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opencc-zeroDec 2015View details →

Data from: Short-term and medium-term survival of critically ill patients with solid tumours admitted to the intensive care unit: a retrospective analysis

Objectives: Patients with cancer frequently require unplanned admission to the Intensive Care Unit (ICU). Our objectives were to assess hospital and 180-day mortality in patients with a non-haematological malignancy and unplanned ICU admission, and to identify which factors present on admission were the best predictors of mortality. Design: Retrospective review of all patients with a diagnosis of solid tumours following unplanned admission to the ICU between 1st August 2008 and 31st July 2012. Setting: Single centre tertiary care hospital in London (UK) Participants: 300 adult patients with non-haematological solid tumours requiring unplanned admission to the ICU. Interventions: None Primary and secondary outcomes: Hospital and 180-day survival Results: 300 patients were admitted to the ICU (median age 66.5 years; 61.7% male). Survival to hospital discharge and 180-days were 69% and 47.8%, respectively. Greater number of failed organ systems on admission was associated with significantly worse hospital survival (p<0.001) but not with 180-day survival (p=0.24). In multivariate analysis, predictors of hospital mortality were the presence of metastases [odds ratio (OR 1.97), 95% confidence interval (CI) 1.08-3.59], Acute Physiology and Chronic Health Evaluation II (APACHE II) score (OR 1.07, 95% CI 1.01-1.13) and a Glasgow Coma Scale score <7 on admission to ICU (OR 5.21, 95% CI 1.65-16.43). Predictors of worse 180-day survival were the presence of metastases (OR 2.82, 95% CI 1.57-5.06), APACHE II score (OR 1.07, 95% CI 1.01-1.13) and sepsis (OR 1.92, 95% CI 1.09-3.38). Conclusions: Short and medium-term survival in patients with solid tumours admitted to ICU is better than previously reported, suggesting that the presence of cancer alone should not be a barrier to ICU admission.

opencc-zeroDec 2016View details →

Data from: Ambulatory versus inpatient management of severe nausea and vomiting of pregnancy: a randomized control trial with patient preference arm

ABSTRACT Objective To determine whether ambulatory (outpatient, OP) treatment of severe nausea and vomiting of pregnancy (NVP) is as effective as inpatient (IP) care. Design Non-blinded randomized control trial (RCT) with patient preference arm Setting Multi-center Participants Women less than 20 weeks pregnant with severe NVP and associated ketonuria Methods Women participating in the RCT were randomized via web-based application to either ambulatory or IP treatment. Women declining randomisation entered the patient preference trial (PPT) arm. Protocols, data collection and follow-up were the same for all participants. Main Outcome Measures Primary outcome was reduction in Pregnancy Unique Quantification of Emesis (PUQE) score at 48 hours. Secondary outcomes were duration of treatment; improvement in symptom scores and ketonuria at 48 hours; re-attendances within 7 days of discharge; and comparison of symptoms at 7 days post discharge Results 152/174 eligible women agreed to participate with 77/152 (51%) recruited to the RCT and 79/152 (49%) to the PPT. Patients were initially compared in 4 groups (randomized IP, randomized OP, non-randomized IP and non-randomized OP). Comprehensive cohort analysis of participants in the (RCT) and (PPT) did not demonstrate any differences in patient demographics or baseline clinical characteristics. Pooled analysis of IP versus OP groups showed no difference in reduction in PUQE score at 48 hours (p=0.86). There was no difference in change in eating score (p=0.69), drinking score (p=0.77), wellbeing rating (p=0.64) or reduction in ketonuria (p=0.47) at 48 hours, with no difference in duration of index treatment episode (p=0.83) or re-attendances within 7 days (p=0.52). Conclusions Ambulatory management is an effective alternative to inpatient management of severe NVP. The trial also demonstrated that many women requiring treatment for HG have a strong preferences regarding treatment setting, which needs to be considered by care providers, especially given the psychological impact of HG.

opencc-zeroMay 2019View details →

Data from: Ophthalmologic evaluation of severely obese patients undergoing bariatric surgery: a pilot, monocentric, prospective, open-label study

