The objective of this randomized controlled trial was to assess the effects of a 1‐year behavioral contract intervention on immunosuppressant therapy (IST) adherence and healthcare utilizations and ...costs among adult renal transplant recipients (RTRs). The sample included adult RTRs who were at least 1 year posttransplant, taking tacrolimus or cyclosporine and served by a specialty pharmacy. Pharmacy refill records were used to measure adherence and monthly questionnaires were used to measure healthcare utilizations. Direct medical costs were estimated using the 2009 Medicare Expenditure Panel Survey. Adherence was analyzed using the GLM procedure and the MIXED procedure of SAS. Rate ratios and 95% confidence intervals were estimated to quantify the rate of utilizing healthcare services relative to treatment assignment. One hundred fifty RTRs were enrolled in the study. Intervention group RTRs (n = 76) had higher adherence than control group RTRs (n = 74) over the study period (p < 0.01). And 76.1% of the intervention group compared with 42.7% of the control group was not hospitalized during the 1‐year study period (RR = 1.785; 95% CI: 1.314, 2.425), resulting in cost savings. Thus, evidence supports using behavioral contracts as an effective adherence intervention that may improve healthcare outcomes and lower costs.
A randomized controlled trial of a behavioral contract intervention targeting immunosuppressant therapy adherence finds that renal transplant recipients in the intervention group experienced improved adherence and outcomes compared to those in the control group.
Background: Inflammatory markers are increased in chronic obstructive pulmonary disease (COPD) and are hypothesised to play an important part in muscle dysfunction and exercise intolerance. Methods: ...The Health Aging and Body Composition (Health ABC) study is a prospective observational cohort of well functioning individuals aged 70–79 years. A cross sectional analysis of the baseline data was conducted to examine the association between inflammatory markers and ventilatory limitation, muscle strength, and exercise capacity. These associations were compared in participants with and without obstructive lung disease (OLD). Results: Of the 3075 participants enrolled in the Health ABC cohort, OLD was identified by spirometric testing in 268 participants and 2005 participants had normal spirometric results. Of the participants with OLD, 35%, 38%, and 27% participants had mild, moderate, and severe OLD, respectively. Participants with OLD had lower quadriceps strength (102.5 Nm v 108.9 Nm, p = 0.02), lower maximum inspiratory pressure (64.7 cm H2O v 74.2 cm H2O, p<0.0001), higher systemic interleukin (IL)-6 levels (2.6 pg/ml v 2.2 pg/ml, p<0.0001), and higher C-reactive protein (CRP) levels (3.5 mg/l v 2.5 mg/l, p<0.0001) than those with normal spirometry. In participants with OLD and those with normal spirometry, forced expiratory volume in 1 second (FEV1) was associated with IL-6 (adjusted regression coefficients (β) = −5.3 (95% CI −9.1 to−1.5) and −3.1 (95% CI −4.3 to −1.9), respectively). IL-6 and TNF were also associated with quadriceps strength among participants with OLD and those with normal spirometry (β = −6.4 (95% CI −12.8 to −0.03) and −3.4 (95% CI −5.4 to −1.3), respectively, for IL-6 and β = −10.1 (95% CI −18.7 to −1.5) and −3.8 (95% CI −7 to −0.6), respectively, for TNF). IL-6, quadriceps strength, and maximum inspiratory pressures were independent predictors of reduced exercise capacity in both groups. Conclusions: In well functioning elderly subjects with or without OLD, IL-6 is associated with reduced FEV1, quadriceps strength, and exercise capacity.
In uncontrolled studies, noninvasive positive pressure ventilation (NPPV) was found useful in avoiding endotracheal intubation in patients with acute respiratory failure (ARF) caused by severe ...community-acquired pneumonia (CAP). We conducted a prospective, randomized study comparing standard treatment plus NPPV delivered through a face mask to standard treatment alone in patients with severe CAP and ARF. Patients fitting the American Thoracic Society criteria for severe CAP were included in presence of ARF (refractory hypoxemia and/or hypercapnia with acidosis). Exclusion criteria were: severe hemodynamic instability, requirement for emergent cardiopulmonary resuscitation, home mechanical ventilation or oxygen long-term supplementation, concomitant severe disease with a low expectation of life, inability to expectorate or contraindications to the use of the mask. Fifty-six consecutive patients (28 in each arm) were enrolled, and the two groups were similar at study entry. The use of NPPV was well tolerated, safe, and associated with a significant reduction in respiratory rate, need for endotracheal intubation (21% versus 50%; p = 0.03), and duration of intensive care unit (ICU) stay (1.8 +/- 0.7 d versus 6 +/- 1.8 d; p = 0.04). The two groups had a similar intensity of nursing care workload, time interval from study entry to endotracheal intubation, duration of hospitalization, and hospital mortality. Among patients with chronic obstructive pulmonary disease (COPD), those randomized to NPPV had a lower intensity of nursing care workload (p = 0.04) and improved 2-mo survival (88.9% versus 37.5%; p = 0.05). We conclude that in selected patients with ARF caused by severe CAP, NPPV was associated with a significant reduction in the rate of endotracheal intubation and duration of ICU stay. A 2-mo survival advantage was seen in patients with COPD.
