Search

Introduction: This pragmatic non-inferiority study assessed quality of care within a nurse-led care (NLC) model for stable patients with rheumatoid arthritis (RA) compared to the traditional rheumatologist-led care (RLC) model. Methods: Data were collected through a chart review. Baseline demographic and clinical characteristics were compared using Chi-square test and t test. The primary outcome measure was the percentage of patients being in remission or low disease activity (R/LDA) with the Disease Activity Score (DAS-28) ≤ 3.2 at 1-year follow-up. Process measures included the percentages of patients with chart documentation of (1) comorbidity screening; (2) education on flare management, and (3) vaccinations screening. Outcomes were summarized using descriptive statistics. Results: Each group included 124 patients. At baseline, demographic and clinical characteristics were comparable between the groups for most variables. Exceptions were the median (Q1, Q3) Health Assessment Questionnaire Disability Index scores [0 (0, 0.25) in NLC and 0.38 (0, 0.88) in RLC, p = 0.01], and treatment patterns with 3% of NLC and 38% of RLC patients receiving a biologic agent, p = 0.01. NLC was non-inferior to RLC with 97% of NLC and 92% of RLC patients being in R/LDA at 1-year follow-up. Patients in the NLC group had better documentation across all process measures. Conclusions: This study provided real-world evidence that the evaluated NLC model providing protocolized follow-up care for stable patients with RA is effective to address patients' needs for ongoing disease monitoring, chronic disease management, education, and support. [ABSTRACT FROM AUTHOR]

The objective of the study was to compare the efficacy and safety of biological disease-modifying antirheumatic drugs (bDMARDs) between elderly-onset rheumatoid arthritis (EORA) and young-onset rheumatoid arthritis (YORA) patients. Patients with rheumatoid arthritis (RA) aged ≧18 years enrolled in a Japanese multicenter observational registry between 2009 and 2018 who had moderate or high disease activity when initiating bDMARDs were included. EORA was defined as RA with onset at 60 or over. After propensity score weighting for differences in confounding factors, generalized estimating equations were used to assess the relationship between the age of RA onset and bDMARD clinical effectiveness at 48 weeks after starting a bDMARD. Among a total of 7183 patients in the registry, 2815 (39.2%) were identified as EORA. The proportion of patients on bDMARDs was lower in the EORA as compared to the YORA (18.3% vs 28.0%, p < 0.001). Of the 989 bDMARD initiators, 364 (36.8%) were identified as EORA. The median follow-up duration was 48 weeks both in the EORA and in the YORA. After adjusting for differences in baseline characteristics between the two age groups, there was no significant difference in Clinical Disease Activity Index scores at 48 weeks (mean difference 1.01, 95% CI = − 0.62 to 2.64, p = 0.22). There was a non-significant trend toward lower remission in EORA (OR = 0.52, 95% CI = 0.24–1.14, p = 0.10), and low disease activity/remission was similar (OR = 0.86, 95% CI = 0.29–2.52, p = 0.77). Drug retention (HR = 0.95, 95% CI = 0.55–1.35, p = 0.78) and discontinuations due to adverse events (HR = 0.78, 95% CI = 0.38–1.18, p = 0.22) were similar between the two age groups after adjustment for confounders. In RA patients initiating bDMARDs, improvements in clinical disease at 48 weeks were similar between EORA and YORA. Drug retention and adverse events discontinuation were similar between the two age groups. [ABSTRACT FROM AUTHOR]

