147 research outputs found

    Introduction

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    BACKGROUND: National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden. METHODS: A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis. RESULTS: An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data. CONCLUSION: While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so

    Persistent High Burden of Heart Failure Across the Ejection Fraction Spectrum in a Nationwide Setting

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    Background Heart failure (HF) has a dramatic impact on worldwide health care systems that is determined by the growing prevalence of and the high exposure to cardiovascular and noncardiovascular events. Prognosis remains poor. We sought to compare a large population with HF across the ejection fraction (EF) spectrum with a population without HF for patient characteristics, and HF, cardiovascular, and noncardiovascular outcomes. Methods and Results Patients with HF registered in the Swedish HF registry in 2005 to 2018 were compared 1:3 with a sex-, age-, and county-matched population without HF. Outcomes were cardiovascular and noncardiovascular mortality and hospitalizations. Of 76 453 patients with HF, 53% had reduced EF, 23% mildly reduced EF, and 24% preserved EF. Compared with those without HF, patients with HF had more cardiovascular and noncardiovascular comorbidities and worse socioeconomic status. Incidence of cardiovascular and noncardiovascular events was higher in people with HF versus non-HF, with increased risk of all-cause (hazard ratio [HR], 2.53 [95% CI, 2.50-2.56]), cardiovascular (HR, 4.67 [95% CI, 4.59-4.76]), and noncardiovascular (HR, 1.49 [95% CI, 1.46-1.52]) mortality, 2- to 5-fold higher risk of first/repeated cardiovascular and noncardiovascular hospitalizations, and ~4 times longer in-hospital length of stay for any cause. Patients with HF with reduced EF had higher risk of HF hospitalizations, whereas those with HF with preserved EF had higher risk of all-cause and noncardiovascular hospitalization and mortality. Conclusions Patients with HF exert a high health care burden, with a much higher risk of cardiovascular, all-cause, and noncardiovascular events, and nearly 4 times as many days spent in hospital compared with those without HF. These epidemiological data may enable strategies for optimal resource allocation and HF trial design

    Forskningsverksamhet och försöksstallar inom nöt- och lammköttsproduktion i Wales, Irland, Skottland och Danmark

