Implications of Blood Glucose Management with Heart Failure Patients with Type 2 Diabetes in an Acute Care Setting

https://digitalcommons.psjhealth.org/stvincent-bootcamp/1007/thumbnail.jp

Ideología y ciencia del castigo en el retraso mental

En este artículo se analiza el conflicto existente entre aquel/os que contemplan las intervenciones terapéuticas aversivas desde un punto de vista ideológico y aquellos que lo hacen desde una perspectiva científica. Se ha dedicado especial atención al estudio más detallado que, sobre procedimientos punitivos para casos de retraso mental existe, y que fue realizado desde una perspectiva ideológica; se trata de una monografía de Guess, Helmstetter, Turnbull y Knowlton publicada en 1986 por la "Asociación para Personas con Incapacidades Severas" (The Association for Persons With Severe Handicaps). Dicha monografía adolece de una serie de defectos graves de índole conceptual y metodológica que impiden que las conclusiones de la misma puedan servir de fundamento a la investigación y a la política social en el campo del retraso mental. Se ha llegadoa la conclusión de que algunos de los que rechazan las intervenciones terapéuticas aversivas, lo hacen debido a que poseen un conocimiento limitado de la ciencia conductual y parten de un marco de referencia fundamentalmente ideológico

Diagnosticando el trastorno autista: aspectos fundamentales y consideraciones prácticas

Tendo como base modelos de prática diagnóstica implementados em outros países, o objetivo do artigo é oferecer uma revisão geral acerca do que vem a ser o transtorno autista e dos fatores críticos que devem ser considerados durante o processo diagnóstico. São discutidos aspectos dos critérios diagnósticos e também das comorbidades, incidência, etiologia e diretrizes para a prática diagnóstica. Tais diretrizes incluem formas de exploração de sintomas de risco durante exames de rotina realizados por profissionais que trabalham com a população infantil e elementos básicos necessários para a realização de uma avaliação minuciosa e criteriosa por uma equipe interdisciplinar. Isso inclui, por exemplo, o uso de instrumentos específicos auxiliares no diagnóstico, elementos importantes para a avaliação médica e psicológica e encaminhamentos para serviços adequados de intervenção e apoio.Based on diagnostic models implemented in other countries, the goal of the article is to offer a general overview about autistic disorder and highlight some critical elements to be taken into account during the diagnostic process. We discuss aspects regarding the diagnostic criteria, as well as regarding comorbidities, incidence, etiology, and some practical guidelines for determining a diagnosis. Such guidelines include the critical aspects to be considered when screening the risk for autism in early childhood population and for a careful and comprehensive evaluation by a specialized interdisciplinary team. A comprehensive evaluation consists of the use of specific tools to help determine the diagnosis, some crucial elements for the medical and psychological evaluation, and the referral to adequate intervention and support services.Teniendo como base modelos de práctica diagnóstica implementados en otros países, el objetivo del artículo es ofrecer una revisión general acerca de lo que viene a ser el trastorno autista y de los factores críticos que deben ser considerados durante el proceso diagnóstico. Son discutidos aspectos de los criterios diagnósticos y también de las comorbidades, incidencia, etiología y directrices para la práctica diagnóstica. Tales directrices incluyen formas de exploración de síntomas de riesgo durante exámenes de rutina realizados por profesionales que trabajan con la población infantil y elementos básicos necesarios para la realización de una evaluación minuciosa y de criterio por un equipo interdisciplinario. Eso incluye, por ejemplo, el uso de instrumentos específicos auxiliares en el diagnóstico, elementos importantes para la evaluación médica y psicológica y encaminamientos para servicios adecuados de intervención y apoyo

Linked symptom monitoring and depression treatment programmes for specialist cancer services: protocol for a mixed-methods implementation study.

INTRODUCTION: There is growing awareness that cancer services need to address patients' well-being as well as treating their cancer. We developed systematic approaches to (1) monitoring patients' symptoms including depression using a 'Symptom Monitoring Service' and (2) providing treatment for those with major depression using a programme called 'Depression Care for People with Cancer'. Used together, these two programmes were found to be highly effective and cost-effective in clinical trials. The overall aims of this project are to: (1) study the process of introducing these programmes into routine clinical care in a large cancer service, (2) identify the challenges associated with implementation and how these are overcome, (3) determine their effectiveness in a routine non-research setting and (4) describe patients' and clinicians' experience of the programmes. METHODS AND ANALYSIS: This is a mixed-methods longitudinal implementation study. We will study the process of implementation in three phases (April 2016-December 2018): 'Pre-implementation' (setting up of the new programmes), 'Early Implementation' (implementation of the programmes in a small number of clinics) and 'Implementation and Maintenance' (implementation in the majority of clinics). We will use the following methods of data collection: (1) contemporaneous logs of the implementation process, (2) interviews with healthcare professionals and managers, (3) interviews with patients and (4) routinely collected clinical data. ETHICS AND DISSEMINATION: The study has been reviewed by a joint committee of Oxford University Hospitals National Health Service Foundation Trust Research and Development Department and the University of Oxford's Clinical Trials and Research Governance Department and judged to be service evaluation, not requiring ethics committee approval. The findings of this study will guide the scaling up implementation of the programmes across the UK and will enable us to construct an implementation toolkit. We will disseminate our findings in publications and at relevant national and international conferences

Classifying atopic dermatitis: protocol for a systematic review of subtypes (phenotypes) and associated characteristics.

