Asthma treatment guidelines recommend increasing corticosteroid dose to control symptoms and reduce exacerbations. This approach is potentially flawed because symptomatic asthma can occur without ...corticosteroid responsive type-2 (T2)-driven eosinophilic inflammation, and inappropriately high-dose corticosteroid treatment might have little therapeutic benefit with increased risk of side-effects. We compared a biomarker strategy to adjust corticosteroid dose using a composite score of T2 biomarkers (fractional exhaled nitric oxide FENO, blood eosinophils, and serum periostin) with a standardised symptom–risk-based algorithm (control).
We did a single-blind, parallel group, randomised controlled trial in adults (18–80 years of age) with severe asthma (at treatment steps 4 and 5 of the Global Initiative for Asthma) and FENO of less than 45 parts per billion at 12 specialist severe asthma centres across England, Scotland, and Northern Ireland. Patients were randomly assigned (4:1) to either the biomarker strategy group or the control group by an online electronic case-report form, in blocks of ten, stratified by asthma control and use of rescue systemic steroids in the previous year. Patients were masked to study group allocation throughout the entirety of the study. Patients attended clinic every 8 weeks, with treatment adjustment following automated treatment-group-specific algorithms: those in the biomarker strategy group received a default advisory to maintain treatment and those in the control group had their treatment adjusted according to the steps indicated by the trial algorithm. The primary outcome was the proportion of patients with corticosteroid dose reduction at week 48, in the intention-to-treat (ITT) population. Secondary outcomes were inhaled corticosteroid (ICS) dose at the end of the study; cumulative dose of ICS during the study; proportion of patients on maintenance oral corticosteroids (OCS) at study end; rate of protocol-defined severe exacerbations per patient year; time to first severe exacerbation; number of hospital admissions for asthma; changes in lung function, Asthma Control Questionnaire-7 score, Asthma Quality of Life Questionnaire score, and T2 biomarkers from baseline to week 48; and whether patients declined to progress to OCS. A secondary aim of our study was to establish the proportion of patients with severe asthma in whom T2 biomarkers remained low when corticosteroid therapy was decreased to a minimum ICS dose. This study is registered with ClinicalTrials.gov, NCT02717689 and has been completed.
Patients were recruited from Jan 8, 2016, to July 12, 2018. Of 549 patients assessed, 301 patients were included in the ITT population and were randomly assigned to the biomarker strategy group (n=240) or to the control group (n=61). 28·4% of patients in the biomarker strategy group were on a lower corticosteroid dose at week 48 compared with 18·5% of patients in the control group (adjusted odds ratio aOR 1·71 95% CI 0·80–3·63; p=0·17). In the per-protocol (PP) population (n=121), a significantly greater proportion of patients were on a lower corticosteroid dose at week 48 in the biomarker strategy group (30·7% of patients) compared with the control group (5·0% of patients; aOR 11·48 95% CI 1·35–97·83; p=0·026). Patient choice to not follow treatment advice was the principle reason for loss to PP analysis. There was no difference in secondary outcomes between study groups and no loss of asthma control among patients in the biomarker strategy group who reduced their corticosteroid dose.
Biomarker-based corticosteroid adjustment did not result in a greater proportion of patients reducing corticosteroid dose versus control. Understanding the reasons for patients not following treatment advice in both treatment strategies is an important area for future research. The prevalence of T2 biomarker-low severe asthma was low.
This study was funded, in part, by the Medical Research Council UK.
Abstract
Background
Peripherally inserted central catheters (PICC) are frequently used for long-term intravenous access in hospitalized patients; however, their use is associated with an increased ...risk of catheter-related bloodstream infection (CRBSI). Midline catheters (MC) have emerged as a potentially safer alternative and are associated with reduced rates of CRBSI but increased risk of thrombosis. Until recently, the use of several vasopressors and antibiotics via MC has been limited due to unknown adverse events. We aimed to compare the hazard ratios for CRBSI, thrombosis, catheter occlusion, and overall adverse events (AE) in adult intensive care unit (ICU) patients receiving vesicant antibiotics or vasopressors through PICC or MC.
Methods
We reviewed patients in 13 ICUs at one quaternary care center from April 2021 to September 2022 who received selected vesicant antibiotics (vancomycin, meropenem, and fluoroquinolones) or vasopressors through either PICC or MC. Patients who received both PICC and MC or other central access during the admission were excluded. Hazard ratios (HR) were compared using Kaplan-Meier survival curves and the log-long rank test. Cox regression was applied to adjust for potential confounding factors, including age, gender, ICU type (medical vs. surgical), duration of therapy, and length of stay.
Results
445 patients (359 MCs, 86 PICCs) were included with 4,897 device days (3,910 MCs, 987 PICCs). Patient characteristics were similar across the two arms (Table 1). Figure 1 shows Kaplan-Meier survival estimate curves comparing PICC and MC. After adjusting for confounders (Table 2), the HR for CRBSI (0.86 95% CI, 0.08 – 9.41) and thrombosis (0.41 95% CI, 0.09- 1.91) were similar between the two devices. Compared to MC, PICCs were associated with higher occlusion rates (HR, 11.93 95% CI, 2.97 – 47.89). There were no significant differences in overall AE between the two groups (HR 1.72 95% CI, 0.81 – 3.64).Table 1:Characteristics of patients who received PICC or MC.MC: Midline Catheter; PICC: Peripherally Inserted Central Catheter; MICU: Medical Intensive Care Unit; SICU: Surgical Intensive Care Unit; DOT: Days of TherapyFigure 1:Kaplan-Meier Survival Estimate Curves Comparing PICC and MC. PICC: Peripherally Inserted Central Catheter; MC: Midline Catheter; The log-rank test was used for statistical significance.Table 2:Cox proportional-hazards multivariable model. DVT: Deep Vein Thrombosis; SVT: Superficial Vein Thrombosis; PICC: Peripherally Inserted Central Catheter; MC: Midline Catheter; SICU: Surgical Intensive Care Unit; MICU: Medical Intensive Care Unit; DOT: Days of Therapy; CI: 95% Confidence Interval
Conclusion
This study suggests similar infection and thrombosis hazards in ICU patients receiving vesicant antibiotics and vasopressors via PICC or MC. Notably, the study was not sufficiently powered to detect differences in outcomes. Larger studies are needed to assess the safety of administering these medications in MCs.
