Impact of clinical and sociodemographic patient characteristics on the outcome of cardiac rehabilitation in older patients

Background Cardiac rehabilitation (CR) seeks to simultaneously improve several outcome parameters related to patient risk factors, exercise capacity and subjective health. A single score, the multiple outcome criterion (MOC), comprised of alterations in 13 outcome variables was used to measure the overall success of CR in an older population. As this success depends on the older patient's characteristics at the time of admission to CR, we attempted to determine the most important influences. Methods The impact of baseline characteristics on the success of CR, measured by MOC, was analysed using a mixed model for 1,220 older patients (70.9 +/- A 7.0 years, 78.3 % men) who enrolled in 12 CR clinics. A multitude of potentially influential baseline patient characteristics was considered including sociodemographic variables, comorbidity, duration of hospital stay, exercise capacity, cardiovascular risk factors, emotional status, and laboratory and echocardiographic data. Results Overall, CR was successful, as indicated by the mean value of the MOC (0.6 +/- A 0.45; min -1.0, max 2.0; positive values denoting improvement, negative ones deterioration). Examples of association with negative MOC values included smoking (MOC -0.15, p < 0.001), female gender (MOC -0.07, p = 0.049), and a longer hospital stay (MOC -0.03, p = 0.03). An example of association with positive MOC value was depression score (MOC 0.06, p = 0.003). Further associations included maximal exercise capacity, blood pressure, heart rate and the rehabilitation centre attended. Conclusion Our results emphasize the necessity to take into consideration baseline characteristics when evaluating the success of CR and setting treatment targets for older patients

Limitation of life-sustaining treatment in NICU: Physicians' beliefs and attitudes in the Buenos Aires region

Objective: To explore the ethical beliefs and attitudes of Argentinean neonatologists regarding limitation of life-sustaining treatment (LST) for very sick infants. Methods: We used an anonymous questionnaire including direct questions and hypothetical clinical cases (inevitable demise and anticipated survival with severe long-term disability). Multivariable analysis was carried out to assess the relation between type of clinical case and physicians' LST attitudes. Results: Overall, 315 neonatologists in 34 units in the Buenos Aires region participated (response rate 54%). Most responders would agree with decisions to start or continue LST. In both clinical cases, continuing current treatment with no therapeutic escalation was the only form of LST limitation acceptable to a substantial proportion (about 60%) of neonatologists. Agreement with LST limitation was slightly but significantly more likely when death was inevitable. Conclusion: Argentinean neonatologists showed a conservative attitude regarding LST limitation. Patient prognosis and options of non-treatment decision significantly influenced their choices.Fil: Silberberg, Agustín. Universidad Austral. Hospital Universitario Austral; ArgentinaFil: Herich, Lena Carolin. Bambino Gesù Children's Hospital; ItaliaFil: Croci, Ileana. Bambino Gesù Children's Hospital; ItaliaFil: Cuttini, Marina. Bambino Gesù Children's Hospital; ItaliaFil: Villar, Marcelo Jose. Universidad Austral. Facultad de Ciencias Biomédicas. Instituto de Investigaciones en Medicina Traslacional. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Instituto de Investigaciones en Medicina Traslacional; ArgentinaFil: Requena Meana, Pablo. Pontificia Università della Santa Croce; Itali

Patient Groups with Different Risk Profiles for Irregular Drop- Out from Forensic Psychiatry ( 64 StGB)

Objective: About 50-70% of the patients with substance abuse disorders who are mandated to forensic treatment according to the section 64 of the German penal code are discharged from treatment irregularly. Previous research identified a number of potential risk factors for irregular treatment dropout. Systematic assessment of risks factors and their consideration for treatment planning may help to improve treatment retention. Therefore, the aim of this study was to identify groups of patients with a comparable risk profile for treatment dropout. Methods: From 2007-2012, patients entering forensic treatment completed the MATE-Crimi and a sociodemographic questionnaire. Results: From 431 patients entering forensic treatment, 357 patients agreed to participate. Of the 357 included patients 35.9% had completed the forensic treatment irregular. Using cox regression, young age, low treatment motivation and a primary criminal behaviour with the substance use as a consequence of criminal behaviour were identified as risk factors for early drop-out. A subsequent analysis of latent classes using these variables resulted in three classes. Conclusions: Our study revealed a small number of risk factors being relevant for treatment drop-out. Furthermore, we identified three groups of patients with different risk profiles. Next steps include the development of treatment pathways for these patient groups

Limitations in Ankle Dorsiflexion Range of Motion, Gait, and Walking Efficiency in Childhood Cancer Survivors