Purpose: The aim of this study was to investigate the pathogenic role of obesity on blinding eye diseases in a population of severely obese patients with no history of eye diseases, and to verify whether weight loss induced by bariatric surgery may have a protective effect. Methods: This was a pilot, monocentric, prospective, and open label study conducted at the University Hospital of Pisa. Fifty-seven severely obese patients with a mean body mass index value of 44.1 ± 6 kg/m2 were consecutively recruited and received a complete ophthalmological evaluation and optical coherence tomography. Twenty-nine patients who underwent gastric bypass were evaluated also 3 months, and 1 year after surgery. Results: At baseline, blood pressure value were directly and significantly related to intraocular pressure values (p<0.05, R = 0.35). Blood pressure values were also significantly and inversely related to retinal nerve fiber layer thickness, particularly in the temporal sector (RE p<0.05 r-0.30; LE p<0.01, R = -0.43). Moreover, minimum foveal thickness values were significantly and inversely associated with body mass index (RE p<0.02, R = -0.40; LE p<0.02, R = -0.30). A significant reduction of body mass index (p<0.05) and a significant (p<0.05) improvement of blood pressure was observed three months and one year after gastric bypass, which were significantly associated with an increase in retinal nerve fiber layer thickness and minimum foveal thickness values in both eyes (p<0.05). Conclusions: The results of this study suggest that obese patients may have a greater susceptibility to develop glaucomatous optic nerve head damage and age-related macular degeneration. Moreover, weight reduction and improvement of comorbidities obtained by bariatric surgery may be effective in preventing eye disease development by improving retinal nerve fiber layer and foveal thickness.

Data from: Self-reported functional status predicts post-operative outcomes in non-cardiac surgery patients with pulmonary hypertension

BACKGROUND: Pulmonary hypertension (PHTN) is associated with increased post-procedure morbidity and mortality. Pre-procedure echocardiography (ECHO) is a widely used tool for evaluation of these patients, but its accuracy in predicting post-procedure outcomes is unproven. Self-reported exercise tolerance has not been evaluated for operative risk stratification of PHTN patients. OBJECTIVE: We analyzed whether self-reported exercise tolerance predicts outcomes (hospi-tal length-of-stay [LOS], mortality and morbidity) in PHTN patients (WHO Class I - V) under-going anesthesia and surgery. METHODS AND FINDINGS: We reviewed 550 non-cardiac, non-obstetric procedures per-formed on 370 PHTN patients at a single institution between 2007 and 2013. All patients had cardiac ECHO documented within 1 year prior to the procedure. Pre-procedure comorbidities and ECHO data were collected. Functional status (< or ? 4 metabolic equivalents of task [METs]) was assigned based on responses to standard patient interview questions during the pre-anesthesia clinic visit. Multiple logistic regression was used to develop a risk score model (Pul-monary Hypertension Outcome Risk Score; PHORS) and determine its value in predicting post-procedure outcomes. In an adjusted model, functional status <4 METs was independently associ-ated with a LOS >7 days (p < .003), as were higher ASA class (p < .002), open surgical approach (p < .002), procedure duration > 2 hours (p < .001), and the absence of systemic hypertension (p = .012). PHORS Score ?2 was associated with an increased 30-day major complication rate (28.7% vs. 19.2%; p < 0.001) and ICU admission rate (8.6% s 2.8%; p = .007), but no statistical difference in hospital readmissions rate (17.6% vs. 14.0%; p = .29), or mortality (3.5% vs. 1.4%; p = .75). Similar ECHO findings did not further improve outcome prediction. CONCLUSIONS: Poor functional status is associated with severe PHTN and predicts increased LOS and post-procedure complications in patients with moderate to severe pulmonary hyperten-sion with different etiologies. A risk assessment model predicts increased LOS with fair accura-cy. A thorough evaluation of underlying etiologies of PHTN should be undertaken in every pa-tient.

