Summary Background Mobile (cell) phone communication has been suggested as a method to improve delivery of health services. However, data on the effects of mobile health technology on patient ...outcomes in resource-limited settings are limited. We aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. Methods WelTel Kenya1 was a multisite randomised clinical trial of HIV-infected adults initiating antiretroviral therapy (ART) in three clinics in Kenya. Patients were randomised (1:1) by simple randomisation with a random number generating program to a mobile phone short message service (SMS) intervention or standard care. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 h. Randomisation, laboratory assays, and analyses were done by investigators masked to treatment allocation; however, study participants and clinic staff were not masked to treatment. Primary outcomes were self-reported ART adherence (>95% of prescribed doses in the past 30 days at both 6 and 12 month follow-up visits) and plasma HIV-1 viral RNA load suppression (<400 copies per mL) at 12 months. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov , NCT00830622. Findings Between May, 2007, and October, 2008, we randomly assigned 538 participants to the SMS intervention (n=273) or to standard care (n=265). Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group (relative risk RR for non-adherence 0·81, 95% CI 0·69–0·94; p=0·006). Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group, (RR for virologic failure 0·84, 95% CI 0·71–0·99; p=0·04). The number needed to treat (NNT) to achieve greater than 95% adherence was nine (95% CI 5·0–29·5) and the NNT to achieve viral load suppression was 11 (5·8–227·3). Interpretation Patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcome in resource-limited settings. Funding US President's Emergency Plan for AIDS Relief.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background There is uncertainty over the risks and benefits of hormone therapy. We performed a Bayesian meta-analysis to evaluate the effect of hormone therapy on total mortality in younger ...postmenopausal women. This analysis synthesizes evidence from different sources, taking into account varying views on the issue. Methods A comprehensive search from 1966 through January 2008 identified randomized controlled trials of at least 6 month's duration that evaluated hormone therapy in women with mean age <60 years and reported at least one death, and prospective observational cohort studies that evaluated the relative risk of mortality associated with hormone therapy after adjustment for confounding variables. Results The results were synthesized using a hierarchical random-effects Bayesian meta-analysis. The pooled results from 19 randomized trials, with 16,000 women (mean age 55 years) followed for 83,000 patient-years, showed a mortality relative risk of 0.73 (95% credible interval 0.52-0.96). When data from 8 observational studies were added to the analysis, the resultant relative risk was 0.72 (credible interval 0.62-0.82). The posterior probability that hormone therapy reduces total mortality in younger women is almost 1. Conclusions The synthesis of data using Bayesian meta-analysis indicates a reduction in mortality in younger postmenopausal women taking hormone therapy compared with no treatment. This finding should be interpreted taking into account the potential benefits and harms of hormone therapy.
ABSTRACTBACKGROUNDThe Health TAPESTRY (Health Teams Advancing Patient Experience: STRengthening QualitY) intervention was designed to improve primary care teamwork and promote optimal aging. We ...evaluated the effectiveness of Health TAPESTRY in attaining goals of older adults (e.g., physical activity, productivity, social connection, medical status) and other outcomes.METHODSWe conducted a pragmatic randomized controlled trial between January and October 2015 in a primary care practice in Hamilton, Ontario. Older adults were randomized (1:1) to Health TAPESTRY ( n = 158) or control ( n = 154). Trained community volunteers gathered information on people’s goals, needs and risks in their homes, using electronic forms. Interprofessional primary care teams reviewed summaries and addressed issues. Participants reported goal attainment (primary outcome), self-efficacy, quality of life, optimal aging, social support, empowerment, physical activity, falls, and access to and comprehensiveness of the health system. We determined use of health care resources through chart audit. RESULTSThere were no differences between groups in goal attainment or many other patient-reported outcome and experience assessments at 6 months. More primary care visits took place in the intervention versus control group over 6 months (mean ± standard deviation SD 4.93 ± 3.86 v. 3.50 ± 3.53; difference of 1.52 95% confidence interval (CI) 0.84 to 2.19). The odds of having 1 or more hospital admission were lower for the intervention group (odds ratio OR 0.44 95% CI 0.20 to 0.95). INTERPRETATIONHealth TAPESTRY did not improve the primary outcome of goal attainment but showed signals of shifting care from reactive to active preventive care. Further evaluation will help in understanding effective components, costs and consequences of the intervention. Trial registration:ClinicalTrials.gov, no. NCT02283723
