We sought to summarize and assess original evaluations of the economic impact of clinical pharmacy services published from 1996–2000, and to provide recommendations and methodologic considerations ...for future research. A systematic literature search was conducted to identify articles that were then blinded and randomly assigned to reviewers who confirmed inclusion and ed key information. Results were compared with those of a similar review of literature published from 1988–1995. In the 59 included articles, the studies were conducted across a variety of practice sites that consisted of hospitals (52%), community pharmacies and clinics (41%), health maintenance organizations (3%), and long‐term or intermediate care facilities (3%). They focused on a broad range of clinical pharmacy services such as general pharmacotherapeutic monitoring (47%), target drug programs (20%), disease management programs (10%), and patient education or cognitive services (10%). Compared with the studies of the previous review, a greater proportion of evaluations were conducted in community pharmacies or clinics, and the types of services evaluated tended to be more comprehensive rather than specialized. Articles were categorized by type of evaluation: 36% were considered outcome analyses, 24% full economic analyses, 17% outcome descriptions, 15% cost and outcome descriptions, and 8% cost analyses. Compared with the studies of the previous review, a greater proportion of studies in the current review used more rigorous study designs. Most studies reported positive financial benefits of the clinical pharmacy service evaluated. In 16 studies, a benefit:cost ratio was reported by the authors or was able to be calculated by the reviewers (these ranged from 1.7:1–17.0:1, median 4.68:1). The body of literature from this 5‐year period provides continued evidence of the economic benefit of clinical pharmacy services. Although the quality of study design has improved, whenever possible, future evaluations of this type should incorporate methodologies that will further enhance the strength of evidence of this literature and the conclusions that may be drawn from it.
Subfebrile body temperature and fever in the first days after stroke are strongly associated with unfavorable outcome. A subgroup analysis of a previous trial suggested that early treatment with ...paracetamol may improve functional outcome in patients with acute stroke and a body temperature of ≥36.5°C. In the present trial, we aimed to confirm this finding.
PAIS 2 (Paracetamol Acetaminophen in Stroke 2) was a multicenter, randomized, double-blind, placebo-controlled clinical trial. We aimed to include 1500 patients with acute ischemic stroke or intracerebral hemorrhage within 12 hours of symptom onset. Patients were treated with paracetamol in a daily dose of 6 g or matching placebo for 3 consecutive days. The primary outcome was functional outcome at 3 months, assessed with the modified Rankin Scale and analyzed with multivariable ordinal logistic regression. Because of slow recruitment and lack of funding, the study was stopped prematurely.
Between December 2011 and October 2015, we included 256 patients, of whom 136 (53%) were allocated to paracetamol. In this small sample, paracetamol had no effect on functional outcome (adjusted common odds ratio, 1.15; 95% confidence interval, 0.74-1.79). There was no difference in the number of serious adverse events (paracetamol n=35 26% versus placebo n=28 24%).
Treatment with high-dose paracetamol seemed to be safe. The effect of high-dose paracetamol on functional outcome remains uncertain. Therefore, a large trial of early treatment with high-dose paracetamol is still needed.
URL: http://www.trialregister.nl. Unique identifier: NTR2365.
Objective:
To investigate the predictive value of self-reported decline in weight, exhaustion, walking difficulty, grip strength and physical activity on development of disabilities in ...community-dwelling elderly people.
Design:
A one-year follow-up study.
Setting:
Participants were recruited via four Dutch general practitioners.
Participants:
Community-dwelling elderly people aged 70 years or older.
Methods:
A total of 687 participants received a questionnaire at baseline regarding weight loss, exhaustion, walking difficulty, grip strength, physical activity and disability. The same questionnaire was sent to them after one year follow-up. Disability was operationalized in two ways: as increased dependence and as increased difficulty in daily activities. Univariate and multivariate logistic regression analyses were used to determine whether self-reported decline in five physical indicators at baseline predicted development of dependence or increased difficulty in daily activities after one year. The analyses were controlled for age, gender and baseline disability.
Results:
Four hundred and one participants with a mean age of 76.9 years (SD 5.2) were included in the analyses. Eighty-four of them reported increased dependence (21%) and 76 reported increased difficulty (19%) in daily activities at one-year follow-up. All physical indicators, except weight loss, were significant univariate predictors of disability. Multivariate analyses revealed that self-reported decrease in physical activity (e.g. walking, cycling, gardening) was a significant predictor of development of dependence (odds ratio (OR) = 1.89, 95% confidence interval (CI) = 1.02–3.51) and development of difficulty (OR = 1.98, 95% CI = 1.05–3.71) in daily activities.
Conclusion:
Community-dwelling elderly people who report decreased physical activity have a higher risk to develop disability at one-year follow-up.
