Assessment of the Effectiveness, Socio-Economic Impact and Implementation of a Digital Solution for Patients with Advanced Chronic Diseases: The ADLIFE Study Protocol.

Due to population ageing and medical advances, people with advanced chronic diseases (ACD) live longer. Such patients are even more likely to face either temporary or permanent reduced functional reserve, which typically further increases their healthcare resource use and the burden of care on their caregiver(s). Accordingly, these patients and their caregiver(s) may benefit from integrated supportive care provided via digitally supported interventions. This approach may either maintain or improve their quality of life, increase their independence, and optimize the healthcare resource use from early stages. ADLIFE is an EU-funded project, aiming to improve the quality of life of older people with ACD by providing integrated personalized care via a digitally enabled toolbox. Indeed, the ADLIFE toolbox is a digital solution which provides patients, caregivers, and health professionals with digitally enabled, integrated, and personalized care, supporting clinical decisions, and encouraging independence and self-management. Here we present the protocol of the ADLIFE study, which is designed to provide robust scientific evidence on the assessment of the effectiveness, socio-economic, implementation, and technology acceptance aspects of the ADLIFE intervention compared to the current standard of care (SoC) when applied in real-life settings of seven different pilot sites across six countries. A quasi-experimental trial following a multicenter, non-randomized, non-concurrent, unblinded, and controlled design will be implemented. Patients in the intervention group will receive the ADLIFE intervention, while patients in the control group will receive SoC. The assessment of the ADLIFE intervention will be conducted using a mixed-methods approach.

"It depends on the people!" - A qualitative analysis of contextual factors, prior to the implementation of digital health innovations for chronic condition management, in a German integrated care network.

Objective: Integrated care and digital health technology interventions are promising approaches to coordinate services for people living with chronic conditions, across different care settings and providers. The EU-funded ADLIFE project intends to provide digitally integrated personalized care to improve and maintain patients' health with advanced chronic conditions. This study conducted a qualitative assessment of contextual factors prior to the implementation of the ADLIFE digital health platforms at the German pilot site. The results of the assessment are then used to derive recommendations for action for the subsequent implementation, and for evaluation of the other pilot sites. Methods: Qualitative interviews with healthcare professionals and IT experts were conducted at the German pilot site. The interviews followed a semi-structured interview guideline, based on the HOT-fit framework, focusing on organizational, technological, and human factors. All interviews were audio recorded, transcribed, and subsequently analysed following qualitative content analysis. Results: The results of the 18 interviews show the interviewees' high openness and motivation to use new innovative digital solutions, as well as an apparent willingness of cooperation between different healthcare professionals. Challenges include limited technical infrastructure and large variability of software to record health data, lacking standards and interfaces. Conclusions: Considering contextual factors on different levels is critical for the success of implementing innovations in healthcare and the transfer into other settings. In our study, the HOT-fit framework proved suitable for assessing contextual factors, when implementing IT innovations in healthcare. In a next step, the methodological approach will be transferred to the six other European pilot sites, participating in the project, for a cross-national assessment of contextual factors.

Effects of Immigrants, Health, and Ageing on Economic Growth in the European Union.

Population ageing and low birth rates are two problems of the EU that have an impact on employment, production, and economic growth. Against this background, immigration, health expenditure, and the health of migrants must become a key element of European policy. For this reason, this paper focused on identifying the effect of immigration, health, and ageing on economic growth in order to highlight their importance from an economic perspective. We constructed different econometric models with Eurostat data for 27 countries and 13 years (2008-2020), whose dependent variable was gross domestic product. Independent variables were the number of immigrants by gender and age, health expenditure per capita (total and by function), immigrants' perception of their health as very good, and the proportion of the population aged 65 years and over. The model selected to analyze the results was Prais-Winsten regression heteroskedastic panels corrected standard errors modeled by applying the option (ar1) to correct for autocorrelation, using Stata software (version 16). The results show that health expenditure has a significant positive effect on economic growth, higher in hospital services, followed by medical products; immigrants' perception as very good is only significant in some models. The number of immigrants has a (positive) effect, although less significant than public expenditure on health. Its effect is larger when the immigrant is aged between 15 and 64 years and smaller for male immigrants than for female immigrants. Without the ageing variable, immigration is not significant. Moreover, there are significant differences between European countries in relation to the variables analyses (immigration, immigrants' perception of their health, ageing and public expenditure on health, and public expenditure on health according to function). This may be due to the different regulations on both immigration and public health in the countries that make up the European Union.

