Asthma and obstructive sleep apnea: Unveiling correlations and treatable traits for comprehensive care.

Asthma and obstructive sleep apnea (OSA) are common respiratory disorders. They share characteristics such as airway obstruction, poor sleep quality, and low quality of life. They are often present as comorbidities, along with obesity, gastroesophageal reflux disease (GERD), and allergic rhinitis (AR), which impacts the disease's control. In recent years, there has been discussion about the association between these conditions and their pathophysiological and clinical consequences, resulting in worse health outcomes, increased healthcare resource consumption, prolonged hospital stays, and increased morbidity and mortality. Some studies demonstrate that treatment with continuous positive airway pressure (CPAP) can have a beneficial effect on both pathologies. This review summarizes the existing evidence of the association between asthma and OSA at their pathophysiological, epidemiological, clinical, and therapeutic levels. It intends to raise awareness among healthcare professionals about these conditions and the need for further research.

Comprehensive Management of Type 2 Diabetes During Pregnancy.

This JAMA Insights Clinical Update discusses a comprehensive approach to treating pregnant patients with type 2 diabetes to reduce adverse perinatal and neonatal outcomes.

Preparación global en materia de violencia familiar del especialista de medicina general integral / Overall preparedness of family medicine specialists with respect to family violence

Introducción: Los especialistas de medicina general integral muestran un insuficiente desempeño en la detección, evaluación e intervención ante casos de violencia. Objetivo: Evaluar la preparación global en materia de violencia familiar del especialista de medicina general integral. Métodos: Se realizó un estudio descriptivo, de corte transversal, durante el primer semestre de 2019, que incluyó a 55 especialistas de medicina general integral, a los que se les aplicó un cuestionario, a partir de las tres dimensiones derivadas de la preparación global: A. prevención del riesgo, detección temprana y patogenia; B. evaluación y diagnóstico; C. intervención y seguimiento. Estas se operacionalizaron a través de veinte indicadores y en su evaluación se definieron cinco categorías o niveles: muy elevado, elevado, medio, bajo y muy bajo. Resultados: En las tres dimensiones exploradas se constató un predominio franco de la alternativa regularmente preparado, seguida por mal preparado. Por su parte, bien preparado, muy bien preparado y excelentemente preparado mostraron los porcentajes más bajos en todas las áreas. El 92,72 por ciento exhibió un nivel de preparación global muy bajo. El nivel de preparación global medio representó el 3,64 por ciento; y el nivel bajo, el 3,64 por ciento. Conclusiones: Existen insuficiencias en el orden cognitivo, axiológico y procedimental, que demuestran que la preparación global de estos profesionales en materia de violencia familiar tiene un limitado alcance para afrontar las variadas formas de expresión de este reprobable comportamiento(AU)

Introduction: Family medicine specialists show insufficient performance in the detection, evaluation and intervention in cases of violence. Objective: To evaluate the overall preparedness of family medicine specialists with respect to family violence. Methods: A descriptive and cross-sectional study was carried out during the first semester of 2019 with 55 family medicine specialists, who were applied a questionnaire, based on the three dimensions derived from overall preparedness: A. risk prevention, early detection and pathogenesis; B. evaluation and diagnosis; and C. intervention and follow-up. These were operationalized through twenty indicators and, through their evaluation, five categories or levels were defined: very high, high, medium, low and very low. Results: In the three explored dimensions, there was a clear predominance of the category fairly prepared, followed by poorly prepared. On the other hand, the categories well prepared, very well prepared and excellently prepared showed the lowest percentages in all the areas. A very low level of overall preparedness was found in 92.72 percent. A medium level of overall preparedness accounted for 3.64 percent, while a low level corresponded to 3.64 percent. Conclusions: There are insufficiencies in the cognitive, axiological and procedural order, which shows that the overall preparedness of these professionals with respect to family violence has a limited scope to face the varied forms of expression of this reprehensible behavior(AU)

[Anti-doping Activities and Comprehensive Health Support for Young Athletes].