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    SLU:s forskningsstation för nöt- och lammköttsproduktion Ă€r belĂ€gen pĂ„ Götala gĂ„rd utanför Skara. HĂ€r bedrivs utfodringsförsök till nöt och lamm baserat pĂ„ vall och bete kompletterat med huvudsakligen inhemska kraftfodermedel, dĂ€r syftet Ă€r att ta fram nöt- och lammkött av hög kvalitet. Djurens vĂ€lfĂ€rd och lantbrukarens ekonomi stĂ„r i centrum för vĂ„r forskning. Under 2010 kommer projektering utföras för nya försöksstallar för nöt och fĂ„r. För att utbyta erfarenheter med forskare inom nöt- och lammproduktion och fĂ„ idĂ©er till smarta byggnadslösningar och utfodringsanlĂ€ggningar i försöksstallar besökte vi under 2009 IBERS, Aberystwyth i Wales, Teagasc Grange Beef Research Centre pĂ„ Irland och SAC Animal Breeding & Development Team i Skottland. I Danmark besökte vi Tjele gods, Forskningscenter Foulum och Kvaegbrugets Forsogscentrum (KFC). Forskningen i Wales, Irland och Skottland hade blivit mer inriktad mot mera tvĂ€rvetenskaplig forskning med klimat och miljö som viktiga faktorer. De nybyggda stallarna pĂ„ IBERS och SAC var stora ljusa, luftiga fribĂ€rande hallar, dĂ€r större delen av vĂ€ggarna bestod av vindvĂ€vsgardiner. Man hade satsat pĂ„ breda foderbord, flexibla boxstorlekar och fantastiska hanteringsanlĂ€ggningar för sortering, vĂ€gning och behandling av djur. Det var imponerande att se deras foderhantering med mĂ„nga silor i olika storlekar och allt under tak. Fullfoder var vanligt och medförde en rationell utfodring. De datastyrda utfodringskrubborna, av bĂ„de den hollĂ€ndska och brittiska modellen, krĂ€vde bĂ„de tillsyn och skötsel för att fungera. Det blir ocksĂ„ en stor mĂ€ngd data att hantera vid anvĂ€ndning av dem. PĂ„ Tjele gods i Danmark hade man satsat pĂ„ en enkel byggnad, med djurhantering i fokus. Mycket av arbetet gjordes maskinellt för att spara arbetskraft. FoderanlĂ€ggningen pĂ„ Foulum gav möjlighet till stor flexibilitet nĂ€r det gĂ€ller att hantera mĂ„nga fodermedel och olika foderblandningar. Fodret utfodrades i de olika stallarna med hjĂ€lp av förarlösa robottruckar. Försöksstallet för mjölkkor var isolerat och inrett med liggbĂ„s och skrapade fodergĂ„ngar. HĂ€r gavs möjlighet att genomföra försök med mĂ„nga behandlingar under exakt samma stallbetingelser. Stallet var utrustat med individuell utfodring av grovfoder. Kraftfoder fanns i automater dĂ€r de kunde ha fyra olika foder samtidigt. Den dammsugare som anvĂ€ndes för att tömma foderkrubborna ansĂ„gs helt nödvĂ€ndig för en rationell foderhantering. All data frĂ„n försöksstallarna registrerades automatiskt och samlades in till en gemensam databank, varifrĂ„n forskarna kunde hĂ€mta information. All datafiltrering sysselsatte fem datatekniker. Det som forskarna pĂ„ Foulum skickade med oss som rĂ„d inför vĂ„r projektering, var att tĂ€nka pĂ„ att ta till ordenligt nĂ€r det gĂ€ller utrymmen, sĂ„ att foder- och djurhantering blir rationell. KFC var en mycket vĂ€lskött försöksgĂ„rd som Ă€gdes av nĂ€ringen. Eftersom de höll pĂ„ att slutföra en om- och tillbyggnation av ladugĂ„rden var det extra intressant för oss att se och höra hur de tĂ€nkt vid projekteringen. De hade t.ex. gĂ„tt ifrĂ„n gummimattor i mjölkkostallets fodergĂ„ngar och satsat pĂ„ betongspalt och gödselrobot, för att fĂ„ torrare miljö och dĂ€rmed bĂ€ttre klövhĂ€lsa. Efter att ha prövat mĂ„nga olika sorter liggunderlag i liggbĂ„sen hade man satsat pĂ„ en 18 cm tjock madrass med smĂ„ luftfyllda gummibollar, vilken höll formen bra. En sjĂ€lvgĂ„ende strövagn pĂ„ rĂ€ls för spĂ„n över liggbĂ„sen, samt Ă€ven en för halm i ungdjurs-avdelningen sparade mycket arbete. Även pĂ„ KFC tillĂ€mpades individuell utfodring till alla mjölkkor och de hade 2-2,5 kor/ fodertrĂ„g. Utfodring gjordes fyra gĂ„nger per dag. I ungdjursstallet var det tvĂ„ fodertrĂ„g per tio djur och utfodringen gjordes tvĂ„ gĂ„nger per dag. Fodergrindar vid varje fodertrĂ„g var nödvĂ€ndigt hos ungdjuren för att inte djuren skulle bli undanknuffade nĂ€r de Ă„t. Personalen pĂ„pekade att den individuella utfodringen krĂ€ver mycket datatekniskt arbete för att installation och funktion ska bli anvĂ€ndarvĂ€nlig. Diskussionen med forskare och försökspersonal har varit oerhört vĂ€rdefull och gett oss mycket att tĂ€nka pĂ„ inför vĂ„r egen planering av nya försöksstallar. Det viktigaste att tĂ€nka pĂ„ vid projektering, enligt vĂ„ra kollegor bĂ„de pĂ„ Brittiska öarna och i Danmark, Ă€r flexibilitet, vĂ€l tilltagna ytor och en genomtĂ€nkt logistik. Det ger förutsĂ€ttningar för stallar med god forsknings- och arbetsmiljö samt en god djurvĂ€lfĂ€r

    Apolipoprotein C-III predicts cardiovascular events and mortality in individuals with type 1 diabetes and albuminuria

