ObjectivesMaternal perinatal depression is a common phenomenon, influencing infants’ development. Studies have shown an inconsistent association between perinatal depression and healthcare resource ...utilisation. This study aimed to assess whether perinatal depression in mothers is associated with their infants’ healthcare utilisation, during the first 2 years of life.DesignA cohort study based on computerised medical records.SettingNationwide primary care clinics in the second largest health maintenance organisation in Israel.Participants593 children of women with depression (the exposed group) and 2310 children of women without depression.Primary and secondary outcome measuresPrimary outcome variables included general practitioner/paediatrician (GP/Paed) visits (regular and telehealth), emergency room (ER) visits, hospital admission rates and child-development clinic visits. Secondary outcomes included antibiotic use and anaemia status. The exposure variable, perinatal depression, was based on Edinburgh Postnatal Depression Scale. A score of ≥10 was classified as depression.ResultsMultivariable analysis of the number of regular visits and telehealth to the GP/Paed showed an adjusted incidence rate ratio (aIRR) of 1.08, 95% CI 1.03 to 1.13 and aIRR 0.95, 95% CI 0.82 to 1.10, respectively. Children of mothers with perinatal depression had more hospital admissions (aIRR 1.21, 95% CI 1.01 to 1.46) and more visits to child development clinics (aIRR 1.33, 95% CI 1.04 to 1.70). There was a non-significant increase in ER visits (IRR 1.26, 95% CI 0.66 to 2.42), and non-significant decrease in antibiotics prescriptions (IRR 0.95, 95% CI 0.86 to 1.05) and anaemia status (IRR 0.93, 95% CI 0.72 to 1.20).ConclusionThis study shows higher health services utilisation among children of mothers with perinatal depression, including regular GP/Paed visits, hospital admission rates, and child-development clinics.
Introduction:
Nurses play a key role in managing care and educating people with diabetes in various healthcare systems worldwide, while physicians play this role in others. In addition, some ...healthcare systems authorize specialist nurses to change patient dose regimens. Therefore, we examined diabetes outcomes in the community by the management of a diabetes-clinic nurse only versus parallel management with a diabetologist.
Methods:
Retrospective data were collected for 100 consecutive people with diabetes registered in a community clinic with a diabetes-clinic nurse specialist as a case manager from 1/2018. About half of the patients selected received parallel advice from a diabetologist. Inclusion criteria included poor control of type 2 diabetes (HbA1c above 9%). Patients using an insulin pump, glucose sensor technologies, or multiple injection insulin programs were excluded.
Results:
One hundred people with diabetes who met the study criteria were included in the study, 64 males and a mean age of 60.03 ± 11.11. In a follow-up of 161.31 ± 68.65 days, HbA1c levels decreased by 3.17% ± 1.95% and did not change in a further follow-up of 162.36 ± 72.75 days. Significant improvement was also observed in controlling the other risk factors examined. Parallel consultation with a diabetologist and the nurse’s use of her authority for dose modifications showed no differences in all parameters. Logistic regression for analyzing the effect of the variables related to the patient showed only a moderate effect.
Conclusions:
Access to professional services remains a significant challenge for healthcare systems in long-term diabetes control. Monitoring poorly controlled people with diabetes with the help of a diabetes-clinic nurse specialist in the community clinic significantly improved diabetes and risk factors control and persisted long after the intervention. Healthcare systems should consider expanding the service of the diabetes-clinic nurse specialist in the community. Further studies will be required to examine the results in different patient subgroups.
Among Parkinson's disease (PD) symptoms, freezing of gait (FoG) is one of the most debilitating. To assess FoG, current clinical practice mostly employs repeated evaluations over weeks and months ...based on questionnaires, which may not accurately map the severity of this symptom. The use of a non-invasive system to monitor the activities of daily living (ADL) and the PD symptoms experienced by patients throughout the day could provide a more accurate and objective evaluation of FoG in order to better understand the evolution of the disease and allow for a more informed decision-making process in making adjustments to the patient's treatment plan. This paper presents a new algorithm to detect FoG with a machine learning approach based on Support Vector Machines (SVM) and a single tri-axial accelerometer worn at the waist. The method is evaluated through the acceleration signals in an outpatient setting gathered from 21 PD patients at their home and evaluated under two different conditions: first, a generic model is tested by using a leave-one-out approach and, second, a personalised model that also uses part of the dataset from each patient. Results show a significant improvement in the accuracy of the personalised model compared to the generic model, showing enhancement in the specificity and sensitivity geometric mean (GM) of 7.2%. Furthermore, the SVM approach adopted has been compared to the most comprehensive FoG detection method currently in use (referred to as MBFA in this paper). Results of our novel generic method provide an enhancement of 11.2% in the GM compared to the MBFA generic model and, in the case of the personalised model, a 10% of improvement with respect to the MBFA personalised model. Thus, our results show that a machine learning approach can be used to monitor FoG during the daily life of PD patients and, furthermore, personalised models for FoG detection can be used to improve monitoring accuracy.
