Advances in secondary prevention mechanisms of macrovascular complications in type 2 diabetes mellitus patients: a comprehensive review.

Type 2 diabetes mellitus (T2DM) poses a significant global health burden. This is particularly due to its macrovascular complications, such as coronary artery disease, peripheral vascular disease, and cerebrovascular disease, which have emerged as leading contributors to morbidity and mortality. This review comprehensively explores the pathophysiological mechanisms underlying these complications, protective strategies, and both existing and emerging secondary preventive measures. Furthermore, we delve into the applications of experimental models and methodologies in foundational research while also highlighting current research limitations and future directions. Specifically, we focus on the literature published post-2020 concerning the secondary prevention of macrovascular complications in patients with T2DM by conducting a targeted review of studies supported by robust evidence to offer a holistic perspective.

Occupational therapy and cooking: A scoping review and future directions.

BACKGROUND: Occupational therapy (OT) has historically used cooking as an intervention and assessment approach across settings. Current practices in OT and the emergence of the multidisciplinary field of culinary medicine highlight the relationship between cooking and health. AIMS/OBJECTIVES: To map the current literature on OT and cooking and to identify key factors that may facilitate collaboration within culinary medicine. MATERIALS AND METHODS: We conducted a scoping review using the Joanna Briggs Institute methodology to identify primary contexts and clinical settings. Publications were analysed using framework thematic analysis to identify OT themes and roles. RESULTS: A total of 56 studies met the criteria for inclusion. The majority of studies (n = 29, 53%) represented home/community settings and brain injury was the largest clinical group (n = 15, 27%). Primary themes related to person (n = 47, 43%), occupation (n = 30 (28%), environment (n = 19, 17%), and psychosocial wellbeing (n = 13, 12%). The primary OT role identified was that of interventionist (n = 48, 86%). CONCLUSIONS/SIGNIFICANCE: OT's holistic practice places cooking within a larger context that can help identify and overcome the barriers to participation. Findings support multiple pathways in which OT can contribute to cooking initiatives for health promotion and potentially expand OT practice in population health.

Evaluation of skin cancer screening in Germany - participation, tumor detection and interval tumors based on SHI data.

BACKGROUND AND GOALS: The rising incidence of skin cancer in Germany has increased the need for secondary prevention measures. For this purpose, a statutory skin cancer screening for insured persons aged 35 and older was introduced on 1 June 2008. The aim of this work package in the Innovation Fund project "Perspectives of a multimodal evaluation of early skin cancer detection" (Pertimo) was to test an evaluation of skin cancer screening using secondary data. PATIENTS AND METHODS: The data basis was statutory insured persons of the DAK Health from the age of 35 who were insured as of 31 December 2010 and were followed up until the end of 2015. The rates of participation, skin tumors detected in skin cancer screening (tumor detections), and interval tumors that occurred within two years after a finding-free skin cancer screening were calculated. RESULTS: The biennial skin cancer screening take-up rate in 2014 and 2015 was 33.6% for women and 32.6% for men. Of those screened, 4.2% had a skin cancer finding (tumor detection) in the course of skin cancer screening. Of all incident skin cancer diagnoses (2012-2015), 50.1% were detected in skin cancer screening. In 1.5% of the insured persons with skin cancer screening without findings, an incidental skin tumor was diagnosed in the following two years (interval tumor). CONCLUSIONS: The data from the statutory health insurance mapped the skin cancer screening occurrence in Germany and highlighted the importance of dermatologists in the screening process. The analysis provided important new insights.

Pharmacodynamic advantages and characteristics of traditional Chinese medicine in prevention and treatment of ischemic stroke.

Ischemic stroke (IS) is a severe cerebrovascular disease with a high incidence, mortality, and disability rate. The first-line treatment for IS is the use of recombinant tissue plasminogen activator (r-tPA). Regrettably, numerous patients encounter delays in treatment due to the narrow therapeutic window and the associated risk of hemorrhage. Traditional Chinese medicine (TCM) has exhibited distinct advantages in preventing and treating IS. TCM enhances cerebral microcirculation, alleviates neurological disorders, regulates energy metabolism, mitigates inflammation, reduces oxidative stress injuries, and inhibits apoptosis, thereby mitigating brain damage and preventing IS recurrence. This article summarizes the etiology, pathogenesis, therapeutic strategies, and relationship with modern biology of IS from the perspective of TCM, describes the advantages of TCM in the treatment of IS, and further reviews the pharmacodynamic characteristics and advantages of TCM in the acute and recovery phases of IS as well as in post-stroke complications. Additionally, it offers valuable insights and references for the clinical application of TCM in IS prevention and treatment, as well as for the development of novel drugs.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS: A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE: This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines.

