Discordance and concordance on perception of quality care at end of life between older patients, caregivers and clinicians: a scoping review.

BACKGROUND: This scoping review aimed to investigate the presence of discordance or concordance in the perceptions of end-of-life (EOL) care quality between consumers (i.e. patients aged over 60 in their last years of life and/or their informal caregivers) and clinicians, to inform further improvements in end-of-life care service delivery. METHODS: A scoping review of qualitative and quantitative studies was systematically undertaken by searching for English language publications in MEDLINE database and manual reference search of eligible articles. Thematic analysis was employed to identify and extract common concordance and discordance themes leading to the development of analytical constructs. Articles were eligible for inclusion if they reported on consumers' (i.e. older patients aged 60 + years in their final years of life and/or their informal caregivers) and clinicians' (doctors, nurses, social workers, etc.) perspectives on quality of medical, surgical or palliative/supportive care administered to older adults in the last year of life across all healthcare settings. RESULTS: Of the 2736 articles screened, 21 articles were included. Four themes identified concordance between consumers' and clinicians' perceptions of care quality: holistic patient care; coordinated care that facilitated EOL; the role of family at EOL; and impact of prognostic uncertainty on care planning. Three themes emerged for discordance of perceptions: understanding the patient needs at EOL; capacity of healthcare system/providers to accommodate family needs; and knowledge and communication of active or palliative care at EOL. CONCLUSIONS: While progress has been made on promoting patient autonomy and respecting the family role in representing patient's best interest, gaps remain in terms of care coordination, communication of prognosis, public understanding of the meaning of goals of care including de-escalation of management and enactment of advance care directives by clinicians for people with diminished decision capacity. Public understanding of the meaning of "comfort" care and the need to prevent over-treatment are essential for their satisfaction with care and their ability to embrace the concept of a good death.

Phage Therapy Related Microbial Succession Associated with Successful Clinical Outcome for a Recurrent Urinary Tract Infection.

We rationally designed a bacteriophage cocktail to treat a 56-year-old male liver transplant patient with complex, recurrent prostate and urinary tract infections caused by an extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli) (UCS1). We screened our library for phages that killed UCS1, with four promising candidates chosen for their virulence, mucolytic properties, and ability to reduce bacterial resistance. The patient received 2 weeks of intravenous phage cocktail with concomitant ertapenem for 6 weeks. Weekly serum and urine samples were collected to track the patient's response. The patient tolerated the phage therapy without any adverse events with symptom resolution. The neutralization of the phage activity occurred with sera collected 1 to 4 weeks after the first phage treatment. This was consistent with immunoassays that detected the upregulation of immune stimulatory analytes. The patient developed asymptomatic recurrent bacteriuria 6 and 11 weeks following the end of phage therapy-a condition that did not require antibiotic treatment. The bacteriuria was caused by a sister strain of E. coli (UCS1.1) that remained susceptible to the original phage cocktail and possessed putative mutations in the proteins involved in adhesion and invasion compared to UCS1. This study highlights the utility of rationally designed phage cocktails with antibiotics at controlling E. coli infection and suggests that microbial succession, without complete eradication, may produce desirable clinical outcomes.

Kinematics of shoulder, trunk, pelvis, and hip while reaching forward to progressively distant targets.

INTRODUCTION: Information on the normal contribution of various body regions to forward reaching provides a basis for assessing the maneuver. The purpose of this study was to describe the kinematics of the shoulder, trunk, pelvis, and hip of healthy young males while they stood and reached toward a target at arm's length and 5%, 10%, 15%, and 20% of body height beyond. METHOD: Twelve healthy adult males were marked with 22 spherical reflective markers. Two trials of unilateral forward reaching were performed towards a target placed at five target distances. Motion was captured via reflective markers and an infrared camera system. RESULTS: Sagittal and transverse plane motions demonstrated high reliability between trials at each target distance (ICC = 0.716 trunk flexion to 0.977 shoulder flexion). Shoulder flexion and horizontal abduction were major contributors to forward reaching with components of trunk flexion and left trunk rotation at all target distances. Hip flexion, pelvic tilt, left pelvis rotation, and hip external rotation made notable contributions at the furthest targets. All motions became more pronounced as target distance increased (P ≤ .001). CONCLUSION: Kinematic analysis demonstrated that right forward reaching requires composite movements at the shoulder, trunk, pelvis, and hip. The contribution of each body region to forward reaching became more pronounced as the target became more distant. These findings may be helpful when identifying localized movement impairments contributing to limited forward reach in a clinical population, although clinical validation is needed.

