The Design, Implementation and Evaluation of a Shared-Care Scheme for Hypertension

Hypertension is a risk factor for stroke and for coronary heart disease but treatment could reduce the incidence of both. However, treatment is costly and requires lifelong follow-up. Current follow-up of hypertension is inadequate with duplication of medical work, inconsistencies in standards of care, poor information and inefficient use of resources. Registers, clinical information systems, nurses, facilitators, community programs, mini-clinics and shared-care have all been used for the follow-up of hypertensive patients Formal evaluation of the costs and benefits of these new methods of care is important and the cost-effectiveness of shared-care for hypertensive patients has not been examined. The West of Scotland Shared-Care Scheme for Hypertension was developed to co-ordinate specialist, general practitioner and laboratory services. The patient carries a summary record and arranges annual reviews with his/her general practitioner after prompting by the Scheme. Results of annual review are screened by a specialist, the computerised medical records are updated and copies are sent to the general practitioner. A rereferral clinic visit is available at short notice if required. The feasibility, acceptability and cost-effectiveness of the Shared-Care Scheme was compared with that of outpatient and nurse-practitioner care by measuring the number of complete reviews in year 2 for three comparable groups of 277 patients (SC, BPC and NPC groups respectively) as well as variables relating to health status, acceptability of each method and costs to the health service and to patients. Over the two years the SC drop-out rate was significantly less than the BPC and NPC rates (3%, 14% and 9% respectively) and the SC group had more complete reviews than the BPC group (82% versus 54%). There were no differences in self-perceived health status. Two thirds of the SC group apparently maintained or improved their blood pressure control over the two years. Seventeen people attended the re-referral clinic and all but 2 returned to shared-care. Mortality was similar in the three groups. Only two general practitioners withdrew from shared-care and 61% wanted the Scheme to continue with a further 25% having no clear opinion. Shared-care increased the number of general practitioner visits by one per year but the patients in the BPC and NPC groups visited the clinic approximately twice per year. SC patients spent less time and money on attending the consultation, The Personal Health Booklet was used by almost all SC patients and only 4% did not like it. Approximately half of the patients preferred shared-care to outpatient care while 22% had no preference. Around one third of general practitioners preferred shared-care but two thirds preferred their own routine care. The cost-effectiveness ratios for total costs wer

Comparison of respiratory health-related quality of life in patients with intractable breathlessness due to advanced cancer or advanced COPD.

OBJECTIVES: Breathlessness is common in patients with advanced cancer and almost universal in advanced chronic obstructive pulmonary disease (COPD), but studies suggest their experiences of breathlessness vary. This report builds on these studies by providing quantitative evidence of differences in respiratory health-related quality of life (HRQoL) between these groups. Further, it explores the validity of the Chronic Respiratory Questionnaire (CRQ) in patients with cancer. METHODS: The CRQ-Original was completed within baseline interviews for a randomised controlled trial of a palliative intervention for intractable breathlessness due to advanced disease. Independent samples Mann-Whitney U tests were performed to identify significant differences in median scores for the four CRQ domains (mastery, dyspnoea, emotional function, fatigue) in patients with advanced COPD (n=73) or advanced cancer (n=67). The Minimally Clinically Important Difference of 0.5 was applied to determine clinical significance. RESULTS: Patients with advanced COPD scored lower across all four CRQ domains. This was statistically significant for dyspnoea, mastery and emotional function (p<0.05), and clinically significant for the latter two, suggesting poorer respiratory HRQoL. CONCLUSIONS: Patients with breathlessness due to advanced COPD have worse respiratory HRQoL than those with advanced cancer. This may result from greater burden of breathlessness in COPD due to condition longevity, lesser burden of breathlessness in cancer due to its episodic nature, or variance in palliative referral thresholds by disease group. Our results suggest that greater access to palliative care is needed in advanced COPD, and that formal psychometric testing of the CRQ may be warranted in cancer. TRIAL REGISTRATION NUMBER: NCT00678405.This paper presents independent research commissioned by the (NIHR under its Research for Patient Benefit (RfPB) programme (Grant Reference Number PB-PG-0107-11134). The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health. MF’s role in the Phase III RCT of CBIS was funded through a Macmillan Cancer Support post-doctoral fellowship.This is the author accepted manuscript. The final version is available from the BMJ Group via http://dx.doi.org/10.1136/bmjspcare-2015-00094

Association of Descriptors of Breathlessness With Diagnosis and Self-Reported Severity of Breathlessness in Patients With Advanced Chronic Obstructive Pulmonary Disease or Cancer.

