch therapy for those patients with virologically suppressed HIV infection. A search for studies related to HIV dual therapy published from January 2000 through April 2014 was performed using Biosis, Derwent Drug File, Embase, International Pharmaceutical Abstracts, Medline, Pascal, SciSearch, and TOXNET databases; seven major trial registries, and the abstracts of major conferences. Using predetermined criteria for inclusion, an expert review committee critically reviewed and qualitatively evaluated all identified trials for efficacy and safety results and potential limitations. Sixteen studies of dual therapy regimens were critiqued for the ARV-naive population. Studies of a protease inhibitor/ritonavir in combination with the integrase inhibitor raltegravir or the nucleoside reverse transcriptase inhibitor lamivudine provided the most definitive evidence supporting a role for dual therapy. In particular, lopinavir/ritonavir or darunavir/ritonavir combined with raltegravir and lopinavir/ritonavir combined with lamivudine demonstrated noninferiority to standard of care triple therapy after 48 weeks of treatment. Thirteen trials were critiqued in ARV-experienced, virologically suppressed patients. The virologic efficacy outcomes were mixed. Although overall data regarding toxicity are limited, when compared with standard triple therapy, certain dual therapy regimens may offer advantages in renal function, bone mineral density, and limb fat changes; however, some dual combinations may elevate lipid or bilirubin levels. The potential benefits of dual therapy regimens include reduced toxicity, improved tolerability and adherence, and reduced cost. Although the data reviewed here provide valuable insights into the

  13. Chronic status patients in a university hospital: bed-day utilization and length of stay.

    PubMed Central

    McClaran, J; Tover-Berglas, R; Glass, K C

    1991-01-01

    OBJECTIVE: To examine the lengths of stay of chronic status patients in an acute care hospital, to identify discharge stages that contribute to excessive stays, to estimate the length of stay at each discharge stage and to link hospital bed-day utilization by the discharge stage to the experience of the patient. DESIGN: Two-year prospective cohort study. The number of hospital days retrospective to the date of the current admission were included in the analysis. SETTING: University hospital. PATIENTS: All 115 inpatients formally declared as achieving chronic status by July 31, 1987. OUTCOME MEASURES: Lengths of stay (total days and days at acute and chronic status) for chronic status patients, including those still in hospital at the end of the study period. Each bed-day was assigned to a discharge stage that corresponded to the patient's status. The disposition of each patient by the end of the study period was reviewed. RESULTS: The study population spent a total of 101 585 days in hospital. The total length of stay per patient was nearly four times that stated in the hospital's annual report, in which the figure was calculated only on the basis of discharge data. On average only 77.2 (8.7%) of the days were spent in acute care. The remaining days were at the chronic level: 24.1% were spent waiting for completion of an application to a long-term care facility, 25.3% for application approval and 41.9% for an available bed in the assigned long-term care institution. For 30 patients no initiation of the discharge process was ever undertaken. As the number of patients in each progressive discharge stage decreased, the wait per patient increased. By the end of the study period only 32 patients had been transferred to a public long-term care facility; 22 were still in hospital, and 35 had died waiting for placement. CONCLUSIONS: Although considered to be a useful measure of hospital efficiency, length of stay determined from discharge data creates an iceberg effect

  14. Impact of state Medicaid coverage on utilization of inpatient rehabilitation facilities among patients with stroke.

    PubMed

    Skolarus, Lesli E; Burke, James F; Morgenstern, Lewis B; Meurer, William J; Adelman, Eric E; Kerber, Kevin A; Callaghan, Brian C; Lisabeth, Lynda D

    2014-08-01

    Poststroke rehabilitation is associated with improved outcomes. Medicaid coverage of inpatient rehabilitation facility (IRF) admissions varies by state. We explored the role of state Medicaid IRF coverage on IRF utilization among patients with stroke. Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample. Medicaid coverage of IRFs (yes versus no) was ascertained. Primary outcome was discharge to IRF (versus other discharge destinations). We fit a logistic regression model that included patient demographics, Medicaid coverage, comorbidities, length of stay, tissue-type plasminogen activator use, state Medicaid IRF coverage, and the interaction between patient Medicaid status and state Medicaid IRF coverage while accounting for hospital clustering. Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) of 42 states. The impact of State Medicaid IRF coverage was limited to Medicaid stroke patients (P for interaction <0.01). Compared with Medicaid stroke patients in states with Medicaid IRF coverage, Medicaid stroke patients hospitalized in states without Medicaid IRF coverage were less likely to be discharged to an IRF of 11.6% (95% confidence interval, 8.5%-14.7%) versus 19.5% (95% confidence interval, 18.3%-20.8%), P<0.01 after full adjustment. State Medicaid coverage of IRFs is associated with IRF utilization among stroke patients with Medicaid. Given the increasing stroke incidence among the working age and Medicaid expansion under the Affordable Care Act, careful attention to state Medicaid policy for poststroke rehabilitation and analysis of its effects on stroke outcome disparities are warranted. © 2014 American Heart Association, Inc.

