Prophylactic Anticoagulation in Patients with Cancer: When and How?

PURPOSE OF REVIEW: Cancer-associated thrombosis is a leading cause of death among patients with cancer. Historically, thromboprophylaxis efforts have focused on the highest risk patients with cancer, including post-operative patients and hospitalized patients. This review covers not only thromboprophylaxis for these groups but also emerging data supporting prophylaxis in ambulatory medical oncology patients. RECENT FINDINGS: Several leading guidelines, backed by clinical trial data, now support the use of direct oral anticoagulants for select high-risk outpatients for primary thromboprophylaxis. However, uptake of these findings remains low. Pharmacologic venous thromboembolism prophylaxis strategies continue to improve. However, it remains challenging to balance competing risks of bleeding and thrombosis. The morbidity and mortality associated with cancer associated thrombosis may be preventable. Understanding advancements in risk prediction, anticoagulant options, and implementation of existing data, is critical to provide optimal patient care.

Interventions Increase Vaccination Rates in Inflammatory Bowel Disease and Rheumatoid Arthritis: A Systematic Review and Meta-Analysis.

BACKGROUND: Patients with immune-mediated conditions such as IBD and RA are at risk for vaccine-preventable infections. Despite guideline recommendations, prior studies have shown suboptimal vaccination rates. AIM: We conducted a systematic review and meta-analysis to compare the different interventions intended to increase vaccination rates. METHODS: A systematic search was conducted of MEDLINE/PubMed, Embase, CINAHL, and Cochrane Library up to 2020 for studies with interventions intended to increase vaccination rates. We performed a random-effects meta-analysis to generate pooled odds ratios (ORs) to assess all interventions against no interventions. Our primary outcome was pneumococcal vaccination (PCV) rate. RESULTS: Our review found 8580 articles, for which 15 IBD and 8 RA articles met the inclusion criteria; 21 articles were included in the analysis. PCV was the predominant vaccination (91%). In our analysis of patients with IBD, almost all interventions (patient-oriented, physician-oriented, or barrier-oriented) increased PCV uptake [OR, 4.74; 95% CI, 2.44-6.56, I2 = 90%] compared to no intervention. The greatest effect was seen in barrier-oriented studies [OR, 12.68; 95% CI, 2.21-72.62, I2 = 92%]. For RA data, all interventions had increased PCV uptake compared to no interventions (OR 2.74; 95% CI, 1.80-4.17, I2 = 95%). CONCLUSION: Our data suggest that many different interventions can increase PCV rates. It appears that barrier-oriented interventions may have the greatest positive effect on increasing PCV uptake. However, clinicians should be encouraged to implement measures best suited to their practice. Future high-quality randomized controlled trials are needed to determine the best approach to optimize vaccination rates.

The Pictorial Fit-Frail Scale-Malay version (PFFS-M): reliability and validity testing in Malaysian primary care.

BACKGROUND: This study investigated the reliability and convergent validity of the PFFS-Malay version (PFFS-M) among patients (with varying educational levels), caregivers, and health care professionals (HCPs). PFFS-M cutoffs for frailty severity were developed. METHODS: This is a cross-sectional study from 4 primary care clinics where 240 patients aged >60 years and their caregivers were enrolled. Patients were assigned to a nurse or a health care assistant (HCA) for 2 separate PFFS-M assessments administered by HCPs of the same profession, as well as by a doctor during the first visit (inter-rater reliability). Patients were also administered the Self-Assessed Report of Personal Capacity & Healthy Ageing (SEARCH) tool, a 40-item frailty index, by a research officer. The correlation between patients' PFFS-M scores and SEARCH tool scores determined convergent validity. Patients returned 1 week later for PFFS-M reassessment by the same HCPs (test-retest reliability). Caregivers completed the PFFS-M for the patient at both clinic visits. Classification cut-points for the PFFS-M were derived against frailty categories defined through the SEARCH tool. RESULTS: The inter-rater (intraclass correlation coefficient [ICC] = 0.92 [95% CI, 0.90-0.93)] and test-retest (ICC = 0.94 [95% CI, 0.92-0.95]) reliability between all raters was excellent, including by patients' education levels. The convergent validity was moderate (r = 0.637, p < 0.001), including for varying educational background. PFFS-M categories were identified as: 0-3, no frailty; 4-5, at risk of frailty; 6-8, mild frailty; 9-12, moderate frailty; and >13, severe frailty. CONCLUSION: PFFS-M is a reliable and valid tool with frailty severity scores now established for use of this tool in primary care clinics.