Various models and datasets related to aflatoxins in the maize and dairy production chain have been developed and used but they have not yet been linked with each other. This study aimed to ...investigate the impacts of climate change on aflatoxin B.sub.1 production in maize and its consequences on aflatoxin M.sub.1 contamination in dairy cow's milk, using a full chain modelling approach. To this end, available models and input data were chained together in a modelling framework. As a case study, we focused on maize grown in Eastern Europe and imported to the Netherlands to be fed-as part of dairy cows' compound feed-to dairy cows in the Netherlands. Three different climate models, one aflatoxin B.sub.1 prediction model and five different carryover models were used. For this particular case study of East European maize, most of the calculations suggest an increase (up to 50%) of maximum mean aflatoxin M.sub.1 in milk by 2030, except for one climate (DMI) model suggesting a decrease. Results from all combinations of carryover and climate models suggest a similar or slight increase (up to 0.6%) of the chance of finding aflatoxin M.sub.1 in milk above the EC limit of 0.05 mug/kg by 2030. Results varied mainly with the climate model data and carryover model considered. The model framework infrastructure is flexible so that forecasting models for other mycotoxins or other food safety hazards as well as other production chains, together with necessary input databases, can easily be included as well. This modelling framework for the first time links datasets and models related to aflatoxin B.sub.1 in maize and related aflatoxin M.sub.1 the dairy production chain to obtain a unique predictive methodology based on Monte Carlo simulation. Such an integrated approach with scenario analysis provides possibilities for policy makers and risk managers to study the effects of changes in the beginning of the chain on the end product.
There are indications that older adults who suffer from poor balance have an increased risk for adverse health outcomes, such as falls and disability. Monitoring the development of balance over time ...enables early detection of balance decline, which can identify older adults who could benefit from interventions aimed at prevention of these adverse outcomes. An innovative and easy-to-use device that can be used by older adults for home-based monitoring of balance is a modified bathroom scale.
The objective of this paper is to study the relationship between balance scores obtained with a modified bathroom scale and falls and disability in a sample of older adults.
For this 6-month follow-up study, participants were recruited via physiotherapists working in a nursing home, geriatricians, exercise classes, and at an event about health for older adults. Inclusion criteria were being aged 65 years or older, being able to stand on a bathroom scale independently, and able to provide informed consent. A total of 41 nursing home patients and 139 community-dwelling older adults stepped onto the modified bathroom scale three consecutive times at baseline to measure their balance. Their mean balance scores on a scale from 0 to 16 were calculated-higher scores indicated better balance. Questionnaires were used to study falls and disability at baseline and after 6 months of follow-up. The cross-sectional relationship between balance and falls and disability at baseline was studied using t tests and Spearman rank correlations. Univariate and multivariate logistic regression analyses were conducted to study the relationship between balance measured at baseline and falls and disability development after 6 months of follow-up.
A total of 128 participants with complete datasets--25.8% (33/128) male-and a mean age of 75.33 years (SD 6.26) were included in the analyses of this study. Balance scores of participants who reported at baseline that they had fallen at least once in the past 6 months were lower compared to nonfallers--8.9 and 11.2, respectively (P<.001). The correlation between mean balance score and disability sum-score at baseline was -.51 (P<.001). No significant associations were found between balance at baseline and falls after 6 months of follow-up. Baseline balance scores were significantly associated with the development of disability after 6 months of follow-up in the univariate analysis--odds ratio (OR) 0.86 (95% CI 0.76-0.98)-but not in the multivariate analysis when correcting for age, gender, baseline disability, and falls at follow-up-OR 0.94 (95% CI 0.79-1.11).
There is a cross-sectional relationship between balance measured by a modified bathroom scale and falls and disability in older adults. Despite this cross-sectional relationship, longitudinal data showed that balance scores have no predictive value for falls and might only have limited predictive value for disability development after 6 months of follow-up.
Background: The Dutch guidelines for esophageal and gastro-esophageal junction (GEJ) cancer recommend discussion of patients by a multidisciplinary tumor board (MDT). Despite this recommendation, one ...previous study in the Netherlands suggested that therapeutic guidance was missing for palliative care of patients with esophageal cancer. The aim of the current study was therefore to assess the impact of an MDT discussion on initial palliative treatment and outcome of patients with esophageal or GEJ cancer.
Material and methods: The population-based Netherlands Cancer Registry was used to identify patients treated for esophageal or GEJ cancer with palliative intent between 2010 and 2017 in 7 hospitals. We compared patients discussed by the MDT with patients not discussed by the MDT in a multivariate analysis. Primary outcome was type of initial palliative treatment. Secondary outcome was overall survival.