  15. Impact of State Medicaid coverage on utilization of inpatient rehabilitation facilities among stroke patients

    PubMed Central

    Skolarus, Lesli E.; Burke, James F.; Morgenstern, Lewis B.; Meurer, William J.; Adelman, Eric E.; Kerber, Kevin A.; Callaghan, Brian C.; Lisabeth, Lynda D.

    2014-01-01

    Background and Purpose Post-stroke rehabilitation is associated with improved outcomes. Medicaid coverage of inpatient rehabilitation facility (IRF) admissions varies by state. We explored the role of state Medicaid IRF coverage on IRF utilization among stroke patients. Methods Working age ischemic stroke patients with Medicaid were identified from the 2010 Nationwide Inpatient Sample (NIS). Medicaid coverage of IRFs (yes versus no) was ascertained. Primary outcome was discharge to IRF (versus other discharge destinations). We fit a logistic regression model that included patient demographics, Medicaid coverage, comorbidities, length of stay, tPA use, state Medicaid IRF coverage and the interaction between patient Medicaid status and state Medicaid IRF coverage while accounting for hospital clustering. Results Medicaid did not cover IRFs in 4 (TN, TX, SC, WV) out of 42 states. The impact of State Medicaid IRF coverage was limited to Medicaid stroke patients (p for interaction <0.01). Compared to Medicaid stroke patients in states with Medicaid IRF coverage, Medicaid stroke patients hospitalized in states without Medicaid IRF coverage were less likely to be discharged to an IRF 11.6% ( 95% CI, 8.5-14.7%) versus 19.5% (95% CI, 18.3-20.8%), p<0.01 after full adjustment. Conclusions State Medicaid coverage of IRFs is associated with IRF utilization among stroke patients with Medicaid. Given the increasing stroke incidence among the working age and Medicaid expansion under the Affordable Care Act, careful attention to state Medicaid policy for post-stroke rehabilitation and analysis of its effects on stroke outcome disparities are warranted. PMID:25005437

  16. A preliminary study of psychiatric, familial, and medical characteristics of high-utilizing sickle cell disease patients.

    PubMed

    Carroll, Patrick C; Haywood, Carlton; Hoot, Michelle R; Lanzkron, Sophie

    2013-04-01

    To identify demographic, medical, and psychosocial characteristics that distinguished sickle cell disease (SCD) patients who were frequent utilizers of urgent or emergent care resources from low-utilizing patients. Patients at a large urban comprehensive SCD treatment center were recruited from clinic or during urgent care visits. Participants who were high utilizers, defined as having >4 acute or emergency care visits in the prior 12 months, were compared with patients with more typical utilization patterns on lifetime complications of SCD, family background, psychiatric history, occupational function, coping, depressive symptoms, and personality. High utilizers were nearly a decade younger on average; despite this they had a similar lifetime history of SCD complications. High-utilizing patients' parents seemed to have greater educational achievement overall. High utilizers reported a nearly 3-fold greater prevalence of psychiatric illness in family members than low utilizers. On other measures, including coping strategies, social support, and personality, the 2 groups were comparable. The study strengthens emerging evidence that disease severity, familial factors related to greater parental education, and psychiatric illness are important factors in high care utilization in patients with SCD.

  17. "If there's no stability around them": experienced therapists' view on the role of patients' social world in recovery in bipolar disorder.

    PubMed

    Veseth, Marius; Binder, Per-Einar; Stige, Signe Hjelen

    2017-01-01

    Recovery in severe mental illness has traditionally been described as a deeply personal process. At the same time, researchers are increasingly attending to the social nature of such processes. In this article, we aim to supplement the growing knowledge base regarding these social aspects by exploring the perspectives of experienced therapists: how do they view the role of the social world in processes of healing and growth for people with bipolar disorder? And in what ways can the social world impede recovery? We conducted 12 semi-structured individual interviews and analyzed the resulting transcripts using a team-based thematic analysis method. We identified three themes: (a) establishing a sense of belonging; (b) backing ongoing therapy; and (c) relational ripple effects. We relate our findings to existing theory and research, discuss clinical implications, and highlight study limitations. We argue that our findings underscore the need to integrate an understanding of recovery as a personal and social process in the mental health care services that we provide.

  18. Long-term medical utilization following ventilator-associated pneumonia in acute stroke and traumatic brain injury patients: a case-control study.

    PubMed

    Yang, Chih-Chieh; Shih, Nai-Ching; Chang, Wen-Chiung; Huang, San-Kuei; Chien, Ching-Wen

    2011-10-31

    The economic burden of ventilator-associated pneumonia (VAP) during the index hospitalization has been confirmed in previous studies. However, the long-term economic impact is still unclear. The aim of this study is to examine the effect of VAP on medical utilization in the long term. This is a retrospective case-control study. Study subjects were patients experiencing their first traumatic brain injury, acute hemorrhagic stroke, or acute ischemic stroke during 2004. All subjects underwent endotracheal intubation in the emergency room (ER) on the day of admission or the day before admission, were transferred to the intensive care unit (ICU) and were mechanically ventilated for 48 hours or more. A total of 943 patients who developed VAP were included as the case group, and each was matched with two control patients without VAP by age ( ± 2 years), gender, diagnosis, date of admission ( ± 1 month) and hospital size, resulting in a total of 2,802 patients in the study. Using robust regression and Poisson regression models we examined the effect of VAP on medical utilization including hospitalization expenses, outpatient expenses, total medical expenses, number of ER visits, number of readmissions, number of hospitalization days and number of ICU days, during the index hospitalization and during the following 2-year period. Patients in the VAP group had higher hospitalization expenses, longer length of stay in hospital and in ICU, and a greater number of readmissions than the control group patients. VAP has a significant impact on medical expenses and utilization, both during the index hospitalization during which VAP developed and in the longer term. © 2011 Yang et al; licensee BioMed Central Ltd.