In this study, we conducted a survey and interviews of young athletes to clarify the actual conditions of medication use and nutritional management (supplement use, etc.) with the aim of enhancing their health support. In addition, a second questionnaire was conducted for pharmacists working at medical institutions to clarify the actual situation of anti-doping (AD) activities by pharmacists, and examined the issues they face to support the health of athletes in the future. The results of the athletes' surveys revealed that the roles of pharmacists in AD activities was not recognized by athletes. In particular, the dissemination of AD education by pharmacists is considered to be critical. In future AD education, it will be necessary not only to provide knowledge of prohibited drugs, but also to provide self-medication support tailored to the individual needs of athletes, such as knowledge of nutrition and health. The results of the pharmacist survey revealed that athletes are treated by pharmacists on a daily basis, but for pharmacists, there are difficulties regarding how to provide information on AD, and it is necessary to enhance AD education at schools of pharmacy as well as in lifelong education seminars. Considering the pharmacists' AD activities as part of health support for athletes, it is considered more effective to collaborate with other health professionals such as sports doctors or nutritionists because it requires a wide range of knowledge such as nutrition.

A surgical needs assessment for airway rapid responses: A retrospective observational study.

BACKGROUND: Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS: A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS: A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION: Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. LEVEL OF EVIDENCE: Epidemiologic/prognostic, level III.

What Is Addiction? History, Terminology, and Core Concepts.

Medicine's acceptance of addiction as a medical concept has waxed and waned over time. Addiction, as a disease, fits with modern disease definitions and scientific advances in elucidating the interactions between neurobiology and environment. Definitions of addiction need to acknowledge the complex interactions of brain circuits, genetics, environmental factors, and individual life experiences. Addiction aligns with diagnostic categories of substance use disorders that do not rely on tolerance and withdrawal as defining characteristics. Shifts in social and political views of addiction continue to propel and mirror changes in addiction treatment approaches and terminology within the medical community.

La superación de la enfermera en la atención integral a la familia con enfermo oncológico / The upgrade of the nurse in the comprehensive care to the family with oncological patients

RESUMEN Introducción: la enfermera que se desempeña en los consultorios de la Atención Primaria de Salud, asume la responsabilidad de propiciar una atención integral al familiar encargado del cuidado del enfermo oncológico. Objetivo: diseñar una propuesta de superación para el perfeccionamiento de la actuación de la enfermera en la atención integral a la familia con enfermo oncológico. Materiales y métodos: se efectuó una investigación de desarrollo en la Facultad de Ciencias Médicas de Matanzas Dr. Juan Guiteras Gener, durante el curso 2018-2019. Se utilizó una muestra de 23 enfermeras de los consultorios de la atención primaria del municipio de Matanzas. Se analizaron los documentos que avalan su desempeño profesional. Se diseñó una encuesta dirigida a la identificación de las necesidades de aprendizaje y una guía de observación para caracterizar el modo de actuación del profesional de Enfermería. Se aplicaron entrevistas a supervisoras y directivos. Resultados: el análisis de las encuestas aplicadas a la muestra seleccionada y las observaciones realizadas a las actividades en el hogar, permitieron detectar las necesidades de aprendizaje para el perfeccionamiento de la atención integral a la familia con enfermo oncológico. Las entrevistas realizadas a supervisoras y directivos corroboraron la necesidad de la propuesta. Conclusiones: se diseñó un curso de posgrado para el perfeccionamiento de la actuación de los profesionales de la Enfermería, relacionado con el cuidado integral a la familia con enfermos oncológicos en la Atención Primaria de Salud (AU).

ABSTRACT Introduction: the nurse who works in the primary health care consultations assumes the responsibility of providing comprehensive care to the relative who takes care of oncological patients. Objective: to design a proposal of upgrading to improve the performance of the nurse in the comprehensive care to the family with an oncological patient. Materials and methods: a development research was conducted in the Faculty of Medical Sciences Dr. Juan Guiteras Gener, of Matanzas, during the school year 2018-2019. The sample was 23 nurses from the primary health care offices of the municipality of Matanzas. The documents that support their professional performance were analyzed. A survey was designed to identify learning needs and also an observation guide to characterize the performance of the nursing professional. Interviews were conducted with supervisors and managers. Results: the analysis of the surveys applied to the chosen sample and the observations made to the activities carried out at home, made it possible to determine the learning needs for the improvement of the comprehensive care to the families with oncological patients. Interviews with supervisors and managers confirmed the necessity of the proposal. Conclusions: a postgraduate course was designed for the improvement of nursing professionals' performance, aimed to the comprehensive care to families with oncological patients in the primary health care (AU).