CONTEXT: Verbal descriptors are important in understanding patients' experience of breathlessness. OBJECTIVES: The aim of this study was to examine the association between selection of breathlessness descriptors, diagnosis, self-reported severity of breathlessness and self-reported distress due to breathlessness. METHODS: We studied 132 patients grouped according to their diagnosis of advanced chronic obstructive pulmonary disease (n = 69) or advanced cancer (n = 63), self-reported severity of breathlessness as mild breathlessness (Numerical Rating Scale [NRS] ≤ 3, n = 53), moderate breathlessness (4 ≤ NRS ≥ 6, n = 59) or severe breathlessness (NRS ≥ 7, n = 20), and distress due to breathlessness as mild distress (NRS ≤ 3, n = 31), moderate distress (4 ≤ NRS ≥ 6, n = 44), or severe distress (NRS ≥ 7, n = 57). Patients selected three breathlessness descriptors. The relationship between descriptors selected and patient groups was evaluated by cluster analysis. RESULTS: Different combinations of clusters were associated with each diagnostic group; the cluster chest tightness was associated with cancer patients. The association of clusters with patient groups differed depending on their severity of breathlessness and their distress due to breathlessness. The air hunger cluster was associated with patients with moderate or severe breathlessness, and the chest tightness cluster was associated with patients with mild breathlessness. The air hunger cluster was associated with patients with severe distress due to breathlessness. CONCLUSION: The relationship between clusters and diagnosis is not robust enough to use the descriptors to identify the primary cause of breathlessness. Further work exploring how use of breathlessness descriptors reflects the severity of breathlessness and distress due to breathlessness could enable the descriptors to evaluate patient status and target interventions.This paper presents independent research commissioned by the (NIHR under its Research for Patient Benefit (RfPB) programme (Grant Reference Number PB-PG-0107-11134). The views expressed are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health. MF’s role in the Phase III RCT of CBIS was funded through a Macmillan Cancer Support Post-Doctoral Fellowship. The funders had no involvement in the study design, the collection, analysis and interpretation of data, the writing of the report or the decision to submit.This is the author accepted manuscript. The final version is available from Elsevier via http://dx.doi.org/10.1016/j.jpainsymman.2016.01.01

Trichostatin A Blocks Aldosterone-Induced Na+ Transport And Control Of Serum- And Glucocorticoid-Inducible Kinase 1 In Cortical Collecting Duct Cells

Background and Purpose: Aldosterone stimulates epithelial Na+ channel (ENaC)-dependent Na+ retention in the cortical collecting duct (CCD) of the kidney by activating mineralocorticoid receptors that promote expression of serum and glucocorticoid-inducible kinase 1 (SGK1). This response is critical to BP homeostasis. It has previously been suggested that inhibiting lysine deacetylases (KDACs) can post-transcriptionally disrupt this response by promoting acetylation of the mineralocorticoid receptor. The present study critically evaluates this hypothesis. Experimental Approach: Electrometric and molecular methods were used to define the effects of a pan-KDAC inhibitor, trichostatin A, on the responses to a physiologically relevant concentration of aldosterone (3 nM) in murine mCCDcl1 cells. Key Results: Aldosterone augmented ENaC-induced Na+ absorption and increased SGK1 activity and abundance, as expected. In the presence of trichostatin A, these responses were suppressed. Trichostatin A-induced inhibition of KDAC was confirmed by increased acetylation of histone H3, H4, and α-tubulin. Trichostatin A did not block the electrometric response to insulin, a hormone that activates SGK1 independently of increased transcription, indicating that trichostatin A has no direct effect upon the SGK1/ENaC pathway. Conclusions and Implications: Inhibition of lysine de-acetylation suppresses aldosterone-dependent control over the SGK1–ENaC pathway but does not perturb post-transcriptional signalling, providing a physiological basis for the anti-hypertensive action of KDAC inhibition seen in vivo

Effect of feeding system on enteric methane emissions from individual dairy cows on commercial farms

This study investigated the effects of feeding system on diurnal enteric methane (CH4) emissions from individual cows on commercial farms. Data were obtained from 830 cows across 12 farms, and data collated included production records, CH4 measurements (in the breath of cows using CH4 analysers at robotic milking stations for at least seven days) and diet composition. Cows received either a partial mixed ration (PMR) or a PMR with grazing. A linear mixed model was used to describe variation in CH4 emissions per individual cow and assess the effect of feeding system. Methane emissions followed a consistent diurnal pattern across both feeding systems, with emissions lowest between 05:00 and 08:59, and with a peak concentration between 17:00 and 20:59. No overall difference in emissions was found between feeding systems studied; however, differences were found in the diurnal pattern of CH4 emissions between feeding systems. The response in emissions to increasing dry matter intake was higher for cows fed PMR with grazing. This study showed that repeated spot measurements of CH4 emissions whilst cows are milked can be used to assess the effects of feeding system and potentially benchmark farms on level of emissions

The effects of a video intervention on posthospitalization pulmonary rehabilitation uptake

Rationale: Pulmonary rehabilitation (PR) after hospitalizations for exacerbations of chronic obstructive pulmonary disease (COPD) improves exercise capacity and health-related quality of life and reduces readmissions. However, posthospitalization PR uptake is low. To date, no trials of interventions to increase uptake have been conducted.Objectives: To study the effect of a codesigned education video as an adjunct to usual care on posthospitalization PR uptake.Methods: The present study was an assessor- and statistician-blinded randomized controlled trial with nested, qualitative interviews of participants in the intervention group. Participants hospitalized with COPD exacerbations were assigned 1:1 to receive either usual care (COPD discharge bundle including PR information leaflet) or usual care plus the codesigned education video delivered via a handheld tablet device at discharge. Randomization used minimization to balance age, sex, FEV1 % predicted, frailty, transport availability, and previous PR experience.Measurements and Main Results: The primary outcome was PR uptake within 28 days of hospital discharge. A total of 200 patients were recruited, and 196 were randomized (51% female, median FEV1% predicted, 36 [interquartile range, 27-48]). PR uptake was 41% and 34% in the usual care and intervention groups, respectively (P = 0.37), with no differences in secondary (PR referral and completion) or safety (readmissions and death) endpoints. A total of 6 of the 15 participants interviewed could not recall receiving the video.Conclusions: A codesigned education video delivered at hospital discharge did not improve posthospitalization PR uptake, referral, or completion