INTRODUCTION: Atopic dermatitis is a complex disease with differing clinical presentations. Many attempts have been made to identify uniform subtypes, or phenotypes, of atopic dermatitis in order to identify different aetiologies, improve diagnosis, estimate more accurate clinical prognoses, inform treatment andmanagement or predict treatment efficacy andeffectiveness. However, no consensus yet exists on exactly what defines these phenotypes or how many there are and whether they are genuine or statistical artefacts. This review aims to identify previously reported phenotypes of atopic dermatitis, the features used to define them and any characteristics or clinical outcomes significantly associated with them. METHODS AND ANALYSIS: We will search Ovid Embase, Ovid MEDLINE and Web of Science from inception to the latest available date at the time of the search for studies attempting to classify atopic dermatitis in humans using any cross-sectional or longitudinal epidemiological or interventional design. Primary outcomes are atopic dermatitis phenotypes, features used to define them and characteristics associated with them in subsequent analyses. A secondary outcome is the methodological approach used to derive them. Two reviewers will independently screen titles and abstracts for inclusion, extract data and assess study quality. We will present the results of this review descriptively and with frequencies where possible. ETHICS AND DISSEMINATION: Ethical approval is not required for this study as it is a systematic review. We will report results from this systematic review in a peer-reviewed journal. The main value of this study will be to inform further research. PROSPERO REGISTRATION NUMBER: CRD42018087500

Atopic eczema in adulthood and mortality: UK population–based cohort study, 1998-2016

BACKGROUND: Atopic eczema affects up to 10% of adults and is becoming more common globally. Few studies have assessed whether atopic eczema increases the risk of death. OBJECTIVE: We aimed to determine whether adults with atopic eczema were at increased risk of death overall and by specific causes and to assess whether the risk varied by atopic eczema severity and activity. METHODS: The study was a population-based matched cohort study using UK primary care electronic health care records from the Clinical Practice Research Datalink with linked hospitalization data from Hospital Episode Statistics and mortality data from the Office for National Statistics from 1998 to 2016. RESULTS: A total of 526,736 patients with atopic eczema were matched to 2,567,872 individuals without atopic eczema. The median age at entry was 41.8 years, and the median follow-up time was 4.5 years. There was limited evidence of increased hazard for all-cause mortality in those with atopic eczema (hazard ratio = 1.04; 99% CI = 1.03-1.06), but there were somewhat stronger associations (8%-14% increased hazard) for deaths due to infectious, digestive, and genitourinary causes. Differences on the absolute scale were modest owing to low overall mortality rates. Mortality risk increased markedly with eczema severity and activity. For example, patients with severe atopic eczema had a 62% increased hazard (hazard ratio = 1.62; 99% CI = 1.54-1.71) for mortality compared with those without eczema, with the strongest associations for infectious, respiratory, and genitourinary causes. CONCLUSION: The increased hazards for all-cause and cause-specific mortality were largely restricted to those with the most severe or predominantly active atopic eczema. Understanding the reasons for these increased hazards for mortality is an urgent priority

Power and sample-size calculations for trials that compare slopes over time: Introducing the slopepower command.

Trials of interventions that aim to slow disease progression may analyze a continuous outcome by comparing its change over time—its slope—between the treated and the untreated group using a linear mixed model. To perform a sample-size calculation for such a trial, one must have estimates of the parameters that govern the between- and within-subject variability in the outcome, which are often unknown. The algebra needed for the sample-size calculation can also be complex for such trial designs. We have written a new user-friendly command, slopepower, that performs sample-size or power calculations for trials that compare slope outcomes. The package is based on linear mixed-model methodology, described for this setting by Frost, Kenward, and Fox (2008, Statistics in Medicine 27: 3717–3731). In the first stage of this approach, slopepower obtains estimates of mean slopes together with variances and covariances from a linear mixed model fit to previously collected user-supplied data. In the second stage, these estimates are combined with user input about the target effectiveness of the treatment and design of the future trial to give an estimate of either a sample size or a statistical power. In this article, we present the slopepower command, briefly explain the methodology behind it, and demonstrate how it can be used to help plan a trial and compare the sample sizes needed for different trial designs

Patterns of Atopic Eczema Disease Activity from Birth through Midlife in 2 British Birth Cohorts