Data from: A risk stratification tool for prehospital triage of patients exposed to a whiplash trauma

Objective: Our aim was to develop a risk stratification model to predict the presence of a potentially more sinister injury in patients exposed to a whiplash trauma. Methods: The study base comprised of 3,115 residents who first sought healthcare contact within one week after being exposed to a whiplash trauma between 1999-2008, from within a defined geographical area, Skaraborg County in south-western Sweden. Information about gender, age, time elapsed prior to seeking care, type of health care contact, and hospitalization was retrieved. Eighteen potential risk factors were identified and evaluated using multivariate logistic regression. Results: Of 3,115 patients, 215 (6.9%) required hospital admission so theoretically 93% could have been initially assessed by primary health care. However, only 46% had their first contact in primary health care. All patients had symptoms resulting in a diagnosis of whiplash injury. Four risk factors were found to be associated with hospital admission: commotio cerebri (OR 31, 19-51), fracture / luxation (OR 11, 5.1-22), serious injury (OR 41, 8.0-210), and the patient sought care during the same day as the trauma (OR 5.9, 3.7- 9.5). These four risk factors explained 27 % of the variation for hospital admission and the area under curve (AUC) was 0.77 (0.74-0.80). Ninety-six percent of patients (2,985) had only a whiplash injury with none of the other four risk factors. These could be split into those attending health care the same day as the trauma, 1,737 (56%) with a 7.1% risk for hospital admission, and those attending health care later, 1,248 (40%) with a 1.3% risk for hospital admission. Conclusion: Patients with no signs of commotio cerebri, no fracture/luxation injury, no serious injury, comprising 96% of all patients exposed to a whiplash trauma can initially be referred to primary health care for initial assessment. However, those contacting the health care the same day as the trauma should be referred to a hospital for evaluation if they can't get an appointment with a general practitioner the same day.

opencc-zeroDec 2016View details →

Data from: The effect of meal frequency in a reduced-energy regimen on the gastrointestinal and appetite hormones in patients with type 2 diabetes: a randomised crossover study

Background: Appetite and gastrointestinal hormones (GIHs) participate in energy homeostasis, feeding behavior and regulation of body weight. We demonstrated previously the superior effect of a hypocaloric diet regimen with lower meal frequency (B2) on body weight, hepatic fat content, insulin sensitivity and feelings of hunger compared to the same diet divided into six smaller meals a day (A6).Studies with isoenergetic diet regimens indicate that lower meal frequency should also have an effect on fasting and postprandial responses of GIHs.The aim of this secondary analysis was to explore the effect of two hypocaloric diet regimens on fasting levels of appetite and GIHs and on their postprandial responses after a standard meal. It was hypothesized that lower meal frequency in a reduced-energy regimen leading to greater body weight reduction and reduced hunger would be associated with decreased plasma concentrations of GIHs: gastric inhibitory peptide (GIP), glucagon-like peptide-1(GLP-1), peptide YY(PYY), pancreatic polypeptide (PP) and leptin and increased plasma concentration of ghrelin. The postprandial response of satiety hormones (GLP-1, PYY and PP) and postprandial suppression of ghrelin will be improved. Methods: In a randomized crossover study, 54 patients suffering from type 2 diabetes (T2D) underwent both regimens.The concentrations of GLP-1, GIP, PP, PYY, amylin, leptin and ghrelin were determined using multiplex immunoanalyses. Results: Fasting leptin and GIP decreased in response to both regimens with no difference between the treatments (p=0.37 and p=0.83, respectively). Fasting ghrelin decreased in A6 and increased in B2 (with difference between regimens p=0.023). Fasting PP increased in B2with no significant difference between regimens (p=0.17). Neither GLP-1 nor PYY did change in either regimen. The decrease in body weight correlated negatively with changes in fasting ghrelin (r=-0.4, p<0.043) and the postprandial reduction of ghrelin correlated positively with its fasting level (r=0.9, p<0.001). The postprandial responses of GIHs and appetite hormones were similar after both diet regimens. Conclusions: Both hypocaloric diet regimens reduced fasting leptin and GIP and postprandial response of GIP comparably. The postprandial responses of GIHs and appetite hormones were similar after both diet regimens. Eating only breakfast and lunch increased fasting plasma ghrelin more than the same caloric restriction split into six meals. The changes in fasting ghrelin correlated negatively with the decrease in body weight. These results suggest that for type 2 diabetic patients on a hypocaloric diet, eating larger breakfast and lunch may be more efficient than six smaller meals during the day.