Barreras identificadas por pacientes con diabetes mellitus de tipo 2 en su atención integral / Barriers identified for patients with type 2 diabetes mellitus in their integral care

Introducción: La diabetes mellitus de tipo 2 es un problema de salud a escala mundial. Existe interés creciente por la calidad de la atención integral a nivel primario y centrada en el paciente. Objetivo: Identificar las principales barreras desde la perspectiva de las personas con diabetes mellitus de tipo 2 sobre su atención integral, en áreas de salud seleccionadas. Métodos: Se realizó una investigación cualitativa, descriptiva y transversal, durante el 2017, para la cual se crearon 6 grupos focales. La muestra estuvo constituida por 56 personas con diabetes mellitus de tipo 2, pertenecientes a los policlínicos José Antonio Echeverría, Héroes del Moncada y el Centro de Atención al Diabético de Cárdenas, provincia de Matanzas, así como los policlínicos Carlos J. Finlay, Julián Grimau y el Centro de Atención al Diabético del municipio de Santiago de Cuba, provincia de igual nombre. Resultados: Predominaron las personas de la tercera edad, del sexo femenino. Las barreras estuvieron relacionadas con el tratamiento farmacológico y no farmacológico, el seguimiento en los servicios de salud, así como el apoyo y la comunicación por parte del personal de salud de los consultorios del médico de la familia; esta última afectó la relación personal de salud - paciente. Conclusión: A pesar de los diferentes contextos geográficos existieron puntos en común. A medida que se intervenga con estrategias acertadas para eliminar las barreras percibidas por los pacientes con diabetes mellitus de tipo 2, existirá mejoraría en su estado de salud.

Introduction: The type 2 diabetes mellitus is a health problem worldwide. There is a growing interest for the quality of integral care at primary level and focused on the patient. Objective: To identify the main barriers from the perspective of people with type 2 diabetes mellitus on their integral care, in selected health areas. Methods: A qualitative, descriptive and cross-sectional investigation was carried out during 2017, for which 6 focal groups were created. The sample was constituted by 56 people with type 2 diabetes mellitus, belonging to José Antonio Echeverría, Héroes del Moncada polyclinics and the Diabetic Care Center, in Cárdenas, the province of Matanzas, as well as Carlos J. Finlay, Julián Grimau polyclinics and the Diabetic Care Center in the municipality of Santiago de Cuba, in the province with the same name. Results: There was a prevalence of the elderly from the female sex. The barriers were related to the pharmacological and non pharmacological treatment, the follow up in the health services, as well as the support and the communication on the part of the health staff in the family doctor offices; this latter affected the relationship health staff - patient. Conclusion: In spite of the different geographical contexts there were points shared by them. As one takes the control with relevant strategies to eliminate the barriers perceived by the patients with type 2 diabetes mellitus, their health state will improve.

A Population-Based Intervention to Improve Care Cascades of Patients With Hepatitis C Virus Infection.

Hepatitis C virus (HCV) infection is common in the United States and leads to significant morbidity, mortality, and economic costs. Simplified screening recommendations and highly effective direct-acting antivirals for HCV present an opportunity to eliminate HCV. The objective of this study was to increase testing, linkage to care, treatment, and cure of HCV. This was an observational, prospective, population-based intervention program carried out between September 2014 and September 2018 and performed in three community health centers, three large multiclinic health care systems, and an HCV patient education and advocacy group in King County, WA. There were 232,214 patients included based on criteria of documented HCV-related diagnosis code, positive HCV laboratory test or prescription of HCV medication, and seen at least once at a participating clinical site in the prior year. Electronic health record (EHR) prompts and reports were created. Case management linked patients to care. Primary care providers received training through classroom didactics, an online curriculum, specialty clinic shadowing, and a telemedicine program. The proportion of baby boomer patients with documentation of HCV testing increased from 18% to 54% during the project period. Of 77,577 baby boomer patients screened at 87 partner clinics, 2,401 (3%) were newly identified HCV antibody positive. The number of patients staged for treatment increased by 391%, and those treated increased by 1,263%. Among the 79% of patients tested after treatment, 95% achieved sustained virologic response. Conclusion: A combination of EHR-based health care system interventions, active linkage to care, and clinician training contributed to a tripling in the number of patients screened and a more than 10-fold increase of those treated. The interventions are scalable and foundational to the goal of HCV elimination.