Towards the provision of medical research and eHealth services, several Health Information Technology (HIT) platforms are blended with communication and software technologies (i.e. mobile and Web applications, wireless sensor networks, Internet of Things and cloud computing). However, an important research issue is whether and to what degree these technologies are efficiently and effectively integrated into medical practice. Accordingly, this study reviews recent literature on HITs that employ RCTs, which are acknowledged as a reliable solution by the community of health stakeholders. Furthermore, it examines the research efforts in the field and evaluates the relevant functionalities. The literature search strategy was based on PRISMA 2009 Checklist and the CONSORT-EHEALTH Checklist that are two standard methodologies for systematic reviews in Evidence Based Medicine and Health Information Technologies. The analysis of the studies included was performed according to the Cochrane Risk of Bias Assessment Tool. The sources considered in this research include the most common clinical trial registries and academic electronic databases. The studies considered were conducted from 2008 until 2016. The authors considered RCTs having published their results in at least one article. As a result, 55 articles from 42 different journals are considered in this review. The benefits of the HIT delivered interventions are clearly presented in the outcomes of the relevant studies. Significant improvements were observed in the findings of 31 trials from a total of 51 (60.78%) including the acceptance, satisfaction, reliability, usefulness, safety, effectiveness and financial benefit of HITs. The results of this review reveal that HIT and eHealth interventions achieve at least equally reliable and safe outcomes compared with the usual support methods of healthcare. Significantly encouraging results are noticed in interventions employing HIT over several healthcare fields. [ABSTRACT FROM AUTHOR]

Copyright of Pädiatrie & Pädologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Myasthenia gravis (MG) is an autoimmune neuromuscular disorder in which disabling muscle weakness may affect health-related quality of life (HRQoL). The aim of this study was to investigate which common motor-functional deficits and corresponding severity are most determinant of poor HRQoL in these patients. In 41 patients, the dichotomized first item of the Italian Myasthenia Gravis Questionnaire (IMGQ), categorizing patients who report "good" and "poor" HRQoL, was chosen as dependent-outcome variable. All items composing the myasthenia gravis-specific scale (MG-ADL), i.e. talking, chewing, swallowing, breathing, impairment of ability to brush teeth or comb hair, impairment of ability to rise from chair, double vision, and eyelid droop were acquired as independent variables and dichotomized. Stepwise backward LR multivariable logistic regression analysis was performed. In addition, the main characteristics of patients were compared. MG-ADL items "chewing" ≥1, i.e. "fatigue chewing solid food", and "breathing" ≥2, i.e. "shortness of breath at rest" proved to be significant determinants. Higher dose of corticosteroid therapy was significantly (p = 0.027; r s  = -0.35), correlated with poor HRQoL. At diagnosis, a decremental response to repetitive nerve stimulation (RNS) from the abductor pollicis brevis was significantly more frequent in patients with poor HRQoL. In conclusion, impaired "chewing" and "breathing" functions indicate the need for careful planning of rehabilitation, re-education and patient management. Moreover, decremental response to RNS at diagnosis may identify patients at risk for poor HRQoL. [ABSTRACT FROM AUTHOR]

Crisis and emergency psychiatric services are an integral part of the healthcare system, yet there are no standardized measures for programs providing these services. We developed the Crisis Reliability Indicators Supporting Emergency Services (CRISES) framework to create measures that inform internal performance improvement initiatives and allow comparison across programs. The framework consists of two components-the CRISES domains (timely, safe, accessible, least-restrictive, effective, consumer/family centered, and partnership) and the measures supporting each domain. The CRISES framework provides a foundation for development of standardized measures for the crisis field. This will become increasingly important as pay-for-performance initiatives expand with healthcare reform. [ABSTRACT FROM AUTHOR]

Background: The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES). Aim: The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions. Material and methods: The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis. Results: From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations. Conclusion: The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice. [ABSTRACT FROM AUTHOR]