Data from: An unfavorable body composition is common in early arthritis patients: a case control study

Background. An unfavorable body composition is often present in chronic arthritis patients. This unfavorable composition is a loss of muscle mass, with a stable or increased (abdominal) fat mass. Since it is unknown when this unfavorable composition develops, we compared body composition in disease-modifying antirheumatic drugs (DMARD)-naive early arthritis patients with non-arthritis controls and explored the association, in early arthritis patients, with disease activity and traditional cardiovascular risk factors. Methods. 317 consecutive early arthritis patients (84% rheumatoid arthritis according to 2010 ACR/EULAR criteria) and 1268 age-/gender-/ethnicity-matched non-arthritis controls underwent a Dual-energy X-ray absorptiometry scan to assess fat percentage, fat mass index, fat mass distribution and appendicular lean (muscle) mass index. Additionally, disease activity, health assessment questionnaire (HAQ), acute phase proteins, lipid profile and blood pressure were evaluated. Results. Loss of muscle mass (corrected for age suspected muscle mass) was 4-5 times more common in early arthritis patients, with a significantly lower mean appendicular lean mass index (females 6% and males 7% lower, p<0.01). Patients had more fat distributed to the trunk (females p<0.01, males p=0.07) and females had a 4% higher mean fat mass index (p<0.01). An unfavorable body composition was associated with a higher blood pressure and an atherogenic lipid profile. There was no relationship with disease activity, HAQ or acute phase proteins. Conclusion. Loss of muscle mass is 4-5 times more common in early arthritis patients, and is in early arthritis patients associated with a higher blood pressure and an atherogenic lipid profile. Therefore, cardiovascular risk is already increased at the clinical onset of arthritis making cardiovascular risk management necessary in early arthritis patients.

opencc-zeroDec 2015View details →

Data from: Neoadjuvant and concurrent chemotherapy have varied impacts on the prognosis of patients with the ascending and descending types of nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

Purpose: To compare the outcomes of patients with ascending type (T4&N0-1) and descending type (T1-2&N3) of nasopharyngeal carcinoma (NPC) treated with concurrent chemoradiotherapy (CCRT), neoadjuvant chemotherapy (NACT) + intensity-modulated radiotherapy (RT) or NACT + CCRT. Methods: Retrospective analysis of 839 patients with ascending or descending types of NPC treated at a single institution between October 2009 to February 2012. CCRT was delivered to 236 patients, NACT + RT to 302 patients, and NACT + CCRT to 301 patients. Results: The 4-year overall survival rate, distant metastasis-free survival rate, local relapse-free survival rate, nodal relapse-free survival rate, loco-regional relapse-free survival rate, and progression free survival rate were 75.2% and 73.4% (P = 0.114), 85.7% and 74.1% (P = 0.008), 88.8% and 97.1% (P = 0.013), 96.9% and 94.1% (P = 0.122), 86.9% and 91.2% (P = 0.384), 73.7% and 66.2% (P = 0.063) in ascending type and descending type. Subgroup analyses indicated that NACT + RT significantly improved distant metastasis-free survival rate and progression-free survival rate when compared with CCRT in the ascending type, and there were no significant differences between the survival curves of NACT +RT and NACT + CCRT. For descending type, there were no significant differences among the survival curves of NACT +RT, CCRT, and NACT + CCRT groups, and the survival benefit mainly came from CCRT. Conclusions: Compared with NACT + CCRT or CCRT, NACT + RT may be a reasonable approach for ascending type; Although concurrent chemotherapy was effective in descending type, NACT + CCRT may be a more appropriate strategy for descending type.

Data from: Missed opportunities for HIV testing among patients newly presenting for HIV care at a Swiss university hospital: a retrospective analysis

Objectives: To determine the frequency of missed opportunities (MOs) among patients newly-diagnosed with HIV, risk factors for presenting MOs, and the association between MOs and late presentation to care. Design: Retrospective analysis Setting: HIV outpatient clinic at a Swiss tertiary hospital Participants: Patients aged ≥18 years old newly presenting for HIV care between 2010 and 2015 Measures: Number of medical visits, up to five years preceding HIV diagnosis, at which HIV testing had been indicated, according to Swiss HIV testing recommendations. A visit at which testing was indicated but not performed was considered a MO for HIV testing. Results: Complete records were available for all 201 new patients of whom 51% were male and 33% from sub-Saharan Africa. Thirty patients (15%) presented with acute HIV infection while 119 patients (59%) were late presenters (LPs) (CD4 counts <350 cells/mm3 at diagnosis). Ninety-four patients (47%) had presented at least one MO, of whom 44 (47%) had multiple MOs. MOs were more frequent among individuals from sub-Saharan Africa, men who have sex with men, and patients under follow-up for chronic disease. MOs were less frequent in LPs than non-LPs (42.5% versus 57.5%, P = 0.03). Conclusions: At our centre, 47% of patients presented at least one MO. Whilst our late presentation rate is higher than the national figure of 49.8%, LPs were less likely to experience MOs, suggesting that these patients were diagnosed late through presenting late, rather than through being failed by our hospital. We conclude that, in addition to optimising physician-initiated testing, access to testing must be improved among patients unaware they are at HIV risk and who do not seek health care.

