MSCopilot, a new multiple sclerosis self-assessment digital solution: results of a comparative study versus standard tests.

BACKGROUND AND PURPOSE: Assessing patients' disability in multiple sclerosis (MS) requires time-consuming batteries of hospital tests. MSCopilot is a software medical device for the self-assessment of patients with MS (PwMS), combining four tests: walking, dexterity, cognition and low contrast vision. The objective was to validate MSCopilot versus the Multiple Sclerosis Functional Composite (MSFC). METHODS: This multicentre, open-label, randomized, controlled, crossover study enrolled 141 PwMS and 76 healthy controls (HCs). All participants performed MSCopilot and MSFC tests at day 0. To assess reproducibility, 46 PwMS performed the same tests at day 30 ± 3. The primary end-point was the validation of MSCopilot versus MSFC for the identification of PwMS against HCs, quantified using the area under the curve (AUC). The main secondary end-point was the correlation of MSCopilot z-scores with MSFC z-scores. RESULTS: In all, 116 PwMS and 69 HCs were analysed. The primary end-point was achieved: MSCopilot performance was non-inferior to that of MSFC (AUC 0.92 and 0.89 respectively; P = 0.3). MSCopilot and MSFC discriminated PwMS and HCs with 81% and 76% sensitivity and 82% and 88% specificity respectively. Digital and standard test scores were highly correlated (r = 0.81; P < 0.001). The test-retest study demonstrated the good reproducibility of MSCopilot. CONCLUSION: This study confirms the reliability of MSCopilot and its usability in clinical practice for the monitoring of MS-related disability.

A simplified blood culture sampling protocol for reducing contamination and costs: a randomized controlled trial.

OBJECTIVES: Blood culture contamination carries risks for patients, such as unnecessary antimicrobial therapy and other additional hazards and costs. One method shown to be effective in reducing contamination is initial blood specimen diversion during collection. We hypothesized that initial blood specimen diversion without a designated device or procedure would suffice for reduction in blood culture contamination rate. METHODS: From 1 September 2017 through to 6 September 2018, we conducted a randomized controlled trial to assess the effect of an initial-specimen diversion technique (ISDT) on the rate of blood-culture contamination by changing the order of sampling using regular vacuum specimen tubes instead of commercially available sterile diversion devices. We included adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests. Additionally, we evaluated the potential economic benefits of an ISDT. This was a researcher-initiated trial, Clinicaltrials.gov NCT03088865. RESULTS: In all, 756 patients were enrolled. This method, compared with the standard procedure in use at our medical centre, reduced contamination by 66% (95% CI 17%-86%), from 20/400 (5%) with the standard method to 6/356 (1.6%) with the ISDT, without compromising detection of true bloodstream infection and at no additional cost. Hospital-wide implementation of ISDT was associated with a 1.1% saving in hospitalization days. CONCLUSIONS: We offer this novel approach as a simple, cost-effective measure to reduce risks to patient safety from contaminated blood cultures, without the need for using costly devices.

Frailty and Constellations of Factors in Aging HIV-infected and Uninfected Women--The Women's Interagency HIV Study.

BACKGROUND: Biological similarities are noted between aging and HIV infection. Middle-aged adults with HIV infection may present as elderly due to accelerated aging or having more severe aging phenotypes occurring at younger ages. OBJECTIVES: We explored age-adjusted prevalence of frailty, a geriatric condition, among HIV+ and at risk HIV- women. DESIGN: Cross-sectional. SETTING: The Women's Interagency HIV Study (WIHS). PARTICIPANTS: 2028 middle-aged (average age 39 years) female participants (1449 HIV+; 579 HIV-). MEASUREMENTS: The Fried Frailty Index (FFI), HIV status variables, and constellations of variables representing Demographic/health behaviors and Aging-related chronic diseases. Associations between the FFI and other variables were estimated, followed by stepwise regression models. RESULTS: Overall frailty prevalence was 15.2% (HIV+, 17%; HIV-, 10%). A multivariable model suggested that HIV infection with CD4 count<200; age>40 years; current or former smoking; income ≤$12,000; moderate vs low fibrinogen-4 (FIB-4) levels; and moderate vs high estimated glomerular filtration rate (eGFR) were positively associated with frailty. Low or moderate drinking was protective. CONCLUSIONS: Frailty is a multidimensional aging phenotype observed in mid-life among women with HIV infection. Prevalence of frailty in this sample of HIV-infected women exceeds that for usual elderly populations. This highlights the need for geriatricians and gerontologists to interact with younger 'at risk' populations, and assists in the formulation of best recommendations for frailty interventions to prevent early aging, excess morbidities and early death.

