Standard vs. intensified management of heart failure to reduce healthcare costs: results of a multicentre, randomized controlled trial.

AIMS: To determine if an intensified form of heart failure management programme (INT-HF-MP) based on individual profiling is superior to standard management (SM) in reducing health care costs during 12-month follow-up (primary endpoint). METHODS AND RESULTS: A multicentre randomized trial involving 787 patients (full analysis set) discharged from four tertiary hospitals with chronic HF who were randomized to SM (n = 391) or INT-HF-MP (n = 396). Mean age was 74 ± 12 years, 65% had HF with a reduced ejection fraction (31.4 ± 8.9%) and 14% were remote-dwelling. Study groups were well matched. According to Green, Amber, Red Delineation of rIsk And Need in HF (GARDIAN-HF) profiling, regardless of location, patients in the INT-HF-MP received a combination of face-to-face (home visits) and structured telephone support (STS); only 9% (`low risk') were designated to receive the same level of management as the SM group. The median cost in 2017 Australian dollars (A$1 equivalent to ∼EUR €0.7) of applying INT-HF-MP was significantly greater than SM ($152 vs. $121 per patient per month; P < 0.001), However, at 12 months, there was no difference in total health care costs for the INT-HF-MP vs. SM group (median $1579, IQR $644 to $3717 vs. $1450, IQR $564 to $3615 per patient per month, respectively). This reflected minimal differences in all-cause mortality (17.7% vs. 18.4%; P = 0.848) and recurrent hospital stay (18.6 ± 26.5 vs. 16.6 ± 24.8 days; P = 0.199) between the INT-HF-MP and SM groups, respectively. CONCLUSION: During 12-months follow-up, an INT-HF-MP did not reduce healthcare costs or improve health outcomes relative to SM.

HIV testing in Acute Care.

Readers may be aware of the need to improve uptake of HIV testing in health care-settings to reduce the number of individuals with undiagnosed infection who later present with advanced disease. Late presentation of HIV infection is associated with a poorer immune response to antiretroviral therapy, an increased morbidity and mortality with a resultant higher cost burden to health-care services. Individuals with undiagnosed HIV infection who inadvertently transmit their infection to others are thought to be responsible for more than half of new HIV infections in the USA.

Care-seeking decisions for worsening symptoms in heart failure: a qualitative metasynthesis.

Over 50 % of heart failure (HF) patients delay seeking help for worsening symptoms until these reach acute levels and require emergency hospitalisation. This metasynthesis aimed to identify and explore factors influencing timely care-seeking in patients with HF. Electronic databases searched were MEDLINE, Embase, and CINAHL. Studies were included if they were peer-reviewed journal articles, written in English, and reported perspectives of HF patients following qualitative data collection and analysis. Forty articles underwent analysis following the approach of Thomas and Harden. Leventhal's self-regulatory model (SRM) was used to organise the literature. Much of the literature fits within the SRM; however, this model did not account for all factors that influence patients' care-seeking for worsening symptoms. Factors not accounted for included patients' appraisals of previous care-seeking experiences, perceived system and provider barriers to accessing care, and the influence of external appraisals. When added to factors already represented in the model, such as misattribution of symptoms, not identifying with HF diagnosis, cognitive status, lack of understanding information provided, adaptation to symptoms, and emotional responses, a more comprehensive account of patients' decision-making was revealed. This metasynthesis identified factors, as yet unaccounted for, in a prominent model, and has suggested a more comprehensive framework for addressing care-seeking in HF patients. This information can be used to tailor education, communication, and service initiatives to improve HF patients' responses to worsening symptoms and target those most at risk of delay.

The prevalence and impact of depression and anxiety in cardiac rehabilitation: A longitudinal cohort study.

BACKGROUND: Co-morbid depression and anxiety symptoms are frequently under-recognised and under-treated in heart disease and this negatively impacts self-management. AIMS: The purpose of this study was to determine the prevalence, correlates and predictors of depression and anxiety in cardiac rehabilitation programmes, the impact of cardiac rehabilitation on moderate depression, anxiety and stress symptoms, and the relationship between moderate depression, anxiety and stress symptoms and cardiac rehabilitation adherence. METHODS: This was a retrospective cohort study of 5908 patients entering cardiac rehabilitation programmes from 2006-2017, across two Sydney metropolitan teaching hospitals. Variables included demographics, diagnoses, cardiovascular risk factors, medication use, participation rates, health status (Medical Outcomes Study Short Form-36) and psychological health (Depression Anxiety Stress Scales) subscale scores. RESULTS: Moderate depression, anxiety or stress symptoms were prevalent in 18%, 28% and 13% of adults entering cardiac rehabilitation programmes, respectively. Adults with moderate depression (24% vs 13%), anxiety (32% vs 23%) or stress (18% vs 10%) symptoms were significantly less likely to adhere to cardiac rehabilitation compared with those with normal-mild symptoms (p < 0.001). Anxiety (odds ratio 4.395, 95% confidence interval 3.363-5.744, p < 0.001) and stress (odds ratio 4.527, 95% confidence interval 3.315-6.181, p < 0.001) were the strongest predictors of depression. Depression (odds ratio 3.167, 95% confidence interval 2.411-4.161) and stress (odds ratio 5.577, 95% confidence interval 4.006-7.765, p < 0.001) increased the risk of anxiety on entry by more than three times, above socio-demographic factors, cardiovascular risk factors, diagnoses and quality of life. CONCLUSION: Monitoring depression and anxiety symptoms on entry and during cardiac rehabilitation can assist to improve adherence and may identify the need for additional psychological health support. Exploring the relevance and use of adjunct psychological support strategies within cardiac rehabilitation programmes is warranted.