opencc-zeroMar 2020View details →

Data from: Three-month modified Rankin Scale as a determinant of five-year cumulative costs after ischemic stroke: an analysis of 11,136 patients in Korea

Objective: Stroke is a devastating and costly disease; however, there is a paucity of information on long-term costs and on how they differ according to 3-month modified Rankin scale (mRS), which is a primary outcome variable in acute stroke intervention trials. Methods: We analyzed a prospective multicenter stroke registry (Clinical Research Collaboration for Stroke in Korea) database through linkage with claims data from the National Health Insurance Service with follow up to December 2016. Healthcare expenditures were converted into daily cost individually, and annual and cumulative costs up to 5 years were estimated and compared according to the 3-month mRS. Results: Between January 2011 and November 2013, 11,136 patients were enrolled in the study. The mean age was 68 years, and 58% were men. The median follow-up period was 3.9 years (range 0–5 years). Mean cumulative cost over 5 years was $117,576 US dollar (USD); the cost in the first year after stroke was the highest ($38,152 USD), which increased markedly from the cost a year before stroke ($8,718 USD). The mean 5-year cumulative costs differed significantly according to the 3-month mRS (P<.001); the costs for a 3-month mRS score of 0 or 5 were $53,578 USD and $257,486 USD, respectively. Three-month mRS was an independent determinant of long-term costs after stroke. Conclusions: We shows that 3-month mRS plays an important role in the prediction of long-term costs after stroke. Such estimates relating to 3-month mRS categories may be valuable when undertaking health economic evaluations related to stroke care.

opencc-zeroNov 2019View details →

Data from: Diagnostic accuracy of presepsin in predicting bacteremia in elderly patients admitted to the emergency department: prospective study in Japan

Objective <a name="_Hlk1399924">Early detection of bacteremia in the elderly is needed in the emergency department (ED). </a> <a name="_Hlk11878757">Design, Setting, and Participants</a> Prospective study in Japan, single center trial in patients who satisfied the sepsis criteria was conducted between September 2014 and March 2016. Forty-six elderly patients aged ≥70 years were included. Interventions Blood sampling to evaluate C-reactive protein (CRP), procalcitonin (PCT) and presepsin plasma levels; two sets of blood sampling for bacterial cultures; and evaluations of the Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were performed upon arrival at the ED. The results were compared between patients with bacteremia and those without bacteremia. <a name="_Hlk11878769">Main Outcome Measure</a> The accuracy of detecting bacteremia Results The presepsin value was significantly higher in the bacteremia group than in the non-bacteremia group (866.6 ± 184.6 pg/mL vs. 639.9 ± 137.1 pg/mL, p = 0.03). The PCT and CRP did not significantly differ between the groups. The area under the receiver-operating-characteristic curve (AUC) values were not significantly different among presepsin (0.69), PCT (0.61), and CRP (0.53). Multivariate analysis showed that presepsin was independently associated with bacteremia (odds ratio, 8.84; 95% confidence interval, 0.95–81.79; p = 0.02). Conclusion<a name="_Hlk1399945"></a> Presepsin could be a good biomarker to predict bacteremia in elderly patients with sepsis criteria admitted to the ED.

opencc-zeroDec 2015View details →

Data from: Preoperative falls predict postoperative falls and other adverse patient-reported outcomes