Objective: In a previous study, we assembled a multidisciplinary Canadian panel and identified 37 International Classification of Diseases-10-Canada Diagnosis Groups (DGs) for which emergency department (ED) management may potentially reduce mortality (emergency-sensitive conditions). Before using these 37 DGs to calculate a hospital standardized mortality ratio (HSMR) specific to emergency care, we aimed to test their face validity with ED care providers. Methods: We conducted a self-administered web survey among Canadian emergency physicians and nurses between November 22 and December 31, 2012. All members (N = 2,507) of the Canadian Association of Emergency Physicians and the National Emergency Nurses Association were surveyed. They were asked to agree or disagree (binary response) with the panel classification for each of the 37 DG emergency-sensitive conditions identified and provide free text responses to identify missing entities. Results: A total of 719 ED providers (719 of 2,507, 29%) completed the survey, of whom 470 were physicians (470 of 1,407, 33%) and 232 were nurses (232 of 1,100, 21%). Information on professional status was not provided for 17 respondents. Of 37 DGs, 32 (e.g., A41 sepsis) were rated by more than 80% of respondents to be emergency-sensitive conditions. The remaining five DGs (e.g., E11 type 2 diabetes mellitus) were rated by 68.5 to 79.7% of the respondents to be emergency-sensitive conditions. Respondents suggested an additional 31 emergency-sensitive diagnoses. Conclusion: We identified 37 emergency-sensitive DGs that had high face validity with emergency physicians and nurses, which will enable the calculation of an ED-HSMR. [ABSTRACT FROM AUTHOR]

Differential diagnosis between Vegetative State and Minimally Conscious State is a challenging task that requires specific assessment scales, involvement of expert neuropsychologists or physicians and use of tailored stimuli for eliciting behavioural responses. Although misdiagnosis rate as high as 40 % has been reported, no clear guidelines are available in literature on the optimal setting for assessment. The present study aims to analyse score differences in behavioural assessments of persons with disorders of consciousness (DOC) with or without family members and to determine whether the presence of caregivers could improve clinical accuracy in diagnostic evaluation. The research was conducted on 92 adults with DOC among 153 consecutive patients enrolled in the Coma Research Centre of the Neurological Institute C. Besta of Milan between January 2011 and May 2013. The results indicate that in almost half of the sample the scoring, thus the performance, observed with caregivers was better than without them. Furthermore, in 16 % of the sample, when assessment was performed with caregivers there was a change in diagnosis, from Vegetative to Minimally Conscious State or from that to Severe Disability. Finally, statistical differences were found in relation to diagnosis between mean scores in the 'visual function' Coma Recovery Scale revised's subscale obtained by raters plus caregiver and rates only assessment. This study demonstrates how the presence of caregivers can positively affect behavioural assessments of persons with DOC, thus contributing to the definition of the optimal setting for behavioural evaluation of patients, to decrease misdiagnosis rates. [ABSTRACT FROM AUTHOR]

Copyright of Psychotherapeut is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

We performed a systematic review for primary studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO host, and The Cochrane Library (Cochrane Central Register of Clinical Trials, Health Technology Assessment Database, NHS Economic Evaluation Database) were searched. Two researchers reviewed the literature independently. Primary studies that met predefined inclusion criteria were assessed for their methodological quality. A total of 15 publications were included: 15 primary studies corresponding with 12 main investigations. Primary studies were evaluated for clinical outcomes, process outcomes, and economic outcomes. The studies assessed a wide range of outcome measures. While a number of divergent clinical outcomes were reported, most studies showed positive results of process management and health-services utilization. In terms of mortality, the results provided evidence for a positive impact of CPs on in-hospital mortality. Most studies also showed a significantly reduced risk of complications, including medical complications, wound infections, and pressure sores. Moreover, time-span process measures showed that an improvement in the organization of care was achieved through the use of CPs. Conflicting results were observed with regard to functional recovery and mobility between patients treated with CPs compared to usual care. Although our review suggests that CPs can have positive effects in patients with HF, the available evidence is insufficient for formal recommendations. There is a need for more research on CPs with selected process and outcome indicators, for in-hospital and postdischarge management of HF, with an emphasis on well-designed randomized trials. [ABSTRACT FROM AUTHOR]

Copyright of Psychotherapeut is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Psychotherapeut is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