No pharmacological therapeutic protocol has been found effective in modifying the clinical course of acute respiratory distress syndrome (ARDS) and mortality remains greater than 50%.
To determine ...the effects of prolonged methylprednisolone therapy on lung function and mortality in patients with unresolving ARDS.
Randomized, double-blind, placebo-controlled trial.
Medical intensive care units of 4 medical centers.
Twenty-four patients with severe ARDS who had failed to improve lung injury score (LIS) by the seventh day of respiratory failure.
Sixteen patients received methylprednisolone and 8 received placebo. Methylprednisolone dose was initially 2 mg/kg per day and the duration of treatment was 32 days. Four patients whose LIS failed to improve by at least 1 point after 10 days of treatment were blindly crossed over to the alternative treatment.
Primary outcome measures were improvement in lung function and mortality. Secondary outcome measures were improvement in multiple organ dysfunction syndrome (MODS) and development of nosocomial infections.
Physiological characteristics at the onset of ARDS were similar in both groups. At study entry (day 9 SD, 3 of ARDS), the 2 groups had similar LIS, ratios of PaO2 to fraction of inspired oxygen (FIO2), and MODS scores. Changes observed by study day 10 for methylprednisolone vs placebo were as follows: reduced LIS (mean SEM, 1.7 0.1 vs 3.0 0.2; P<.001); improved ratio of PaO2 to FIO2 (mean SEM, 262 19 vs 148 35; P<.001); decreased MODS score (mean SEM, 0.7 0.2 vs 1.8 0.3; P<.001); and successful extubation (7 vs 0; P=.05). For the treatment group vs the placebo group, mortality associated with the intensive care unit was 0 (0%) of 16 vs 5 (62%) of 8 (P=.002) and hospital-associated mortality was 2 (12%) of 16 vs 5 (62%) of 8 (P=.03). The rate of infections per day of treatment was similar in both groups, and pneumonia was frequently detected in the absence of fever.
In this study, prolonged administration of methylprednisolone in patients with unresolving ARDS was associated with improvement in lung injury and MODS scores and reduced mortality.
The size distribution of particles, which is essential for many properties of nanomaterials, is equally important for the mechanical behaviour of the class of alloys whose strength derives from a ...dispersion of nanoscale precipitates. However, particle size distributions formed by solid-state precipitation are generally not well controlled. Here we demonstrate, through the example of core-shell precipitates in Al-Sc-Li alloys, an approach to forming highly monodisperse particle size distributions by simple solid-state reactions. The approach involves the use of a two-step heat treatment, whereby the core formed at high temperature provides a template for growth of the shell at lower temperature. If the core is allowed to grow to a sufficient size, the shell develops in a 'size focusing' regime, where smaller particles grow faster than larger ones. These results suggest strategies for manipulating precipitate size distributions in similar systems through simple variations in thermal treatments.
Abstract Long chain polyunsaturated fatty acids (LCPUFA) are added to infant formula but their effect on long-term growth of children is under studied. We evaluated the effects of feeding ...LCPUFA-supplemented formula ( n =54) compared to control formula ( n =15) throughout infancy on growth from birth-6 years. Growth was described using separate models developed with the MIXED procedure of SAS® that included maternal smoking history and gender. Compared to children fed control formula, children who consumed LCPUFA supplemented formula had higher length-/stature-/and weight-for-age percentiles but not body mass index (BMI) percentile from birth to 6 years. Maternal smoking predicted lower stature (2–6 years), higher weight-for-length (birth-18 months) and BMI percentile (2–6 years) independent of LCPUFA effects. Gender interacted with the effect of LCPUFA on stature, and the relationship between smoking and BMI, with a larger effect for boys. Energy intake did not explain growth differences. A relatively small control sample is a limitation.