BACKGROUND: Falls are common and linked to morbidity. Our objectives were to characterize postoperative falls, and determine whether preoperative falls independently predicted postoperative falls (primary outcome), functional dependence, quality of life, complications, and readmission. METHODS: This prospective cohort study included 7982 unselected patients undergoing elective surgery. Data were collected from the medical record, a baseline survey, and follow-up surveys approximately 30days and one year after surgery. RESULTS: Fall rates (per 100 person-years) peaked at 175 (hospitalization), declined to 140 (30-day survey), and then to 97 (one-year survey). After controlling for confounders, a history of one, two, and ≥three preoperative falls predicted postoperative falls at 30days (adjusted odds ratios [aOR] 2.3, 3.6, 5.5) and one year (aOR 2.3, 3.4, 6.9). One, two, and ≥three falls predicted functional decline at 30days (aOR 1.2, 2.4, 2.4) and one year (aOR 1.3, 1.5, 3.2), along with in-hospital complications (aOR 1.2, 1.3, 2.0). Fall history predicted adverse outcomes better than commonly-used metrics, but did not predict quality of life deterioration or readmission. CONCLUSIONS: Falls are common after surgery, and preoperative falls herald postoperative falls and other adverse outcomes. A history of preoperative falls should be routinely ascertained.

opencc-zeroDec 2014View details →

Data from: Self-cannulation for haemodialysis: patient attributes, clinical correlates and self-cannulation predilection models

Background and objectives: With emerging evidence in support of home haemodialysis (HHD), patient factors which determine uptake of the modality need to be better understood. Self-cannulation (SC) is a major step towards enabling self-care 'in-centre' and home HD and remains the foremost barrier to its uptake. Human factors governing this aspect of HD practice are poorly understood. The aim of this study is to better understand self-cannulation preferences and factors which define them in end stage renal disease (ESRD). Design: In this multicentre study, 508 of 535 patients from predialysis (Group A: n=222), in-centre (Group B: n= 213), and home HD (Group C: n= 100) responded to a questionnaire with 3 self-cannulation questions. Simultaneously, data on clinical, cognitive and psychosocial variables were ascertained. The primary outcome measure was 'perceived ability to self-cannulate AV access'. Predictive models were developed using logistic regression analysis. Results: 36.6% of predialysis patients (A) and 29.1% of the 'in-centre' haemodialysis patients (B) felt able to consider SC for HD. Technical-skills related apprehension was highest in Group B (14.4%) patients. Response to routine venepuncture and the types of SC concerns were significant predictors of perceived ability to self-cannulate. There was no significant difference in concern for pain across the groups. In multivariable regression analysis, age, education level, 3MS score, hypoalbuminemia in Groups B & C and additionally, attitude to routine phlebotomy and the nature of specific concern for self-cannulation in Groups A, B and C, are significant predictors of SC preference. The unadjusted c-statistics of models 1 (derived from Group A and validated on A) and 2 (derived from B+C and validated on B), are 0.76(95% CI 0.69, 0.83) and 0.80 (95% CI 0.74, 0.87) respectively. Conclusions: There is high prevalence of perceived ability to self-cannulate. Modifiable SC concerns exist in ESRD. The use of predictive models to objectively define and target education and training strategies could potentially impact on HD self-management and future uptake of home HD.

Data from: Airflow analysis of Pyeongtaek St. Mary's Hospital during hospitalization of the First Middle East respiratory syndrome patient in Korea

Middle East Respiratory Syndrome (MERS) is known to be transmitted through close contact. However, epidemiological surveys of MERS in Korea indicated that some secondary patients were infected without close contact. Therefore, the possibility of other transmission routes must be identified. In this study, the possibility of MERS spreading through airflow was investigated on the 8th floor of Pyeongtaek St. Mary's Hospital. Computational fluid dynamics was used to analyze the indoor airflow and passive tracer diffusion during the index patient's stay. Six cases were simulated for different outdoor wind directions and indoor mechanical ventilation operations. When a passive tracer was released in ward 8104, where the index patient was hospitalized, the passive tracer spread through the indoor airflow, which was created by the outdoor airflow. Ward 8109, which had the largest number of infected cases and was far distant from ward 8104, showed passive tracer concentration in all cases. This result indicates that MERS may have spread through airflow. The study results do not imply that the infection pathway of MERS is airborne. However, the results show the possibility of MERS spreading through airflow in specific environments such as poor ventilation environments.