Analysis of the first 5 years of an interdisciplinary Rheumatology-Dermatology clinic.

BACKGROUND: Multispeciality clinics, such as combined psoriasis-psoriatic arthritis clinics, have shown improved outcomes in various diseases. At Massachusetts General Hospital, we are entering our ninth year of having an interdisciplinary Rheumatology-Dermatology (R-D) clinic. AIM: To evaluate the contribution of an R-D clinic by comparing care of patients pre- and post-evaluation in the combined clinic. As proxies of care, rates and comprehensiveness of evaluations (capillaroscopic examination, skin and joint examination) were compared between the combined clinic and standard Rheumatology or Dermatology clinic. METHODS: This was a retrospective chart review of patients at the R-D clinic in Massachusetts General Hospital during the period November 2012 to December 2017. RESULTS: Prior to the patients visiting the R-D only 5% of capillaroscopic examinations were documented, only 5% of rheumatologists specifically described a rash even when present, and pruritus was documented in only 6% of rheumatology notes. By contrast, in the R-D clinic, capillaroscopic, skin and joint examinations were documented in 100% of visits, and 19% of patients were given a different or a refined diagnosis. Although all our patients had cutaneous manifestations of their disease (hair loss, rash, itch, Raynaud phenomenon, ulcerations, calcinosis) only 34% had seen a dermatologist prior to the combined clinic and only 5% of those had had their concerns addressed by the rheumatologist. This suggests that 95% had a more complete evaluation and management of all aspects of their disease by attendance at the R-D clinic. CONCLUSION: Despite this study being limited by its retrospective nature, we found that it is an efficient model to achieve more comprehensive and potentially lower medication costs. Collaboration between dermatologists and rheumatologists in a combined clinic led to more complete skin and joint examinations, consistent tracking of capillaroscopic examination, better description of rash and improved management. Having this clinic helped in reaching a diagnosis and overall better disease control and outcome.

Slow medicine: a philosophical conception for a humanized geriatric practice / Slow medicine: uma concepção filosófica para uma prática geriátrica humanizada

Expansion of the concept of health, care fragmentation, and technology overvaluation have fostered discussions about the limitations of the biomedical model. The post-COVID-19 era can be one of the largest and best windows of opportunity for implementation of interventions aimed at promoting health equity, particularly in geriatrics. The mission of Slow Medicine can be summarized in three keywords: measured, because it acts with moderation, gradually and without waste; respectful, because it seeks to preserve the dignity and values of each person; and equitable, because it is committed to ensuring access to appropriate care for all. Operationally, the Slow Medicine movement is known internationally for the "Doing more does not mean doing better" campaign, whose objective is essentially to reflect upon and try to engage physicians in reflective practices to avoid the overuse of medical resources, both diagnostically and therapeutically. In this article, we present a brief historical summary and the principles that guide the praxis of the Slow Medicine movement, and invite the reader to reflect on a "geriatrics without haste."

A ampliação do conceito de saúde, a fragmentação do cuidado e a hipervalorização das tecnologias têm fomentado discussões acerca das limitações do modelo biomédico. A era pós-COVID-19 pode ser uma das maiores e melhores janelas de oportunidade para a promoção de intervenções destinadas à promoção da equidade em saúde, particularmente na geriatria. A missão da Slow Medicine pode ser sintetizada em três palavras-chave: sóbria, porque atua com moderação, gradativamente e sem desperdícios; respeitosa, porque zela pela preservação da dignidade e dos valores de cada pessoa; equitativa, porque tem o compromisso de garantir o acesso a cuidados adequados para todos. Operacionalmente, o movimento Slow Medicine é conhecido internacionalmente pela campanha "Fazer mais não significa fazer melhor", cujo objetivo é essencialmente refletir e tentar implantar entre os médicos práticas reflexivas que combatam a sobreutilização de recursos médicos, tanto diagnósticos como terapêuticos. Neste artigo, apresentamos um breve resumo histórico e dos princípios que pautam a práxis do movimento Slow Medicine, e convidamos o leitor a refletir sobre uma "geriatria sem pressa"