  19. Long-term medical utilization following ventilator-associated pneumonia in acute stroke and traumatic brain injury patients: a case-control study

    PubMed Central

    2011-01-01

    Background The economic burden of ventilator-associated pneumonia (VAP) during the index hospitalization has been confirmed in previous studies. However, the long-term economic impact is still unclear. The aim of this study is to examine the effect of VAP on medical utilization in the long term. Methods This is a retrospective case-control study. Study subjects were patients experiencing their first traumatic brain injury, acute hemorrhagic stroke, or acute ischemic stroke during 2004. All subjects underwent endotracheal intubation in the emergency room (ER) on the day of admission or the day before admission, were transferred to the intensive care unit (ICU) and were mechanically ventilated for 48 hours or more. A total of 943 patients who developed VAP were included as the case group, and each was matched with two control patients without VAP by age ( ± 2 years), gender, diagnosis, date of admission ( ± 1 month) and hospital size, resulting in a total of 2,802 patients in the study. Using robust regression and Poisson regression models we examined the effect of VAP on medical utilization including hospitalization expenses, outpatient expenses, total medical expenses, number of ER visits, number of readmissions, number of hospitalization days and number of ICU days, during the index hospitalization and during the following 2-year period. Results Patients in the VAP group had higher hospitalization expenses, longer length of stay in hospital and in ICU, and a greater number of readmissions than the control group patients. Conclusions VAP has a significant impact on medical expenses and utilization, both during the index hospitalization during which VAP developed and in the longer term. PMID:22040214

  20. The utility of abbreviated patient-reported outcomes for predicting survival in early stage colorectal cancer.

    PubMed

    Hsu, Tina; Speers, Caroline H; Kennecke, Hagen F; Cheung, Winson Y

    2017-05-15

    Patient-reported outcomes (PROs) are increasingly used in clinical settings. Prior research suggests that PROs collected at baseline may be associated with cancer survival, but most of those studies were conducted in patients with breast or lung cancer. The objective of this study was to determine the correlation between prospectively collected PROs and cancer-specific outcomes in patients with early stage colorectal cancer. Patients who had newly diagnosed stage II or III colorectal cancer from 2009 to 2010 and had a consultation at the British Columbia Cancer Agency completed the brief Psychosocial Screen for Cancer (PSSCAN) questionnaire, which collects data on patients' perceived social supports, quality of life (QOL), anxiety and depression, and general health. PROs from the PSSCAN were linked with the Gastrointestinal Cancers Outcomes Database, which contains information on patient and tumor characteristics, treatment details, and cancer outcomes. Cox regression models were constructed for overall survival (OS), and Fine and Gray regression models were developed for disease-specific survival (DSS). In total, 692 patients were included. The median patient age was 67 years (range, 26-95 years), and the majority had colon cancer (61%), were diagnosed with stage III disease (54%), and received chemotherapy (58%). In general, patients felt well supported and reported good overall health and QOL. On multivariate analysis, increased fatigue was associated with worse OS (hazard ratio [HR], 1.99; P = .00007) and DSS (HR, 1.63; P = .03), as was lack of emotional support (OS: HR, 4.36; P = .0003; DSS: HR, 1.92; P = .02). Although most patients described good overall health and QOL and indicated that they were generally well supported, patients who experienced more pronounced fatigue or lacked emotional support had a higher likelihood of worse OS and DSS. These findings suggest that abbreviated PROs can inform and assist clinicians to identify patients who have a worse

  1. Hepatitis C Viral Evolution in Genotype 1 Treatment-Naïve and Treatment-Experienced Patients Receiving Telaprevir-Based Therapy in Clinical Trials

    PubMed Central

    Kieffer, Tara L.; De Meyer, Sandra; Bartels, Doug J.; Sullivan, James C.; Zhang, Eileen Z.; Tigges, Ann; Dierynck, Inge; Spanks, Joan; Dorrian, Jennifer; Jiang, Min; Adiwijaya, Bambang; Ghys, Anne; Beumont, Maria; Kauffman, Robert S.; Adda, Nathalie; Jacobson, Ira M.; Sherman, Kenneth E.; Zeuzem, Stefan; Kwong, Ann D.; Picchio, Gaston