Abstract Objective Persistent thoracotomy pain syndrome (PTPS) is a recognized complication and is considered to be less after video-assisted thoracoscopic surgery (VATS) compared with open thoracic ...surgery (OTS). The primary objective was to compare the incidence of PTPS at 6 months. Secondary objectives were to compare the incidence of neuropathic pain between VATS and OTS and to report perioperative factors associated with the development of PTPS. Methods This historical cohort study involved patient contact by a questionnaire regarding the presence of PTPS and its type. Patient, surgical, and analgesia factors were collected from health records, acute pain, and thoracic surgery databases. The data were analyzed using a multivariable logistic regression analysis, with results reported as adjusted odds ratio (OR) (95% confidence interval; P value). Results Of 308 patients, 130 returned their questionnaire, and 106 responses were analyzed. The incidence of PTPS was 35% and 54% with VATS and OTS respectively, with an adjusted OR, 0.33 (95% confidence interval, 0.13-0.86), P = .024. The percentage of neuropathic pain was 18% and 48%, with VATS and OTS respectively, with an adjusted OR, 0.18 (0.04-0.85), P = .031. The diagnosis of cancer and previous chronic pain history were observed to be significantly associated with PTPS. Conclusions Our study indicates that PTPS is significantly more common and has a higher chance of being neuropathic with OTS. Despite being relatively less traumatic, VATS still carries a significant potential for PTPS. A diagnosis of cancer and history of previous pain are highly predictive of its development.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Radioactive iodine remnant ablation (RRA) is used to destroy residual normal thyroid tissue after complete gross surgical resection of papillary or follicular thyroid cancer. The article updates a ...prior systematic review of the literature to determine whether RRA decreases the risk of thyroid cancer-related death or recurrence at 10 years after initial surgery, including data from 28 studies. No long-term randomized trials were identified, so the review is limited to observational studies. The incremental benefit of RRA in low risk patients with well-differentiated thyroid cancer after total or near-total thyroidectomy who are receiving thyroid hormone suppressive therapy remains unclear.
Background A major limitation of primary percutaneous coronary intervention (PPCI) for the treatment of ST-elevation myocardial infarction (STEMI) is impaired microvascular perfusion due to ...embolization and obstruction of microcirculation with thrombus. Manual thrombectomy has the potential to reduce distal embolization and improve microvascular perfusion. Clinical trials have shown mixed results regarding thrombectomy. Objective The objective of this study is to evaluate the efficacy of routine upfront manual aspiration thrombectomy during PPCI compared with percutaneous coronary intervention alone in patients with STEMI. Design This is a multicenter, prospective, open, international, randomized trial with blinded assessment of outcomes. Patients with STEMI undergoing PPCI are randomized to upfront routine manual aspiration thrombectomy with the Export catheter (Medtronic CardioVascular, Santa Rosa, CA) or to percutaneous coronary intervention alone. The primary outcome is the composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or new or worsening New York Heart Association class IV heart failure up to 180 days. The trial uses an event-driven design and will recruit 10,700 patients. Summary The TOTAL trial will determine the effect of routine manual aspiration thrombectomy during PPCI on clinically important outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
ABSTRACT BACKGROUND Low-income older adults who live in subsidized housing have higher mortality and morbidity. We aimed to determine if a community paramedicine program — in which paramedics provide ...health care services outside of the traditional emergency response — reduced the number of ambulance calls to subsidized housing for older adults. METHODS We conducted an open-label pragmatic cluster-randomized controlled trial (RCT) with parallel intervention and control groups in subsidized apartment buildings for older adults. We selected 6 buildings using predefined criteria, which we then randomly assigned to intervention (Community Paramedicine at Clinic CP@clinic for 1 yr) or control (usual health care) using computer-generated paired randomization. CP@clinic is a paramedic-led, community-based health promotion program to prevent diabetes, cardiovascular disease and falls for residents 55 years of age and older. The primary outcome was building-level mean monthly ambulance calls. Secondary outcomes were individual-level changes in blood pressure, health behaviours and risk of diabetes assessed using the Canadian Diabetes Risk Questionnaire. We analyzed the data using generalized estimating equations and hierarchical linear modelling. RESULTS The 3 intervention and 3 control buildings had 455 and 637 residents, respectively. Mean monthly ambulance calls in the intervention buildings (3.11 standard deviation (SD) 1.30 calls per 100 units/mo) was significantly lower (−0.88, 95% confidence interval CI −0.45 to −1.30) than in control buildings (3.99 SD 1.17 calls per 100 units/mo), when adjusted for baseline calls and building pairs. Survey participation was 28.4% ( n = 129) and 20.3% ( n = 129) in the intervention and control buildings, respectively. Residents living in the intervention buildings showed significant improvement compared with those living in control buildings in quality-adjusted life years (QALYs) (mean difference 0.09, 95% CI 0.01 to 0.17) and ability to perform usual activities (odds ratio 2.6, 95% CI 1.2 to 5.8). Those who received the intervention had a significant decrease in systolic (mean change 5.0, 95% CI 1.0 to 9.0) and diastolic (mean change 4.8, 95% CI 1.9 to 7.6) blood pressure. INTERPRETATION A paramedic-led, community-based health promotion program (CP@clinic) significantly lowered the number of ambulance calls, improved QALYs and ability to perform usual activities, and lowered systolic blood pressure among older adults living in subsidized housing. Trial registration: Clinicaltrials.gov , no. NCT02152891