AIM: The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS: A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE: This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Omega-3 Fatty Acids in Arterial Hypertension: Is There Any Good News?

Omega-3 polyunsaturated fatty acids (ω-3 PUFAs), including alpha-linolenic acid (ALA) and its derivatives eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are "essential" fatty acids mainly obtained from diet sources comprising plant oils, marine blue fish, and commercially available fish oil supplements. Many epidemiological and retrospective studies suggested that ω-3 PUFA consumption decreases the risk of cardiovascular disease, but results of early intervention trials have not consistently confirmed this effect. In recent years, some large-scale randomized controlled trials have shed new light on the potential role of ω-3 PUFAs, particularly high-dose EPA-only formulations, in cardiovascular prevention, making them an attractive tool for the treatment of "residual" cardiovascular risk. ω-3 PUFAs' beneficial effects on cardiovascular outcomes go far beyond the reduction in triglyceride levels and are thought to be mediated by their broadly documented "pleiotropic" actions, most of which are directed to vascular protection. A considerable number of clinical studies and meta-analyses suggest the beneficial effects of ω-3 PUFAs in the regulation of blood pressure in hypertensive and normotensive subjects. These effects occur mostly through regulation of the vascular tone that could be mediated by both endothelium-dependent and independent mechanisms. In this narrative review, we summarize the results of both experimental and clinical studies that evaluated the effect of ω-3 PUFAs on blood pressure, highlighting the mechanisms of their action on the vascular system and their possible impact on hypertension, hypertension-related vascular damage, and, ultimately, cardiovascular outcomes.

Implementing an Innovative Lipid Management Technique Using siRNA LDL-C Lowering Therapy: Lessons Learned in an NHS Primary Care Practice With Worked Case Examples.

INTRODUCTION: The UK Government partnered with industry to tackle cardiovascular disease (CVD) in the first NHS population health agreement. The ambition was to prevent 150 000 strokes, heart attacks and dementia cases over the next 10 years with a new siRNA LDL-C lowering therapy (Inclisiran) delivered within Integrated Care Services by primary care to support a comprehensive approach to lipid management. Following the approval of inclisiran, and guidance published by the National Institute for Health & Care Excellence (NICE) on its use, this paper has been created by a UK general practice to share real-world observations of cases and the potential service benefits of rolling out this innovative drug treatment. The process of identifying patients at risk of atherosclerotic cardiovascular disease (ASCVD) and lessons learned from implementing in practice is also addressed. Workstreams were developed to rapidly roll out a low clinical burden enhanced lipid management program incorporating siRNA LDL-C lowering therapy into primary care practice. APPROACH/METHOD: (1) Multi-disciplinary team (MDT) education program based on freely available Academic Health Science Network (AHSN), National Institute for Health & Care Excellence (NICE), and commercial materials. (2) Automated searches using a software program were run to identify "at-risk" patients alongside manual case-finding in everyday clinics. (3) Patients were invited for review using multi-channel modalities. (4) Where appropriate, treatment was commenced after consent was obtained. (5) Automated recall systems are used to ensure follow-up; initially at 3 months, then every 6 months. DISCUSSION AND CONCLUSIONS: Enhanced lipid management as a secondary prevention measure is achievable in line with national guidance and objectives. The methodology and education/training processes used in combination with reconstructing the management process can help practice staff realize the program benefits, which in turn can lead to a shift in behavior where all staff embed manual case-finding of high-risk patients into everyday consultations and reviews; enabling rapid identification of eligible patients. Taking a multi-disciplinary, holistic approach to new initiatives reduces service burden, particularly for GPs. Leveraging resources from the AHSN and others removes additional training pressures often associated with new initiatives and provides a wealth of educational material to support primary care MDT upskilling.

"I Assumed It Would Be Somebody Who Had a Stroke That Was Doing This": Views of Stroke Survivors, Caregivers, and Health Professionals on Tailoring a Relaxation and Mindfulness Intervention.