Background
Little is known about the achievement of low density lipoprotein cholesterol (LDL-C) targets in patients at cardiovascular risk receiving stable lipid-lowering therapy (LLT) in countries ...outside Western Europe.
Methods
This cross-sectional observational study was conducted in 452 centres (August 2015−August 2016) in 18 countries in Eastern Europe, Asia, Africa, the Middle East and Latin America. Patients (n = 9049) treated for ≥3 months with any LLT and in whom an LDL-C measurement on stable LLT was available within the previous 12 months were included.
Results
The mean±SD age was 60.2 ± 11.7 years, 55.0% of patients were men and the mean ± SD LDL-C value on LLT was 2.6 ± 1.3 mmol/L (101.0 ± 49.2 mg/dL). At enrolment, 97.9% of patients were receiving a statin (25.3% on high intensity treatment). Only 32.1% of the very high risk patients versus 51.9% of the high risk and 55.7% of the moderate risk patients achieved their LDL-C goals. On multivariable analysis, factors independently associated with not achieving LDL-C goals were no (versus lower dose) statin therapy, a higher (versus lower) dose of statin, statin intolerance, overweight and obesity, female sex, neurocognitive disorders, level of cardiovascular risk, LDL-C value unknown at diagnosis, high blood pressure and current smoking. Diabetes was associated with a lower risk of not achieving LDL-C goals.
Conclusions
These observational data suggest that the achievement of LDL-C goals is suboptimal in selected countries outside Western Europe. Efforts are needed to improve the management of patients using combination therapy and/or more intensive LLTs.
Evaluating the prevalence of long-COVID symptoms in patients with a history of mild or asymptomatic infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the factors ...associated with developing long-COVID.
A nationwide cohort study. Using a centralized database, we have identified patients with and without a history of SARS-CoV-2 infection 1-6 months before data collection. Patients were asked to fill out an online questionnaire through text messages.
Israeli general practice.
2755 persons participated in the study in September 2021 (a response rate of 7.5%): 819 with and, 936 without a history of SARS-CoV-2 infection.
We asked patients to provide details about their demographic status, medical history, COVID-related variables and the presence of long-COVID symptoms.
Most prevalent long-COVID symptoms were decreased smell sensation (35.1% vs. 4.3%, p < 0.001), decreased taste sensation (25.2% vs. 3.2%, p < 0.001), memory disturbances (36.9% vs. 14.4%, p < 0.001), dyspnea (24.2% vs. 10.7%, p < 0.001) and arthralgia (33% vs. 16.3%, p < 0.001). Risk factors associated with long-COVID included female gender, symptomatic COVID-19, overweight or obesity and the presence of dyslipidemia. About 34.6% of participants reported not returning to their baseline health condition after the acute illness.
Long-COVID is frequently seen following a mild symptomatic COVID-19 infection and, to a lesser extent, following an asymptomatic SARS-CoV-2 infection. Primary care physicians should be aware of these symptoms and consider this option in their differential diagnosis. Health policymakers should expect a significant impact of this syndrome on public health.
Key Points
Long-COVID has emerged as a significant health problem with a serious impact on normal daily function
* Long-COVID symptoms were evident in patients with mild symptomatic disease and in asymptomatic patients to a lesser extent.
* Risk factors for having Long-COVID symptoms include female gender, symptomatic disease, increased BMI, and the presence of dyslipidemia.
* Fatigue, dyspnea, weakness, decreased libido, weight changes, memory, and sleep disturbances were associated with not returning to the baseline health state.