Disclosures
Sabra L. Shay, BSN, MPH, Premier Inc.: Employee
In this paper we discuss a case study investigating how the academic and personal development of first year students on an undergraduate sports education degree can be supported and enhanced with ...mobile SMS communication. SMS-based technologies were introduced in response to studentsâ?? particular needs (in transition to Higher Education) and characteristics (â??digital nativesâ??). Despite being unaccustomed to using their mobile phones for academic study, students willingly participated in SMS communication with their tutor via a texting management service. Drawing on evidence from two student surveys, focus groups and a tutorâ??s journal, we illustrate the potential that mobile SMS communication has to link and establish continuity between face to face teaching sessions and online learning activities in the Virtual Learning Environment (VLE). Many students perceived the SMS communication to have had a positive impact on their management of study time. We link our findings with the existing literature and argue that mobile text based communication has the potential to support the development of time management skills, an important component of self regulatory learning, a skill which has been shown to be key in making a successful transition.
The purpose of this hermeneutic phenomenological study was to explore elderly patients’ perspectives regarding discharge instructions related to self-management of their chronic illnesses once they ...were discharged from the hospital to their home. The combination of the growing elderly population, inadequate health literacy, and the prevalence of comorbidity illustrate the complex needs of this population of patient in regards to self-management of chronic illnesses once discharged (National Research Council of the National Academies, 2012). Study participants were recruited from two cardiovascular hospital-based clinics located in a large medical center in Texas. A purposive sampling was used to secure a sample of 20 participants meeting the following inclusion criteria: older than 65 years of age, diagnosis of any type of cardiovascular disease, cognitive competence, length of stay in the hospital greater than 3 days, discharged home rather than to long term care facility or nursing home, first follow-up doctor visit 2-4 weeks after discharge from the hospital and English speaking. Data were collected using a demographic questionnaire, a cognitive screening test (Mini Cog) and semi-structured audio-recorded interviews that lasted approximately 30-45 minutes. Trustworthiness was established using Lincoln and Guba’s framework (1985) to secure credibility, transferability, dependability, and confirmability. Analysis was conducted using the Lindseth and Norberg’s (2004) hermeneutical interpretation method which includes three steps: naïve reading, structural analysis and comprehensive understanding. A major finding was that patients’ perceptions of their discharge instructions did not match the reality of their post-discharge needs. Four themes emerged, reflecting aspects about transition from hospital to home: Just-in-time Discharge Process, I Thought the Instructions Were Good, But…, What Would I do Without My Caregiver, and It Would Help If I Had… This study identified gaps in discharge instructions and the degree to which they did or failed to prepare elderly patients to self-manage their chronic illness once discharged home. Such gaps potentially result in poor self-management and subsequent rehospitalization. Without strengthening the hospital discharge instruction process, self-management of illness in the elderly patient population will continue to be a major challenge.
The purpose of this study was to determine how education and training empower poor single mothers to get off welfare. When welfare reforms began the overwhelming discovery of welfare recipients was ...that it did not pay to get off welfare. Many users returned to welfare when they discovered they did not earn enough wages to be self-sufficient. The study shows that welfare cannot lift poor single mothers out of poverty. Welfare reforms must offer attractive incentives to encourage users to get off welfare. Adequate education and training must be provided to assist welfare recipients in obtaining higher paying jobs. Empowerment of the growing group of poor single mothers will only be accomplished by choosing a model that works, by devising a plan that addresses both short and long-term goals for welfare reform, poverty reduction and self-sufficiency.
Thesis (M.S.)--West Virginia University, 2003.
Title from document title page. Document formatted into pages; contains xi, 180 p. : ill. (some col.), maps (some col.). Includes abstract. Includes ...bibliographical references (p. 77-81).
This study attempted to model the decision to subdivide in Hampshire County, West Virginia as a function of landowner characteristics identified through a survey of landowners in Hampshire County, ...attributes of the parcel including information on land use, and spatial attributes of the parcel obtained from existing GIS information sources. Specific objectives addressed through this research included identifying landowner and parcel characteristics that impact the decision to subdivide. Regression analysis was used to estimate a logit model of the landowner's decision to subdivide a parcel as a function of spatial, external, and internal variables. The three sets of variables were combined to model the decision to subdivide, which yielded a model that explained the decision to subdivide 93-percent of the time. The final model included highly significant variables as well as some that increased significantly the predictive power of the model for those that subdivided.
This research set out to examine whether the collaborative efforts of community, parents, and school could help lower the school dropout rate through a concentrated focus on attendance and an ...attendance program. The research questions posed were as follows: (1) Can a community-site-based partnership program between school and home help promote and create a positive working relationship benefiting students? (2) Can teachers be encouraged, through participatory action research, to involve parents in school and classroom activities or programs? The research determined the problems to be examined and solved. The collaborative team defined its goals, encouraged a place for the partnership within the system and the community, and created a project to meet the goals. In this study, the specific method used was case study review. This methodology described what took place in the study, what took place in the program, what the interactions and settings were, and what participants said or wrote down. This qualitative research method was used in three case studies.
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