Informe de Rotación Electiva

El presente informe tiene la intención de dar cuenta de las actividades desarrolladas y aprendizajes en el marco de la Rotación Electiva en la Residencia Interdisciplinaria en Salud Mental en el Hospital Nacional en Red "Lic. Laura Bonaparte", especializado en Salud Mental y Adicciones. La institución se encuentra en la Ciudad Autónoma de Buenos Aires, siendo de dependencia nacional. El período de rotación es del 11/01/2021 al 19/03/2021, y los objetivos perseguidos en la rotación fueron los adquirir conocimientos y herramientas acerca de la atención en salud desde las perspectivas de Salud Mental Comunitaria, y de Salud Integral; y la capacitación y reflexión en torno al campo de Salud Mental desde una perspectiva interdisciplinaria. (AU)

Providing person-centered care for patients with complex healthcare needs: A qualitative study.

BACKGROUND: People with chronic conditions have complex healthcare needs that lead to challenges for adequate healthcare provision. Current healthcare services do not always respond adequately to their needs. A modular perspective, in particular providing visualization of the modular service architecture, is promising for improving the responsiveness of healthcare services to the complex healthcare needs of people with chronic conditions. The modular service architecture provides a comprehensive representation of the components and modules of healthcare provision. In this study, we explore this further in a qualitative multiple case study on healthcare provision for children with Down syndrome in the Netherlands. METHODS: Data collection for four cases involved 53 semi-structured interviews with healthcare professionals and 21 semi-structured interviews with patients (the parents of children with Down syndrome as proxy). In addition, we gathered data by means of practice observations and analysis of relevant documents. The interviews were audio-recorded, transcribed verbatim and analyzed utilizing the Miles and Huberman approach. RESULTS: Our study shows that the perspectives on healthcare provision of professionals and patients differ substantially. The visualization of the modular service architecture that was based on the healthcare professionals' perspective provided a complete representation of (para)medical outcomes relevant to the professionals' own discipline. In contrast, the modular service architecture based on the patients' perspective, which we define as a person-centered modular service architecture, provided a representation of the healthcare service that was primarily based on functional outcomes and the overall wellbeing of the patients. CONCLUSION: Our study shows that visualization of the modular service architecture can be a useful tool to better address the complex needs and requirements of people with a chronic condition. We suggest that a person-centered modular service architecture that focuses on functional outcomes and overall wellbeing, enables increased responsiveness of healthcare services to people with complex healthcare needs and provision of truly person-centered care.

The effect of comprehensive assessment and multi-disciplinary management for the geriatric and frail patient: A multi-center, randomized, parallel controlled trial.

BACKGROUND: A comprehensive geriatric assessment (CGA) of elderly patients is useful for detecting the patients vulnerabilities. Exercise and early rehabilitation, nutritional intervention, traditional Chinese medicine (TCM), standardized medication guidance, and patient education can, separately, improve and even reverse the physical frailty status. However, the effect of combining a CGA and multi-disciplinary management on frailty in elderly patients remains unclear. The present study assessed the effects of a CGA and multi-disciplinary management on elderly patients with frailty in China. METHODS: In this study, 320 in patients with frailty ≥70 years old will be randomly divided into an intervention group and a control group. The intervention group will be given routine management, a CGA and multi-disciplinary management involving rehabilitation exercise, diet adjustment, multi-drug evaluation, acupoint massage in TCM and patient education for 12 months, and the control group will be followed up with routine management for basic diseases. The primary outcomes are the Fried phenotype and short physical performance battery (SPPB). The secondary outcomes are the clinical frailty scale (CFS), non-elective hospital readmission, basic activities of daily living (BADL), 5-level European quality of life 5 dimensions index (EQ-5D), nutrition risk screening-2002 (NRS-2002), medical insurance expenses, fall events, and all-cause mortality. In addition, a cost-effectiveness study will be carried out. DISCUSSION: This paper outlines the protocol for a randomized, single-blind, parallel multi-center clinical study. This protocol, if beneficial, will demonstrate the interaction of various intervention strategies, will help improve elderly frailty patients, and will be useful for clinicians, nurses, policymakers, public health authorities, and the general population. TRIAL REGISTRATION: Chinese Clinical Trials Register, ChiCTR1900022623. Registered on April 19, 2019, http://www.chictr.org.cn/showproj.aspx?proj=38141.