Braidwood Mgmt. v. Becerra & a Texas District Court's Decision to Stop Enforcement of Preventive Care Coverage Requirements under the ACA.

This article discusses how in March of 2023 a District Court in Texas enjoined the U.S. government from enforcing certain preventive care requirements under the ACA for private health insurers. The current order by the Court enjoined enforcement of the ACA preventive care requirements based on those recommendations made on or after the date of March 23, 2010, by the U.S. Preventive Services Task Force. This article discusses the Court's analysis and the remedy the Court decided on after finding violations under the RFRA and Appointments Clause. The article also discusses the implications and effects of this decision on whether previously covered services that the ACA didn't allow cost sharing for will now have cost sharing by private health insurers and how that will affect consumers. The article concludes that despite lack of enforcement, private health insurers should not require cost sharing for previously covered services that the ACA didn't allow cost sharing for before this most recent decision. Cost sharing for previously covered services would increase costs for those enrolled in private health insurance plans and could lead to a reduction in access to preventive services and healthcare.

Family physicians' perspectives on the impact of COVID-19 on preventative care in primary care: findings from a qualitative study.

INTRODUCTION: Health system disruptions, caused by unexpected emergencies such as disease outbreaks, natural disasters, and cybercrimes, impact the delivery of routine preventative care. As comprehensive care providers, family physicians (FPs) devote significant time to prevention. However, without emergency and pandemic plans in place in primary care, FPs face added barriers to prioritizing and sustaining preventative care when health systems are strained, which was evident during the COVID-19 pandemic. This study aims to describe FPs' experiences providing preventative care during the COVID-19 pandemic and their perceptions of the impacts of disrupted preventative care in primary care settings. METHODS: Using a qualitative descriptive approach, we conducted semistructured interviews with FPs across 4 provinces in Canada (i.e. Newfoundland and Labrador, Nova Scotia, Ontario, British Columbia) between October 2020 and June 2021 as part of a larger multiple case study. These interviews broadly explored the roles and responsibilities of FPs during the COVID-19 pandemic. Interviews were coded thematically and codes from the larger study were analysed further using an iterative, phased process of thematic analysis. RESULTS: Interviews averaged 58 min in length (range 17-97 min) and FPs had a mean of 16.9 years of experience. We identified 4 major themes from interviews with FPs (n = 68): (i) lack of capacity and coordination across health systems, (ii) patient fear, (iii) impacts on patient care, and (iv) negative impacts on FPs. Physicians voiced concerns with managing patients' prevention needs when testing availability and coordination of services was limited. Early in the pandemic, patients were also missing or postponing their own primary care appointments. Change in the provision and coordination of routine preventative care had negative impacts on both patients and physicians, affecting disease incidence/progression, physician workload, and psychological wellbeing. CONCLUSION: During the COVID-19 pandemic, upstream care efforts were impacted, and FPs were forced to reduce their provision of preventative care. FPs contribute direct insight to primary care delivery that can support pandemic planning to ensure preventative care is sustained during future emergencies.

Electronic medical record alert increases HIV screening rates: the Foch hospital pilot POP-up project.

BACKGROUND: Despite significant national human immunodeficiency virus (HIV) screening activity, there are persistent delays in screening, and many missed diagnostic opportunities. To facilitate targeted screening, an electronic medical record (EMR) alert reminder was applied in the Foch hospital. Screening rates after implementation were reported. METHODS: A prospective cohort analysis was performed in Foch Hospital between 24 April 2018 and 4 October 2019 among hospitalized patients born in high HIV prevalence countries and/or having social vulnerability criteria (universal health coverage). From the admissions software, when specific low health coverage was provided and/or high-prevalence country of birth was registered, an electronic alert (EMR alert) appeared on the ward where the patient was hospitalized. The EMR alert database was examined for HIV screening and activity responses from each service of the Hospital. RESULTS: Eight thousand one hundred eighty-one alerts were recovered during the period for 1448 patients. 27 services used the EMR alert. Most of the alerts were directly closed (74.4%), 14.5% of the alerts were closed due to doctors declaring that they did not have time to respond. 297 (3.6%) of the 8181 alerts resulted in a prescription of HIV serology corresponding for 20.5% of the patients. CONCLUSION: EMR alert can help to increase the rate of HIV screening in hospital care practice. Through this EMR alert system, HIV screening can be implemented as a common practice like any other medical alternative. Future research should examine the factors influencing physicians' attitudes to this alert system to improve the HIV screening rate.

