What does it take to make integrated care work? A ‘cookbook’ for large-scale deployment of coordinated care and telehealth

The Advancing Care Coordination & Telehealth Deployment (ACT) Programme is the first to explore the organisational and structural processes needed to successfully implement care coordination and telehealth (CC&TH) services on a large scale. A number of insights and conclusions were identified by the ACT programme. These will prove useful and valuable in supporting the large-scale deployment of CC&TH. Targeted at populations of chronic patients and elderly people, these insights and conclusions are a useful benchmark for implementing and exchanging best practices across the EU. Examples are: Perceptions between managers, frontline staff and patients do not always match; Organisational structure does influence the views and experiences of patients: a dedicated contact person is considered both important and helpful; Successful patient adherence happens when staff are engaged; There is a willingness by patients to participate in healthcare programmes; Patients overestimate their level of knowledge and adherence behaviour; The responsibility for adherence must be shared between patients and health care providers; Awareness of the adherence concept is an important factor for adherence promotion; The ability to track the use of resources is a useful feature of a stratification strategy, however, current regional case finding tools are difficult to benchmark and evaluate; Data availability and homogeneity are the biggest challenges when evaluating the performance of the programmes

Electromagnetic Meson Production in the Nucleon Resonance Region

Recent experimental and theoretical advances in investigating electromagnetic meson production reactions in the nucleon resonance region are reviewed.Comment: 75 pages, 42 figure

Impact of strain variation of Dichelobacter nodosus on disease severity and presence in sheep flocks in England

AprV2 and aprB2 are variants of the apr gene of Dichelobacter nodosus, the cause of footrot in sheep. They are putative markers for severe and mild disease expression. The aim of our study was to investigate the distribution of aprV2 and aprB2 in flocks with and without footrot. Our hypotheses were that both strains are present in endemically affected flocks, with aprB2 and aprV2 associated with mild and virulent phenotypes respectively but that D. nodosus is not present in flocks without footrot. Alternatively, aprB2 persists in flocks without footrot. Despite extensive searching over 3 years only three flocks of sheep without footrot were identified. D. nodosus was not detected in these three flocks. In one further flock, only mild interdigital dermatitis was observed, and only aprB2 was detected. Twenty-four flocks with endemic footrot of all severities were sampled on three occasions and all were positive for D. nodosus and the aprV2 variant; aprB2 was detected in only 11 of these flocks. AprB2 was detected as a co-infection with aprV2 in the 22% of samples positive for aprB2 and was more likely in mild footrot phenotypes than severe. Dichelobacter nodosus serogroups were not associated with footrot phenotype. We conclude that D. nodosus, even aprB2 strains, do not persist in flocks in the absence of footrot. Our results support the hypothesis that aprB2 is associated with mild footrot phenotypes. Finally, we conclude that given the small number of flocks without footrot that were identified, footrot is highly endemic in English sheep flocks

A randomised trial of high vs low intensity training in breathing techniques for breathless patients with malignant lung disease: A feasibility study

Background: Breathlessness remains a refractory symptom in malignant lung disease. Breathing training is an effective, non-pharmacological intervention but it is unclear how this should be delivered. This feasibility study aimed to assess recruitment and retention, best end point and variability of breathlessness scores in order to calculate sample size for a future study. Method: This was a single centre, randomised controlled non-blinded parallel group feasibility study. Eligible participants (breathless patients with intrathoracic malignancy) received three breathlessness management training sessions or a single session only. Follow-up was for eight weeks and endpoints were: numerical rating scales (NRS) of breathlessness severity; breathlessness distress; HADS questionnaire; coping (BriefCOPE and our NRS coping question); EQ-5D and EQ-VAS. Results: 22 patients were randomised over 12 months; 55% of expected recruitment from pilot data. Screening logs indicated this resulted, in part, from excluding patients who were receiving or who had recently received chemotherapy or radiotherapy. There was 40% drop-out by week four. The most useful NRS scores for breathlessness severity were for " worst" and " average" over past 24. h. From the variability data for " worst breathlessness" , a sample size of 270 should allow detection of a 30% improvement in area under the curve in the three-session group compared with single-session, (90% power; p=0.05, two-tailed; 2:1 randomisation single:three sessions) allowing 50% drop out at four weeks. Conclusions: The follow-on study will test the hypothesis that three sessions of training improve breathlessness better than a single session. It will include patients undergoing palliative anti-cancer therapy. Stratification by centre will allow for differences in rates of chemotherapy or radiotherapy and variations in breathlessness service configuration. © 2010 Elsevier Ireland Ltd

