Pulmonary rehabilitation and severe exacerbations of COPD: solution or white elephant?

Hospitalisations for severe exacerbations of chronic obstructive pulmonary disease are associated with significant physical and psychological consequences including an increase in symptom severity, severe reductions in physical activity, a deleterious effect on skeletal muscle, impaired exercise tolerance/ability to self-care, decline in quality of life, and increased anxiety and depression. As these consequences are potentially amenable to exercise training, there is a clear rationale for pulmonary rehabilitation in the peri/post-exacerbation setting. Although a 2011 Cochrane review was overwhelmingly positive, subsequent trials have shown less benefit and real-life observational studies have revealed poor acceptability. Qualitative studies have demonstrated that the patient experience is a determining factor while the presence of comorbidities may influence referral, adherence and response to pulmonary rehabilitation. Systematic reviews of less supervised interventions, such as self-management, have shown limited benefits in the post-exacerbation setting. The recent update of the Cochrane review of peri-exacerbation pulmonary rehabilitation showed that benefits were associated with the “comprehensive” nature of the intervention (the number of sessions received, the intensity of exercise training and education delivered, and the degree of supervision) but implementation is demanding. The challenge is to develop interventions that are deliverable and acceptable around the time of an acute exacerbation but also deliver the desired clinical impact

Cost management and cross-functional communication through product architectures

Product architecture decisions regarding, for example, product modularity, component commonality, and design re-use, are important for balancing costs, responsiveness, quality, and other important business objectives. Firms are challenged with complex tradeoffs between competing design priorities, face the need to facilitate communication between functional silos, and want to learn from past experiences. In this paper, we present a qualitative approach for systematically evaluating the product architecture of a product family, comparing the original architecture objectives and actual experiences. The intended contribution of our research is threefold: (1) to present a framework that brings together a diverse set of product architecture-related decisions and business performance; (2) to provide a set of metrics that operationalise the variables in the framework, and (3) to provide a workshop protocol that is based on the framework and the metrics. This workshop aims to improve cross-functional communication about the product architecture of an existing product family, and it results in practical improvement actions for future architecture design projects. Experiences with this approach are reported in pilots with Philips Domestic Appliances and Personal Care, and Philips Consumer Electronics

Myocard Infarct en Cerebrovasculair Accident keten (MICK) studie

For patients with acute coronary syndrome (ACS) and stroke prompt diagnosis and treatment is essential. Before a patient reaches the hospital he may have had contact with a general practitioner (GP), a GP cooperative (GPC), ambulance service, or Emergency Department. Optimal use and efficient functioning of the acute health care chain is imperative. The aim of the MICK study is to obtain insight into circumstances in which symptoms of patients occur, medical contacts throughout the acute care chain, delays, door-to-balloon and door-to-needle time. This is a prospective observational study including 202 patients suspected of having ACS and 239 suspected of ischemic stroke. Patients filled out a questionnaire and additional data was obtained using registries.\ud Over 40% of all patients suspected of ACS waited more than 6 hours before contacting a health care provider and over 30% of all patients suspected of having a stroke waited more than 4 hours. Patients reached the hospital through many different health care chains. Once a care provider was contacted, 45% of all patients with ACS were hospitalized within 90 minutes at the CCU and 65% of patients with stroke within 4 hours at the stroke unit.\ud Most patients first contacted the GP or GPC. For patients who immediately called 112 time to hospitalization was the shortest.\ud Overall are noticeable the long patient delays in seeking care, the various chains through which patients reach the CCU or stroke unit and the different throughput times

Four patients with a history of acute exacerbations of COPD: implementing the CHEST/Canadian Thoracic Society guidelines for preventing exacerbations

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Rethinking the "mirroring" hypothesis: implications for technological modularity, tacit coordination, and radical innovation