Evaluation of a National Comprehensive Cancer Network Guidelines-Based Decision Support Tool in Patients With Non-Small Cell Lung Cancer: A Nonrandomized Clinical Trial.

Importance: The association of guideline-based decision support with the quality of care in patients with non-small cell lung cancer (NSCLC) is not known. Objective: To evaluate the association of exposure to the National Comprehensive Cancer Center (NCCN) guidelines with guideline-concordant care and patients' decisional conflict. Design, Setting, and Participants: A nonrandomized clinical trial, conducted at a tertiary care academic institution, enrolled patients from February 23, 2015, to September 28, 2017. Data analysis was conducted from July 19, 2019, to April 22, 2020. A cohort of 76 patients with NSCLC seen at diagnosis or disease progression and a retrospective cohort of 157 patients treated before the trial were included. Adherence to 6 NCCN recommendations were evaluated: (1) smoking cessation counseling, (2) adjuvant chemotherapy for patients with stage IB to IIB NSCLC after surgery, (3) pathologic mediastinal staging in patients with stage III NSCLC before surgery, (4) pathologic mediastinal staging in patients with stage III NSCLC before nonsurgical treatment, (5) definitive chemoradiotherapy for patients with stage III NSCLC not having surgery, and (6) molecular testing for epidermal growth factor receptor and anaplastic lymphoma kinase alterations for patients with stage IV NSCLC. Subgroup analysis was conducted to compare the rates of guideline concordance between the prospective and retrospective cohorts. Secondary end points included decisional conflict and satisfaction. Interventions: An online tool customizing the NCCN guidelines to patients' clinical and pathologic features was used during consultation, facilitated by a trained coordinator. Main Outcomes and Measures: Concordance of practice with 6 NCCN treatment recommendations on NSCLC and patients' decisional conflict. Results: Of the 76 patients with NSCLC, 44 were men (57.9%), median age at diagnosis was 68 years (interquartile range [IQR], 41-87 years), and 59 patients (77.6%) had adenocarcinoma. In the retrospective cohort, 91 of 157 patients (58.0%) were men, median age at diagnosis was 66 years (IQR, 61-65 years), and 105 patients (66.9%) had adenocarcinoma. After the intervention, patients received more smoking cessation counseling (4 of 5 [80.0%] vs 1 of 24 [4.2%], P < .001) and less adjuvant chemotherapy (0 of 7 vs 7 of 11 [63.6%]; P = .012). There was no significant change in mutation testing of non-squamous cell stage IV disease (20 of 20 [100%] vs 48 of 57 [84.2%]; P = .10). There was no significant change in pathologic mediastinal staging or initial chemoradiotherapy for patients with stage III disease. After consultation with the tool, decisional conflict scores improved by a median of 20 points (IQR, 3-34; P < .001). Conclusions and Relevance: The findings of this study suggest that exposure to the NCCN guidelines is associated with increased guideline-concordant care for 2 of 6 preselected recommendations and improvement in decisional conflict. Trial Registration: ClinicalTrials.gov Identifier: NCT03982459.

D-CARE: The Dementia Care Study: Design of a Pragmatic Trial of the Effectiveness and Cost Effectiveness of Health System-Based Versus Community-Based Dementia Care Versus Usual Dementia Care.

BACKGROUND/OBJECTIVES: Although several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown. DESIGN: Pragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad. SETTING: Four clinical trial sites (CTSs) based in academic and clinical health systems. PARTICIPANTS: A total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers. INTERVENTIONS: Eighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline. MEASUREMENTS: Primary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales. SECONDARY OUTCOMES: NPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims. RESULTS: The results will be reported in the spring of 2024. CONCLUSION: D-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.

STEPS to Care: Translating an Evidence-Informed HIV Care Coordination Program Into a Field-Tested Online Practice Improvement Toolkit.

