How to improve drug dosing for patients with renal impairment in primary care - a cluster-randomized controlled trial

Background: Patients with chronic kidney disease (CKD) are at increased risk for inappropriate or potentially harmful prescribing. The aim of this study was to examine whether a multifaceted intervention including the use of a software programme for the estimation of creatinine clearance and recommendation of individual dosage requirements may improve correct dosage adjustment of relevant medications for patients with CKD in primary care. Methods: A cluster-randomized controlled trial was conducted between January and December 2007 in small primary care practices in Germany. Practices were randomly allocated to intervention or control groups. In each practice, we included patients with known CKD and elderly patients (>=70 years) suffering from hypertension. The practices in the intervention group received interactive training and were provided a software programme to assist with individual dose adjustment. The control group performed usual care. Data were collected at baseline and at 6 months. The outcome measures, analyzed across individual patients, included prescriptions exceeding recommended maximum daily doses, with the primary outcome being prescriptions exceeding recommended standard daily doses by 30% or more. Results: Data from 44 general practitioners and 404 patients are included. The intervention was effective in reducing prescriptions exceeding the maximum daily dose per patients, with a trend in reducing prescriptions exceeding the standard daily dose by more than 30%. Conclusions: A multifaceted intervention including the use of a software program effectively reduced inappropriately high doses of renally excreted medications in patients with CKD in the setting of small primary care practices

Satisfação e autoconfiança de estudantes de enfermagem como atuantes e observadores em simulação realística

Objetivo: Analisar a satisfação e a autoconfiança de estudantes de Enfermagem com a aprendizagem, nos papéis de atuantes e observadores, em cenários de simulação realística.Método: Estudo observacional com 44 estudantes de Enfermagem de instituições de ensino superior do sul do país. A coleta de dados foi no período de setembro a novembro de 2018, através da Escala de Satisfação e Autoconfiança com a Aprendizagem após participação em cenários de simulação realística. Os dados foram analisados através da estatística descritiva e do modelo de Equações de Estimativas Generalizadas complementado por Bonferroni.Resultados: O nível de satisfação foi de 4,78 (± 0,35) e o de autoconfiança com a aprendizagem, de 4,46 (± 0,39). Os alunos dos 8º e 9º semestres foram os que apresentaram maiores médias em relação aos demais no fator da autoconfiança (p < 0,001).Conclusão: Conclui-se que não houve diferença estatisticamente significativa na satisfação e na autoconfiança com a aprendizagem de estudantes de Enfermagem com papéis diferentes no cenário de simulação. Palavras-chave: Educação em enfermagem. Treinamento com simulação de alta fidelidade. Segurança do paciente. Estudantes de enfermagem. Aprendizagem baseada em problemas. Ensino

In-Person and Online-Delivered Acceptance and Commitment Therapy for Hoarding Disorder: A Multiple Baseline Study

Hoarding disorder (HD) is associated with distress and functional impairment not only for the individual but also for their family members and community. Acceptance and commitment therapy (ACT) already has broad empirical support and may be helpful for treating HD. In this nonconcurrent multiple baseline study (N = 6), we examined the effect of ACT on HD symptom severity, functional impairment, quality of life, co-occurring symptoms, and other outcomes. Participants consistently reported decreases in HD severity, clutter, functional impairment due to clutter, and depression at posttreatment. Scores were maintained at follow-up for two of three participants. Changes in other variables like quality of life and psychological inflexibility were less consistent. Overall, our findings preliminarily support the efficacy of ACT for HD especially for symptom severity, but the reliability of its effect on other outcomes like quality of life and psychological inflexibility is unclear. Limitations include a homogeneous (100% White women) sample

Classes of depression symptom trajectories in patients with major depression receiving a collaborative care intervention

Purpose Collaborative care is effective in improving symptoms of patients with depression. The aims of this study were to characterize symptom trajectories in patients with major depression during one year of collaborative care and to explore associations between baseline characteristics and symptom trajectories. Methods We conducted a cluster-randomized controlled trial in primary care. The collaborative care intervention comprised case management and behavioral activation. We used the Patient Health Questionnaire-9 (PHQ-9) to assess symptom severity as the primary outcome. Statistical analyses comprised latent growth mixture modeling and a hierarchical binary logistic regression model. Results We included 74 practices and 626 patients (310 intervention and 316 control recipients) at baseline. Based on a minimum of 12 measurement points for each intervention recipient, we identified two latent trajectories, which we labeled \u27fast improvers\u27 (60.5%) and \u27slow improvers\u27 (39.5%). At all measurements after baseline, \u27fast improvers\u27 presented higher PHQ mean values than \u27slow improvers\u27. At baseline, \u27fast improvers\u27 presented fewer physical conditions, higher health-related quality of life, and had made fewer suicide attempts in their history. Conclusions A notable proportion of 39.5% of patients improved only \u27slowly\u27 and probably needed more intense treatment. The third follow-up in month two could well be a sensible time to adjust treatment to support \u27slow improvers\u27. (DIPF/Orig.