Stroke survivors and informal caregivers experience high levels of stress and anxiety, linked to heightened risk of secondary stroke in survivors. Relaxation and mindfulness could reduce stress and anxiety; being most effective when tailored to the target populations. Aims of the PPI include to: (1) consult on possible alterations to an existing relaxation and mindfulness intervention, delivered via YouTube/DVD and (2) discuss relevance and preference of prompts and cues designed to facilitate the daily practice of the intervention. Eleven UK PPI contributors were consulted during 2020: four stroke survivors (F = 2, M = 2), three caregivers (F = 1, M = 2), and four HCPs (F = 4) (range = 23-63 years). Contributors watched the existing intervention and provided feedback via online discussions. Transcripts were analysed using thematic analysis. Five themes were identified, highlighting several necessary alterations to the intervention: "Who represents the stroke population?"; "The paradox of age"; "Specifically selected language"; "Visual presentation of the intervention"; and the "Audio qualities". Contributors ranked the prompts and cues in order of preference with setting alarms and email alerts as the most popular. The PPI consultations resulted in several alterations enabling a revised version of the intervention. Including a PPI consultation at an early stage of the research improves the relevance and appropriateness of the research. The revised intervention is more representative of the stroke population thus more likely to be practised by survivors and caregivers, which will enhance the extent of effectiveness, reducing the risk of a secondary stroke.

Intervenções não farmacológicas na prevenção da doença mental em adolescentes / Non-pharmacological interventions for preventing mental illness in adolescents

O presente Relatório tem como objetivo narrar as experiências em contexto de Estágio, por forma a adquirir competências de EE e Mestre e a espelhar a prestação de cuidados de EE ESMP, numa abordagem holística, previligiada pela relação, baseada num padrão de qualidade que garanta a recuperação das Pessoas cuidadas. Este Relatório foi delineado em três partes, nomeadamente a implementação do Projeto de Estágio; as atividades desenvolvidas no contexto de Comunidade, num serviço de internamento de Pedopsiquiatria e na Enfermagem de Ligação; e a aquisição de competências. A SM é uma área da Saúde cada vez mais prioritária, visto que a violação dos direitos humanos, aliado à vulnerabilidade de vários grupos na comunidade, compõe a base do desenvolvimento de perturbações mentais, promovendo estigma e descriminação. A atuação na prevenção primária e secundária é fundamental na promoção de estratégias que ajudem o Adolescente a ultrapassar o seu período de transição desenvolvimental, crítico e permeável a fatores de risco no desenvolvimento de doenças mentais, pela sua Vulnerabilidade acrescida. Estar em relação com adolescentes em sofrimento mental implica disponibilidade e criatividade na implementação de estratégias que fomentem o reconhecimento dos seus recursos internos e direitos fundamentais, numa parceria de cuidados no processo de prevenção da doença mental e recuperação da saúde. Para responder às intervenções de Enfermagem que previnem a doença mental nos Adolescentes, foi realizada uma revisão sistemática da literatura. O programa de intervenção: "Intervenções não farmacológicas na prevenção da doença mental em Adolescentes", realizado num serviço de internamento, teve como finalidade o desenvolvimento de intervenções psicossociais que se revelaram num meio holístico de relação e cuidado. Diferentes intervenções terapêuticas com jovens com diferentes necessidades emocionais, geraram diversas oportunidades no desenvolvimento de hábitos sociais e emocionais cruciais para a sua SM, facilitando a reintegração psicossocial e representando-se fundamental nesta fase de Vida.

The present report aims to narrate the experiences in the internship context, in order to acquire Psychiatric Nursing and Master skills and to mirror the provision of specialized nursing care in Mental and Psychiatric Health, in a holistic approach, privileged by the relationship, based on a quality standard that ensures the recovery of the people cared for. This Report was outlined in three parts, namely the implementation of the Intervention Program, the activities performed in the Community context, in a Paediatric inpatient service and in Liaison Nursing; and the acquisition of skills. Mental Health is an increasingly priority area of Health, since the violation of human rights, combined with the vulnerability of several groups in the community, forms the basis for the development of mental disorders, promoting stigma and discrimination. The action in primary and secondary prevention is fundamental in promoting strategies that help Adolescents to overcome their developmental transition period, which is critical and permeable to risk factors in the development of mental illnesses, due to their increased vulnerability. Being in relationship with adolescents in mental suffering implies availability and creativity in the implementation of strategies that promote the recognition of their internal resources and fundamental rights, in a care partnership to prevent mental illness and health recovery. To respond to Nursing interventions that prevent mental illness in Adolescents, a systematic literature review was carried out. The intervention program: "Non-medical interventions in the prevention of mental illness in Adolescents", was carried out in an inpatient service, aimed at the development of Psychosocial interventions that proved to be a holistic means of relationship and care. Different therapeutic interventions with young people with different emotional needs generated several opportunities to develop social and emotional habits, crucial to their mental health, promoting psychosocial reintegration and representing fundamental in this stage of life.