ObjectivesTo estimate the prevalence of long COVID symptoms in children with and without a history of SARS-CoV-2 infection and to evaluate factors associated with long COVID.DesignA nationwide ...cross-sectional study.SettingPrimary care.Participants3240 parents of children aged 5–18 with and without SARS-CoV-2 infection completed an online questionnaire (11.9% response rate); 1148 and 2092 with/without a history of infection, respectively.Primary and secondary outcome measuresPrimary outcome was the prevalence of long COVID symptoms in children with/without a history of infection. Secondary outcomes were the factors associated with the presence of long COVID symptoms and with failure to return to baseline health status in children with a history of infection including gender, age, time from illness, symptomatic illness and vaccine status.ResultsMost long COVID symptoms were more prevalent in children with a history of SARS-CoV-2 infection: headaches (211 (18.4%) vs 114 (5.4%), p<0.001), weakness (173 (15.1%) vs 70 (3.3%), p<0.001), fatigue (141 (12.3%) vs 133 (6.4%), p<0.001) and abdominal pain (109 (9.5%) vs 79 (3.8%), p<0.001). Most long COVID symptoms in children with a history of SARS-CoV-2 infection were more prevalent in the older age group (12–18) compared with the younger age group (5–11). Some symptoms were more prevalent in children without a history of SARS-CoV-2 infection, including attention problems with school malfunctioning (225 (10.8%) vs 98 (8.5%), p=0.05), stress (190 (9.1%) vs 65 (5.7%), p<0.001), social problems (164 (7.8%) vs 32 (2.8%)) and weight changes (143 (6.8%) vs 43 (3.7%), p<0.001).ConclusionThis study suggests that the prevalence of long COVID symptoms in children with a history of SARS-CoV-2 infection might be higher and more prevalent in adolescents than in young children. Some of the symptoms, mainly somatic symptoms, were more prevalent in children without a history of SARS-CoV-2 infection, highlighting the impact of the pandemic itself rather than the infection.
Background and Aim:
Dapagliflozin and empagliflozin have demonstrated favorable clinical outcomes among patients with chronic kidney disease (CKD). However, their comparative monetary value for ...improving outcomes in CKD patients is unestablished. We examined the cost-per-outcome implications of utilizing dapagliflozin as compared to empagliflozin for prevention of renal and cardiovascular events in CKD patients.
Methods:
For calculation of preventable events we divided the allocated budget by the cost needed to treat (CNT) for preventing a single renal or cardiovascular event. CNT was derived by multiplying the annualized number needed to treat (aNNT) by the annual therapy cost. The aNNTs were determined based on data from the DAPA-CKD and EMPEROR-KIDNEY trials. The budget limit was defined based on the threshold recommended by the United States’ Institute for Clinical and Economic Review.
Results:
The aNNT was 42 both dapagliflozin (95% confidence interval CI: 34-59) and empagliflozin (CI: 33-66). The CNT estimates for the prevention of one primary event for dapagliflozin and empagliflozin were comparable at $201,911 (CI: $163,452-$283,636) and $209,664 (CI: $164,736-$329,472), respectively. However, diabetic patients had a higher CNT with dapagliflozin ($201,911 CI: $153,837-$346,133) than empagliflozin ($134,784 CI: $109,824-$214,656), whereas non-diabetic patients had lower CNT for dapagliflozin ($197,103 CI: $149,029-$346,133) than empagliflozin ($394,368 CI: $219,648-$7,093,632). The CNT for preventing CKD progression was higher for dapagliflozin ($427,858 CI: $307,673-$855,717) than empagliflozin ($224,640 CI: $169,728-$344,448). For preventing cardiovascular death (CVD), the CNT was lower for dapagliflozin ($1,634,515 CI: $740,339-∞) than empagliflozin ($2,990,208 CI: $1,193,088-∞).
Conclusion:
Among patients with CKD, empagliflozin provides a better monetary value for preventing the composite renal and cardiovascular events in diabetic patients while dapagliflozin has a better value for non-diabetic patients. Dapagliflozin provides a better monetary value for the prevention of CVD, whereas empagliflozin has a better value for the prevention of CKD progression.
•Older adults prefer SDM or ISDM processes in health care based on specific factors.•Understanding relationship between doctor and patient impacts decision processes.•Information sharing approach ...between doctor and patient impacts decision processes.•Changes in information delivery approach impact health care professionals.•Transition to digital information sources will impact elderly population.
To examine the relationship between the media, through which medical information was made available (e.g. digital versus printed), and the patients’ desire to play an active part in a medical decision in an SDM or an ISDM-based process. The goal of this research was to expand knowledge concerning social and personal factors that affect and explain patients’ willingness to participate in the process.
A questionnaire was distributed in this empirical study of 103 third-age participants. A theoretical model formed the basis for the study and utilized a variety of factors from technology acceptance, as well as personal and environmental influences to investigate the likelihood of subjects preferring a certain decision-making approach. The research population included men and women aged 65 or older who resided in five assisted living facilities in Israel. The sample was split randomly into 2 groups. One group used digital information and the other print. A path analysis was conducted, using Structural Equation Modelling (SEM) in AMOS SPSS, to determine the influence of the information mode of presentation on the patient’s choice of the SDM or ISDM model.