Data from: Diagnostic pathways and direct medical costs incurred by new adult pulmonary tuberculosis patients prior to anti-tuberculosis treatment – Tamil Nadu, India

Background: Tuberculosis (TB) patients face substantial delays prior to treatment initiation, and out of pocket (OOP) expenditures often surpass the economic productivity of the household. We evaluated the pre-diagnostic cost and health seeking behaviour of new adult pulmonary TB patients registered at Primary Health Centres (PHCs) in Vellore district, Tamil Nadu, India. Methods: This descriptive study, part of a randomised controlled trial conducted in three rural Tuberculosis Units from Dec 2012 to Dec 2015, collected data on number of health facilities, dates of visits prior to the initiation of anti-tuberculosis treatment, and direct OOP medical costs associated with TB diagnosis. Logistic regression analysis examined the factors associated with delays in treatment initiation and OOP expenditures. Results: Of 880 TB patients interviewed, 34.7% presented to public health facilities and 65% patients sought private health facilities as their first point of care. The average monthly individual income was $77.79 (SD 57.14). About 69% incurred some pre-treatment costs at an average of $39.74. Overall, patients experienced a median of 6 days (3-11 IQR) of time to treatment initiation and 21 days (10-30 IQR) of health systems delay. Age ≤ 40 years (aOR: 1.73; CI: 1.22 - 2.44), diabetes (aOR: 1.63; CI: 1.08 - 2.44) and first visit to a private health facility (aOR: 17.2; CI: 11.1 - 26.4) were associated with higher direct OOP medical costs, while age ≤ 40 years (aOR: 0.64; CI: 0.48 - 0.85) and first visit to private health facility (aOR: 1.79, CI: 1.34 - 2.39) were associated with health systems delay. Conclusion: The majority of rural TB patients registering at PHCs visited private health facilities first and incurred substantial direct OOP medical costs and delays prior to diagnosis and anti-tuberculosis treatment initiation. This study highlights the need for PHCs to be made as the preferred choice for first point of contact, to combat TB more efficiently.

opencc-zeroMay 2020View details →

Data from: An exploratory study of staff perceptions of shift safety in the critical care unit and routinely available data on workforce, patient and organisational factors

Objectives To explore: bedside professional reported (BPR) perceptions of safety in intensive care staff; and the relationships between BPR safety, staffing, patient and work environment characteristics. Design An exploratory study of self-recorded staff perceptions of shift safety and routinely collected data. Setting A large teaching hospital comprising 70 critical care beds. Participants All clinical staff working in adult critical care. Interventions Staff recorded whether their shift felt "safe, unsafe or very unsafe" for 29 consecutive days. We explored these perceptions and relationships between these and routine data on staffing, patient and environmental characteristics. Outcome measures Relationships between BPR safety and staffing, patient and work environment characteristics. Results 2836 BPR scores were recorded over 29 consecutive days (response rate 57.7%). Perceptions of safety varied between staff, including within the same shift. There was no correlation between perceptions of safety and two measures of staffing; care hours per patient day (r= 0.13 p=0.108) and Safecare Allocate (r= -0.19 p=0.013). We found a significant, positive relationship between perceptions of safety and the percentage of Level 3 (most severely ill) patients (r=0.32, p=0.0001). There was a significant inverse relationship between perceptions of safety and the percentage of Level 1 patients on a shift (r= -0.42, p=<0.0001). Perceptions of safety correlated negatively with increased numbers of patients (r= -0.44, p=0.0006) and higher percentage of patients located side rooms (r=0.63, p<0.0001). We found a significant relationship between perceptions of safety and the percentage of staff with a specialist critical care course (r=0.42. p=0.0001). Conclusion Existing staffing models, which are primarily influenced by staff:patient ratios may not be sensitive to patient need. Other factors may be important drivers of staff perceptions of safety and should be explored further. Trial registration- UK Health Research Authority approval was obtained (ID249248).

opencc-zeroApr 2020View details →

Data from: How self-stigma affects patient activation in persons with type 2 diabetes