Integrative Medicine in Equine Practice.

Integrative medicine is based on a model of being proactive and promoting health and wellness, rather than being reactive and solely focusing on episodic disease processes. Integrative medicine incorporates a holistic approach to clinical practice that encourages owner involvement with a focus on individualized care, maintained wellness, optimized performance, and disease prevention. Health promotion and preventative care require a different set of clinical skills and perspectives than is typically provided by a traditional veterinary education. Productive interprofessional collaborations are an essential component to the effective delivery of integrative medicine services.

Hospitalizations for Respiratory Syncytial Virus and Vaccine Preventable Infections following Pediatric Heart Transplantation.

OBJECTIVE: To determine the risk factors for acquiring a respiratory syncytial virus (RSV) and vaccine-preventable infections (R/VPI) in pediatric heart transplant recipients and the associated morbidity and hospital resource use. STUDY DESIGN: Patients <18 years who underwent heart transplantation from September 2003 to December 2018 at hospitals using the Pediatric Health Information System database were identified. Their transplant hospitalization and subsequent hospitalizations for R/VPI through December 2018 were analyzed. Risk factors for R/VPI hospitalizations were evaluated using negative regression binomial models adjusted for demographic and clinical confounders. Total hospital costs were adjusted for 2018 US$. RESULTS: Of 3815 transplant recipients, 681 (17.9%) had an R/VPI hospitalization during 23 746 available person-years of follow-up. There were 984 R/VPIs diagnosed during 951 hospitalizations, and 440 (44.7%) occurred the first year after transplantation. The most common causes were RSV (n = 380; 38.6%), influenza (n = 265; 26.9%), and pneumococcus (n = 105; 10.7%). In adjusted analyses, there was an increased risk of R/VPI hospitalization in patients requiring mechanical circulatory support before transplantation, patients receiving induction with ≥2 immunosuppressive agents, and patients <2 years in the first year after transplantation. The median length of stay for an R/VPI hospitalization was 4 days (IQR, 2-8 days) with a median total cost of $11 081 (IQR, $6215-$24 322). CONCLUSIONS: Hospitalization for R/VPIs occurred frequently after heart transplantation and were associated with significant costs. Potential strategies to minimize R/VPI include expanding vaccine use through accelerated immunization schedules, further studies of use of palivizumab beyond 2 years of age, and immunogenicity monitoring after vaccination with re-immunization based on guidelines.

Improving Primary Care Delivery for Patients Receiving Maintenance Hemodialysis.

The beneficial impact of primary care, focused on all aspects of a patient's health (rather than a disease-specific focus) is well established. Recognized benefits include greater receipt of preventive care and counseling, lower use of emergency care and hospitalization for ambulatory care-sensitive conditions, and decreased early mortality. Although the importance of primary care and care coordination at the primary care/specialty interface is well recognized, the role of primary care within traditional and emerging care models for patients receiving in-center maintenance hemodialysis remains ill-defined. In this perspective article, we will describe: (1) the role of primary care for patients receiving maintenance hemodialysis and the current evidence regarding the receipt of primary care among these patients; (2) the key challenges to delivery of primary care in these complex cases, including suboptimal care coordination between nephrology and primary care providers, the intensity of dialysis care, and the limited capacity of nephrologists and primary care providers to meet the broad health needs of hemodialysis patients; (3) potential strategies for improving the delivery of primary care for patients receiving hemodialysis; and (4) future research requirements to improve primary care delivery for this high-risk population.

Neuroscience Education as Therapy for Migraine and Overlapping Pain Conditions: A Scoping Review.