Diversity in orthopaedic trauma: where we are and where we need to be.

Diversity has multiple dimensions, and individuals' interpretation of diversity varies broadly. The Orthopaedic Trauma Association (OTA) leadership recognized the need to address issues of diversity within the organization and appointed the OTA Diversity Committee in 2020. The OTA Diversity Committee has produced a statement that was confirmed by the OTA's board of directors reflecting the organization's position on diversity: "The OTA promotes and values diversity and inclusion at all levels with the goal of creating an environment where every member has the opportunity to excel in leadership, education, and culturally-competent orthopaedic trauma care." The OTA Diversity Committee surveyed its 1907 OTA members in the United States and Canada to assess its membership's attitudes toward and interpretation of this important topic. METHODS: Two surveys were distributed. One 15-question survey was sent to 1907 OTA members with different membership categories in the United States and Canada requesting basic demographic information and asking how members felt about the degree to which women and underrepresented minorities (URM) are represented within the OTA and within its leadership. A second 11-question survey was sent to 30 past chairs of 2017-2019 OTA educational courses and meetings evaluating their criteria for choosing faculty for OTA courses. Comments were reviewed and summarized to identify recurring themes. RESULTS: Two hundred seven responses from the membership and 14 from course chairs were received from the 1907 surveys that were emailed to OTA members in the United States and Canada. The results reveal awareness of the limited female and URM representation within the OTA. However, there is disagreement in how or even whether this should be addressed at an organizational level. Review of comments from both surveys reveals a number of common themes on these important topics. CONCLUSION: The members and course chairs surveyed recognize that there is limited diversity at the OTA leadership and faculty level. Many members feel that the OTA would benefit from increasing female and URM representation in committees, within the leadership, and as faculty at OTA-sponsored courses. However, survey comments reveal that many members and course chairs feel it is not the organization's role to regulate diversity and that diversity initiatives themselves may introduce an unnecessary form of bias.

A radiological score for the assessment of tuberculosis progression: Validation in mouse models.

The sensitivity of in vivo low-dose high-resolution micro-computed tomography imaging enables monitoring the lung damage caused by tuberculosis. Here, we propose a radiological score integrated in the experimental workflow that enables longitudinal monitoring for prospective efficacy studies in drug development programs. The score is based on an automatic measurement of total unaffected lung volume in vivo normalized for inter-subject comparison. It was validated on well-characterized progression of chronic tuberculosis in Erdman and H37Rv strains in C3HeB/FeJ-based models. We demonstrated that a decrease in the score value indicates increasing adverse effects and vice versa. The colony-forming units count confirmed the variability in the host response suggested by the score values. The correlation between changes in the mice's weight and the score is consistent with disease progression. The classification of disease extent by k-means clustering of the score values provided the definition of the lung damage severity according to the bacillus strain. The proposed score will reduce sources of bias and improve the statistical robustness of studies by the attrition of non-infected subjects or subjects with a weak immune response. Readily available quantifications allow for a fast assessment of the therapeutic potential in drug-resistant tuberculosis strains.

X-ray-based virtual slicing of TB-infected lungs.

Hollow organs such as the lungs pose a considerable challenge for post-mortem imaging in preclinical research owing to their extremely low contrast and high structural complexity. The aim of our study was to enhance the contrast of tuberculosis lesions for their stratification by 3D x-ray-based virtual slicing. Organ samples were taken from five control and five tuberculosis-infected mice. Micro-Computed Tomography (CT) scans of the subjects were acquired in vivo (without contrast agent) and post-mortem (with contrast agent). The proposed contrast-enhancing technique consists of x-ray contrast agent uptake (silver nitrate and iodine) by immersion. To create the histology ground-truth, the CT scan of the paraffin block guided the sectioning towards specific planes of interest. The digitalized histological slides reveal the presence, extent, and appearance of the contrast agents in lung structures and organized aggregates of immune cells. These findings correlate with the contrast-enhanced micro-CT slice. The abnormal densities in the lungs due to tuberculosis disease are concentrated in the right tail of the lung intensity histograms. The increase in the width of the right tail (~376%) indicates a contrast enhancement of the details of the abnormal densities. Postmortem contrast agents enhance the x-ray attenuation in tuberculosis lesions to allow 3D visualization by polychromatic x-ray CT, providing an advantageous tool for virtual slicing of whole lungs. The proposed contrast-enhancing technique combined with computational methods and the diverse micro-CT modalities will open the doors to the stratification of lesion types associated with infectious diseases.

Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization.

INTRODUCTION: Besides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value. METHODS: We analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices. RESULTS: BR or DR at admission were recommended in 37% (32-44) and 24% (19-30) of the patients respectively. In 81% (71-87) and 33% (21-45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92-98) had VL and 25% (19-32) UC. VL were not used in 10% (6-12), UC had no indications for insertion in 21% (11-35) and for maintenance in 31% (12-46) patients. Fifty-seven percent (49-64) of the patients were administered VTP and 69% (62-76) were prescribed SUP. Twenty-two percent (15-31) of patients with VTP and 52% (43-60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53-75) with BAF was prescribed in 38% (25-52) of them. An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results. CONCLUSION: These results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.

Intraoperative CT in the assessment of posterior wall acetabular fracture stability.

Posterior wall acetabular fractures that involve 10% to 40% of the posterior wall may or may not require an open reduction and internal fixation. Dynamic stress examination of the acetabular fracture under fluoroscopy has been used as an intraoperative method to assess joint stability. The aim of this study was to demonstrate the value of intraoperative ISO computed tomography (CT) examination using the Siemens ISO-C imaging system (Siemens Corp, Malvern, Pennsylvania) in the assessment of posterior wall acetabular fracture stability during stress examination under anesthesia. In 5 posterior wall acetabular fractures, standard fluoroscopic images (including anteroposterior pelvis and Judet radiographs) with dynamic stress examinations were compared with the ISO-C CT imaging system to assess posterior wall fracture stability during stress examination. After review of standard intraoperative fluoroscopic images under dynamic stress examination, all 5 cases appeared to demonstrate posterior wall stability; however, when the intraoperative images from the ISO-C CT imaging system demonstrated that 1 case showed fracture instability of the posterior wall segment during stress examination, open reduction and internal fixation was performed. The use of intraoperative ISO CT imaging has shown an initial improvement in the surgeon's ability to assess the intraoperative stability of posterior wall acetabular fractures during stress examination when compared with standard fluoroscopic images.

Direct cellular vs. indirect pager communication during orthopaedic surgical procedures: a prospective study.

BACKGROUND: Cellular phone use within the hospital setting has increased as physicians, nurses, and ancillary staff incorporate wireless technologies in improving efficiencies, cost, and maintaining patient safety and high quality healthcare [11]. Through the use of wireless, cellular communication, an overall improvement in communication accuracy and efficiency between intraoperative orthopaedic surgeons and floor nurses may be achieved. METHODS: Both communication types occurred while the surgeon was scrubbed in the operating room (OR). Indirect communication occurred when the pager call was answered by the OR circulating nurse with communication between the surgeon, circulating nurse, and floor nurse. Direct communication consisted of cell phone and Jabra Bluetooth BT200 wireless ear piece used by the surgeon. The surgeon answered the floor nurse's cellular call by phone ring-activated automatic answering. The study was conducted during scheduled orthopaedic procedures. An independent observer measured time variables with a stop-watch while orthopaedic nurses randomly called via pager or cell phone. The nurses asked for patient caregiver confirmation and answers to 30 different patient-care questions. RESULTS: Sixty trials were performed with 30 cell and 30 page communications. Direct cellular communication showed a better response rate than indirect page (Cell 100%, Page 73%). Indirect page communication allowed a 27% and 33% error rate with patient problem and surgeon solution communications, respectively. There were no reported communication errors while using direct wireless, cellular communication. When compared to page communications, cellular communications showed statistically significant improvements in mean time intervals in response time (Cell = 11s, Page = 211s), correct patient identification (Cell = 5s, Page = 172s), patient problem and solution time (Cell = 13s, Page = 189s), and total communication time (Cell = 32s, Page = 250s) (s = seconds, all P < 0.001). Floor nurse satisfaction ratings (dependent on communication times and/or difficulties) were improved with direct cellular communication (Cell = 29 excellent, Page = 11 excellent). Intraoperative case interruptions (defined as delaying surgical progress) were more frequent with indirect page communication (10 page v. 0 cell). CONCLUSION AND SIGNIFICANCE: Our study demonstrates that direct wireless communication may be used to improve intraoperative communication and enhance patient safety. Direct wireless, cellular intraoperative communication improves communication times, communication accuracy, communication satisfaction, and minimizes intraoperative case interruption. As a result of this study, we hope to maintain our transition to direct wireless, cellular intraoperative orthopaedic communication to reduce medical errors, improve patient care, and enhance both orthopaedic surgeon and nursing efficiencies.