Trajectories of depression in sepsis survivors: an observational cohort study

Background: Advances in critical care medicine have led to a growing number of critical illness survivors. A considerable part of them suffers from long-term sequelae, also known as post-intensive care syndrome. Among these, depressive symptoms are frequently observed. Depressive symptom trajectories and associated factors of critical illness survivors have rarely been investigated. Study objective was to explore and compare different trajectories of depressive symptoms in sepsis survivors over 1 year after discharge from ICU. Methods: Data of a randomized controlled trial on long-term post-sepsis care were analyzed post hoc. Depressive symptoms were collected at 1, 6 and 12 months post-ICU discharge using the Major Depression Inventory (MDI), among others. Statistical analyses comprised descriptive analysis, univariate and multivariate, linear and logistic regression models and Growth Mixture Modeling. Results: A total of 224 patients were included into this analysis. We identified three latent classes of depressive symptom trajectories: Over the course of 1 year, 152 patients recovered from mild symptoms, 27 patients showed severe persistent symptoms, and 45 patients recovered from severe symptoms. MDI sum scores significantly differed between the three classes of depressive symptom trajectories at 1 and 6 months after ICU discharge (p = 35 on the Posttraumatic Stress Scale 10 vs. 48.1%/33.3%, p < 0.003); and higher levels of health-related quality of life (HRQOL) using the Short Form-36 scale within 1 month after ICU discharge (p < 0.035). Conclusions: In the first year after discharge from ICU, sepsis survivors showed three different trajectories of depressive symptoms. Course and severity of depressive symptoms were associated with chronic pain, posttraumatic stress and reduced HRQOL at discharge from ICU. Regular screening of sepsis survivors on symptoms of depression, chronic pain and posttraumatic stress within 1 year after ICU may be considered

Análise de Convergência do Método Giltt para Problemas em Dispersão de Poluentes na Atmosfera

In this paper, we present a convergence analysis of the GILTT method for pollutant dispersion problems consolidating the solution of the problem in analytical representation. There have been many advances in the GILTT technique over the past few years. The advection-diffusion equation was solved for the multidimensional case and applied to various situations, mainly in pollutant dispersion. The theorem of Cauchy-Kowalewsky guarantees the existence and uniqueness of an analytic solution for the advection-diffusion equation. In this paper, we present a convergence analysis for the GILTT method to pollutant dispersion problems. Numerical results are presented.Neste trabalho, apresenta-se uma análise de convergência da técnica GILTT para problemas de dispersão de poluentes consolidando a solução do problema em representação analítica. Muitos foram os avanços da técnica GILTT ao longo dos últimos anos. A equação de advecção-difusão foi resolvida para os casos multidimensionais  e aplicada a diversas situações, principalmente na dispersão de poluentes . O teorema de Cauchy-Kowalewsky garante a existência e unicidade de uma solução analítica para a equação de advecção-difusão. Neste trabalho, apresenta-se uma análise de convergência da técnica GILTT para problemas de dispersão de poluentes. Resultados numéricos são apresentados

Cut points of the conicity index and associated factors in Brazilian rural workers

Background: Metabolic syndrome is associated with cardiovascular complications. Therefore, this study aims to establish cut points for the conicity index based on the components of metabolic syndrome and to associate it with characteristic sociodemographic, food consumption, and occupational factors in Brazilian rural workers; (2) Methods: A cross-sectional study carried out with farmers. The receiver operating characteristic curve was calculated and the cut-off points for the conicity index were identified by the area under the curve, sensitivity, and specificity. The variables included in the binary logistic regression analysis were selected by considering p < 0.20 in the bivariate test; (3) Results: The cut points were similar in females according to both criteria, resulting in a single cut-off of 1.269. In males, the cut points showed differences, resulting in 1.272 according to the NCEP-ATP III and 1.252 according to the IDF. We have shown that younger people, those who work more than 40 h a week, and the lowest contribution of culinary ingredients are associated with increased odds of abdominal obesity, while the consumption of the products they sell or produce decreases these chances; (4) Conclusions: The conicity index showed high discriminatory power for the identification of abdominal obesity in rural workers. Therefore, there is a need to improve eating habits and promote healthier eating environments for individuals, respecting traditional food culture, mainly to contain the advance of MS in rural areas.This study was developed with FAPES’ resources—Brazilian public agency for the pro- motion of scientific research.info:eu-repo/semantics/publishedVersio