Expansion of genetic services utilizing a general genetic counseling clinic.

We established a general genetic counseling clinic (GCC) to help reduce long wait times for new patient appointments and to enhance services for a subset of patients. Genetic counselors, who are licensed in Tennessee, were the primary providers and MD geneticists served as medical advisors. This article describes the clinic referral sources, reasons for referral and patient dispositions following their GCC visit(s). We obtained patients by triaging referrals made to our medical genetics division. Over 24 months, our GCC provided timely visits for 321 patients, allowing the MD geneticists to focus on patients needing a clinical exam and/or complex medical management. Following their GCC visit(s), over 80 % of patients did not need additional appointments with an MD geneticist. The GCC allowed the genetic counselor to spend more time with patients than is possible in our traditional medical genetics clinic. Patient satisfaction surveys (n = 30) were very positive overall concerning the care provided. Added benefits for the genetic counselors were increased professional responsibility, autonomy and visibility as health care providers. We conclude that genetic counselors are accepted as health care providers by patients and referring providers for a subset of clinical genetics cases. A GCC can expand genetic services, complement more traditional genetic clinic models and utilize the strengths of the genetic counselor health care provider.

Applying complex models to poultry production in the future--economics and biology.

The ability to determine the optimal broiler feed nutrient density that maximizes margin over feeding cost (MOFC) has obvious economic value. To determine optimal feed nutrient density, one must consider ingredient prices, meat values, the product mix being marketed, and the projected biological performance. A series of 8 feeding trials was conducted to estimate biological responses to changes in ME and amino acid (AA) density. Eight different genotypes of sex-separate reared broilers were fed diets varying in ME (2,723-3,386 kcal of ME/kg) and AA (0.89-1.65% digestible lysine with all essential AA acids being indexed to lysine) levels. Broilers were processed to determine carcass component yield at many different BW (1.09-4.70 kg). Trial data generated were used in model constructed to discover the dietary levels of ME and AA that maximize MOFC on a per broiler or per broiler annualized basis (bird × number of cycles/year). The model was designed to estimate the effects of dietary nutrient concentration on broiler live weight, feed conversion, mortality, and carcass component yield. Estimated coefficients from the step-wise regression process are subsequently used to predict the optimal ME and AA concentrations that maximize MOFC. The effects of changing feed or meat prices across a wide spectrum on optimal ME and AA levels can be evaluated via parametric analysis. The model can rapidly compare both biological and economic implications of changing from current practice to the simulated optimal solution. The model can be exploited to enhance decision making under volatile market conditions.

[Natalizumab (Tysabri) prescription practices of neurologists in southern France]. / Enquête auprès des neurologues sur les prescriptions de natalizumab en région Provence-Alpes-Côte-d'Azur.

INTRODUCTION: Tysabri is indicated as single-drug disease-modifying therapy in patients with highly active relapsing remitting multiple sclerosis (RRMS). Potential risk for opportunistic infection and especially for progressive multifocal leucoencephalopathy has implied specific guidelines for use. The purpose of this study was to ascertain the prescription practices of neurologists in southern France and to learn more about how the drug is used in clinical practice compared with management guidelines stated in the product's characteristics and national recommendations. METHODS: We developed a questionnaire which was sent to all neurologists practicing in our region, whether they had multiple sclerosis patients or not. Questions regarded demographic data (geography, practice in hospital or private office), current knowledge on natalizumab (mechanism of action, indications), monitoring of treated patients (pre-therapeutic and therapeutic check-up), rescue decisions and overall experience with using natalizumab. RESULTS: Two hundred fifty neurologists, practicing in eight administrative districts in our region, were contacted. Demographic data showed that most of them were prescribing Tysabri. Patients treated with Tysabri were mostly followed in teaching hospitals (79%). Concerning knowledge about natalizumab, neurologists applied the recommended check-up (73%) but most of them preferred prescribing Tysabri as a second line of treatment after IFN failure (66%). Inefficacy was mainly evaluated on clinical parameters (one or two relapses under treatment with sequels or EDSS progression in each answer); MRI was only useful to confirm clinical conclusions, but for the neurologists, gadolinium enhancement was required to confirm lack of efficacy. DISCUSSION: Results tended to show that, in clinical practice, despite some deviation from national guidelines, the recommended precautions are applied for the use of Tysabri. Neurologists considered that Tysabri is other immunosuppressant drugs used in RRMS. Further medical information might be useful to improve compliance with all of the recommended indications and standard practices for patient follow-up. CONCLUSION: This survey enabled an assessment of current knowledge about Tysabri as a treatment for RRMS patients and to learn more about how it was used in real life practice during its first year of marketing in France.