    2012-01-01

    Background In patients with genotype 1 chronic hepatitis C infection, telaprevir (TVR) in combination with peginterferon and ribavirin (PR) significantly increased sustained virologic response (SVR) rates compared with PR alone. However, genotypic changes could be observed in TVR-treated patients who did not achieve an SVR. Methods Population sequence analysis of the NS3•4A region was performed in patients who did not achieve SVR with TVR-based treatment. Results Resistant variants were observed after treatment with a telaprevir-based regimen in 12% of treatment-naïve patients (ADVANCE; T12PR arm), 6% of prior relapsers, 24% of prior partial responders, and 51% of prior null responder patients (REALIZE, T12PR48 arms). NS3 protease variants V36M, R155K, and V36M+R155K emerged frequently in patients with genotype 1a and V36A, T54A, and A156S/T in patients with genotype 1b. Lower-level resistance to telaprevir was conferred by V36A/M, T54A/S, R155K/T, and A156S variants; and higher-level resistance to telaprevir was conferred by A156T and V36M+R155K variants. Virologic failure during telaprevir treatment was more common in patients with genotype 1a and in prior PR nonresponder patients and was associated with higher-level telaprevir-resistant variants. Relapse was usually associated with wild-type or lower-level resistant variants. After treatment, viral populations were wild-type with a median time of 10 months for genotype 1a and 3 weeks for genotype 1b patients. Conclusions A consistent, subtype-dependent resistance profile was observed in patients who did not achieve an SVR with telaprevir-based treatment. The primary role of TVR is to inhibit wild-type virus and variants with lower-levels of resistance to telaprevir. The complementary role of PR is to clear any remaining telaprevir-resistant variants, especially higher-level telaprevir-resistant variants. Resistant variants are detectable in most patients who fail to achieve SVR, but their levels decline over

  2. Development and first assessment of a questionnaire for health care utilization and costs for cardiac patients

    PubMed Central

    Schweikert, Bernd; Hahmann, Harry; Leidl, Reiner

    2008-01-01

    Background The valid and reliable measurement of health service utilization, productivity losses and consequently total disease-related costs is a prerequisite for health services research and for health economic analysis. Although administrative data sources are usually considered to be the most accurate, their use is limited as some components of utilization are not systematically captured and, especially in decentralized health care systems, no single source exists for comprehensive utilization and cost data. The aim of this study was to develop and test a questionnaire for the measurement of disease-related costs for patients after an acute cardiac event (ACE). Methods To design the questionnaire, the literature was searched for contributions to the assessment of utilization of health care resources by patient-administered questionnaires. Based on these findings, we developed a retrospective questionnaire appropriate for the measurement of disease-related costs over a period of 3 months in ACE patients. Items were generated by reviewing existing guidelines and by interviewing medical specialists and patients. In this study, the questionnaire was tested on 106 patients, aging 35–65 who were admitted for rehabilitation after ACE. It was compared with prospectively measured data; selected items were compared with administrative data from sickness funds. Results The questionnaire was accepted well (response rate = 88%), and respondents completed the questionnaire in an average time of 27 minutes. Concordance between retrospective and prospective data showed an intraclass correlation (ICC) ranging between 0.57 (cost of medical intake) and 0.9 (hospital days) with the other main items (physician visits, days off work, medication) clustering around 0.7. Comparison between self-reported and administrative data for days off work and hospitalized days were possible for n = 48. Respective ICCs ranged between 0.92 and 0.94, although differences in mean levels were

  3. Factors associated with the utilization and costs of health and social services in frail elderly patients

    PubMed Central

    2012-01-01

    Background Universal access is one of the major aims in public health and social care. Services should be provided on the basis of individual needs. However, municipal autonomy and the fragmentation of services may jeopardize universal access and lead to variation between municipalities in the delivery of services. This paper aims to identify patient-level characteristics and municipality-level service patterns that may have an influence on the use and costs of health and social services of frail elderly patients. Methods Hierarchical analysis was applied to estimate the effects of patient and municipality-level variables on services utilization. Results The variation in the use of health care services was entirely due to patient-related variables, whereas in the social services, 9% of the variation was explained by the municipality-level and 91% by the patient-level characteristics. Health-related quality of life explained a major part of variation in the costs of health care services. Those who had reported improvement in their health status during the preceding year were more frequent users of social care services. Low informal support, poor functional status and poor instrumental activities of daily living, living at a residential home, and living alone were associated with higher social services expenditure. Conclusions The results of this study showed municipality-level variation in the utilization of social services, whereas health care services provided for frail elderly people seem to be highly equitable across municipalities. Another important finding was that the utilization of social and health services were connected. Those who reported improvement in their health status during the preceding year were more frequently also using social services. This result suggests that if municipalities continue to limit the provision of support services only for those who are in the highest need, this saving in the social sector may, in the long run, result in