Reliability of intra-abdominal pressure measurements using the modified Kron technique.

OBJECTIVES: Assessment of intra-abdominal pressure (IAP) and the likelihood of abdominal compartment syndrome using valid and reliable measures is an important tool in the assessment of critically ill patients. The current method of relying on a single IAP per measurement period to determine patient clinical status raises the question: is a single intermittent IAP measurement an accurate indicator of clinical status or should more than one measurement be taken per measurement period? METHODS: This study sought to assess the reliability of IAP measurements. Measurements were taken using the modified Kron technique. A total of two transvesical intra-abdominal pressure measurements were undertaken per patient using a standardized protocol. Recordings were taken at intervals of 5 minutes. RESULTS: The majority of participants (58%) were surgical patients. Thirty-two were males and the mean age was 58 years (SD: 16·7 years). The concordance correlation coefficient between the two measurements was 0·95. Both the scatter and Bland-Altman plots demonstrate that the comparisons of two measurements are highly reproducible. CONCLUSION: The findings of this study suggest that conducting two IAP measurements on single patient produce comparable results; therefore, there appears to be no advantage in doing two IAP measurements on a single patient. The measurement of an IAP requires the implementation of a standardized protocol and competent and credentialed assessors trained in the procedure.

Short-term growth hormone administration at the time of opportunistic infections in HIV-positive patients.

OBJECTIVES: A 12-week course of recombinant human growth hormone is an effective but expensive therapy for established HIV-related wasting. Wasting in HIV disease is often episodic, coinciding with bouts of acute opportunistic infection. We hypothesized that a short course of growth hormone, targeted at the time of opportunistic infection, might improve protein metabolism thereby reducing lean tissue loss. METHODS: HIV-infected men with acute opportunistic infections, who received standard antimicrobial treatment for their infection as well as intensive nutritional counselling and oral energy supplements, were randomized to receive growth hormone or placebo for 14 days. Principal assessments were protein metabolism (measured by 13C-leucine infusion), body composition (measured by DEXA) and safety. RESULTS: There were no significant changes in outcome parameters in the placebo group (n = 11). In the growth hormone group (n = 9), protein catabolic rate decreased by 60% in the fasted state (P = 0.02 versus placebo), lean body mass increased by 2.2 kg (P = 0.03 versus baseline) and fat mass decreased by 0.7 kg (P = 0.002 versus baseline). There was no increase in adverse or serious adverse events in the growth hormone as compared with the placebo group. CONCLUSIONS: A two-week course of growth hormone at the time of acute opportunistic infection in HIV-infected patients improves protein metabolism and body composition during therapy and appears to be safe. This may represent a rational and economical approach to the use of growth hormone therapy.

A fatal case of Vibrio vulnificus septicemia.

A fatal case of Vibrio vulnificus septicemia in a 60 yr old man is described. This man displayed many of the classical features seen in fulminant infections with this organism. The epidemiology of V. vulnificus infections is discussed in this report.

Clostridium beijerinckii endophthalmitis secondary to penetrating ocular injury.

Endophthalmitis occurs in five to 10% of injuries involving intraocular foreign bodies. A 52 year old abattoir worker sustained such penetrating ocular trauma and developed fulminant endophthalmitis. Clostridium beijerinckii was isolated from the vitreous humor. Intravitreal vancomycin and amikacin and intravenous penicillin and clindamycin were given. Despite therapeutic vancomycin and amikacin levels in the vitreous, vision was lost and enucleation was ultimately required.

Clostridium tertium bacteremia: 2 cases and review.