Clinical determinants of poor six-minute walk test performance in patients with left ventricular systolic dysfunction and no major structural heart disease

Background: The clinical determinants of six-minute walk test (6-MWT) performance in patients with left ventricular systolic dysfunction (LVSD) have rarely been investigated, and it is not clear whether they differ from patients referred for the assessment of symptoms of heart failure who do not have major structural heart disease (MSHD). Methods and Results: 571 patients with LVSD enrolled in a chronic disease management programme (79% male; mean age 71 ± 10 years; BMI 28 ± 5) completed a 6-MWT with a mean distance 337 ± 103 m. 688 patients referred with suspected heart failure but in whom MSHD was excluded (49% male; mean age 70 ± 11 years; BMI 28 ± 6) had a mean 6-MWT distance of 391 ± 106 m (P 300 m. In patients with LVSD, predictors of poor walking distance (≤ 300 m) included age ≥ 75 years (OR = 4.0, 95% CI = 2.4-6.4); low BMI ( 80 beats·min - 1 (OR = 2.2, 95% CI = 1.3-3.5); and being female (OR = 2.0, 95% CI = 1.3-3.0). Serum creatinine and NT-proBNP showed dose-response effects, as did self-perceived feelings of depression and anxiety. Determinants of 6-MWT in patients without MSHD were similar including age ≥ 75 years (OR = 6.0, 95% CI = 3.4-10.4), anaemia (OR = 2.8, 95% CI = 1.6-4.9), resting HR > 80 beats·min - 1 (OR = 2.5, 95% CI = 1.4-4.4) and being female (OR = 1.6, 95% CI = 1.9-2.4). NT-proBNP and self-perceived feelings of depression and anxiety also showed dose-response effects. Conclusion: The determinants of poor 6-MWT performance depend on physical-cardiovascular and non-cardiovascular, and psychological factors. Clinical predictors for poor walking performance are similar for patients with LVSD and without MSHD. © 2005 European Society of Cardiology

The reproducibility and sensitivity of the 6-min walk test in elderly patients with chronic heart failure

Aims: The 6-min walk test (6-MWT) is used to estimate functional capacity. However, in elderly patients with chronic heart failure (CHF): (i) 1 year reproducibility of the 6-MWT; (ii) sensitivity of the 6-MWT to self-perceived changes in symptoms of heart failure; and (iii) implications for patient numbers required for studies using the 6-MWT as an endpoint have not been described. Methods and results: One thousand and seventy-seven patients with CHF, aged > 60, with NYHA Class ≥II were recruited. Heart failure symptom assessment was determined using a questionnaire related to aspects of physical function, and patients performed a baseline 6-MWT, with follow-up 1 year later. Seventy-four patients with unchanged symptoms had an unchanged 6-MWT distance, with an overall intraclass correlation coefficient of 0.80 (95% CI = 0.69-0.87). Four hundred and twenty-three patients reported an improvement in symptoms during follow-up. There was a negative correlation (r = -0.55; P = 0.0001) between Δ symptoms and Δ 6-MWT (i.e. a reduced 6-MWT distance is associated with reduced symptom severity at follow-up). Five hundred and sixteen patients reported worsening symptoms of heart failure, a moderate inverse correlation (r = -0.53; P = 0.0001) was displayed between Δ symptoms and Δ 6-MWT. For all patients, irrespective of symptom status, a high inverse correlation (r = -0.75; P = 0.0001) was evident. On the basis of the data for patients with unchanged symptoms, it is calculated that to detect an increase in 6-MWT of 50 m, with 90% power, a study size of approximately 120 is required. Conclusion: In elderly patients with CHF, the 6-MWT shows satisfactory agreement when repeated 1 year later. Change in 6-MWT distance is sensitive to change in self-perceived symptoms of heart failure. © The European Society of Cardiology 2005. All rights reserved