  4. Breast MRI: patterns of utilization and impact on patient management in the community hospital setting.

    PubMed

    Lobrano, Mary Beth; Stolier, Alan; L'Hoste, Robert; Luttrell, Carol Anne

    2012-01-01

    The objective of our study was to investigate the indications for breast magnetic resonance imaging, or MRI, in our community hospital, determine how many probably benign MRI findings were malignant at follow-up, determine how many cancers were identified by MRI in screening patients, and evaluate the utility of MRI for surgical planning and problem-solving. Five hundred twenty-eight contrast-enhanced MRI's of the breast in 434 patients were retrospectively reviewed. MRI images/reports were compared to surgical pathology reports and the results of follow-up studies. Screening was the most common indication for breast MRI in our patient population. Five percent of findings termed "probably benign" on MRI proved to be malignant at follow-up. Eight malignancies were detected in six of 202 screened patients. Ten malignancies were diagnosed in 66 patients referred to MRI for problem-solving. In two of 74 patients with known breast cancer, an unsuspected ipsilateral cancer was identified on MRI. MRI proved useful in the community hospital setting for screening high-risk patients and problem-solving. The rate of malignancy in probably benign MRI findings was higher than the corresponding rate in mammography. The detection of additional ipsilateral and contralateral cancers in pre-operative patients with known breast cancer was not as high as expected, based on prior studies.

  5. Clinical utility of wireless motility capsule in patients with suspected multiregional gastrointestinal dysmotility.

    PubMed

    Arora, Zubin; Parungao, Jose Mari; Lopez, Rocio; Heinlein, Cynthia; Santisi, Janice; Birgisson, Sigurbjorn

    2015-05-01

    Patients with gastrointestinal (GI) dysmotility often experience overlapping upper and lower GI symptoms suggestive of multiregional involvement. Wireless motility capsule (WMC) provides a full GI tract transit profile and may be able to detect and diagnose multiregional dysmotility. To determine the clinical utility and diagnostic yield of WMC in patients with upper and lower GI symptoms suggestive of multiregional GI dysmotility. Retrospective chart review of all patients who had undergone WMC testing for suspected multiregional GI dysmotility from January 2009 to December 2012 at our institution was performed. Information regarding demographics, symptoms, medication use, prior diagnostic studies, and results of WMC testing was collected. A total of 161 patients were included in the analysis. Mean age was 43 ± 15 years, and 83 % were female. WMC was abnormal in 109 (67.7 %) subjects. Of these, 17 (15.6 %) patients had isolated delayed gastric emptying, 13 (11.9 %) patients had isolated delayed small bowel transit, and 25 (22.9 %) patients had isolated delayed large bowel transit. Multiregional dysmotility was diagnosed in 54 (49.5 %) patients. There was no significant difference in past medical or past surgical history between patients with isolated regional versus multiregional involvement. The presence or absence of various patient-reported symptoms by history did not predict an abnormal WMC study. Patients' symptoms are poor predictors of GI dysmotility and its anatomical extent. WMC can be a useful diagnostic test in these patients as it provides a comprehensive evaluation of the motility profile of the entire GI tract and provides objective evidence of multiregional involvement.

  6. Utility of endoscopic retrograde cholangiopancreatography on biliopancreatic diseases in patients with Billroth II-reconstructed stomach

    PubMed Central

    Sakai, Yuji; Tsuyuguchi, Toshio; Mikata, Rintaro; Sugiyama, Harutoshi; Yasui, Shin; Miyazaki, Masaru; Yokosuka, Osamu

    2017-01-01

    AIM To examine the utility of endoscopic retrograde cholangiopancreatography (ERCP) on biliopancreatic diseases in the patients with Billroth II-reconstructed stomach. METHODS For 26 cases of biliopancreatic diseases in patients with Billroth II-reconstructed stomach, ERCP was conducted using a straight-view scope or a retrograde oblique-viewing endoscope. All the cases were patients aiming at selective insertion into the bile duct. One patient aimed at diagnosis, and 25 patients aimed at treatment. The cases in which the endoscope reached the duodenal papilla and anastomosis, and insertion into the bile duct became possible, were considered successful. RESULTS The rate of reaching the duodenal papilla and anastomosis was 84.7% (22/26 patients). Among the cases without reaching the duodenal papilla and anastomosis, there were 2 in which the endoscope did not pass due to tumor-induced duodenal infiltration. In 1 case, the fiber did not reach the duodenal papilla due to long afferent loop. The success rate of insertion into the bile duct in patients in which the endoscope reached the duodenal papilla and anastomosis was 90.9% (20/22 patients), and the success rate of procedures including treatment was 86.3% (19/22 patients). After treatment, mild cholangitis was observed in 1 patient (4.5%, 1/22 patients) but relieved conservatively. No other accidental symptom was observed. CONCLUSION It was considered that the ERCP for biliopancreatic diseases in patients with Billroth II-reconstructed stomach will become a less invasive, safe and useful examination and treatment approach. PMID:28360974

  7. Utility of Brainstem Trigeminal Evoked Potentials in Patients With Primary Trigeminal Neuralgia Treated by Microvascular Decompression.