Docosahexaenoic acid (DHA: 22:6n-3) is important for normal visual development. We hypothesized that preterm infants fed formulas with marine oil as a source of DHA would have better visual acuity ...than infants fed formulas without marine oil, as measured by the Teller Acuity Card procedure. Marine oil (P 0.001) and age (P 0.0001) influenced visual acuity, by repeated-measures analysis of variance (ANOVA) corrected for the effect of subject. Marine-oil-supplemented infants had better visual acuity than those fed standard formulas at 2 and 4 mo of age, by Fishers' least-squares difference (LSD). Acuity of both dietary groups improved through 6.5 mo of age, then plateaued. Through 4 mo of age, acuity was inversely related to oxygen supplementation (log10 h) and positively related to DHA status, by general-linear-models (GLM) analysis. After 4 mo of age, birth weight and gestational age were the only variables consistently related to visual acuity by GLM. We conclude that marine-oil-supplemented formula improved visual acuity of preterm infants through 4 mo of age by improving DHA status
Diets deficient in the ω-6 fatty acid linoleic acid reduce arachidonic acid (Ach) concentrations and retard growth of developing animals and humans. Nevertheless, plasma phosphatidylcholine Ach ...concentrations declined from 84 ± 23 mg/liter at birth to a nadir of 38 ± 11 mg/liter at 4 mo of age in preterm infants fed commercial formulas with linoleic acid, and weight normalized to that of term infants fell progressively beginning at 2 mo of age. The nadir of plasma phosphatidylcholine Ach (31 ± 7 mg/liter) and growth were further reduced by formula containing marine oil compared with the commercial formulas. Ach status (defined as the mean plasma phosphatidylcholine Ach concentration at 2, 4, and 6.5 mo) correlated with one or more measures of normalized growth through 12 mo. Ach status and maternal height accounted for as much as 59% of the weight variance and 68% of the length variance in infants fed standard formulas. Better Ach status was not from higher energy intakes. A conditional Ach deficiency in preterm infants may contribute to growth over the first year of life. On the strength of the relationship between Ach status and growth, we hypothesize that dietary Ach could improve first year growth of preterm infants.
BACKGROUND: Although malnutrition contributes to morbidity, studies of pre- and postoperative nutrition often include well-nourished patients unlikely to benefit from therapy and usually do not ...stratify by the site of surgical pathology. This study evaluates whether perceived preoperative markers of nutritional status recorded in charts correlates with postoperative complications and resource use in patients who receive no preoperative nutrition support and reinterprets the results of several conflicting randomized, prospective studies in this context. METHODS: This is a retrospective cohort study of 526 surgical patients who had preoperative serum albumin levels measured and were undergoing elective esophageal, gastric, pancreaticoduodenal, or colon surgery between 1992 and 1996 who could have received preoperative nutrition but did not. RESULTS: Most medical records contained inadequate analysis of preoperative nutritional status, but preoperative albumin correlated inversely with complications, length of stay, postoperative stay, intensive care unit (ICU) stay, mortality, and resumption of oral intake. Patients undergoing esophageal or pancreatic procedures sustained a significantly higher complication rate at most albumin levels, whereas colonic surgery resulted in lower complication rates at the same albumin levels. Resource use (eg, length of stay and ICU stay) related to these complication rates; esophageal and pancreatic procedures used the most resources and colon procedures used the fewest at most albumin levels. This lack of appreciation for nutritional risk and operative site can explain discrepancies in outcome noted in several randomized, prospective nutritional studies and must be applied to the design and implementation of new studies. CONCLUSIONS: Elective, non-emergent esophageal and pancreatic procedures performed in patients who could have had surgery delayed for preoperative nutrition, but did not, result in higher risk than colon surgery at any given level of serum albumin below 3.25 g/dL. Patient populations in trials should be stratified by operative site and by markers of nutritional status. Degree of hypoalbuminemia and other potential markers of nutritional status may explain many of the discrepancies between trials of nutrition support. Preexisting hypoalbuminemia in patients undergoing elective surgery remains underappreciated, unrecognized, and untreated in many hospitalized patients.
Resource use increases as preoperative albumin decreases in patients undergoing elective gastrointestinal surgery, but site of operation is influential. These findings have significant implications for the design and interpretation of nutrition support trials.
Healthy preterm infants fed formula with long-chain n-3 fatty acids (n-3 LCFAs) from marine oil have better early visual acuity but lower plasma phosphatidylcholine (PC) arachidonic acid (AA) and ...growth than infants fed formula containing linolenic acid (LLA) as the sole n-3 fatty acid. This randomized, double-blind trial was designed to study the effects of a different source of n-3 LCFAs and a shorter feeding interval on visual acuity (by Teller Acuity Card) and growth of preterm infants (n = 59; 747–1275 g birth wt), some of whom required long periods of supplemental oxygen and developed bronchopulmonary dysplasia (BPD). Infants were studied at 0, 2, 4, 6, 9, and 12 mo past term. Plasma PC AA, and normalized weight, length, and head circumference were not influenced by BPD or n-3 LCFAs except that n-3 LCFA-supplemented infants weighed less at 6 (P>0.05) and 9 (P>0.01) mo and had smaller head circumferences at 9 mo (P>0.05). Compared with control infants, however, those fed n-3 LCFAs had lower weight-for-length at 2, 6, 9, and 12 mo (P>0.0003, P>0.0114, P>0.0008, and P>0.006, respectively). n-3 LCFAs improved early (2-mo) but not later acuity among infants without BPD (P>0.02). Regardless of diet, infants with BPD had poorer grating acuity at 2 (P>0.0002) and 4 (P>0.04) mo but not thereafter.
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