Inpatient suicide in psychiatric settings: Evaluation of current prevention measures.

The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.

Naoxintong Capsule for Secondary Prevention of Ischemic Stroke: A Multicenter, Randomized, and Placebo-Controlled Trial.

OBJECTIVE: To examine whether the combination of Naoxintong Capsule with standard care could further reduce the recurrence of ischemic stroke without increasing the risk of severe bleeding. METHODS: A total of 23 Chinese medical centers participated in this trial. Adult patients with a history of ischemic stroke were randomly assigned in a 1:1 ratio using a block design to receive either Naoxintong Capsule (1.2 g orally, twice a day) or placebo in addition to standard care. The primary endpoint was recurrence of ischemic stroke within 2 years. Secondary outcomes included myocardial infarction, death due to recurrent ischemic stroke, and all-cause mortality. The safety of drugs was monitored. Results were analyzed using the intention-to-treat principle. RESULTS: A total of 2,200 patients were enrolled from March 2015 to March 2016, of whom 143 and 158 in the Naoxintong and placebo groups were lost to follow-up, respectively. Compared with the placebo group, the recurrence rate of ischemic stroke within 2 years was significantly lower in the Naoxintong group [6.5% vs. 9.5%, hazard ratio (HR): 0.665, 95% confidence interval (CI): 0.492-0.899, P=0.008]. The two groups showed no significant differences in the secondary outcomes and safety, including rates of severe hemorrhage, cerebral hemorrhage and subarachnoid hemorrhage (P>0.05). CONCLUSION: The combination of Naoxintong Capsule with standard care reduced the 2-year stroke recurrence rate in patients with ischemic stroke without increasing the risk of severe hemorrhage in high-risk patients. (Trial registration No. NCT02334969).

Mindfulness and Relaxation Techniques for Stroke Survivors with Aphasia: A Feasibility and Acceptability Study.

Stroke survivors with aphasia (SsWA) tend to experience high levels of anxiety and stress, leading to an increased risk of recurrent strokes. Mindfulness and/or relaxation that does not require language outputs could reduce psychosocial stress; however, these approaches work best if they consist of a range of techniques and are modified to suit the needs of SsWA. Using a mixed-methods approach, we examined the feasibility and acceptability of a set of tailored mindfulness and relaxation techniques for SsWA. Nine SsWA were recruited (six men and three women, median age = 51 years). Four relaxation and mindfulness techniques which had been tailored for SsWA were filmed into a DVD/YouTube video and were given to participants together with a practice diary for home practice once daily for 5 weeks. The participants joined focus group discussions and completed a feasibility scale 5 weeks later. The participants perceived these techniques as easy, user-friendly and acceptable for SsWA in general. Although practised less often than instructed, many participants reported benefits of regular practice. The perceived relevance of these techniques to the participants' own situations and the intention to continue varied. Future research could encourage the regular practice of self-help interventions by incorporating behavioural change techniques such as using prompts and cues.

Profile and 3-month evolution of geriatric patients after a hip fracture followed-up at a Fracture Liaison Service (FLS).

INTRODUCTION: There are few studies on Fracture Liaison Service (FLS) that evaluate older patients after a hip fracture (HF) through comprehensive geriatric assessment. We aim to determine these patients' characteristics, outcomes, and prescribed treatments. METHODS: A retrospective observational study of a cohort of patients older than 65 years admitted with HFs to an orthogeriatric unit between February 25th (2013) and December 16th (2016). After hospitalization, those patients with a good baseline social, functional, and cognitive situation were referred to the FLS. A comprehensive geriatric assessment and treatment adjustment were conducted. A comparison between FLS patients and HF patients non-referred was made. RESULTS: From 1887 patients admitted to the orthogeriatric unit, 469 (23%) were referred to the FLS. Of those, 335 were women (77.2%) and 337 (77.6%) lived in the community. The FLS patients had a better functional status (97.1% of the patients with independent gait versus 79.2%) than non-FLS patients (p<0.001). After 3 months in the FLS, 356 (82%) patients had independent gait and had improved their analytical values. Antiosteoporotic treatment was prescribed to 322 patients (74%), vitamin D supplements to 397 (91.5%), calcium to 321 (74%), and physical exercise to 421 (97%). CONCLUSIONS: Patients referred to an FLS were younger, with a better functional and cognitive situation. At hospital discharge, they frequently presented gait impairment and laboratory abnormalities (anemia, hypoproteinemia, vitamin D deficiency) that presented good recovery due to the patient's previous baseline. These patients benefit from comprehensive treatment (pharmacological and non-pharmacological).