    PubMed

    Zhu, Jin; Zhang, Xin; Zhao, Hua; Tang, Yin-Da; Ying, Ting-Ting; Li, Shi-Ting

    2017-09-01

    To investigate the characteristics of brainstem trigeminal evoked potentials (BTEP) waveform in patients with and without trigeminal neuralgia (TN), and to discuss the utility of BTEP in patients with primary TN treated by microvascular decompression (MVD). A retrospective review of 43 patients who underwent BTEP between January 2016 and June 2016, including 33 patients with TN who underwent MVD and 10 patients without TN. Brainstem trigeminal evoked potentials characteristics of TN and non-TN were summarized, in particular to compare the BTEP changes between pre- and post-MVD, and to discover the relationship between BTEP changes and surgical outcome. Brainstem trigeminal evoked potentials can be recorded in patients without trigeminal neuralgia. Abnormal BTEP could be recorded when different branches were stimulated. After decompression, the original W2, W3 disappeared and then replaced by a large wave in most patients, or original wave poorly differentiated improved in some patients, showed as shorter latency and (or) amplitude increased. Brainstem trigeminal evoked potentials waveform of healthy side in patients with trigeminal neuralgia was similar to the waveform of patients without TN. In 3 patients, after decompression the W2, W3 peaks increased, and the latency, duration, IPLD did not change significantly. Until discharge, 87.9% (29/33) of the patients presented complete absence of pain without medication (BNI I) and 93.9% (31/33) had good pain control without medication (BNI I-II). Brainstem trigeminal evoked potentials can reflect the conduction function of the trigeminal nerve to evaluate the functional level of the trigeminal nerve conduction pathway. The improvement and restoration of BTEP waveforms are closely related to the postoperative curative effect.

  8. Experienced Teachers Handbook. First Edition.

    ERIC Educational Resources Information Center

    IMPACT II--The Teachers Network, New York, NY.

    This book for experienced elementary and secondary school teachers was written by teachers and combines personal anecdotes and model program ideas with effective practical "how-tos." The first chapter asks the experienced teacher to assess how far he or she has come in years of teaching. The second chapter addresses learning and teaching…

  9. Reinduction with Certolizumab Pegol in Patients with Crohn's Disease Experiencing Disease Exacerbation: 7-Year Data from the PRECiSE 4 Study

    PubMed Central

    Rubin, David T.; Sandborn, William J.; Randall, Charles; Younes, Ziad; Schreiber, Stefan; Schwartz, David A.; Burakoff, Robert; Binion, David; Dassopoulos, Themos; Arsenescu, Razvan; Gutierrez, Alexandra; Scherl, Ellen; Kayhan, Cem; Hasan, Iram; Kosutic, Gordana; Spearman, Marshall; Sen, David; Coarse, Jason; Hanauer, Stephen

    2016-01-01

    Background: Patients with Crohn's disease in whom tumor necrosis factor antagonist therapy fails have limited treatment options, and the benefit of reintroducing the same therapy remains unclear. Here, we report results from PRECiSE 4 (NCT00160706), an open-label extension study of certolizumab pegol in patients who withdrew from the placebo-controlled studies PRECiSE 1 or 2. Methods: Patients eligible for PRECiSE 4 had Crohn's disease exacerbation on placebo or primary or secondary failure to certolizumab pegol in PRECiSE 1 or 2, and received 400 mg certolizumab pegol subcutaneously at weeks 0, 2, and 4 and every 4 weeks thereafter up to 360 weeks. We assessed safety (adverse events) and efficacy (clinical remission) of extended certolizumab pegol therapy. Results: Patients enrolled in PRECiSE 4 (N = 310; mean age, 37 yr; 58% female; 95% white) had a mean Crohn's disease duration of 8.5 years before entering the qualifying studies. At weeks 52, 104, and 156, remission rates were 28.5%, 17.5%, and 12.6% by nonremitter imputation, and 63.8%, 60.0%, and 63.5% by observed cases, with 47.4%, 31.9%, and 23.2% of patients, respectively, remaining on therapy. By study end (7.5 yr), 92.3% of patients discontinued therapy, 49% on account of adverse events. No new safety signals emerged. Incidence rate (new cases)/100 patient-years was 6.11 for serious infections and 1.29 for malignancies. Conclusions: Certolizumab pegol was effective in many patients who previously discontinued certolizumab pegol for lack or loss of response. Thus, discontinuation of therapy may not always be necessary. Safety was consistent with previous findings. PMID:27400222

  10. Long-term efficacy and safety of emtricitabine plus tenofovir DF vs. tenofovir DF monotherapy in adefovir-experienced chronic hepatitis B patients.

    PubMed

    Berg, Thomas; Zoulim, Fabien; Moeller, Bernd; Trinh, Huy; Marcellin, Patrick; Chan, Sing; Kitrinos, Kathryn M; Dinh, Phillip; Flaherty, John F; McHutchison, John G; Manns, Michael