Primary care management for optimized antithrombotic treatment [PICANT]: study protocol for a cluster-randomized controlled trial

Background: Antithrombotic treatment is a continuous therapy that is often performed in general practice and requires careful safety management. The aim of this study is to investigate whether a best practice model that applies major elements of case management, including patient education, can improve antithrombotic management in primary health care in terms of reducing major thromboembolic and bleeding events. Methods: This 24-month cluster-randomized trial will be performed in 690 adult patients from 46 practices. The trial intervention will be a complex intervention involving general practitioners, health care assistants and patients with an indication for oral anticoagulation. To assess adherence to medication and symptoms in patients, as well as to detect complications early, health care assistants will be trained in case management and will use the Coagulation-Monitoring-List (Co-MoL) to regularly monitor patients. Patients will receive information (leaflets and a video), treatment monitoring via the Co-MoL and be motivated to perform self-management. Patients in the control group will continue to receive treatment-as-usual from their general practitioners. The primary endpoint is the combined endpoint of all thromboembolic events requiring hospitalization, and all major bleeding complications. Secondary endpoints are mortality, hospitalization, strokes, major bleeding and thromboembolic complications, severe treatment interactions, the number of adverse events, quality of anticoagulation, health-related quality of life and costs. Further secondary objectives will be investigated to explain the mechanism by which the intervention is effective: patients' assessment of chronic illness care, self-reported adherence to medication, general practitioners' and health care assistants' knowledge, patients' knowledge and satisfaction with shared decision making. Practice recruitment is expected to take place between July and December 2012. Recruitment of eligible patients will start in July 2012. Assessment will occur at three time points: baseline (T0), follow-up after 12 (T1) and after 24 months (T2). Discussion: The efficacy and effectiveness of individual elements of the intervention, such as antithrombotic interventions, self-management concepts in orally anticoagulated patients and the methodological tool, case-management, have already been extensively demonstrated. This project foresees the combination of several proven instruments, as a result of which we expect to profit from a reduction in the major complications associated with antithrombotic treatment

Highly Endemic, Waterborne Toxoplasmosis in North Rio de Janeiro State, Brazil

In Campos dos Goytacazes, northern Rio de Janeiro state, Brazil, reports of uveitis consistent with toxoplasmosis led to a survey of the prevalence and risk factors for Toxoplasma gondii infection in 1997–1999. The survey population was selected randomly from schools, randomly chosen communities, and an army battalion. Serum samples from 1,436 persons were tested. With results adjusted for age, 84% of the population in the lower socioeconomic group was seropositive, compared with 62% and 23% of the middle and upper socioeconomic groups, respectively (p<0.001). When multivariate analysis was performed, drinking unfiltered water was found to increase the risk of seropositivity for the lower socioeconomic (odds ratio [OR]: 3.0, 95% confidence interval [CI] 1.3 to 6.9) and middle socioeconomic (OR: 1.7, 95% CI 1.2 to 2.3) populations. We also found a high T. gondii seroprevalence in this Brazilian community. Drinking unfiltered water increased the risk of T. gondii seropositivity, indicating the potential importance of oocyst transmission in water in this region

Comunicação efetiva para a segurança do paciente: nota de transferência e Modified Early Warning Score

Objetivo: Analisar o registro da Nota de Transferência (NT) e a emissão do Modified EarlyWarning Score (MEWS) realizados pelo enfermeiro em pacientes adultos transferidos doServiço de Emergência como estratégia de comunicação efetiva para a segurança do paciente.Método: Estudo transversal retrospectivo desenvolvido em um hospital de ensino no Sul doBrasil que avaliou 8028 prontuários eletrônicos no ano de 2017. Procedeu-se a análisedescritiva.Resultados: A realização da NT atingiu a meta institucional de 95% nos meses de janeiro efevereiro, ficando abaixo da meta nos demais meses. A mensuração do MEWS foi realizadaem 85,6% (n=6.870) dos prontuários. Destes pacientes, 96,8% (n=6.652) possuíam MEWSnão alterado.Conclusão: A NT e o MEWS estão inseridos no trabalho do enfermeiro, no entanto, sãonecessárias ações com vistas a qualificar a segurança do paciente, melhorando a comunicaçãoefetiva e, por conseguinte, diminuindo a possibilidade de ocorrências de eventos adversos.Palavras-chave: Cuidados críticos. Emergências. Enfermagem. Indicadores de qualidade emassistência à saúde. Segurança do paciente