Comparison of American and European Guidelines for Primary Prevention of Cardiovascular Disease: JACC Guideline Comparison.

This review compares the primary prevention recommendations of the recent 2021 European Society of Cardiology (ESC) and 2019 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on cardiovascular disease (CVD) prevention. Although the 2019 ACC/AHA guideline represents its inaugural version, the ESC guideline is an update to its 2016 statement. Both guidelines address prevention using a holistic approach and agree on the importance of lifestyle optimization and intensified risk factor management. Cardiovascular (CV) risk assessment tools differ, reflecting the unique populations being screened as well as philosophical differences to their approach. Conventional risk factors are used to estimate CV risk, but each guideline acknowledges the role of risk modifiers to refine risk calculation. The ESC guideline recognizes the importance of nonclassical risk factors, including environmental issues, that impact CV health at the population level and calls for legislative action at the local, regional, and national levels.

Atrial Fibrillation Specific Exercise Rehabilitation: Are We There Yet?

Regular physical activity and exercise training are integral for the secondary prevention of cardiovascular disease. Despite recent advances in more holistic care pathways for people with atrial fibrillation (AF), exercise rehabilitation is not provided as part of routine care. The most recent European Society of Cardiology report for AF management states that patients should be encouraged to undertake moderate-intensity exercise and remain physically active to prevent AF incidence or recurrence. The aim of this review was to collate data from primary trials identified in three systematic reviews and recent real-world cohort studies to propose an AF-specific exercise rehabilitation guideline. Collating data from 21 studies, we propose that 360-720 metabolic equivalent (MET)-minutes/week, corresponding to ~60-120 min of exercise per week at moderate-to-vigorous intensity, could be an evidence-based recommendation for patients with AF to improve AF-specific outcomes, quality of life, and possibly prevent long-term major adverse cardiovascular events. Furthermore, non-traditional, low-moderate intensity exercise, such as Yoga, seems to have promising benefits on patient quality of life and possibly physical capacity and should, therefore, be considered in a personalised rehabilitation programme. Finally, we discuss the interesting concepts of short-term exercise-induced cardioprotection and 'none-response' to exercise training with reference to AF rehabilitation.

Development and evaluation of the MAINTAIN instrument, selecting patients suitable for secondary or tertiary preventive manual care: the Nordic maintenance care program.

BACKGROUND: Chiropractic maintenance care (MC) has been found to be effective for patients classified as dysfunctional by the West Haven-Yale Multidimensional Pain Inventory (MPI). Although displaying good psychometric properties, the instrument was not designed to be used in clinical practice to screen patients for stratified care pathways. The aim was to develop a brief clinical instrument with the intent of identifying dysfunctional patients with acceptable diagnostic accuracy. METHODS: Data from 249 patients with a complete MPI dataset from a randomized clinical trial that investigated the effect and cost-effectiveness of MC with a 12-month follow-up was used in this cross-sectional analysis. A brief screening instrument was developed to identify dysfunctional patients, with a summary measure. Different cut-offs were considered with regards to diagnostic accuracy using the original instrument's classification of dysfunctional patients as a reference. Very good diagnostic accuracy was defined as an area under the curve (AUC) metric between 0.8 and 0.9. The instrument was then externally validated in 3 other existing datasets to assess model transportability across populations and medical settings. RESULTS: Using an explorative approach, the MAINTAIN instrument with 10 questions (0-6 Likert responses) capturing 5 dimensions (pain severity, interference, life control, affective distress, and support) was developed, generating an algorithm-based score ranging from - 12 to 48. Reporting a MAINTAIN score of 18 or higher, 146 out of the 249 patients were classified as dysfunctional with 95.8% sensitivity and 64.3% specificity. At a score of 22 or higher, 109/249 were classified as dysfunctional with 81.1% sensitivity and 79.2% specificity. AUC was estimated to 0.87 (95% CI 0.83, 0.92) and Youden's index was highest (0.70) at a score of 20. The diagnostic accuracy was similar and high across populations with minor differences in optimal thresholds for identifying dysfunctional individuals. CONCLUSION: The MAINTAIN instrument has very good diagnostic accuracy with regards to identifying dysfunctional patients and may be used as a decision aid in clinical practice. By using 2 thresholds, patients can be categorized into "low probability (- 12 to 17)", "moderate probability (18 to 21)", and "high probability (22 to 48)" of having a good outcome from maintenance care for low back pain. TRIAL REGISTRATION: Clinical trials.gov; NCT01539863; registered February 28, 2012; https://clinicaltrials.gov/ct2/show/NCT01539863 .