Background: Improvements in survival rates in pediatric oncology have resulted in a growing need to identify adverse effects and improve rehabilitation in this population. Objective: This cross-sectional study aimed to investigate active ankle dorsiflexion (DF) range of motion (ROM), gait, walking efficiency, and motor performance in a mixed childhood cancer survivor population in comparison to healthy peers. Methods: Active ankle DF-ROM (goniometer), gait (Microgate Optogait 2D Gait Analysis), walking efficiency (6-minute walk test), and motor performance (German Motor Test 6-18) were assessed in a mixed childhood cancer survivor population after cessation of medical treatment (n = 13) in comparison to healthy children matched for age and gender (n = 13). Results: Active ankle DF-ROM, gait (stance, swing, and preswing phase), and walking efficiency were significantly impaired in survivors compared with control subjects. No significant difference between groups was found in motor performance. Conclusion: Despite sufficient total motor performance levels, specific limitations in physical functioning were identified in a mixed childhood cancer survivor sample. This highlights the importance of the present findings. Implication for Practice: The results from this study highlight the potential significance of limited ankle DF function, inhibited gait, and reduced walking efficiency as adverse effects of various types of childhood cancer. It is hoped this enhanced recognition by pediatric cancer patients, parents, and exercise professionals will initiate specific supportive strategies and potentially prevent further limitations

Effect evaluation of an interprofessional medication therapy management approach for multimorbid patients in primary care: a cluster-randomized controlled trial in community care (WestGem study protocol)

Background: Pharmaceutical practice worldwide is developing towards patient care. Medication Review (MR) and Medication Therapy Management (MTM) are evolving as the most prominent services in pharmaceutical care and have a strong potential to provide a large benefit for patients and society. MTMs can only be performed in an interprofessional, collaborative setting. Several international studies have explored the effects of a MTM on the quality of therapy and costs. For Germany the data is still deficient. This study aims to provide data on the effects of an interprofessional MTM regarding quality of therapy, quality of life, costs and cost-effectiveness. Method/Design: The study is designed as a cluster-randomized controlled trial in primary care, involving 12 outpatient clinics (clusters) and 165 patients. Primary care units are allocated to interventions using a Stepped Wedge Design. All units are initially assigned to the control group. After a 6 month observation period, general practitioners (GP) are randomly allocated to one of three groups and the interprofessional medication therapy management approach is implemented sequentially per each group with a lag of 3 months between. The primary outcome is the change in the quality of therapy measured by the MAI (Medication Appropriateness Index). Secondary outcomes include changes in the number of drug related problems, medication complexity, changes in drug-adherence, changes in health-status and function, quality of life, direct costs and the incremental cost-effectiveness ratio. The acceptance of the interprofessional Medication Therapy Management approach is assessed by qualitative methods. Discussion: The patient interview and brown bag review are activities, typically provided by the pharmacist. In this trial the patient is blinded to the pharmacist. The strength of having the patient blinded to the pharmacists is to exclude skepticism of the patient toward unknown pharmacies, which might be a major confounder in a regional and community setting. A weakness is that some patient related data might reach the pharmacists in a way, which might differ from self-acquired data

Risk of Developmental Coordination Disorder in Italian very preterm children at school age compared to general population controls

Background Developmental Coordination Disorder (DCD) is a neurodevelopmental disorder that involves difficulties in goal-directed motor coordination, with ineffective control of fine and gross motor movements in the absence of sensory impairment or neurological condition. DCD is frequently reported in children born very preterm (VP) who survive without CP. Aims To measure the risk of DCD at school age in a large area-based cohort of VP children and general population controls, adjusting for gender, birth weight by gestational age and age at assessment. Methods VP children (N = 608) were part of a prospective cohort study in Italy. Controls (N = 370) were participants in the DCDQ-Italian validation study in the same age range. The Italian version of Developmental Coordination Disorder Questionnaire (DCDQ-Italian) was used to measure the performances in motor coordination during ordinary activities from the parental point of view. Multivariable regression analysis was used to obtain adjusted risk ratios of screening positive for DCD. Results VP children had scores significantly lower than peers, and about 30% of them appeared at risk of DCD using the 15th percentile cut-off of the Italian validation study. Birth-weight &lt;10th percentile for gestational age and male gender were significant predictors. A slight trend effect was present, with extremely preterm children (&lt;28 weeks gestation) showing the highest risk. Conclusions Our study confirmed the higher DCD risk in VP children, particularly when males and SGA

Breathlessness, Functional Status, Distress and Palliative Care Needs Over Time in Patients With Advanced Chronic Obstructive Pulmonary Disease or Lung Cancer:A Cohort Study