Clostridium tertium bacteremia is unusual, seen most often with gastrointestinal disease and/or neutropenia. Two cases are described. The first was a 19-yr-old female with acute leukemia, who developed gastrointestinal symptoms and C. tertium bacteremia while neutropenic. The second was a 57-yr-old female with quiescent ulcerative colitis, who presented with fever, rigors and epigastric pain. Four organisms including C. tertium were isolated from blood cultures. This patient responded to broad spectrum antimicrobial therapy, whereas the first patient required the addition of specific agents to recover. C. tertium is aerotolerant and thus can be misidentified as a Bacillus or Corynebacterium spp. Our isolates had a distinctive Gram stain morphology, were catalase negative and failed to sporulate aerobically--this aided in the recognition of this significant Gram-positive bacillus.

The infection control management of MRSA in acute care.

BACKGROUND: Many acute care facilities report endemic methicillin-resistant Staphylococcus aureus (MRSA), while others describe the occurrence of sporadic disease outbreaks. The timely implementation of effective infection control measures is essential to minimise the incidence of MRSA cases and the magnitude of disease outbreaks. Management strategies for the containment and control of MRSA currently vary between facilities and demonstrate varying levels of effectiveness. OBJECTIVES: This review sought to systematically review the best available research regarding the efficacy of infection control practices in controlling endemic MRSA or MRSA outbreaks in the acute hospital setting. It updates an original review published in 2002. SEARCH STRATEGY: A systematic search for relevant published or unpublished English language literature was undertaken using electronic databases, the reference lists of retrieved papers and the Internet. This extended the search of the original review. Databases searched included: Medline, CINAHL, EMBASE, Cochrane Library and Joanna Briggs Institute Evidence Library. SELECTION CRITERIA: All research reports published between 1990 and August 2005 in the English language that focused upon the infection control strategies that were implemented in response to either a nosocomial outbreak of MRSA or endemic MRSA within an acute clinical setting were included. Only studies that reported interventions which were implemented following the collection of baseline data were included. DATA COLLECTION AND ANALYSIS: Two reviewers assessed each paper against the inclusion criteria and a validated quality scale. Data extraction was undertaken using a purposely designed tool. Given the heterogeneity of the interventions and outcomes measures, statistical comparisons of findings were not possible, therefore, the findings of this review are presented in a narrative format. RESULTS: Fourteen papers met the inclusion criteria for this review. Of these, 11 papers achieved a quality score above the threshold and were included in the review. Of the included papers, five describe MRSA outbreaks, while the remaining six describe endemic MRSA. All included studies used either exploratory descriptive or comparative designs.The varying combinations of interventions described in the included studies make it impossible to differentiate the efficacy of individual or even groups of interventions. The fact that most studies reported positive findings may reflect the bias towards publication of effective interventions. IMPLICATIONS FOR CLINICAL PRACTICE: This review provides evidence that the use of multifaceted strategies can reduce nosocomial MRSA transmission in both outbreaks of MRSA and settings where MRSA is endemic. The heterogeneous nature of the topic, combinations of interventions implemented and methodological weaknesses of the studies impairs the ability to aggregate data and develop specific recommendations for practice.

Barriers and facilitators to the implementation of the collaborative method: reflections from a single site.

BACKGROUND: A collaborative is an effective method of implementing evidence-based practice across multiple sites through the sharing of experience and knowledge of others in a similar setting, over a short period of time. Collaborative methods were first used in the USA but have been adopted internationally. AIM: This paper sought to document the facilitators and barriers to the implementation of the collaborative method, based on a single site's experience of participating in a multisite, state-wide heart failure collaborative. METHOD: Qualitative data was collected using three complementary METHODS: participant observation, reflective journalling and key informant interviews. Quantitative monitoring of team performance occurred monthly according to prespecified performance indicators. FINDINGS: Barriers and facilitators that were identified by this study included: organisational factors, team composition, dynamics and networking, changing doctor behaviour, clinical leadership and communication. CONCLUSION: The findings from this study underscore the importance of leadership, communication and team cohesion for the successful implementation of the collaborative method at individual sites. In addition, the importance of a preparatory stage that deals with known barriers and facilitators to the collaborative method before the commencement of the official study period was highlighted. The potential for the collaborative approach to improve clinical outcomes warrants further systematic evaluation of process issues and consideration of the barriers and facilitators to implementation in various settings.

Another look at the medical "generation gap".

A 1969 survey of attitudes held by medical students and recent graduates was repeated in 1972, using the same samples of respondents and adding a new freshman group. Findings from both surveys showed that a "generation gap" existed on many issues.Furthermore, a comparison of the two studies suggested that two kinds of attitude change are occurring simultaneously. On some issues, the next generation of physicians will probably continue to differ from their predecessors. Perhaps the primary thread woven through this cluster of attitudes is that today's medical students and young physicians perceive themselves as members of a larger structure for providing health care.However, many of the students' attitudes held early in their medical careers appear to have been modified in the process of becoming physicians. It appears that medical education continues to convey many traditional professional values to students, and it seems likely that tomorrow's physicians will retain a core of those values.