Cardiac rehabilitation in rural and remote areas of North Queensland: How well are we doing?

OBJECTIVE: To address access to cardiac rehabilitation (CR) for people in R&R areas, this research aimed to investigate: (1) post discharge systems and support for people returning home from hospital following treatment for heart disease (HD). (2) propose changes to improve access to CR in R&R areas of NQ. SETTING: Four focus communities in R&R areas of NQ. PARTICIPANTS: Focus communities' health staff (resident/visiting) (57), community leaders (10) and community residents (44), discharged from hospital in past 5 years following treatment for heart disease (purposeful sampling). DESIGN: A qualitative descriptive case study, with data collection via semi-structured interviews. Inductive/deductive thematic analysis was used to identify primary and secondary themes. Health service audit of selected communities. RESULTS: Health services in the focus communities included multipurpose health services, and primary health care centres staffed by resident and visiting staff that included nurses, Aboriginal and Torres Strait Islander Health Workers, medical officers, and allied health professionals. Post-discharge health care for people with HD was predominantly clinical. Barriers to CR included low referrals to community-based health professions by discharging hospitals; poorly defined referral pathways; lack of guidelines; inadequate understanding of holistic, multidisciplinary CR by health staff, community participants and leaders; limited centre-based CR services; lack of awareness, or acceptance of telephone support services. CONCLUSION: To address barriers identified for CR in R&R areas, health care systems' revision, including development of referral pathways to local health professionals, CR guidelines and in-service education, is required to developing a model of care that focuses on self-management and education: Heart: Road to Health.

Estimated Aggregate Treatment Benefit With Addition of Multiple Novel Medications for Secondary Prevention of Atherosclerotic Cardiovascular Disease.

PURPOSE: Interest in improving residual cardiovascular (CV) risk by targeting multiple causative pathways has been growing. Several medications including icosapent ethyl, rivaroxaban, and ezetimibe have been shown to individually improve outcomes in the secondary prevention of atherosclerotic cardiovascular disease (ASCVD) beyond conventional therapy consisting of aspirin and statins. While each drug has been shown to individually improve outcomes, the expected treatment benefit of the combined use of these drugs for enhanced secondary prevention of ASCVD is not known. METHODS: In this cross-trial analysis, we estimated the aggregate treatment effect of comprehensive medical therapy consisting of icosapent ethyl, rivaroxaban, and ezetimibe added to background aspirin and statin therapy through established methods of indirect comparisons of the results of three key clinical trials (REDUCE-IT [n = 8,179], COMPASS [n = 27,395], and IMPROVE-IT [n = 18,144]). The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke. Secondary endpoints included each individual component of the primary endpoint. RESULTS: The hazard ratio (HR) of the imputed aggregate treatment effects for enhanced secondary prevention of ASCVD with comprehensive disease modifying therapy compared to aspirin and statin alone for the primary endpoint was 0.51 (95% confidence interval [CI] 0.42-0.61). The HR for CV death was 0.62 (95% CI 0.46-0.85), non-fatal MI was 0.52 (95% CI 0.40-0.69), and non-fatal stroke was 0.35 (95% CI 0.23-0.54). The results were similar in sensitivity analyses. CONCLUSION: The estimated aggregate treatment effect of enhanced secondary prevention of ASCVD through comprehensive medical therapy is substantial. This exploratory analysis supports further study of comprehensive therapy to reduce residual CV risk for the secondary prevention of ASCVD.