BACKGROUND: Neuroscience education therapy (NET) has been successfully used for numerous overlapping pain conditions, but few studies have investigated NET for migraine. OBJECTIVE: We sought to 1) review the literature on NET used for the treatment of various pain conditions to assess how NET has been studied thus far and 2) recommend considerations for future research of NET for the treatment of migraine. DESIGN/METHODS: Following the PRISMA guideline for scoping reviews, co-author (TR), a medical librarian, searched the MEDLINE, PsychInfo, Embase, and Cochrane Central Clinical Trials Registry databases for peer-reviewed articles describing NET to treat migraine and other chronic pain conditions. Each citation was reviewed by two trained independent reviewers. Conflicts were resolved through consensus. RESULTS: Overall, a NET curriculum consists of the following topics: pain does not equate to injury, pain is generated in the brain, perception, genetics, reward systems, fear, brain plasticity, and placebo/nocebo effects. Delivered through individual, group, or a combination of individual and group sessions, NET treatments often incorporate exercise programs and/or components of other evidence-based behavioral treatments. NET has significantly reduced catastrophizing, kinesiophobia, pain intensity, and disability in overlapping pain conditions. In migraine-specific studies, when implemented together with traditional pharmacological treatments, NET has emerged as a promising therapy by reducing migraine days, pain intensity and duration, and acute medication intake. CONCLUSION: NET is an established treatment for pain conditions, and future research should focus on refining NET for migraine, examining delivery modality, dosage, components of other behavioral therapies to integrate, and migraine-specific NET curricula.

Chronic Stress and Preconception Health Among Latina Women in Metro Atlanta.

BACKGROUND: Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta. DESIGN: We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma. RESULTS: Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)). CONCLUSIONS: Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

Pediatric Practice Redesign with Group Well Child Care Visits: A Multi-Site Study.

OBJECTIVES: Multiple barriers exist to delivering efficient, effective well child care, especially in low-income, immigrant communities. Practice redesign strategies, including group well child care, have shown promise in improving care delivery and healthcare outcomes. To assess the feasibility of a group well child care program at multiple urban, academic practices caring for underserved, mostly immigrant children, and to evaluate health outcomes and process measures compared to traditional care. METHODS: Prospective, intervention control study with participants recruited to group well child care visits or traditional visits during the first year of life. A culturally sensitive curriculum was designed based on American Academy of Pediatrics (AAP) recommendations. Process and health outcomes were analyzed via patient surveys and medical record information. RESULTS: One hundred and one families enrolled in group care and 74 in traditional care. Group care participants had higher rates of all recommended postpartum depression screening and domestic violence screening (65% vs 37%, 38% vs 17% respectively), higher anticipatory guidance retention (67% vs 37%) and higher patient satisfaction with their provider. The group care redesign did not increase length of time spent in clinic. CONCLUSIONS FOR PRACTICE: Group well child care is a feasible method for practice redesign, which allows for increased psychosocial screening and anticipatory guidance delivery and retention compared to traditional visits, for low income, predominantly immigrant families. Parental satisfaction with group care is higher and these visits provide greater face-to-face time with the provider, without increasing time spent in the practice.

Impact of Medical Blog Reading and Information Presentation on Readers' Preventative Health Intentions: Mixed Methods, Multistudy Investigation.

BACKGROUND: Medical blogs have become valuable information sources for patients and caregivers. Most research has focused on patients' creation of blogs as therapy. But we know less about how these blogs affect their readers and what format of information influences readers to take preventative health actions. OBJECTIVE: This study aimed to identify how reading patient medical blogs influences readers' perceived health risk and their intentions to engage in preventative health actions. Further, we aimed to examine the format of the medical blog and the reader's response. METHODS: We surveyed 99 university participants and a general-population, online panel of 167 participants. Both studies randomly assigned participants to conditions and measured blog evaluation, intentions for preventative health action, and evaluation of health risk and beliefs, and allowed open-ended comments. The second study used a different sample and added a control condition. A third study used a convenience sample of blog readers to evaluate the link between reading medical blogs and taking preventative health action. RESULTS: Across 3 studies, participants indicated a desire to take future preventative health action after reading patient blogs. Studies 1 and 2 used experimental scenario-based designs, while Study 3 employed a qualitative design with real blog readers. The 2 experimental studies showed that the type of blog impacted intentions to engage in future preventative health actions (Study 1: F2,96=6.08, P=.003; Study 2: F3,166=2.59, P=.06), with a statistical blog being most effective in both studies and a personal narrative blog showing similar effectiveness in Study 2, contrary to some prior research. The readers' perceptions of their own health risk did not impact the relationship between the blog type and health intentions. In contrast, in one study, participants' judgments about the barriers they might face to accessing care improved the fit of the model (F2,95=13.57, P<.001). In Study 3's sample of medical blog readers, 53% (24/45) reported taking preventative health action after reading a health blog, including performing a self-check, asking a doctor about their health risk, or requesting a screening test. Additionally, these readers expressed that they read the blogs to follow the author (patient) and to learn general health information. All studies demonstrated the blogs were somewhat sad and emotional but also informative and well-written. They noted that the blogs made them appreciate life more and motivated them to consider taking some action regarding their health. CONCLUSIONS: Reading patient blogs influences intentions to take future health actions. However, blog formats show different efficacy, and the readers' disease risk perceptions do not. Physicians, medical practitioners, and health organizations may find it useful to curate or promote selected medical blogs to influence patient behavior.