To analyse the influence on the prognosis of intensive care unit (ICU) patients with acute myocardial infarction (AMI): prognostic index score, Killip class, AMI site, thrombolysis and other variables that might improve prognostic capacity and functioning of the APACHE-II index. Cohort study using prospectively gathered ARIAM project data. ICUs from 129 Spanish hospitals. ICU-admitted AMI patients in ARIAM database during 4-year period were retrospectively studied. The sample comprised 6,458 patients, 76.8% males, age 64.97 ± 12.56 years, APACHE-II score 9.49 ± 7.03 points and ICU mortality 8.9%. Mortality was higher for females ( p < 0.001), anterior AMI site ( p < 0.001), previous AMI ( p < 0.001), delay-to-hospital arrival >180 min ( p = 0.003) and non-receipt of thrombolysis ( p = 0.015). ICU mortality was related to age ( p < 0.001) and APACHE-II score ( p < 0.001). In multivariate analysis, it was related to APACHE-II (OR 1.16), age (OR 1.05), gender (OR 1.64), previous AMI (OR 1.57), anterior AMI (OR 2.05) and delay >180 min (OR 1.37). Killip class, gathered in 1,893 patients, was significantly associated with ICU mortality, and two predictive models were constructed for this group using multivariate analysis. Area under ROC curve was 0.94 in one (Killip class, age, gender, APACHE-II) versus 0.92 in the other (same variables without APACHE-II). APACHE-II score and Killip class are useful for assessing the severity of patients with AMI and are complementary. Each can be used with a few commonly gathered clinical variables to construct prognostic models to assess severity. Their joint application yields a model with excellent discrimination capacity. [ABSTRACT FROM AUTHOR]

Methadone is effective treatment for opioid addiction, but regulations restrict its use. Methadone medical maintenance treats stabilized methadone patients in a medical setting, but only experimental programs have been studied.To evaluate the implementation of the first methadone medical maintenance program established outside a reseach setting.One-year program evaluation.A public hospital and a community opioid treatment program.Methadone patients with>1 year of clinical stability. Eleven generalist physicians and 4 hospital pharmacists.Regulatory exemptions were requested. Physicians and pharmacists were trained. Patients were transferred to the medical setting and permitted 1-month supplies of methadone.Patient eligibility and willingness to enroll, treatment retention, urine toxicology results, change in addiction severity and functional status, medical services provided, patient and physician satisfaction, and physician attitudes toward methadone maintenance.Regulatory exemptions were obtained after a 14-month process, and the program was cited in federal policy as acceptable for widespread implementation. Forty-nine of 684 patients (7.2%) met stability criteria, and 30 enrolled. Twenty-eight were retained for 1 year, and 2 transferred to other programs. Two patients had opioid-positive urine tests and were managed in the medical setting. Previously unmet medical needs were addressed, and the Addiction Severity Index (ASI) medical composite score improved over time (P=.02). Patient and physician satisfaction were high, and physician attitudes toward methadone maintenance treatment became more positive (P=.007).Methadone medical maintenance is complex to arrange but feasible outside a research setting, and can result in good clinical outcomes. [ABSTRACT FROM AUTHOR]

We performed a retrospective utilization study covering a four-year period to determine how physicians familiar with colon transit scintigraphy (CTS) use it to manage patients with chronic constipation. Following CTS, there was a change is both frequency and likelihood of diagnosis. The diagnosis was changed in 51% of patients-37% of those considered to have slow transit constipation (STC) before CTS, 43% with obstructed defecation, and 64% with functional bowel disease (FBD). CTS increased the diagnostic likelihood in all groups. Of patients with the diagnosis of STC, 16% were considered "almost certain" before CTS while 83% were considered "almost certain" after CTS. For FBD comparable percentages were 13% and 62%. CTS may play a major role in the diagnostic work-up of patients with chronic constipation, both altering diagnosis and increasing diagnostic certainty. [ABSTRACT FROM AUTHOR]

Over a period of 3 years since the first in a lifetime onset of an episode of non-affective functional psychosis a cohort of 82 Dutch patients was studied at set intervals with regard to prognosis and outcome. Prognostic statements on remission, relapse, duration of episode, length of stay in hospital, and occupational, family and overall social adjustment were checked against actual outcome after I year. In general, the research team of three psychiatrists, a psychologist and a sociologist began quite optimistically, but became slightly more pessimistic with time. However, their predictions proved hardly better than chance statements. The team appeared to be more pessimistic about the diagnosis of schizophrenia than about that of reactive psychosis, although they were not correct with one diagnostic category more often than with the other. [ABSTRACT FROM AUTHOR]