Management of an unstable pelvic ring disruption in a 20-month-old patient.

A 20-month-old patient with a markedly displaced pelvic ring disruption was successfully managed with fluid resuscitation, immobilization using bolsters, and percutaneous screw fixation of the posterior ring coupled with hip spica casting.

Giant cardiac myxoma in an asymptomatic 57-year-old woman: a case report.

Primary cardiac neoplasms are rare and left atrial myxomas represent the most common form of primary cardiac masses. We present the case of a 57-year-old woman with Diabetes Mellitus and arterial hypertension who was incidentally found to have a giant myxoma in the left atrium. She was asymptomatic but given the high risk of embolization and sudden cardiac death, surgical removal of the tumor was performed. A 6.0 x 5.0 x 4.5 cm mass was recovered, confirmed to be a benign cardiac myxoma on microscopic examination. Symptoms associated with cardiac masses will depend upon tumor location and size, usually related to flow obstruction and embolization. An inflammatory response due to secretion of cytokines may also be observed. In this case, the patient had no symptoms despite the size of the tumor that occupied virtually 90% of the left atrial volume.

Unstable angina and non ST elevation acute coronary syndromes.

Acute coronary syndromes (ACSs) are the most common cause of hospital admission in patients with coronary artery disease (CAD). The term ACS refers to a spectrum of acute life-threatening disorders that includes: unstable angina (UA), non ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). The pathophysiology is similar: coronary atherosclerosis plaque rupture and subsequent thrombus formation. Such plaques usually are lesions with <50% stenosis severity prior to ACS, but are lipid-rich soft plaques (vulnerable plaques). The clinical presentation depends on the degree of partial (UA/NSTEMI) or complete lumen obstruction of the culprit coronary artery (STEMI). This article reviews the UA/NSTEMI ACS, since these two entities are closely related and usually, it is not possible to distinguish them upon presentation at the emergency department (ED). It presents the latest advancement on the pathophysiology, clinical presentations, diagnosis, risk stratification and management. It emphasizes on the selection of the optimal management approach which includes early invasive versus initial conservative strategies. Besides, it discusses the different approaches being used in the light of the information provided by the latest clinical trials. Although, at the present time, the optimal management approach remains unsettled, ACSs are usually managed using an early invasive strategy in tertiary care hospitals in the USA. The application of clinical practice guidelines developed by the American College of Cardiology and the American Heart Association (ACC/AHA) has confirmed definite improvement of patient care. Part of the information presented in this article, particularly in its management, is based on these guidelines (3). Evidence base scientific data insists upon using aggressive medical therapy (statins, anti-platelets, beta blockers [BBs], angiotensin converting enzyme inhibitors [ACE-Is], and control of coronary risk factors) as well as mechanical reperfusion, whether by percutaneous coronary intervention (PCI) or by coronary artery bypass graft (CABG). These approaches are considered complementary rather than as opposing strategies.

Navigated pedicle screw placement: experimental comparison between CT- and 3D fluoroscopy-based techniques.