Context. Breathlessness is a distressing symptom in advanced disease. Understanding its patterns, burden, and palliative care (PC) needs over time is important to improve patients' quality of life. Objectives. To describe and compare the courses of refractory breathlessness, functional status, distress, and PC needs in patients with advanced chronic obstructive pulmonary disease (COPD) or lung cancer (LC) over time. Methods. This was a cohort study of patients with COPD (Stage III/IV) or LC. Data were assessed monthly with up to 12 telephone interviews, using the modified Borg Scale, Karnofsky Performance Status Scale, Distress Thermometer, and Palliative care Outcome Scale as outcomes measures. Descriptive analysis compared all outcomes between COPD and LC at baseline and over time (forward from study entry and backward from death). Results. A total of 82 patients (50 COPD and 32 LC), mean (SD) age of 67.2 (7.8), and 36% female were included (8 COPD and 23 LC deceased). The patients with COPD perceived higher levels of breathlessness and distress at lower functional status steadily over time. The LC patients' breathlessness, distress, and PC needs increased, whereas functional status decreased toward death. The PC needs were similar between disease groups. Breathlessness was negatively correlated with functional status (COPD = mean r = -0.20, P = 0.012; LC = mean r = -0.277, P = 0.029) and positively correlated with PC needs in COPD patients (mean r = 0.343, P < 0.001). Death was significantly predicted by diagnosis (LC: hazard ratio = 7.84, P < 0.001) and functional status (10% decline: hazard ratio = 1.52, P = 0.001). Conclusion. The PC needs of patients with advanced COPD are comparable with LC patients, and breathlessness severity and distress are even higher. The care for COPD patients requires further improvement to address symptom burden and PC needs. (C) 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved

Implantation of venous access devices under local anesthesia: patients' satisfaction with oral lorazepam

Objective: The aim of the study reported here was to evaluate patients' satisfaction with implantation of venous access devices under local anesthesia (LA) with and without additional oral sedation. Materials and methods: A total of 77 patients were enrolled in the prospective descriptive study over a period of 6 months. Subcutaneous implantable venous access devices through the subclavian vein were routinely implanted under LA. Patients were offered an additional oral sedative (lorazepam) before each procedure. The level of anxiety/tension, the intensity of pain, and patients' satisfaction were evaluated before and immediately after the procedure using a visual analog scale (ranging from 0 to 10) with a standardized questionnaire. Results: Patients' satisfaction with the procedure was high (mean: 1.3 +/- 2.0) with no significant difference between the group with premedication and the group with LA alone (P=0.54). However, seven out of 30 patients (23.3%) in the group that received premedication would not undergo the same procedure without general anesthesia. There was no significant influence of lorazepam on the intensity of pain (P=0.88). In 12 out of 30 patients (40%) in the premedication group, the level of tension was higher than 5 on the visual analog scale during the procedure. In 21 out of 77 patients (27.3%), the estimate of the level of tension differed between the interventionist and the patient by 3 or more points in 21 out of 77 patients (27.3%). Conclusion: Overall patient satisfaction is high for implantation of venous access devices under LA. A combination of LA with lorazepam administered orally might not be adequate for patients with a high level of anxiety and tension. The level of tension is often underestimated by the interventionist. Pre-procedural standardized questionnaires could be used to identify patients for whom a gradual approach of individualized sedation may be more effective

Low socio-economic conditions and prematurity-related morbidities explain healthcare use and costs for 2-year-old very preterm children

Aim: To estimate healthcare use and related costs for 2-year-old very preterm (VP) children after discharge from the neonatal unit. Methods: As part of a European project, we recruited an area-based cohort including all VP infants born in three Italian regions (Lazio, Emilia-Romagna and Marche) in 2011-2012. At 2 years corrected age, parents completed a questionnaire on their child health and healthcare use (N = 732, response rate 75.6%). Cost values were assigned based on national reimbursement tariffs. We used multivariable analyses to identify factors associated with any rehospitalisation and overall healthcare costs. Results: The most frequently consulted physicians were the paediatrician (85% of children), the ophthalmologist (36%) and the neurologist/neuropsychiatrist (26%); 38% of children were hospitalised at least once after the initial discharge, for a total of 513 admissions and over one million euros cost, corresponding to 75% of total healthcare costs. Low maternal education and parental occupation index, congenital anomalies and postnatal prematurity-related morbidities significantly increased the risk of rehospitalisation and total healthcare costs. Conclusion: Rehospitalisation and outpatient care are frequent in VP children, confirming a substantial health and economic burden. These findings should inform the allocation of resources to preventive and rehabilitation services for these children