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    Publisher Copyright: © 2021 The Association for the Publication of the Journal of Internal MedicineObjectives: We studied apolipoprotein C-III (apoC-III) in relation to diabetic kidney disease (DKD), cardiovascular outcomes, and mortality in type 1 diabetes. Methods: The cohort comprised 3966 participants from the prospective observational Finnish Diabetic Nephropathy Study. Progression of DKD was determined from medical records. A major adverse cardiac event (MACE) was defined as acute myocardial infarction, coronary revascularization, stroke, or cardiovascular mortality through 2017. Cardiovascular and mortality data were retrieved from national registries. Results: ApoC-III predicted DKD progression independent of sex, diabetes duration, blood pressure, HbA1c, smoking, LDL-cholesterol, lipid-lowering medication, DKD category, and remnant cholesterol (hazard ratio [HR] 1.43 [95% confidence interval 1.05–1.94], p = 0.02). ApoC-III also predicted the MACE in a multivariable regression analysis; however, it was not independent of remnant cholesterol (HR 1.05 [0.81–1.36, p = 0.71] with remnant cholesterol; 1.30 [1.03–1.64, p = 0.03] without). DKD-specific analyses revealed that the association was driven by individuals with albuminuria, as no link between apoC-III and the outcome was observed in the normal albumin excretion or kidney failure categories. The same was observed for mortality: Individuals with albuminuria had an adjusted HR of 1.49 (1.03–2.16, p = 0.03) for premature death, while no association was found in the other groups. The highest apoC-III quartile displayed a markedly higher risk of MACE and death than the lower quartiles; however, this nonlinear relationship flattened after adjustment. Conclusions: The impact of apoC-III on MACE risk and mortality is restricted to those with albuminuria among individuals with type 1 diabetes. This study also revealed that apoC-III predicts DKD progression, independent of the initial DKD category.Peer reviewe

    Plasmodium falciparum population dynamics during the early phase of anti-malarial drug treatment in Tanzanian children with acute uncomplicated malaria

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    BACKGROUND\ud \ud This study aimed to explore Plasmodium falciparum population dynamics during the early phase of anti-malarial drug treatment with artemisinin-based combination therapy in children with clinical malaria in a high transmission area in Africa.\ud \ud METHODS\ud \ud A total of 50 children aged 1-10 years with acute uncomplicated P. falciparum malaria in Bagamoyo District, Tanzania, were enrolled. Participants were hospitalized and received supervised standard treatment with artemether-lumefantrine according to body weight in six doses over 3 days. Blood samples were collected 11 times, i.e. at time of diagnosis (-2 h) and 0, 2, 4, 8, 16, 24, 36, 48, 60 and 72 h after initiation of treatment. Parasite population dynamics were assessed using nested polymerase chain reaction (PCR)-genotyping of merozoite surface protein (msp) 1 and 2.\ud \ud RESULTS\ud \ud PCR-analyses from nine sequential blood samples collected after initiation of treatment identified 20 and 21 additional genotypes in 15/50 (30%) and 14/50 (28%) children with msp1 and msp2, respectively, non-detectable in the pre-treatment samples (-2 and 0 h combined). Some 15/20 (75%) and 14/21 (67%) of these genotypes were identified within 24 h, whereas 17/20 (85%) and 19/21 (90%) within 48 h for msp1 and msp2, respectively. The genotype profile was diverse, and varied considerably over time both within and between patients, molecular markers and their respective families.\ud \ud CONCLUSION\ud \ud PCR analyses from multiple blood samples collected during the early treatment phase revealed a complex picture of parasite sub-populations. This underlines the importance of interpreting PCR-outcomes with caution and suggests that the present use of PCR-adjustment from paired blood samples in anti-malarial drug trials may overestimate assessment of drug efficacy in high transmission areas in Africa.The study is registered at http://www.clinicaltrials.gov with identifier NCT00336375

    Eligibility for vericiguat in a real-world heart failure population according to trial, guideline and label criteria:Data from the Swedish Heart Failure Registry