OBJECTIVE: Even with CT-based navigation, the misplacement rate for pedicle screws is reported to be as high as 10%. Using fluoroscopy-based 3D navigation, misplacement rates of 1.7 to 6% occur. The purpose of this study was to compare the accuracy of CT-based and Iso-C-based navigation in an experimental context. METHODS: A foam spine model and the SurgiGATE navigation system were used. First, a determination of point accuracy measured the difference between the real positions of markers placed on selected vertebrae and their positions as determined by the navigation system. In the verification mode, the pointer is placed exactly on the markers displayed on the monitor screen, and the deviation of the pointer tip and marker is measured in reality using a caliper. Secondly, pedicle accuracy was measured using pre-drilled holes for pedicle screws. A trajectory was planned into the visible hole and the navigated pointer was placed. RESULTS: The measured accuracy for the markers showed a statistically significant difference between the results with CT and Iso-C navigation for one of six markers placed on the vertebra. Iso-C-based navigation demonstrated a lower mean deviation of 0.5 mm, compared to 1 mm with CT-based navigation. The deviation within the pre-drilled holes was lower when using the Iso-C3D scan. Using Iso-C3D navigation, 76.6% of the measurements showed no deviation at the entrance point, compared with 43% when using CT-based navigation. Also, with Iso-C3D navigation, 78.3% of the inserted pedicle awls hit the defined trajectories in the pre-drilled holes correctly, compared to 66.6% with CT-based navigation. CONCLUSION: The overall image-to-reality accuracy for CT- and Iso-C-based navigation was assessed in the described experimental setup. An apparent tendency towards higher accuracy with Iso-C-based navigation was evaluated; however, the differences were not significant.

Aortic valvular heart disease in adults

Valvular Heart Disease (VHD) is an important cardiovascular problem in the adult population. The knowledge of the physiology involved, prompt recognition and diagnosis are of paramount importance for the primary care physician who is in the front line of patient care. This article is the second of a series of two that deals with valvular problems in the adults in concise and practical form (11). Each topic will be presented using the following format: description, etiology, pathophysiology, natural history, essential of diagnosis and management. In this second and final article we will discuss aortic valve disorders.

Aortic valvular heart disease in adults.

Valvular Heart Disease (VHD) is an important cardiovascular problem in the adult population. The knowledge of the physiology involved, prompt recognition and diagnosis are of paramount importance for the primary care physician who is in the front line of patient care. This article is the second of a series of two that deals with valvular problems in the adults in concise and practical form (11). Each topic will be presented using the following format: description, etiology, pathophysiology, natural history, essential of diagnosis and management. In this second and final article we will discuss aortic valve disorders.

The need to comply with guidelines applied in practice (GAP) in order to improve cardiovascular patient care in Puerto Rico.

The aim of this article is to provide important information to the medical community about Clinical Practice Guidelines (CPG) in general, and particularly those developed by the American College of Cardiology and the American Heart Association (ACC/AHA). The optimal CPG is defined and the selection, writing and preparation of the guides are succinctly described. Despite counting with 19 high-quality evidence based ACC/AHA guidelines in various important cardiovascular topics and evidence that adherence to them have demonstrated improvement in the outcome of cardiovascular patient care, there is a large gap in the integration of the guidelines to everyday practice. In response to this realty the ACC/AHA developed the program, Guidelines Applied in Practice (GAP) to foster the implementation of the guidelines into clinical practice. As a plea to the application of the principles of evidence-based CPG, The Puerto Rico Chapter of the ACC has developed two programs oriented to disseminate and help physicians put the guidelines into practice. These are: (1) ACC/ AHA guidelines dissemination through traditional continuing medical education programs and (2) Developing in accord to medical advances a GAP (Guidelines Applied in Practice) in Puerto Rico on acute coronary syndromes (ACS-GAP in Puerto Rico), adapting standardized protocols to local conditions.

Mitral valvular heart disease in the adults

Valvular Heart Disease (VHD) is an important cardiovascular problem in the adult population. The knowledge of the physiology involved, prompt recognition and diagnosis are of paramount importance for the primary care physician who is in the front line of patient care. This article is the first of a series of two that will discuss valvular problems in the adults in concise and practical form. Each topic will be presented using the following format: description, etiology, pathophysiology, natural history, essential of diagnosis and management. In this first article we will discuss mitral valve disorders including mitral valve prolapse (MVP)

Mitral valvular heart disease in the adults.

Valvular Heart Disease (VHD) is an important cardiovascular problem in the adult population. The knowledge of the physiology involved, prompt recognition and diagnosis are of paramount importance for the primary care physician who is in the front line of patient care. This article is the first of a series of two that will discuss valvular problems in the adults in concise and practical form. Each topic will be presented using the following format: description, etiology, pathophysiology, natural history, essential of diagnosis and management. In this first article we will discuss mitral valve disorders including mitral valve prolapse (MVP).