    2014-04-01

    Suboptimal virologic response to nucleos(t)ide analogs may represent a significant risk factor for resistance development in patients with chronic hepatitis B virus infection; treatment options have not been well studied. We evaluated long-term efficacy and safety of tenofovir alone and in combination with emtricitabine in a prospective, placebo-controlled trial in patients who remained viremic on adefovir therapy. Hepatitis B e antigen-positive and -negative patients with hepatitis B virus DNA ⩾ 1000 copies/ml despite up to 96 weeks of adefovir were randomized to double-blind tenofovir or emtricitabine/tenofovir for 168 weeks. Patients with hepatitis B virus DNA ⩾ 400 copies/ml (⩾ 69IU/ml) at or after week 24 could switch to open-label emtricitabine/tenofovir. Overall, 90/105 (86%) patients (46/53 tenofovir and 44/52 emtricitabine/tenofovir) completed the 168-week study period, including 74/105 (70%) patients (35/53 tenofovir and 39/52 emtricitabine/tenofovir) who completed the study on their initial randomized treatment. Long-term viral suppression (hepatitis B virus DNA <400 copies/ml) was maintained at week 168 in 84% and 82% of patients receiving either emtricitabine/tenofovir combination or tenofovir monotherapy, respectively (non-completer equal to failure analysis). Baseline viral load as well as the presence of lamivudine and/or adefovir resistance-associated mutations at baseline had no impact on long-term treatment response. No resistance to tenofovir was observed through 168 weeks. Both treatments had a favorable safety profile. Tenofovir monotherapy is as effective as emtricitabine/tenofovir combination therapy in maintaining long-term viral suppression in patients with a suboptimal response to adefovir, and is well tolerated in this population. Copyright © 2013 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

  11. Deficits in foot skin sensation are related to alterations in balance control in chronic low back patients experiencing clinical signs of lumbar nerve root impingement.

    PubMed

    Frost, Lydia R; Bijman, Marc; Strzalkowski, Nicholas D J; Bent, Leah R; Brown, Stephen H M

    2015-05-01

    Chronic low back pain (LBP) patients with radiculopathy, or sciatica, experience pain, tingling or numbness radiating down their leg due to compression of the lumbar nerve root. The resulting reduction in somatosensory information from the foot sole may contribute to deficits in standing balance control. This work was designed to investigate the relationship between foot skin sensitivity and standing balance control in chronic LBP patients with associated radiculopathy. Patients (n=9) and matched healthy controls (n=9) were recruited to the study, and were tested for balance control in both quiet standing as well as during rapid arm raise perturbation trials on a force plate. Foot skin sensitivity was tested bilaterally for vibratory threshold (3, 40 and 250 Hz) and touch (monofilament) threshold. Results demonstrate that patients had reduced sensitivity to 250 Hz vibration in their affected compared to unaffected foot (at the great toe and heel), as well as compared to controls (at the great toe), but there were no differences with lower frequency vibratory testing or with monofilament testing. While there were no significant between-group differences in balance measures, moderate statistically significant correlations between 250 Hz sensitivity and quiet standing balance parameters were uncovered. Thus, patients demonstrate reduced high-frequency vibratory sensitivity at the foot sole, and correlations with quiet standing balance measures indicate a connection between these foot skin sensitivity deficits and alterations in balance control. Clinically, this identifies high frequency vibration testing as an important measure of skin sensitivity in patients with radiculopathy.

  12. Impact of lung function on exacerbations, health care utilization, and costs among patients with COPD

    PubMed Central

    Ke, Xuehua; Marvel, Jessica; Yu, Tzy-Chyi; Wertz, Debra; Geremakis, Caroline; Wang, Liya; Stephenson, Judith J; Mannino, David M

    2016-01-01

    Objective To evaluate the impact of lung function, measured as forced expiratory volume in 1 second (FEV1) % predicted, on health care resource utilization and costs among patients with COPD in a real-world US managed-care population. Methods This observational retrospective cohort study utilized administrative claim data augmented with medical record data. The study population consisted of patients with one or more medical claims for pre- and postbronchodilator spirometry during the intake period (July 1, 2012 to June 30, 2013). The index date was the date of the earliest medical claim for pre- and postbronchodilator spirometry. Spirometry results were abstracted from patients’ medical records. Patients were divided into two groups (low FEV1% predicted [,50%] and high FEV1% predicted [≥50%]) based on the 2014 Global Initiative for Chronic Obstructive Lung Disease report. Health care resource utilization and costs were based on the prevalence and number of discrete encounters during the 12-month postindex follow-up period. Costs were adjusted to 2014 US dollars. Results A total of 754 patients were included (n=297 low FEV1% predicted group, n=457 high FEV1% predicted group). COPD exacerbations were more prevalent in the low FEV1% predicted group compared with the high group during the 12-month pre- (52.5% vs 39.6%) and postindex periods (49.8% vs 36.8%). Mean (standard deviation) follow-up all-cause and COPD-related costs were $27,380 ($38,199) and $15,873 ($29,609) for patients in the low FEV1% predicted group, and $22,075 ($28,108) and $10,174 ($18,521) for patients in the high group. In the multivariable analyses, patients in the low FEV1% predicted group were more likely to have COPD exacerbations and tended to have higher COPD-related costs when compared with patients in the high group. Conclusion Real-world data demonstrate that patients with COPD who have low FEV1% predicted levels use more COPD medications, have more COPD exacerbations, and incur higher

  13. Stressors experienced by injured athletes.

    PubMed

    Evans, Lynne; Wadey, Ross; Hanton, Sheldon; Mitchell, Ian

    2012-05-01

    The purpose of this study was twofold: (a) to examine the stressors experienced by injured athletes during three phases of their recovery from sport injury, and (b) to explore the differences in the stressors experienced by team as compared to individual-sport athletes. Participants comprised previously injured high-level rugby union players (n = 5) and golfers (n = 5). Semi-structured interviews were used to explore the stressors participants experienced during three phases of injury (onset, rehabilitation and return to competitive sport). Within- and cross-case analyses showed that athletes experienced sport, medical/physical, social and financial stressors. There were a number of differences in the stressors experienced across the three phases and between team and individual-sport athletes. Findings have important implications for the design and implementation of interventions aimed at managing the potentially stressful sport injury experience and facilitating injured athletes' return to competitive sport.