Objective: To determine the impact of prospective payment by diagnosis-related groups (DRGs) on length of stay in the hospital, ambulatory status, and level of post-hospital care needed for patients hospitalized with hip fracture.Design: Retrospective chart review of a consecutive series of cases before and after the reference date of implementation of the prospective payment system (PPS).Setting: Academic, tertiary-care hospital.Patients/participants: 181 patients 69 years of age or older admitted with International Classification of Diseases (ICD) or DRG codes for hip fracture.Results: Length of stay was shorter by 1.37 days in the post-PPS era (p = 0.05). Poorer discharge ambulation was found in the post-PPS group (p = 0.089). At one year, differences in ambulation and nursing home residence were found to be related not to the implementation of PPS, but rather to the nursing home to which the patient was discharged. Patients discharged to a facility with active physical rehabilitation were less likely to remain institutionalized (p = 0.0025) than those in "ordinary" nursing homes and ambulated more independently (p = 0.05).Conclusions: The PPS did not have a significant long-term impact on hip fracture outcome. Post-hospital care may be of crucial importance to the future quality of life of hip fracture patients. [ABSTRACT FROM AUTHOR]

Objective: To customize the Acute Physiology and Chronic Health Evaluation (APACHE) III mortality equation for Spanish admissions to the intensive care unit (ICU) and evaluate its discrimination and calibration.Design: Prospective multicenter inception cohort study.Setting: 86 ICUs located in all regions of Spain.Patients: 10,929 adult patients selected by a systematic sampling method. All types of critical care patients were included, including coronary bypass patients, but excluding those with burn injury, those admitted for pacemaker implants, patients under 16 years of age, and patients with length of ICU stay < 6 h.Measurements and Results: Data collection in the first 24 h after patient admission included: APACHE III score, treatment location prior to ICU admission, and main ICU admission diagnosis. Using these variables, a model for predicting hospital mortality was constructed, adapted to Spain, and its discriminating ability was assessed by the area below the ROC curve, which was 0.83. The model was validated using the jacknife method and the area below the receiver operating characteristic (ROC) curve for the cross-validated predictions was 0.82. The percentage of patients correctly classified at 0.50 risk of death was 82.3%. Model calibration was evaluated by analysis of the agreement between the observed and cross-validated predicted mortality using the Hosmer-Lemeshow test, which gave a value of (H) 12.27, with no statistical significance, i.e., good calibration.Conclusions: We have customized the APACHE III mortality prediction system for the Spanish population. This adapted model has demonstrated the requisite validation, calibration, and discrimination for its use among Spanish critical care patients. [ABSTRACT FROM AUTHOR]

A prospective cohort study of schizophrenia was carried out in São Paulo, Brazil, in order to investigate clinical and social outcomes in schizophrenia and related psychoses after hospitalization. A sample of 124 individuals who were living in a defined catchment area and had been consecutively admitted to psychiatric hospitals in that area with clinical diagnoses of non-affective functional psychoses was followed up for 2 years. Assessments of clinical status and social adjustment at inclusion and at 2-year follow-up were carried out by means of standardized instruments, the PSE and the DAS. At the end of the follow-up period, 120 subjects (96.8%) were traced, and 103 (83.1%) were re-assessed. At the second assessment, the proportion of subjects with a nuclear syndrome of schizophrenia had halved (from 68.3% to 32.7%), 23.8% were symptom free and 60.2% showed at least one psychotic symptom. Presence of psychotic symptoms at follow-up was best predicted by educational level (less than 4 years of formal education) and an initial DSM-III-R diagnosis of schizophrenia. The distribution of global social adjustment levels at 2-year follow-up was similar to that observed at the outset, with approximately one third of subjects showing good, one third showing intermediate and one third showing poor global social adjustment. Social disability was best predicted by longer duration of illness, worse social adjustment levels at inclusion and lower educational level. [ABSTRACT FROM AUTHOR]