Role of politics in public sector organizational change

In this paper we will address issues of organizational changes in public sector where the relevance of management has not diminished during the last two decades of the neo‐liberal market philosophy. Public sector organizations are susceptible to greater and more open accountability with politicians, pressure groups, taxpayers and voters all having an interest in the performance of it. In late 1990s Estonian government initiated reforms of health care system in the country. Estonian Hospital Master Plan (EHMP) 2015 was launched in 2000 which, within the others, was initiating the merge of seven Tallinn hospitals into North Estonian Regional Hospital (NERH). To evaluate efficacy of organizational changes during implementation of EHMP‐model into health care system in Estonia we utilized personal interviews of top and middle managers and annual reports of merged hospitals to benchmark these measures to earlier merged Univerity Hopsital and other EU hospitals. We conclude that even NERH was established and the reform‐initiated changes were mostly introduced by the deviation from first‐line governmental plans and introduction of new political directions in 2003 lead to new organizational changes and managerial efforts to gain the goals with, unfortunately, prolonged change process. First published online: 14 Oct 201

Telemonitoring in Chronic Obstructive Pulmonary Disease (CHROMED). A Randomized Clinical Trial

Rationale: Early detection of COPD exacerbations using tele-monitoring of physiological variables might reduce the frequency of hospitalisation. Objectives: To evaluate the efficacy of home monitoring of lung mechanics by the forced oscillation technique (FOT) and cardiac parameters in older COPD patients with co-morbidities. Methods: This multicentre, randomized clinical trial recruited 312 GOLD grade II-IV COPD patients (median age 71 years [IQR:66-76], 49.6% grade II, 50.4% grade III-IV), with a history of exacerbation in the previous year and at least one non-pulmonary co-morbidity. Patients were randomised to usual care (n=158) or tele-monitoring (n=154) and followed for 9 months. All tele-monitoring patients self-assessed lung mechanics daily and in a subgroup with congestive heart failure (n=37) cardiac parameters were also monitored. An algorithm identified deterioration, triggering a telephone contact to determine appropriate interventions. Measurements and Main results: Primary outcomes were time to first hospitalisation (TTFH) and change in EQ-5D utility index score. Secondary outcomes included: rate of antibiotic/corticosteroid prescriptions, hospitalisation, CAT, PHQ-9 and MLHF questionnaire scores, quality-adjusted life years and healthcare costs. Tele-monitoring did not affect TTFH, EQ-5D utility index score, antibiotic prescriptions, hospitalization rate and questionnaire scores. In an exploratory analysis, tele-medicine was associated with fewer repeat hospitalizations (-54%, p=0.017). Conclusions: In older COPD patients with co-morbidities remote monitoring of lung function by FOT and cardiac parameters did not change TTFH and EQ-5D. Clinical trial registration available at www.clinicaltrials.gov, ID NCT01960907

Randomised controlled trial of telemonitoring with addition of daily forced oscillation in older people with COPD and co-morbidity

Evidence of clinical benefit and cost-effectiveness from daily symptom and simple telemonitoring in COPD is unproven. The CHROMED study explored the effect of telemonitoring in older people with COPD and significant co-morbidity who performed daily forced oscillation measurements via RESMON PRO DIARY to identify early physiological change associated with an exacerbation. Six centres in 5 countries randomised 312 people to 9 months telemonitoring (154) or daily symptom questionnaires (158). Each day the monitored group recorded symptoms, pulse, BP, oxygen saturation and airway resistance and reactance. An alert was generated if results exceeded pre-determined parameters and the participant was contacted by their local clinical centre to consider additional treatment. Baseline characteristics were evenly matched: mean age 71 years, FEV1 1.3L (50% predicted) and SGRQ score 49. 61% of subjects had 2+ exacerbations and 42% had been hospitalised in the previous year. Time to first hospitalisation did not differ albeit the monitoring group had fewer hospitalisations (79 vs 103; p=ns) and days in hospital (329 vs. 650; p=ns). However, subjects hospitalized with an AE COPD in the previous year (n=128) had a lower hospitalisation rate (p<0.04). Quality of life (EQ-5D) and health status (CAT) did not differ between groups. Mean cost in the monitored group was marginally lower (€4,615 vs €4,831; p=ns). Telemonitoring including daily forced oscillation impacted neither time to first hospitalisation nor health status. Reduction in hospitalisation rate in subjects with previous hospitalisation suggests these individuals may benefit from telemonitoring and earlier treatment