Research assessment of elder neglect and its risk factors in a hospital setting.

BACKGROUND: The aims of this experiment were to assess the rate of neglect in hospitalized patients and to identify risk factors for neglect. METHODS: During 2004-2006, patients aged 70 years and older hospitalized in internal departments were screened for signs of neglect. Principal caregivers were interviewed too. RESULTS: Signs of neglect were identified in 14.1% of the patients. Neglected patients differed from the non-neglected in level of education and had poorer economic status and more frailty, lower albumin level, higher incontinence problem and higher subjective caregiving burden reported by their caregivers. Mean risk scores, based on patients' and caregivers' risk indicators, were higher in the neglect group. CONCLUSION: Health, functional and psychosocial factors correlated to the presence of neglect. These factors should be used as warning signs to draw attention to professional help.

Detection of acute HIV infections among sexually transmitted disease clinic patients: a practice in Guangxi Zhuang Autonomous Region, China.

Detection of people with acute HIV infection (AHI) affords an important opportunity for early HIV treatment and prevention. HIV RNA reverse transcriptase-polymerase chain reaction (RT-PCR) testing with two-stage pooling scheme was used to detect the AHI in specimens collected from sexually transmitted disease (STD) clinic patients in Guangxi, China. A total of 246 HIV RNA tests were required to screen 11 395 samples negative for conventional enzyme immunoassay (EIA) and Western blot assays, and five AHI cases (0.04%, 95%CI 0.02% to 0.10%) with a high viral load (median of 265,677 copies per ml) were detected. The total expenditure for RT-PCR testing reflected an added cost of $2.9 per specimen screened and $6575 per additional case of AHI identified among the study population. This study supports the feasibility of pooled RNA testing in addition to detection of HIV infections among patients at STD clinics in China, but the cost effectiveness should be carefully considered.

Are national quality standards for traditional Chinese herbal medicine sufficient? Current governmental regulations for traditional Chinese herbal medicine in certain Western countries and China as the Eastern origin country.

Traditional Chinese herbal Medicine (TCHM) has been gaining interest and acceptance world wide. TCHM provides on the one side promising perspective of scientific interest and on the other side possible health risks if TCHM drugs are not controlled with respect to quality standards or if practitioners for TCHM are not well trained. This paper outlines an introduction to the scientific aspects and potential risks of TCHM therapy followed by a brief, exploratory overview of the current status of TCHM regulations in certain Western countries like the USA, United Kingdom, Germany, Australia and in China as the Eastern origin country of TCHM. Legal foundations to establish quality and safety standards for TCHM crude drugs and ready-made formulas exist in some countries on a local basis but in practice are poorly enforced, where this products have no drug status. In addition practitioners treating patients with TCHM should be well versed in the pharmacology, side effects, and interactions of these substances with Western medicines and should be certified on a regular basis.

Medication safety program reduces adverse drug events in a community hospital.