Highlights • This is the first study to account for any time-dependent bias; previous studies have incorrectly modeled antimicrobial stewardship interventions (ASis) as though present on admission, ...but this study models ASis as a time-dependent variable in the final survival analysis. • This is the first community-acquired pneumonia length of stay study to use a stepped-wedge design to ensure contemporaneous controls. • There has only been 1 previous community-acquired pneumonia length of stay study modeled as a time to event outcome, and this study is the first to test the assumption of noninformative censoring by using a competing risks survival analysis. • This is the first community-acquired pneumonia length of stay observational study to use propensity score weighting to minimize the impact of selection bias.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background Little is known regarding the prenatal determinants of innate immune responses in relation to infant allergic risk. Environmental exposures, including microbial stimuli, might predispose ...susceptible subjects to atopy and asthma in early infancy or even in utero. Objective Because Toll-like receptors (TLRs) recognize microbial products and because cord blood (CB) progenitor alterations have been observed in neonates at risk for atopy, we investigated the expression and function of TLRs on CB hematopoietic progenitors in relation to atopic risk, as defined by maternal allergic sensitization. Methods Thirty-two (15 with low and 17 with high atopic risk) infant CB samples were assessed for phenotypic and functional alterations in CD34+ cells by means of flow cytometry and methylcellulose culture, respectively. CD34+ hematopoietic progenitors were stained for TLR-2, TLR-4, TLR-9, GM-CSF receptor α, IL-5 receptor α, and IL-3 receptor α or cultured in methylcellulose assays for hematopoietic cytokine-stimulated eosinophil-basophil (Eo/B) colony-forming units (CFUs) with or without LPS. Results High-atopic-risk infants had significantly lower CB CD34+ cell TLR-2, TLR-4, and TLR-9 expression ( P = .009). High-risk infant progenitors gave rise to significantly more Eo/B CFUs ( P = .002) with hematopoietic cytokine (IL-3, IL-5, or GM-CSF) stimulation ex vivo . Although LPS costimulation induced Eo/B CFUs from both low- and high-risk infant CB CD34+ cells, this response was significantly ( P = .020) muted in the high-risk CB progenitors. Conclusions Neonatal CB CD34+ hematopoietic progenitor cell TLR expression and functional responsiveness are altered in CB from atopic at-risk infants. Maternal allergic sensitization might modulate hematopoietic progenitor TLR expression and function in utero ; specifically, Eo/B “lineage priming” at birth might be circumvented through engagement of TLR pathways in early life.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Objectives Colorectal cancer (CRC) screening uptake remains poor. Until we understand patient motivation and preferences for undertaking screening, it is unlikely the uptake will be optimal. ...Our objective is to examine patient preferences for CRC screening modalities and uptake rates using utility-based methods. Methods The preference survey was mailed to a random sample of Canadian subjects aged 40 to 60 years from a primary care network. A fractional factorial experimental design maximized D-efficiency and included four blocks with 12 choice tasks in a conditional two-step design, two-alternative discrete choice format with five screening attributes (process, pain, preparation, sensitivity, and specificity). Bivariate probit regression analysis was used to estimate patient preferences for attributes, choice probabilities for alternative modalities and expected rates of uptake. Results Five hundred forty-seven of 1047 surveys were returned. Almost 30% of respondents preferred no screening. The most preferred test attribute levels were noninvasiveprocess (e.g., CT), no preparation, no pain, 100% specificity, and 90% sensitivity. Accuracy-related attributes were more important than test process-related attributes. Virtual colonoscopy was the most preferred, followed by colonoscopy, barium enema, sigmoidoscopy, and fecal DNA testing, based on simulated choice probability estimates. Fecal occult blood testing (FOBT) was least preferred. Adjusted screening uptake rate estimates showed the greatest impact (42% increase) would be achieved if all CRC screening modalities were available rather than FOBT alone. Conclusion Our findings emphasize the important role of patient preferences for no screening and in selecting alternative CRC screening modalities. CRC screening implementation in Canada should consider patient preferences to optimize uptake.
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BFBNIB, DOBA, FZAB, GEOZS, GIS, IJS, IMTLJ, IZUM, KILJ, KISLJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, SBMB, UILJ, UKNU, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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