Studies of the 'mirroring' hypothesis have demonstrated the relationships between technological modularity and explicit coordination, yet little is known about the 'mirroring' relationship between technological modularity and tacit coordination, and how the 'mirroring' relationship may affect radical innovation. This paper contributes to the 'mirroring' hypothesis by identifying the interaction mechanisms embedded in and surrounded over the mirroring relationships. Using survey data of 121 high-tech firms in China, our study indicates that technological modularity enhances interfirm tacit coordination between module-makers ('mirroring' hypothesis), and will also positively influence radical innovation ('outcome' hypothesis). Moreover, tacit coordination negatively moderates the impact of technological modularity on radical innovation ('interaction' hypothesis), indicating that the 'mirroring' relationship may offset the benefit obtained from modularization. It also suggests that, in a high-technology industry in underdeveloped areas, tacit coordination could lead to exposure of hidden knowledge, thus lowering module-makers' motivation for technology breakthrough

Self-management for bronchiectasis.

Background Bronchiectasis is a long term respiratory condition with an increasing rate of diagnosis. It is associated with persistent symptoms, repeated infective exacerbations, and reduced quality of life, imposing a burden on individuals and healthcare systems. The main aims of therapeutic management are to reduce exacerbations and improve quality of life. Self-management interventions are potentially important for empowering people with bronchiectasis to manage their condition more effectively and to seek care in a timely manner. Self-management interventions are beneficial in the management of other airways diseases such as asthma and COPD (chronic obstructive pulmonary disease) and have been identified as a research priority for bronchiectasis. Objectives To assess the efficacy, cost-effectiveness and adverse effects of self-management interventions for adults and children with non-cystic fibrosis bronchiectasis. Search methods We searched the Cochrane Airways Specialised Register of trials, clinical trials registers, reference lists of included studies and review articles, and relevant manufacturers’ websites up to 13 December 2017. Selection criteria We included all randomised controlled trials of any duration that included adults or children with a diagnosis of non-cystic fibrosis bronchiectasis assessing self-management interventions delivered in any form. Self-management interventions included at least two of the following elements: patient education, airway clearance techniques, adherence to medication, exercise (including pulmonary rehabilitation) and action plans. Data collection and analysis Two review authors independently screened searches, extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were, health-related quality of life, exacerbation frequency and serious adverse events. Secondary outcomes were the number of participants admitted to hospital on at least one occasion, lung function, symptoms, self-efficacy and economic costs. We used a random effects model for analyses and standard Cochrane methods throughout. Main results Two studies with a total of 84 participants were included: a 12-month RCT of early rehabilitation in adults of mean age 72 years conducted in two centres in England (UK) and a six-month proof-of-concept RCT of an expert patient programme (EPP) in adults of mean age 60 years in a single regional respiratory centre in Northern Ireland (UK). The EPP was delivered in group format once a week for eight weeks using standardised EPP materials plus disease-specific education including airway clearance techniques, dealing with symptoms, exacerbations, health promotion and available support. We did not find any studies that included children. Data aggregation was not possible and findings are reported narratively in the review. For the primary outcomes, both studies reported health-related quality of life, as measured by the St George's Respiratory Questionnaire (SGRQ), but there was no clear evidence of benefit. In one study, the mean SGRQ total scores were not significantly different at 6 weeks', 3 months' and 12 months' follow-up (12 months mean difference (MD) -10.27, 95% confidence interval (CI) -45.15 to 24.61). In the second study there were no significant differences in SGRQ. Total scores were not significantly different between groups (six months, MD 3.20, 95% CI -6.64 to 13.04). We judged the evidence for this outcome as low or very low. Neither of the included studies reported data on exacerbations requiring antibiotics. For serious adverse events, one study reported more deaths in the intervention group compared to the control group, (intervention: 4 of 8, control: 2 of 12), though interpretation is limited by the low event rate and the small number of participants in each group. For our secondary outcomes, there was no evidence of benefit in terms of frequency of hospital admissions or FEV1 L, based on very low-quality evidence. One study reported self-efficacy using the Chronic Disease Self-Efficacy scale, which comprises 10 components. All scales showed significant benefit from the intervention but effects were only sustained to study endpoint on the Managing Depression scale. Further details are reported in the main review. Based on overall study quality, we judged this evidence as low quality. Neither study reported data on respiratory symptoms, economic costs or adverse events. Authors' conclusions There is insufficient evidence to determine whether self-management interventions benefit people with bronchiectasis. In the absence of high-quality evidence it is advisable that practitioners adhere to current international guidelines that advocate self-management for people with bronchiectasis. Future studies should aim to clearly define and justify the specific nature of self-management, measure clinically important outcomes and include children as well as adults