Importance: Atopic eczema is characterized by a heterogenous waxing and waning course, with variable age of onset and persistence of symptoms. Distinct patterns of disease activity such as early-onset/resolving and persistent disease have been identified throughout childhood; little is known about patterns into adulthood. Objective: This study aimed to identify subtypes of atopic eczema based on patterns of disease activity through mid-adulthood, to examine whether early life risk factors and participant characteristics are associated with these subtypes, and to determine whether subtypes are associated with other atopic diseases and general health in mid-adulthood. Design, Setting, and Participants: This study evaluated members of 2 population-based birth cohorts, the 1958 National Childhood Development Study (NCDS) and the 1970 British Cohort Study (BCS70). Participant data were collected over the period between 1958 and 2016. Data were analyzed over the period between 2018 and 2020. Main Outcomes and Measures: Subtypes of atopic eczema were identified based on self-reported atopic eczema period prevalence at multiple occasions. These subtypes were the outcome in models of early life characteristics and an exposure variable in models of midlife health. Results: Latent class analysis identified 4 subtypes of atopic eczema with distinct patterns of disease activity among 15939 individuals from the NCDS (51.4% male, 75.4% White) and 14966 individuals from the BCS70 (51.6% male, 78.8% White): rare/no (88% to 91%), decreasing (4%), increasing (2% to 6%), and persistently high (2% to 3%) probability of reporting prevalent atopic eczema with age. Sex at birth and early life factors, including social class, region of residence, tobacco smoke exposure, and breastfeeding, predicted differences between the 3 atopic eczema subtypes and the infrequent/no atopic eczema group, but only female sex differentiated the high and decreasing probability subtypes (odds ratio [OR], 1.99; 95% CI, 1.66-2.38). Individuals in the high subtype were most likely to experience asthma and rhinitis, and those in the increasing subtype were at higher risk of poor self-reported general (OR, 1.29; 95% CI, 1.09-1.53) and mental (OR 1.45; 95% CI, 1.23-1.72) health in midlife. Conclusions and Relevance: The findings of this cohort study suggest that extending the window of observation beyond childhood may reveal clear subtypes of atopic eczema based on patterns of disease activity. A newly identified subtype with increasing probability of activity in adulthood warrants additional attention given observed associations with poor self-reported health in midlife.

Common mental health disorders in adults with inflammatory skin conditions: nationwide population-based matched cohort studies in the UK

BACKGROUND: Psoriasis and atopic eczema are common inflammatory skin diseases. Existing research has identified increased risks of common mental disorders (anxiety, depression) in people with eczema and psoriasis; however, explanations for the associations remain unclear. We aimed to establish the risk factors for mental illness in those with eczema or psoriasis and identify the population groups most at risk. METHODS: We used routinely collected data from the UK Clinical Practice Research Datalink (CPRD) GOLD. Adults registered with a general practice in CPRD (1997-2019) were eligible for inclusion. Individuals with eczema/psoriasis were matched (age, sex, practice) to up to five adults without eczema/psoriasis. We used Cox regression to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for hazards of anxiety or depression in people with eczema/psoriasis compared to people without. We adjusted for known confounders (deprivation, asthma [eczema], psoriatic arthritis [psoriasis], Charlson comorbidity index, calendar period) and potential mediators (harmful alcohol use, body mass index [BMI], smoking status, and, in eczema only, sleep quality [insomnia diagnoses, specific sleep problem medications] and high-dose oral glucocorticoids). RESULTS: We identified two cohorts with and without eczema (1,032,782, matched to 4,990,125 without), and with and without psoriasis (366,884, matched to 1,834,330 without). Sleep quality was imbalanced in the eczema cohorts, twice as many people with eczema had evidence of poor sleep at baseline than those without eczema, including over 20% of those with severe eczema. After adjusting for potential confounders and mediators, eczema and psoriasis were associated with anxiety (adjusted HR [95% CI]: eczema 1.14 [1.13-1.16], psoriasis 1.17 [1.15-1.19]) and depression (adjusted HR [95% CI]: eczema 1.11 [1.1-1.12], psoriasis 1.21 [1.19-1.22]). However, we found evidence that these increased hazards are unlikely to be constant over time and were especially high 1-year after study entry. CONCLUSIONS: Atopic eczema and psoriasis are associated with increased incidence of anxiety and depression in adults. These associations may be mediated through known modifiable risk factors, especially sleep quality in people with eczema. Our findings highlight potential opportunities for the prevention of anxiety and depression in people with eczema/psoriasis through treatment of modifiable risk factors and enhanced eczema/psoriasis management

How the EMERGE guideline on medication adherence can improve the quality of clinical trials.

Medication adherence in drug trials is suboptimal, affecting the quality of these studies and adding significant costs. Nonadherence in this setting can lead to null findings, unduly large sample sizes and the need for dose modification after a drug has been approved. Despite these drawbacks, adherence behaviours are not consistently measured, analysed or reported appropriately in trial settings. The ESPACOMP Medication Adherence Reporting Guideline (EMERGE) offers a solution by facilitating a sound protocol design that takes this crucial factor into account. This article summarises key evidence on traditional and newer measurements of adherence, discusses implementation in clinical trial settings and makes recommendations about the analysis and interpretation of adherence data. Given the potential benefits of this approach, the authors call on regulators and the pharmaceutical industry to endorse the EMERGE guideline