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    Aim: We investigated the eligibility for vericiguat in a real-world heart failure (HF) population based on trial, guideline and label criteria. Methods and results: From the Swedish HF registry, 23 573 patients with HF with reduced ejection fraction (HFrEF) enrolled between 2000 and 2018, with a HF duration ≄6 months, were considered. Eligibility for vericiguat was calculated based on criteria from (i) the Vericiguat Global Study in Subjects with Heart Failure and Reduced Ejection Fraction (VICTORIA) trial; (ii) European and American guidelines on HF; (iii) product labelling according to the Food and Drug Administration and European Medicines Agency. Estimated eligibility for vericiguat in the trial, guidelines, and label scenarios was 21.4%, 47.4%, and 47.4%, respectively. Prior HF hospitalization within 6 months was the criterion limiting eligibility the most in all scenarios (met by 49.1% of the population). In the trial scenario, other criteria meaningfully limiting eligibility were elevated N-terminal pro-B-type natriuretic peptide levels and nitrate use. In all scenarios, eligibility was higher among patients hospitalized for HF at baseline (44.3% vs. 21.4% [trial scenario] and 97.3% vs. 47.4% [guideline/label scenarios] for hospitalized vs. non-hospitalized patients). Overall, eligible patients were older, had more severe HF, more comorbidities, and consequently higher cardiovascular mortality and HF hospitalization rates compared with ineligible patients across all scenarios. Conclusion: In a large and contemporary real-world HFrEF cohort, we estimated that 21.4% of patients would be eligible for vericiguat according to the VICTORIA trial selection criteria, 47.4% based on guidelines and labelling. Eligibility for vericiguat translated into the selection of a population at high risk of morbidity/mortality.</p

    Association between potassium level and outcomes in heart failure with reduced ejection fraction: a cohort study from the Swedish Heart Failure Registry

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    AimsHyperkalaemia and hypokalaemia are common in heart failure and associated with worse outcomes. However, the optimal potassium range is unknown. We sought to determine the optimal range of potassium in patients with heart failure and reduced ejection fraction (5.0- mmol/L. Potassium 5.0- mmol/L were more common with lower estimated glomerular filtration rate and heart failure of longer duration and greater severity. The potassium level associated with the lowest hazard risk for mortality at 30- days, 12 months, and maximal follow- up was 4.2- mmol/L, and there was a steep increase in risk with both higher and lower potassium levels. In adjusted strata analyses, lower potassium was independently associated with all- cause mortality at 12 months and maximal follow- up, while higher potassium levels only increased risk at 30- days.ConclusionIn this nationwide registry, the relationship between potassium and mortality was U- shaped, with an optimal potassium value of 4.2- mmol/L. After multivariable adjustment, hypokalaemia was associated with increased long- term mortality but hyperkalaemia was associated with increased short- term mortality.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/162724/3/EJHF1757-sup-0001-APPS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/162724/2/ejhf1757_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/162724/1/ejhf1757.pd

    Eligibility for dapagliflozin and empagliflozin in a real-world heart failure population

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    Background: We investigated eligibility for dapagliflozin and empagliflozin in a real-world heart failure (HF) cohort based on selection criteria of DAPA-HF, DELIVER, and EMPEROR trials. Methods and Results: Selection criteria were applied to the Swedish HF registry out-patient population according to three scenarios: (i) a “trial scenario” applying all selection criteria; (ii) a “pragmatic scenario” applying the most clinically relevant criteria; (iii) a “label scenario” following the regulatory agencies labels. Of 49,317 patients, 55% had ejection fraction (EF)&lt;40% and were assessed for eligibility based on DAPA-HF and EMPEROR-Reduced, 45% had EF≄40% and were assessed based on EMPEROR-Preserved and DELIVER. Eligibility using trial, pragmatic and label scenarios was: 35%, 61% and 80% for DAPA-HF; 31%, 55% and 81% for EMPEROR-Reduced; 30%, 61% and 74% for DELIVER; 32%, 59% and 75% for EMPEROR-Preserved. Main selection criteria limiting eligibility were HF duration and NT-proBNP. Eligible patients had more severe HF, more comorbidities, higher use of HF treatments and higher mortality/morbidity. Conclusions: In a real-world HF setting, eligibility for SGLT2i was similar whether selection criteria from DAPA-HF or EMPEROR-Reduced were applied in HFrEF, or EMPEROR-Preserved or DELIVER in HFpEF. These data might help stakeholders assessing the consequences of future trial eligibility

    Polymorphisms in Plasmodium falciparum chloroquine resistance transporter and multidrug resistance 1 genes: parasite risk factors that affect treatment outcomes for P. falciparum malaria after artemether-lumefantrine and artesunate-amodiaquine.