Objectives Self-stigma is associated with lower patient activation levels for self-care in persons with type 2 diabetes mellitus (T2DM). However, the causal pathway linking self-stigma with patient activation for self-care has not been shown. In order to determine how self-stigma affects patient activation for self-care, we tested a two-path hypothetical model both directly and as mediated by self-esteem and self-efficacy. Design A cross-sectional study Setting 2 university hospitals, 1 general hospital, and 1 clinic in Japan Participants T2DM outpatients receiving treatment (n = 209) completed a self-administered questionnaire comprising the Self-Stigma Scale, Patient Activation Measure, Rosenberg Self-Esteem Scale, General Self-Efficacy Scale, Patient Health Questionnaire, hemoglobin A1c test, age, sex, and BMI. Primary and Secondary Outcome Measures Self-stigma levels were measured by using the Self-Stigma Scale. Patient activation levels were measured by the Patient Activation Measure. Results Path analysis showed a strong relationship between self-stigma and patient activation (χ2 = 27.55, p = 0.120; GFI = 0.97; AGFI = 0.94; CFI = 0.98; RMSEA = 0.04). Self-stigma had a direct effect on patient activation (β = −0.20; p = 0.002). Indirectly, self-stigma affected patient activation along two paths (β = 0.31; p < 0.001) by reducing self-esteem (β = −0.22; p < 0.001) and self-efficacy (β = −0.36; p < 0.001). Conclusions Due to the cross-sectional design of the study, longitudinal changes between all the variables cannot be established. However, the findings indicate that self-stigma affected patient activation for self-care, both directly and as mediated by self-esteem and self-efficacy. Interventions that increase self-esteem and self-efficacy may decrease self-stigma in T2DM patients, thus increasing patient activation for self-care.

Data from: If you build it, they may not come: modifiable barriers to patient portal use among pre- and post-kidney transplant patients

Background: Patient access to health information using electronic patient portals is increasingly common. Portal use has the potential to improve patients' engagement with their health and is particularly important for patients with chronic illness; however, patients' abilities, attitudes, and use of portals is poorly understood. Methods: A single-center, cross-sectional survey was conducted of 240 consecutive pre- and post-kidney transplant patients of all levels of technological proficiency who presented to an urban transplant center in the United States. The Patient Information and Technology Assessment-Patient Portal (PITA-PP) was used to assess patients' attitudes toward the use of patient portals. Results: Most patients surveyed did not use the patient portal (n = 176, 73%). Patients were more likely to use the patient portal if they were White, highly educated, in the post-transplant period, more comfortable with technology, and reported being a frequent internet user (p < 0.05). The most common reasons for not using the patient portal included: (1) preference for traditional communication, (2) not being aware of the portal, (3) low technological proficiency, and (4) poor interoperability between the portal at the transplant center and the patient's primary care center. Conclusions: We identified several modifiable barriers to patient portal use. Some barriers can be addressed by patient education and training on portal use, and federal initiatives are underway to improve interoperability; however, a preference for traditional communications represents the most prominent barrier. Additional strategies are needed to improve portal adoption by encouraging acceptance of technologies as a way of clinical communication.

Data from: Clinical characteristics and lipid lowering treatment of patients initiated on Proprotein convertase subtilisin/kexin type 9 inhibitors – a nationwide cohort study

Objectives: Given the novelty of proprotein convertase subtilisin–kexin type 9 inhibitors (PCSK9i), little is known regarding overall implementation or clinical characteristics among patients who initiate treatment. We aimed to assess the total number of patients initiated on PCSK9i along with a description of the clinical characteristics and lipid lowering treatment (LLT) of such patients. Setting: A register based descriptive cohort study of patients receiving a PCSK9i in the time period from 01-01-2016 to 31-03-2017 using a cross-linkage between three nationwide Danish registers. Information regarding PCSK9i prescriptions, patient demographics, concurrent pharmacotherapy, comorbidities, and previous coronary procedures was identified. Results: Overall, 137 patients initiated treatment with PCSK9i in the study period from 11 in the first quarter of 2016 to 40 in the first quarter of 2017. The majority had a history of ischemic heart disease (67.9%) with ischemic stroke and diabetes mellitus being present in 7.3% and 16.8% of patients, respectively. All patients initiated on PCSK9i had been previous prescribed statin treatment with Atorvastatin and Simvastatin being most frequently prescribed in 53% and 36% of patients, respectively. The majority of patients had received both statins and Ezetimibe (94.9%) and approximately half of these patients had also received bile acid sequestrant (45.3%). Clinical characteristics mainly differed in patients receiving triple LLT compared to patients not receiving triple LLT in the regards of heart failure. Conclusion: Patients treated with PCSK9i were rare, characterized by having ischemic heart disease and had received various and intensive conventional LLT prior to PCSK9i initiation in agreement with current international guidelines.