Lung function assessed by home forced oscillation and self reported symptoms during COPD exacerbations

CHROMED (clinical trials for elderly people with multiple diseases, www.chromed.eu) is an EU-funded project involving 9 partners from 7 European countries aimed at evaluating the impact of a new home care approach to reduce costs and improve quality of life in elderly patients with COPD and comorbidity. The trial involves 300 patients with a prior history of exacerbations randomly assigned to a monitoring or observational arm. Monitored patients performed daily self-assessment of lung mechanics with a FOT (Forced Oscillation Technique) device (RESMON PRO DIARY, Restech srl, Italy) and completed a symptom diary card on touchscreen device (HOME PATIENT MONITOR, EBM srl, Italy). Any detected worsening in lung mechanics generated an alert triggering a phone interview directed at verifying the patient's status and optimizing treatment. By the end of March 2015, 70 monitored patients had completed the trial resulting in 16198 measurements with an adherence of 90.1%. Based on lung mechanics, 311 worsening events were detected, resulting in 0.65±0.3 alerts/patient/month. At least one major symptom (dyspnea, sputum purulence and volume) was reported in 70% of events and 41% were associated with an exacerbation according to diary cards (Seemungal et al., Am J Respir Crit Care Med 1998). A total of 77 exacerbations were confirmed during the phone interview and treated, but 48% of them were not associated with an exacerbation defined by diary cards only. These results suggest that a significant percentage of exacerbations cannot be identified by diary cards only. Self-assessment of lung mechanics using FOT provides complementary information which can be useful to manage COPD patients at home

Les Folles buttes

Texte abordant la transformation du quartier des Buttes Chaumont à Paris depuis 1863 à 1980 et l'existence du stade Bergeyre. Evoque également la littérature, la musique et le cinéma et les combats politiques

Understanding Drug Uptake and Binding within Targeted Disease Micro-Environments in Patients: A New Tool for Translational Medicine

For many common global diseases, such as cancer, diabetes, neurodegenerative and cardiovascular diseases there is an unmet need for diagnosing early indications of disease that could enable medical intervention and early treatment. For example, cigarette smoking causes a variety of deadly diseases including lung cancer, hypertension, chronic obstructive pulmonary disease (COPD) and cardiovascular diseases. The treatment of these diseases will require detailed knowledge of targeted pathways involved in disease pathogenesis but also the mode of drug actions at the biological location on these targets. New methods, such as matrix assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) are ready to provide insights into the fate (destinations and distributions) of administered drugs. Translational medicine is a new area of research where expert from different disciplines involved in basic science and clinical disciplines meet and join forces. The ultimate goal is to identify bridging comprehension that forms a knowledge base that can be used by society to develop a better treatment and medicine for patients

Direct demonstration of tissue uptake of an inhaled drug: proof-of-principle study using matrix assisted laser desorption ionization mass spectrometry imaging

Drug therapy is often directed to specific organ and tissue compartments where the mode of action of the compound effects specifically targeted biological processes. However, the direct measurement of drug uptake in terms of a time kinetic and concentrations attained at the local sites has not been readily available as a clinical index for most drugs. A proof-of-principle study was conducted to test the utility of applying MALDI mass spectrometry imaging (MALDI-MSI) to demonstrate the qualitative distribution pattern of a locally administered drug within tissue sites of targeted action. Here we have measured the occurrence of an inhaled bronchodilator, the muscarinic receptor antagonist ipratropium, within human bronchial biopsies obtained by fiber optic bronchoscopy shortly after dosing exposure. Cryo-preserved biopsy samples from five subjects being evaluated for airway obstruction or potential tumor development were prepared as thin frozen sections. Samples coated with a MALDI matrix were analyzed by a MALDI LTQ Orbitrap XL mass spectrometer at large (100 μm) and small (30 μm) raster size. Our results demonstrate that ipratropium is rapidly absorbed into the airway wall. Ipratropium parent ion (m/z 332.332) and daughter ions (m/z 166.2 and 290.2) were coincidently partitioned within submucosal spaces containing targeted airway smooth muscle in 4/5 subjects. The signal intensity of ipratropium fragment ions provided estimates that local drug concentrations between 3-80 nM were achieved within the airway wall. To our knowledge, this is the first reported study in man applying MALDI-MSI to demonstrate the localization of a drug administered at therapeutic levels. The study highlights the potential benefit of MALDI-MSI to provide important measurements of drug efficacy in clinical settings