BACKGROUND: There is widespread interest in improving medication safety, particularly in the hospital setting. Numerous suggestions have been made as to how this should be done, but there is a paucity of data demonstrating the effectiveness of any of the interventions that have been proposed. OBJECTIVES: To assess the impact of a wide ranging, community hospital based patient safety program on patient harm as measured by the rate of adverse drug events. DESIGN: An audit of discharged hospital patients was conducted from January 2001 to December 2003. Baseline data were collected for the first 6 months and multiple drug protocols and other interventions were instituted on the nursing units and in the pharmacy department over the subsequent 9 months (transition period). These interventions were largely based on information about medication risks acquired from internal medication event reporting. Each month of the study adverse drug events (ADE) were sought from a random sample of inpatient charts. A trigger tool was used to detect clues to ADEs, the presence of which was confirmed or excluded by detailed manual chart review. The severity of these events was categorized using the classification system of the National Coordinating Council for Medication Error and Reporting and Prevention. MAIN OUTCOME MEASURES AND RESULTS: Median ADEs per 1000 doses of medication dispensed declined significantly from 2.04 to 0.65 (p<0.001). Median ADEs per 100 patient days declined significantly from 5.07 to 1.30 (p<0.001). The proportion of inpatients with one or more ADE in the baseline period was 31% and declined threefold (p<0.001). The severity of reported medication events also declined. The number of ADEs associated conclusively with patient harm was 1.67 per total doses delivered in the baseline period and declined eightfold (p<0.001). CONCLUSION: The implementation of a carefully planned series of low cost interventions focused on high risk medications, driven by information largely from internal event reporting, and designed to improve a hospital's medication safety leads to a significant decrease in patient harm.

Incidence and management of "no-reflow" following percutaneous coronary interventions.

No-reflow is a complex condition associated with inadequate myocardial perfusion of the coronary artery in the absence of epicardial obstruction. It can occur in several settings, including percutaneous coronary intervention, especially in complex thrombotic lesions of native arteries and vein grafts and in primary angioplasty. The causes of no-reflow are not completely understood, and current treatments consist of intracoronary vasodilators, antithrombotic therapies, and mechanical devices (including aspiration thrombectomy catheters and embolic protection devices).

Ethical problems arising in evidence based complementary and alternative medicine.

Complementary and alternative medicine has become an important section of healthcare. Its high level of acceptance among the general population represents a challenge to healthcare professionals of all disciplines and raises a host of ethical issues. This article is an attempt to explore some of the more obvious or practical ethical aspects of complementary and alternative medicine.

Dissatisfaction with medical care among women with HIV: dimensions and associated factors.

Studies have shown that women with HIV/AIDS in the USA are less likely than men to have access to appropriate health care and to utilize services, including the latest antiretroviral drug therapies. One explanation for this underutilization is patient dissatisfaction with medical care. Dissatisfaction with care has been shown to be associated not only with treatment underutilization, but also with discontinuity of care and poor clinical outcomes. Using Patient Satisfaction Questionnaire data from a national cohort of women with HIV, this study examines levels of dissatisfaction across seven established dimensions of care, and uses multivariate analysis to identify patient characteristics associated with these dimensions (N = 1,303). Women were most dissatisfied with access to care and the technical quality of care, and least dissatisfied with financial aspects of care and their providers' interpersonal manner. Women who reported poor health, who had depressive symptomatology, who were not receiving antiretroviral therapy (ART), who had no consistent care providers or who were Hispanic/Latina were more likely to be dissatisfied across most dimensions of care. Implications for enhancing clinical care for women with HIV/AIDS and overcoming barriers to utilization of care and treatment are discussed.

HIV multidisciplinary teams work: support services improve access to and retention in HIV primary care.

The multidisciplinary team model of HIV care evolved out of necessity due to the diverse characteristics and needs of people living with HIV disease. Though it is now accepted as the international standard of care, it represents a significant departure from methods of care for other infectious diseases, and debate continues regarding the effectiveness of its interventions. The debate has been largely uninformed by data; for example, little is known about the relationship between ancillary support services and primary care outcomes. We hypothesized that support services increase access to and retention in HIV primary care in an inner city public hospital clinic. We conducted a retrospective analysis of clinical data sets on 2,647 patients at the CORE Center, Chicago from 1997-1998 to investigate the relationship between four support services-case management (CM), transportation (TRANS), mental health (MH) and chemical dependency (CD)-and access to and retention in HIV primary care. We found that patients who received each of these services were significantly more likely to receive any care, regular care and had more visits than patients with no service, and retention increased by 15-18%. Female gender, younger age, self-pay status and IDU predicted less regular care. Need for all services was substantial and significantly greater in women. Outcomes improved to the greatest extent among patients who needed and received each service. We conclude that support services significantly increased access to and retention in HIV primary care. Our findings validate the multidisciplinary team model of HIV care, and suggest that health services that are tailored to the express needs of patients lead to better care and improved health outcomes. Further testing of changes in health care delivery to meet the rapidly changing needs of people living with HIV disease and respond to the constantly changing practice of HIV medicine is urgently needed to maintain and extend the advances in HIV care outcomes of the past decade.