  14. Treatment patterns, health care resource utilization, and costs in U.S. patients diagnosed with chronic hepatitis C infection who received telaprevir or boceprevir.

    PubMed

    Le, T Kim; Kalsekar, Anupama; Macaulay, Dendy; Yuan, Yong; Sorg, Rachael A; Behrer, Christopher R; Wei, Jin; Wu, Eric Q

    2015-04-01

    % (n = 82) of telaprevir and 7% (n = 20) of boceprevir patients had decompensated cirrhosis at baseline. Less than 1% (n = 9) of patients were HIV co-infected. Approximately 54% (n = 470) of telaprevir and 74% (n = 210) of boceprevir patients did not complete the minimum duration of therapy as per the prescribing information (telaprevir: 12 weeks of triple + 12 weeks of dual; boceprevir: 3 weeks of lead-in + 24 weeks of triple). In multivariable analyses, females (vs. males) and patients taking boceprevir (vs. telaprevir) were more likely to not complete therapy (P = 0.011). CHC patients experienced high medical and drug-related resource utilization. Telaprevir patients had numerically higher study period unadjusted medical (boceprevir: $16,927; telaprevir: $19,519) and drug costs (boceprevir: $59,953; telaprevir: $76,497) than boceprevir patients; however, after adjusting for baseline characteristics, only drug costs remained significantly different (P  less than  0.001).  These results indicate that a large proportion of CHC patients receiving telaprevir or boceprevir did not complete minimum duration of therapy as per the prescribing information. CHC patients on a DAA regimen also experienced high resource utilization and high medical and drug costs.

  15. Analysis of the outcome for patients experiencing myocardial infarction and cardiopulmonary resuscitation refractory to conventional therapies necessitating extracorporeal life support rescue.

    PubMed

    Chen, Jer-Shen; Ko, Wen-Je; Yu, Hsi-Yu; Lai, Lin-Ping; Huang, Shu-Chein; Chi, Nai-Hsin; Tsai, Chang-Her; Wang, Shoei-Shen; Lin, Fang-Yu; Chen, Yih-Sharng

    2006-04-01

    To analyze the results of acute myocardial infarction (AMI) complicated with refractory shock necessitating extracorporeal life support (ECLS) rescue and to search for associated risk factors. Retrospective review of our 9-yr experience with patients initially presenting with AMI with shock necessitating ECLS rescue; analysis of patient outcomes. A university-affiliated tertiary referral medical center. Between 1994 and 2003 inclusively, 36 consecutive patients (age [mean +/- sd], 57 +/- 10 yrs) with AMI complicated by refractory shock and undergoing cardiopulmonary resuscitation (CPR) necessitating emergent ECLS rescue were enrolled in this study. All patients underwent CPR before ECLS, although 30 patients (83.3%) received ECLS during CPR because spontaneous circulation failed to return. All patients underwent intraaortic counterpulsation either before or following rescue. Seven patients underwent angioplasty only, and one underwent heart transplantation without any intervention. Twenty-eight patients underwent coronary artery bypass grafting (CABG), in which the beating-heart technique was used for 20 patients. The pre-ECLS blood lactate level was high (13.4 +/- 8.5 mmol/L), as was the inotropic score (121.4 +/- 117.3 microg/kg/min). Twenty-five patients (69.4%) were successfully weaned off ECLS, and 12 (48%) survived to discharge (one had a neurologic deficit). The overall mortality rate was 66.7%. A lower inotropic score, reduced blood lactate level, shorter CPR duration, surgical revascularization, and a reduced total maximal Sepsis-related Organ Failure Assessment (SOFA) score were noted among survivors. Liver failure, central nervous system failure, and renal failure mainly occurred in nonsurvivors after ECLS. The technique used for surgical revascularization (beating heart or arrested heart) did not influence the outcome. ECLS is associated with a lower mortality rate than that expected (>90%) from the resultant total maximal SOFA score (16.6 +/- 3

  16. [Questionnaire for the utilization of the Emergency Department : Department implications for the patient survey].

    PubMed

    Frick, J; Möckel, M; Schmiedhofer, M; Searle, J; Erdmann, B; Erhart, M; Slagman, A

    2017-09-12

    For several years, Emergency Departments (ED) in Germany have observed increasing patient numbers, resulting in ED crowding. This leads to the question of whether patients with nonurgent conditions could also receive adequate treatment in primary care. Our objective was to develop a quantitative questionnaire to investigate in a larger patient group the reasons for this and to describe the implications for a patient survey in the ED. The development of the questionnaire was based on a literature search and the results of the qualitative EPI