Survey of blood cultures from five community hospitals in south-western Sydney, Australia, 1993-1994.

BACKGROUND: Blood culture results have profound implications for patients. Comprehensive overviews of blood cultures have been uncommon, and focused on tertiary referral hospitals. AIM: To present a review of blood culture results from a laboratory servicing community hospitals in Sydney, Australia. METHODS: Retrospective chart review of patients with positive blood cultures from 1 June 1993 to 31 May 1994. RESULTS: During the survey period there were 107,382 hospital admissions; 12,109 blood culture sets from 9292 patients were processed. Of these 1197 sets were positive, representing 974 febrile episodes in 923 patients. There were 476 episodes of contamination. Of the episodes of true bacteraemia, Escherichia coli was isolated in 139, Staphylococcus aureus in 91 (22 methicillin-resistant), other enterobacteriaceae in 60, and Streptococcus pneumoniae in 5 1. The diagnoses attributable to bacteraemia included intravenous catheter-related sepsis (122 episodes), urinary tract infection (88), bacteraemia from unknown source (79), intra-abdominal and biliary sepsis (91), pneumonia (35), and meningitis (21). Sixty-eight patients died directly due to bacteraemia. Multivariate analysis showed underlying disease (OR 3.97) or shock (OR 28.1) predicted death. Blood cultures confirmed clinical diagnoses in 258 episodes, but made a de novo diagnosis in 205 episodes. CONCLUSIONS: This study describes the clinical and laboratory features of bacteraemias occurring in smaller public hospitals, as distinct from tertiary referral centres. It demonstrated that intravenous catheter-related sepsis was very common in smaller hospitals. The clinical diagnosis was frequently confirmed, and a de novo diagnosis was often established by a positive blood culture. Unfortunately nearly half the positive blood cultures represented contamination.

Autologous apoptotic T cells interact with dendritic cells, but do not affect their surface phenotype or their ability to induce recall immune responses.

Dendritic cells (DCs) play an important role in determining immunogenicity and the subsequent immune response. They may also have a role in maintaining peripheral tolerance to self-antigens by initiating an immune response only in the context of danger signals released from cells during stress, damage or death. These signals may originate from surrounding T cells as well as from other cells. Therefore, in this study the effect of autologous T cell injury on DC morphology and function has been investigated. Co-incubation of apoptotic or necrotic T cells with immature DCs altered their morphology towards a more mature appearance, with more cells showing activation as judged by spreading and formation of arborizing long processes. The apoptotic autologous T cells were rarely phagocytosed by immature DCs, compared to macrophages. The DC surface phenotype was not affected by the co-incubation with autologous injured T cells. The ability of DCs to elicit a secondary immune response was not altered by exposure to autologous injured T cells. These findings suggest that DC can continue to function in T cell activation, rather than in tolerogenic mode, even in the presence of large numbers of dying autologous T cells, such as may be present in the aftermath of an acute antiviral response.

Dendritic cell activation and cytokine production induced by group B Neisseria meningitidis: interleukin-12 production depends on lipopolysaccharide expression in intact bacteria.

Interactions between dendritic cells (DCs) and microbial pathogens are fundamental to the generation of innate and adaptive immune responses. Upon stimulation with bacteria or bacterial components such as lipopolysaccharide (LPS), immature DCs undergo a maturation process that involves expression of costimulatory molecules, HLA molecules, and cytokines and chemokines, thus providing critical signals for lymphocyte development and differentiation. In this study, we investigated the response of in vitro-generated human DCs to a serogroup B strain of Neisseria meningitidis compared to an isogenic mutant lpxA strain totally deficient in LPS and purified LPS from the same strain. We show that the parent strain, lpxA mutant, and meningococcal LPS all induce DC maturation as measured by increased surface expression of costimulatory molecules and HLA class I and II molecules. Both the parent and lpxA strains induced production of tumor necrosis factor alpha (TNF-alpha), interleukin-1alpha (IL-1alpha), and IL-6 in DCs, although the parent was the more potent stimulus. In contrast, high-level IL-12 production was only seen with the parent strain. Compared to intact bacteria, purified LPS was a very poor inducer of IL-1alpha, IL-6, and TNF-alpha production and induced no detectable IL-12. Addition of exogenous LPS to the lpxA strain only partially restored cytokine production and did not restore IL-12 production. These data show that non-LPS components of N. meningitidis induce DC maturation, but that LPS in the context of the intact bacterium is required for high-level cytokine production, especially that of IL-12. These findings may be useful in assessing components of N. meningitidis as potential vaccine candidates.