Geospatial Analyses of Accessibility to Down Syndrome Specialty Care.

OBJECTIVE: To assess whether the location of 71 Down syndrome specialty care clinics in the US make them inaccessible to a considerable portion of the American population. STUDY DESIGN: Using a population-based representative sample of 64 761 individuals with Down syndrome and a Google Maps Application Programming Interface Python program, we calculated the distance each patient with Down syndrome would need to travel to reach the nearest clinic. Two conceptualizations were used-the state fluidity method, which allowed an individual to cross state lines for care and the state boundary method, which required individuals receive care in their state of residence. RESULTS: Almost 1 in 5 US individuals face significant geographic obstacles to receiving specialty care. This finding is especially prominent in the South, where >33% of patients with Down syndrome must travel >2 hours to reach their nearest clinic. CONCLUSIONS: Down syndrome specialty care clinics are inaccessible to a considerable portion of American society. Innovative usage of technology might be useful to minimize these disparities in healthcare accessibility.

Factors related to removable denture use in independent older people: A cross-sectional study.

BACKGROUND: Denture use for recovery of major tooth loss can reduce the need for care, and thus, it is important for dentists to identify the types of patients who use removable dentures. OBJECTIVE: To identify factors associated with removable denture use in independent older Japanese people. METHODS: This cross-sectional study investigated the oral condition; demographics; lifestyle; dental visit behaviour; and higher-level functional capacity, as assessed using the Tokyo Metropolitan Institute of Gerontology index of competence (TMIG index), of independent older people aged 65-74 years. Participants were divided into four groups based on sex and condition of the posterior occluding pairs (POPs). Multivariate-adjusted logistic regression analyses were performed for each group, with denture use or non-use as the dependent variable and the other items as independent variables. RESULTS: Denture use or non-use was significantly associated with only dental consultation behaviour (regular dental visits and time since the last dental visit) in all groups. Subsequent analyses excluding dental consultation behaviour demonstrated that denture use or non-use was significantly associated with educational background in female participants with decreased POPs, with the type of household in male participants with lost POPs and with the TMIG index (social role) in female participants with lost POPs. CONCLUSIONS: Denture use was associated with dental consultation behaviour. We revealed factors related to denture use or non-use in females with decreased POPs and both males and females with lost POPs.

Chronic wounds and novel therapeutic approaches.

In the past decade, the frequency of chronic wounds in older population has increased, and their impact on quality of life is substantial. Chronic wounds are a public health problem associated with very high economic and psychosocial costs. These wounds result from various pathologies and comorbidities, such arterial and venous insufficiency, diabetes mellitus and continuous skin pressure. Recently, the role of infection and biofilms in the healing of chronic wounds has been the subject of considerable research. This paper presents an overview of various methods and products used to manage chronic wounds and discusses recent advances in wound care. To decide on the best treatment for any wound, it is crucial to holistically assess the patient and the wound. Additionally, multiple strategies could be used to prevent or treat chronic wounds.

A Mixed Methods Evaluation of an Inclusive Sexual History Taking and HIV Prevention Curriculum for Trainees.