Blue-Light Therapy for Acne Vulgaris: A Systematic Review and Meta-Analysis.

PURPOSE: Antibiotic use in acne treatment raises concerns about increased resistance, necessitating alternatives. We assessed the effectiveness of blue-light therapy for acne. METHODS: We analyzed randomized controlled trials comparing blue light with nonlight interventions. Studies included people of any age, sex, and acne severity, in any setting, and reported on investigator-assessed change in acne severity, patients' assessment of improvement, change in inflammatory or noninflammatory lesions, and adverse events. Where data were sufficient, mean differences were calculated. RESULTS: Eighteen references (14 trials) including 698 participants were included. Most of the trials were small and short (<12 weeks) and had high risk of bias. Investigator-assessed improvement was quantitatively reported in 5 trials, of which 3 reported significantly greater improvement in blue light than comparator, and 2 reported improvement. Patients' assessments of improvement were quantitatively reported by 2 trials, favoring blue light. Mean difference in the mean number of noninflammatory lesions was nonsignificant between groups at weeks 4, 8, and 10-12 and overall (mean difference [MD] = 3.47; 95% CI, -0.76 to 7.71; P = 0.11). Mean difference in the mean number of inflammatory lesions was likewise nonsignificant between groups at any of the time points and overall (MD = 0.16; 95% CI, -0.99 to 1.31; P = 0.78). Adverse events were generally mild and favored blue light or did not significantly differ between groups. CONCLUSION: Methodological and reporting limitations of existing evidence limit conclusions about the effectiveness of blue light for acne. Clinicians and patients should therefore consider the balance between its benefits and adverse events, as well as costs.

A systematic review and meta-analysis of the effects of Qigong and Tai Chi for depressive symptoms.

BACKGROUND: Qigong and Tai Chi are the two most popular traditional Chinese exercises, known as mind-body movement therapies. Previous studies suggest that Qigong and Tai Chi may be beneficial in reducing depressive symptoms. This was the first study to systematically review and compare the effects of Qigong and Tai Chi on depressive symptoms. METHODS: A systematic search of six electronic databases was undertaken through to February 2014, for randomized controlled trials (RCTs) which reported depressive symptoms measured by a depressive symptom rating scale. The standardized mean difference in depressive symptoms score between Qigong or Tai Chi and a control group (at the end of follow-up) was extracted as a primary outcome. The secondary outcome was the standardized mean gain in symptom score (SMG) relative to the baseline from individual arms of the RCTs for various forms of care including Qigong, Tai Chi, usual care, other exercise, education and miscellaneous interventions. RESULTS: Thirty studies with a total of 2328 participants (823 males and 1505 females) were included. A significant effect was found for the Qigong interventions (Cohen's d -0.48 95% CI -0.48 to -0.12; SMG -0.52, 95% CI -0.79 to -0.26). There was no significant effect seen for Tai Chi for the primary endpoint. No mean change in symptom scores were seen for Tai Chi, usual care, other exercises, education and the 'miscellaneous' group in pre-post assessment in single arms. The Qigong results were found to be robust in sensitivity analyses. CONCLUSIONS: Qigong appears to be beneficial for reducing depressive symptom severity. However, given the low quality of the included studies and the documented evidence of publication bias, these results should be viewed cautiously.

The Impact of Acupuncture on Neurological Recovery in Spinal Cord Injury: A Systematic Review and Meta-Analysis.

Spinal cord injury (SCI) has become a significant social and economic burden for patients and their families. The effect of acupuncture on neurological recovery in individuals with SCI remains inconclusive despite previous studies and meta-analyses. The aim of the current study was to perform a more rigorous systematic review and bias-adjusted meta-analysis of studies so that the overall impact of acupuncture on neurological recovery in SCI can be determined. Randomized controlled trials (RCTs) only were included and were searched for in seven databases through to August 2014. Four key outcomes were assessed: neurological recovery, motor function, sensory function, and functional recovery. Several statistical approaches were compared, models were tested for robustness using sensitivity analysis, and results are presented as weighted mean difference (WMD) or standardized mean difference (SMD) for continuous outcomes and relative risk (RR) for binary outcomes. The included studies' susceptibility to bias was also assessed. A total of 12 studies were included after exclusions were applied. Heterogeneity was evident among the studies included. Pooled analyses showed that acupuncture may have a beneficial effect on neurological recovery (RRs: 1.28, 95% confidence interval [CI]: 1.12-1.50), motor function (WMD: 6.86, 95% CI: 0.41-13.31), and functional recovery (SMD: 0.88, 95% CI: 0.56-1.21) and all statistical approaches concurred. Sensitivity analyses suggested that the smaller studies (sample size <30), those with acute disease, and studies that used varying acupuncture sessions demonstrated a larger magnitude of effect. However, studies were generally of poor quality and publication bias favoring positive studies was evident. Therefore, the benefit of acupuncture we report is by no means definitive and well-designed future studies are recommended to confirm this.