Non-prescription complementary treatments used by rheumatoid arthritis patients attending a community-based rheumatology practice.

BACKGROUND: Over 80% of rheumatoid arthritis (RA) patients have used some type of complementary medicine (CM) at some time. Little is known about RA patients' perceptions of the efficacy, hazards and costs associated with CM use relative to physician-prescribed medicine. These data may be helpful in better understanding patients' needs and in improving their care. AIMS: To determine the prevalence and features of CM use among RA patients attending a community-based private rheumatology practice. CM was defined as treatment that was initiated by the patient, excluding treatment that had been prescribed or specifically recommended by their doctor. telephone-administered questionnaire was used to survey a stratified random sample of 200 RA patients who had attended the practice within the preceding year. The main outcome measures were: (i) CM use in the past year, (ii) patient expenditure on CM, (iii) patients' perceptions of CM and (iv) characteristics of patients using CM. RESULTS: One hundred and six patients responded (response rate 53%) and 101 completed the interview. Seventy-four patients (73.3%) had used some form of CM in the past year. There were 68 (67.3%) patients who had utilized complementary therapies and 32 patients (31.7%) who had consulted a complementary practitioner for their RA. The most commonly used treatments were dietary (64 instances) and behavioural/cognitive therapies (45 instances). Prescription medicine was considered more beneficial than either form of CM, and users and non-users of CM held a similar perception of the efficacy of prescription medicine. The median amount spent on RA treatment per month was $A7 (range 0-91) for complementary treatments, $A26 (1-270) for complementary practitioners and $A7 (0-80) for prescription medicine. Women were more likely to have consulted a CM practitioner (OR = 1.5; 95% CI: 1.2-1.9), as were patients who were not receiving a pension (OR = 1.7; 95% CI: 1.1-2.6). CONCLUSIONS: This study confirmed that CM use is prevalent among RA patients attending a community-based private rheumatology practice. Despite lesser perceived benefit, patients spent at least as much money on CM as they did on prescription medicine. These findings suggest that there are other factors motivating the use of alternative treatments.

Major long-term factors influencing dental education in the twenty-first century.

With evolutionary advances in oral science over the long term, clinical reliance on chemotherapeutics, bacterial replacement therapy, and immunization will necessitate a broader background in medicine. The dramatic increase in the old age population will also require a much stronger medical background. By 2050, those over fifty-five years of age will represent 56 percent of the population, and 25 percent of these will be sixty-five years of age and older. The merging of dental and medical education is predicted to occur within the twenty-first century. Other topics addressed include research activities, with recommended strategies to enhance the integration of scientific and clinical dental approaches; the problem of dental faculty isolation; and the implications of financial constraint and accountability.

A multivariable model for predicting the need for blood transfusion in patients undergoing first-time elective coronary bypass graft surgery.

BACKGROUND: The incidence of blood transfusion in coronary artery bypass graft (CABG) surgery remains high. Preoperative identification of those at high risk for requiring blood will allow for the cost-effective use of some blood conservation modalities. Multivariable analysis techniques were used in this study to develop a prediction rule for such a purpose. STUDY DESIGN AND METHODS: Data were prospectively collected for all patients undergoing elective first-time CABG surgery from January 1997 to September 1998 at a tertiary-care teaching hospital (n = 1007). The prediction rule was developed on the first two-thirds of the sample by using logistic regression methods to examine the relationship of patient demographics, comorbidities, and preoperative Hb with perioperative blood transfusion. The remaining one-third of the sample was used to validate the rule. RESULTS: The transfusion rate was 29.4 percent. The prediction rule included preoperative Hb (g/dL, OR 0.928, p<0.0001), weight (kg, OR 0.938, p<0.0001), age (years, OR 1.037, p<0.01), and sex (male/female, OR 0.493, p<0.01); receiver operating characteristic = 0.86. When externally validated, the rule had a sensitivity of 82.1 percent and a specificity of 63.6 percent (at a selected probability cutoff). CONCLUSION: A simple and valid prediction rule is developed for predicting the risk of blood transfusion in patients undergoing first-time elective CABG surgery.