Results: A total of 389/948 (41%) patients with esophageal or GEJ cancer were discussed by the MDT before initial palliative treatment. MDT discussion compared to non-MDT discussion was associated with more patients treated with palliative intent external beam radiotherapy (38% vs. 21%, OR 2.7 95% CI 1.8-3.9) and systemic therapy (30% vs. 23%, OR 1.6 95% CI 1.0-2.5), and fewer patients treated with stent placement (4% vs. 12%, OR 0.3 95% CI 0.1-0.6) and best supportive care alone (12% vs. 33%, OR 0.2 95% CI 0.1-0.3). MDT discussion was also associated with improved survival (169 days vs. 107 days, HR 1.3 95% CI 1.1-1.6).
Conclusion: Our study shows that MDT discussion of patients with esophageal or GEJ cancer resulted in more patients treated with initial palliative radiotherapy and chemotherapy compared with patients not discussed by the MDT. Moreover, MDT discussion may have a positive effect on survival, highlighting the importance of MDT meetings at all stages of treatment.
We aimed to develop a consensus-based rehabilitation guideline specifically designed to reduce apprehension following arthroscopic Bankart repair after traumatic anterior shoulder dislocation.
...Delphi-based consensus.
A comprehensive list of interventions for potential inclusion in a postoperative rehabilitation guideline was developed. American and European physiotherapists and orthopedic surgeons were invited to participate in a Delphi panel, engaging in 3 survey rounds. The health professionals were surveyed about their level of agreement on both initially listed and newly suggested interventions. Consensus was established when a "critical-to-include" rating was given in ≥70% of all responses. Ten former patients were consulted to identify the intervention during standard care rehabilitation that had the most impact on reducing postoperative apprehension following ABR. Any interventions not initially listed in the first round were added to the second survey round of the Delphi process.
Forty-four health professionals reached consensus on a set of 27 interventions for managing apprehension after arthroscopic Bankart repair. New interventions included gradual exposure to shoulder positions eliciting apprehension, training in anterior stability-provoking positions, and education addressing the impact of psychosocial factors. Former patients identified specific interventions that were effective in reducing postoperative apprehension following ABR. These interventions encompassed medicine ball throws, active-assisted wall slides, and kinetic chain exercises in anterior stability-provoking positions.
Our Delphi process informed expert recommendations for various interventions aimed at addressing apprehension associated with ABR. The recommendations were the foundation for developing a rehabilitation guideline (REGUIDE). The REGUIDE integrates principles from cognitive-behavioral therapy to improve rehabilitation and mitigate apprehension.
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The COVID-19 pandemic and associated lockdowns disrupted health care worldwide. High-income countries observed a decrease in preterm births during lockdowns, but maternal pregnancy–related outcomes ...were also likely affected. This study investigates the effect of the first COVID-19 lockdown (March–June 2020) on provision of maternity care and maternal pregnancy–related outcomes in the Netherlands.
National quasi-experimental study.
Multiple linked national registries were used, and all births from a gestational age of 24+0 weeks in 2010–2020 were included. In births starting in midwife-led primary care, we assessed the effect of lockdown on provision of care. In the general pregnant population, the impact on characteristics of labour and maternal morbidity was assessed. A difference-in-regression-discontinuity design was used to derive causal estimates for the year 2020.
A total of 1,039,728 births were included. During the lockdown, births to women who started labour in midwife-led primary care (49%) more often ended at home (27% pre-lockdown, +10% 95% confidence interval: +7%, +13%). A small decrease was seen in referrals towards obstetrician-led care during labour (46%, −3% −5%,−0%). In the overall group, no significant change was seen in induction of labour (27%, +1% −1%, +3%). We found no significant changes in the incidence of emergency caesarean section (9%, −1% −2%, +0%), obstetric anal sphincter injury (2%, +0% −0%, +1%), episiotomy (21%, −0% −2%, +1%), or post-partum haemorrhage: >1000 ml (6%, −0% −1%, +1%).
During the first COVID-19 lockdown in the Netherlands, a substantial increase in homebirths was seen. There was no evidence for changed available maternal outcomes, suggesting that a maternity care system with a strong midwife-led primary care system may flexibly and safely adapt to external disruptions.
To the Editor: SARS-CoV-2, the cause of COVID-19, has posed a significant threat to global health. No specific treatment or effective prophylaxis has been established, and care of severely ill ...patients is largely supportive, with poor outcomes in those requiring ICU admission. Experimental therapies include antiviral agents such as remdesivir, lopinavir/ritonavir and favipiravir, hydroxychloroquine/chloroquine, interleukin-6 inhibitors such as tocilizumab, siltuximab and sarilumab, and COVID-19 convalescent plasma (CCP).
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