Multipurpose prevention technologies: products in development.

Multipurpose prevention technologies (MPTs) are broadly defined as products capable of simultaneously addressing multiple sexual and reproductive health needs including unintended pregnancy, STIs including HIV-1, and other reproductive tract infections. MPTs have been discussed for a few decades but little product development has occurred. With the recent proof-of-concept that a topically applied antiretroviral (ARV) can effectively reduce sexual transmission of HIV-1 (tenofovir 1% gel) the impetus to develop MPTs is gaining momentum. Products currently in development are broadly categorized as either long-acting or on-demand. Long-acting MPTs include intravaginal rings (IVRs) and long-acting injectable products. Several IVR MPTs are under development including one designed to release tenofovir to prevent transmission of HIV-1 and levonorgestrel (LNG) to prevent unintended pregnancy over a 90-day period. Another MPT IVR under development is designed to release the ARV dapivirine and LNG for 2 months. Long-acting injectable pre-exposure prophylaxis (PrEP) formulations of rilpivirine (TMC278) and GSK1265744 have entered clinical evaluation and could form the basis of long-acting injectable products for HIV-1 prevention and prevention of unintended pregnancy. On-demand products include TFV 1% gel (HIV-1/HSV-2 prevention), a zinc/carrageenan zinc gel (HIV-1/HSV-2 prevention), and the SILCS diaphragm administered with TFV 1% gel. Significant technical, funding, and regulatory hurdles must be overcome to develop most MPTs; however, the significant reproductive health benefits to many women around the world should provide motivation to overcome these hurdles. This article is based on a presentation at the "Product Development Workshop 2013: HIV and Multipurpose Prevention Technologies", held in Arlington, Virginia on February 21-22, 2013. It forms part of a special supplement to Antiviral Research.

Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management.

OBJECT: Chiropractic manipulation of the cervical spine is a known cause of craniocervical arterial dissections. In this paper, the authors describe the patterns of arterial injury after chiropractic manipulation and their management in the modern endovascular era. METHODS: A prospectively maintained endovascular database was reviewed to identify patients presenting with craniocervical arterial dissections after chiropractic manipulation. Factors assessed included time to symptomatic presentation, location of the injured arterial segment, neurological symptoms, endovascular treatment, surgical treatment, clinical outcome, and radiographic follow-up. RESULTS: Thirteen patients (8 women and 5 men, mean age 44 years, range 30-73 years) presented with neurological deficits, head and neck pain, or both, typically within hours or days of chiropractic manipulation. Arterial dissections were identified along the entire course of the vertebral artery, including the origin through the V(4) segment. Three patients had vertebral artery dissections that continued rostrally to involve the basilar artery. Two patients had dissections of the internal carotid artery (ICA): 1 involved the cervical ICA and 1 involved the petrocavernous ICA. Stenting was performed in 5 cases, and thrombolysis of the basilar artery was performed in 1 case. Three patients underwent emergency cerebellar decompression because of impending herniation. Six patients were treated with medication alone, including either anticoagulation or antiplatelet therapy. Clinical follow-up was obtained in all patients (mean 19 months). Three patients had permanent neurological deficits, and 1 died of a massive cerebellar stroke. The remaining 9 patients recovered completely. Of the 12 patients who survived, radiographic follow-up was obtained in all but 1 of the most recently treated patients (mean 12 months). All stents were widely patent at follow-up. CONCLUSIONS: Chiropractic manipulation of the cervical spine can produce dissections involving the cervical and cranial segments of the vertebral and carotid arteries. These injuries can be severe, requiring endovascular stenting and cranial surgery. In this patient series, a significant percentage (31%, 4/13) of patients were left permanently disabled or died as a result of their arterial injuries.