BACKGROUND: Health disparities exist in HIV risk in the USA among the lesbian-gay-bisexual-transgender-queer (LGBTQ) community. There is also scarce literature on curricula for HIV prevention and pre-exposure prophylaxis (PrEP) for trainees. AIM: To create a curriculum to train residents to perform inclusive sexual history taking and HIV prevention care. The curriculum covers sexual history, LGBTQ health, sexually transmitted infections, and HIV risk assessment and risk reduction counseling including use of PrEP. SETTING: A dedicated PrEP Clinic was created within an Academic Medical Center Outpatient HIV Clinic. Patients were primarily LGBTQ identified, but also included HIV sero-discordant couples, cisgender individuals, heterosexual invididuals, and those with experience of homelessness, sex work, and substance abuse. PARTICIPANTS: Thirty-four internal medicine residents completed the course between November 2017 and May 2018. PROGRAM DESCRIPTION: The curriculum was delivered as Just in Time Teaching (JiTT) via online virtual patient cases followed by directly observed clinical care at a large urban PrEP clinic. PROGRAM EVALUATION AND RESULTS: The effectiveness of the curriculum was assessed through paired pre/post-self-assessment surveys (n = 19), additional post-surveys on the online modules (n = 22), and interviews (n = 9). Many respondents reported no prior training or inadequate prior training in the course content. As a result of the course, participants reported statistically significant increased confidence and comfort in all seven HIV prevention topic areas, with the greatest gains in safe sex counseling for LGBTQ patients and in discussing PrEP (mean changes of 1.21, 1.58 on 5-point Likert scale, respectively, p < 0.0001). Six of nine interviewees post-course had applied what they learned to patient care; five indicated their learning would benefit patients. DISCUSSION: An HIV prevention curriculum focused on cultural humility in care can improve trainee's skills in HIV risk reduction counseling, including PrEP, among all patients including those identifying as LGBTQ.

Use of Emergency Departments for Preventative Care Among Adults in the United States: Estimates From the 2017 National Health Interview Survey.

BACKGROUND: Use of the emergency department (ED) for routine or preventative care has been an abiding concern for policy makers and public health practitioners. OBJECTIVES: We utilized recent data to examine health-related, socioeconomic, and demographic factors associated with use of the ED for routine or preventative care using a national sample of adults. METHODS: Data from the 2017 National Health Interview Survey, a nationally representative sample of 26,742 adults ≥18 years of age was used for this investigation. Bivariate and multivariate analyses were used to assess the association between reported use of EDs as a usual source of preventative care and health-related, socioeconomic, and demographic factors. RESULTS: In 2017, approximately 2 million adults nationwide reported the ED as their usual source of preventative health care. Individuals experiencing ≥2 health care-related barriers were more likely to use the ED as a source of usual preventative care (odds ratio = 2.78 [95% confidence interval 1.64-4.72]). Individuals without insurance had higher odds (odds ratio = 9.52 [95% confidence interval 5.60-16.19]) of using the ED for care compared with those who were privately insured. In addition, those using the ED for preventative care were more likely to be younger, poorer, less educated, to identify as Asian or African American, and to reside in the Northeast United States. CONCLUSION: This study provides a current perspective into characteristics and factors contributing to use of the ED for preventative care. Overall, our findings suggest that the ED continues to provide crucial safety net services to a small subset of the population experiencing significant barriers to timely medical care.

An observational cohort study of exercise and education for people with chronic obstructive pulmonary disease not meeting criteria for formal pulmonary rehabilitation programmes.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. Pulmonary rehabilitation (PR) is offered to patients with functional breathlessness. However, access to PR is limited. The objective of this study was to evaluate whether a 4-week education and exercise programme offered to COPD patients with Medical Research Council (MRC) dyspnoea 1-2 improves disease self-management. Patients were recruited by their GP to attend four weekly 2-h sessions provided by a multidisciplinary team. Patients completed outcome measures before and after the program. Forty-two patients entered the programme and 26 out of 42 (61.9%) completed all sessions. The Bristol COPD Knowledge Questionnaire and Patient Activation Measure improved (both p ≤ 0.001). Disease burden was not reduced according to the COPD assessment test. All patients accepted a referral for ongoing exercise. Fourteen current smokers (81.3%) accepted a referral for smoking cessation, three patients with anxiety or depression (37.5%) accepted a psychological therapies referral. The programme improved COPD disease knowledge, patient activation and stimulated referrals to further services supporting disease management. Randomised controlled trials are warranted for similar interventions for COPD patients with early stage disease.

Clinical Evaluation and Preventative Care in Donkeys.

Clinical evaluation and preventative care in donkeys should follow similar guidelines as for horses. There are species-specific differences due to the desert-adapted physiology of the donkey. Donkeys are mainly used as pack animals, companions and for production of meat or milk - they may be kept well into old age. Diseases often present late or may go unrecognized leading to poor welfare and quality of life. Basic knowledge of nutrition, blood values, pharmacology and common disease recognition will help veterinarians improve the health and welfare of donkeys.