When digital media was accessible, the information’s perceived usefulness (PU) led participants to choose an ISDM-based process; this was not true with printed information. When information was available online, higher self-efficacy (SE) led participants to prefer an SDM-based process. When the information was available in print, a direct positive influence was found on the participant’s choice of SDM, while a direct negative influence was found on their choice of an ISDM-based process. PU was found to be affected by external peer influences, particularly when resources were made available in print. This meant that digital resources tended to be accepted at face value more readily. Cognitive absorption had a positive effect on the research variables only when the information was available digitally. The findings suggest the use of digital information may be related to cognitive functions of older adults, since the use of digital technology and information requires more cognitive effort.
The study illustrates factors that make patients choose SDM or ISDM-based processes in third-age populations. In general, the results suggest that, even though a physician may attempt to place the patient in the center of the decision process, printed information does not empower the patient in the same way that digital resources do. This may have wider ramifications if the patient does not buy into the treatment plan is and becomes less motivated to be compliant with the treatment. Another key contribution of this research is to identify processes that reflect information assessment and adoptions, and the behaviors related to medical decision making, both as a model and as a process. This study suggests what health care professionals should expect to see as the transition to more digital information sources becomes the norm among the elderly population. Future research is needed to examine this model under different conditions, and to check for other variables and mechanisms perceived as mediators in the choice of SDM or ISDM processes.
Objective: To assess diabetes management and control measures in a central multidisciplinary primary care clinic, conducted by a nurse.
Design: A cross sectional study.
Setting: Central, ...multidisciplinary, primary care clinic.
Subjects: Randomly selected 100 people with diabetes.
Interventions: People with diabetes with suspected non optimal glucose control (HbA1c > 7%), were invited to the clinic nurse to discuss optimal personal diabetes control, treatment and follow up. All were provided the necessary referrals to consultants and were called in for follow up visits, and received telephone reminders. All interventions were made according to the current American Diabetes Association Standards of Medical Practice recommendations.
Main outcome measures: Retrospective data were collected. Data included demographics and diabetes control measures (e.g. HbA1c, LDL, blood pressure, ophthalmologic examination etc.). Data was collected for three x 6 months periods: 1) six months before the nurse visit; 2) six months following the first nurse visit (the intervention); and 3) for patients who were followed up for at least one year after the intervention, the last six months of follow up.
Results: With a median follow up of 25 months, HbA1c, LDL and systolic blood pressure levels dropped significantly from before starting the clinic through the intervention and remained low in the last half year of follow up. GP, Ophthalmologist and Dietician visits increased significantly during the study. Non-significant trends were observed with total and diabetes related hospitalisations decreased, foot examination rates increased and mild weight loss.
Conclusion: Multidisciplinary intervention managed by a nurse, improve diabetes management and control measures. Observed changes persisted after the intervention period.
The use of opioids has increased dramatically over the past several years in Israel. The aim of this study was to explore the trends of opioid consumption in Israel over a decade (2010-2020) ...stratified by socioeconomic status (SES), residence in the periphery, and ethnic background.
This cross-sectional study included all adult Maccabi Healthcare Services (MHS) patients who filled at least one prescription for opioids during the past decade. In order to standardize dosages and compare different opioid medications, we used the Morphine Milligram Equivalent (MME) conversion factor. We performed The Mann-Kendall test with autocorrelation correction to assess each trend. We then checked the differences between the trends with the Mann-Whitney test (for periphery) and the Kruskal Wallis (for SES and ethnic background).
Between the years 2010-2020, 261,270 MHS members met the study's inclusion criteria. The proportions of opioids consumption were 23.9/1000 patients in 2010 and 27.6/1000 patients in 2020, representing a 15% increase. The average daily consumption of opioids was 4.6 and 10.5 MME in 2010 and 2020, respectively, an increase of 227%. The daily MME during 2020 was higher for residents of the periphery compared to non-periphery residents (daily MME of 14.0 compared to 10.1, respectively). Average daily MME increased gradually during the study period for all levels of SES; the values were highest for the low SES group and the lowest for the high SES group (daily MME in 2020 for the lowest, middle, and high SES groups were 15.2 vs. 11.8 vs. 6.7 respectively).
This study highlights that the primary concern in the increase of opioid use is the increasing dosages. The increase in the number of patients using opioids is also significant but to a minor extent. These phenomena disproportionately impact vulnerable populations. Education programs should be offered to physicians regarding the possible harms of long-term use of opioids. These programs should emphasize the risk factors associated with the development of opioid use disorder (OUD) and the caution needed when increasing dosages or switching to higher-potency drugs. Pain clinics and centers for rehabilitation for patients with chronic pain or OUD should be available, not only in central areas but also in the periphery of the country. These clinics and centers should use a holistic approach and a multidisciplinary team that includes specialists in pain and addiction. They should be financially accessible for patients from low SES group and provide solutions in multiple languages.
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