Post-stroke self-management interventions: a systematic review of effectiveness and investigation of the inclusion of stroke survivors with aphasia

Purpose: To systematically review self-management interventions to determine their efficacy for people with stroke in relation to any health outcome and to establish whether stroke survivors with aphasia were included. Method: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, The Cochrane Library, and IBSS and undertook gray literature searches. Randomized controlled trials were eligible if they included stroke survivors aged 18 + in a “self-management” intervention. Data were extracted by two independent researchers and included an assessment of methodological quality. Results: 24 studies were identified. 11 out of 24 reported statistically significant benefits in favor of self-management. However, there were significant limitations in terms of methodological quality, and meta-analyses (n= 8 studies) showed no statistically significant benefit of self-management upon global disability and stroke-specific quality of life at 3 months or ADL at 3 or 6 months follow-up. A review of inclusion and exclusion criteria showed 11 out of 24 (46%) studies reported total or partial exclusion of stroke survivors with aphasia. Four out of 24 (17%) reported the number of stroke survivors with aphasia included. In nine studies (38%) it was unclear whether stroke survivors with aphasia were included or excluded. Conclusions: Robust conclusions regarding the effectiveness of poststroke self-management approaches could not be drawn. Further trials are needed, these should clearly report the population included. •Implications for rehabilitation •There is a lack of evidence to demonstrate the effectiveness of self-management approaches for stroke survivors. •It is unclear whether self-management approaches are suitable for stroke survivors with aphasia, particularly those with moderate or severe aphasia. •Further research is needed to understand the optimal timing for self-management in the stroke pathway and the format in which self-management support should be offered

Prehospital paths and hospital arrival time of patients with acute coronary syndrome or stroke, a prospective observational study

Background: Patients with a presumed diagnosis of acute coronary syndrome (ACS) or stroke may have had contact with several healthcare providers prior to hospital arrival. The aim of this study was to describe the various prehospital paths and the effect on time delays of patients with ACS or stroke. Methods: This prospective observational study included patients with presumed ACS or stroke who may choose to contact four different types of health care providers. Questionnaires were completed by patients, general practitioners (GP), GP cooperatives, ambulance services and emergency departments (ED). Additional data were retrieved from hospital registries. Results: Two hundred two ACS patients arrived at the hospital by 15 different paths and 243 stroke patients by ten different paths. Often several healthcare providers were involved (60.8 % ACS, 95.1 % stroke). Almost half of all patients first contacted their GP (47.5 % ACS, 49.4 % stroke). Some prehospital paths were more frequently used, e.g. GP (cooperative) and ambulance in ACS, and GP or ambulance and ED in stroke. In 65 % of all events an ambulance was involved. Median time between start of symptoms and hospital arrival for ACS patients was over 6 h and for stroke patients 4 h. Of ACS patients 47.7 % waited more than 4 h before seeking medical advice compared to 31.6 % of stroke patients. Median time between seeking medical advice to arrival at hospital was shortest in paths involving the ambulance only (60 min ACS, 54 min stroke) or in combination with another healthcare provider (80 to 100 min ACS, 99 to 106 min stroke). Conclusions: Prehospital paths through which patients arrived in hospital are numerous and often complex, and various time delays occurred. Delays depend on the entry point of the health care system, and dialing the emergency number seems to be the best choice. Since reducing patient delay is difficult and noticeable differences exist between various prehospital paths, further research into reasons for these different entry choices may yield possibilities to optimize paths and reduce overall time delay