Increasing care engagement is essential to meet HIV prevention goals and achieve viral suppression. It is difficult, however, for agencies to establish the systems and practice improvements required to ensure coordinated care, especially for clients with complex health needs. We describe the theory-driven, field-informed transfer process used to translate key components of the evidence-informed Ryan White Part A New York City Care Coordination Program into an online practice improvement toolkit, STEPS to Care (StC), with the potential to support broader dissemination. Informed by analyses of qualitative and quantitative data collected from eight agencies, we describe our four phases: (1) review of StC strategies and key elements, (2) translation into a three-part toolkit: Care Team Coordination, Patient Navigation, and HIV Self-Management, (3) pilot testing, and (4) toolkit refinement for national dissemination. Lessons learned can guide the translation of evidence-informed strategies to online environments, a needed step to achieve wide-scale implemention.

Effects of an integrative approach to bipolar disorders combining psychoeducation, mindfulness-based cognitive therapy and functional remediation: study protocol for a randomized controlled trial / Efectos de un abordaje integral para el trastorno bipolar combinando la psicoeducación, terapia cognitiva basada en el mindfulness y rehabilitación funcional: protocolo para un ensayo clínico controlado y aleatorizado

INTRODUCTION: Bipolar disorder is related to a high level of personal, familial, social and economic burden. There is a need for feasible adjunctive psychological interventions easy to implement in clinical practice in order to enhance aspects that medication alone cannot achieve. This study aims to evaluate the impact of a 12-session adjunctive integrative program designed for patients with bipolar disorder. METHODS: This is a single-blind prospective, randomized controlled trial involving a total of 132 outpatients with bipolar disorder who will be recruited from the Hospital Clinic of Barcelona. All participants will be randomly assigned to two arms. All the patients will receive treatment as usual (TAU) but in addition the experimental group will receive an integrative approach consisting of 12-sessions of 90 min each in which contents of psychoeducation for patients have been combined with a session for family members, and complemented with aspects related to health promotion, mindfulness training, and strategies for cognitive and functional enhancement. The whole sample will be assessed at baseline, after completion (3-months) and at 12 months from baseline regarding demographic and clinical variables, psychosocial and cognitive functioning, wellbeing and quality of life. The primary outcome measure will be improvement in psychosocial functioning. CONCLUSIONS: If the integrative approach is effective, it would allow clinicians to cover different areas that may be affected by bipolar disorder, by means of a brief intervention that can therefore be easily generalized to clinical practice

INTRODUCCIÓN: El trastorno bipolar se asocia a un nivel elevado de carga personal, familiar, social y económica. Existe la necesidad de intervenciones psicológicas complementarias factibles y fáciles de implementar en la práctica clínica para mejorar aspectos que la medicación no consigue alcanzar. Este estudio tiene como objetivo evaluar el impacto de un programa integral de 12 sesiones complementario al tratamiento farmacológico para pacientes con trastorno bipolar. MÉTODOS: Ensayo clínico aleatorizado, controlado, a simple ciego. Serán reclutados del Hospital Clínic de Barcelona 132 pacientes ambulatorios diagnosticados de trastorno bipolar. Los participantes serán asignados aleatoriamente a dos grupos. Todos los pacientes recibirán el tratamiento habitual (TAU) pero, además, el grupo experimental recibirá un abordaje integral que consistirá en 12 sesiones de 90 min en las que se han combinado los contenidos de psicoeducación para pacientes con una sesión para familiares, complementándose con aspectos relacionados con la promoción de la salud, el entrenamiento en atención plena y estrategias para la potenciación cognitiva y funcional. La muestra completa será evaluada al inicio del estudio, a los 3 meses y a los 12 meses de seguimiento respecto a variables sociodemográficas y clínicas, de funcionamiento psicosocial y cognitivo, bienestar y calidad de vida. El principal resultado esperado será la mejoría en el funcionamiento psicosocial. CONCLUSIONES: Si el abordaje integral es efectivo, permitiría a los clínicos cubrir diferentes áreas que pueden verse afectadas por el trastorno bipolar, mediante una breve intervención que, por lo tanto, puede generalizarse fácilmente a la práctica clínica