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    Adequate clinical and parasitologic cure by artemisinin combination therapies relies on the artemisinin component and the partner drug. Polymorphisms in the Plasmodium falciparum chloroquine resistance transporter (pfcrt) and P. falciparum multidrug resistance 1 (pfmdr1) genes are associated with decreased sensitivity to amodiaquine and lumefantrine, but effects of these polymorphisms on therapeutic responses to artesunate-amodiaquine (ASAQ) and artemether-lumefantrine (AL) have not been clearly defined. Individual patient data from 31 clinical trials were harmonized and pooled by using standardized methods from the WorldWide Antimalarial Resistance Network. Data for more than 7,000 patients were analyzed to assess relationships between parasite polymorphisms in pfcrt and pfmdr1 and clinically relevant outcomes after treatment with AL or ASAQ. Presence of the pfmdr1 gene N86 (adjusted hazards ratio = 4.74, 95% confidence interval = 2.29 - 9.78, P < 0.001) and increased pfmdr1 copy number (adjusted hazards ratio = 6.52, 95% confidence interval = 2.36-17.97, P < 0.001 : were significant independent risk factors for recrudescence in patients treated with AL. AL and ASAQ exerted opposing selective effects on single-nucleotide polymorphisms in pfcrt and pfmdr1. Monitoring selection and responding to emerging signs of drug resistance are critical tools for preserving efficacy of artemisinin combination therapies; determination of the prevalence of at least pfcrt K76T and pfmdr1 N86Y should now be routine

    Incidence rates of narcolepsy diagnoses in Taiwan, Canada, and Europe: The use of statistical simulation to evaluate methods for the rapid assessment of potential safety issues on a population level in the SOMNIA study

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    BACKGROUND & OBJECTIVES: Vaccine safety signals require investigation, which may be done rapidly at the population level using ecological studies, before embarking on hypothesis-testing studies. Incidence rates were used to assess a signal of narcolepsy following AS03-adjuvanted monovalent pandemic H1N1 (pH1N1) influenza vaccination among children and adolescents in Sweden and Finland in 2010. We explored the utility of ecological data to assess incidence of narcolepsy following exposure to pandemic H1N1 virus or vaccination in 10 sites that used different vaccines, adjuvants, and had varying vaccine coverage.METHODS: We calculated incidence rates of diagnosed narcolepsy for periods defined by influenza virus circulation and vaccination campaign dates, and used Poisson regression to estimate incidence rate ratios (IRRs) comparing the periods during which wild-type virus circulated and after the start of vaccination campaigns vs. the period prior to pH1N1 virus circulation. We used electronic health care data from Sweden, Denmark, the United Kingdom, Canada (3 provinces), Taiwan, Netherlands, and Spain (2 regions) from 2003 to 2013. We investigated interactions between age group and adjuvant in European sites and conducted a simulation study to investigate how vaccine coverage, age, and the interval from onset to diagnosis may impact the ability to detect safety signals.RESULTS: Incidence rates of narcolepsy varied by age, continent, and period. Only in Taiwan and Sweden were significant time-period-by-age-group interactions observed. Associations were found for children in Taiwan (following pH1N1 virus circulation) and Sweden (following vaccination). Simulations showed that the individual-level relative risk of narcolepsy was underestimated using ecological methods comparing post- vs. pre-vaccination periods; this effect was attenuated with higher vaccine coverage and a shorter interval from disease onset to diagnosis.CONCLUSIONS: Ecological methods can be useful for vaccine safety assessment but the results are influenced by diagnostic delay and vaccine coverage. Because ecological methods assess risk at the population level, these methods should be treated as signal-generating methods and drawing conclusions regarding individual-level risk should be avoided
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