Continuity of care in dual diagnosis treatment: definitions, applications, and implications.

OBJECTIVE: The goal of this work is to review the current literature on continuity of care in the treatment of people with dual diagnosis. In particular, this review set out to clarify how continuity of care has been defined, applied, and assessed in treatment and to enhance its application in both research and clinical practice. METHODS: To identify articles for review, the term "continuity" and combinations of "substance" and "treatment" were searched in electronic databases. The search was restricted to quantitative articles published in English after 1980. Papers were required to discuss "continuity" in treatment samples that included a proportion of patients with a dual diagnosis. RESULTS: A total of 18 non-randomized studies met the inclusion criteria. Analysis revealed six core types of continuity in this treatment context: continuity of relationship with provider(s), continuity across services, continuity through transfer, continuity as regularity and intensity of care, continuity as responsive to changing patient need, and successful linkage of the patient. Patient age, ethnicity, medical status, living status, and the type of mental health and/or substance use disorder influenced the continuity of care experienced in treatment. Some evidence suggested that achieving continuity of care was associated with positive patient and treatment-related outcomes. CONCLUSIONS: This review summarizes how continuity of care has been understood, applied, and assessed in the literature to date. Findings provide a platform for future researchers and service providers to implement and evaluate continuity of care in a consistent manner and to determine its significance in the treatment of people with a dual diagnosis.

An improved model of care for inflammatory bowel disease (IBD).

Recommendations from the 3rd round of the Report of the results for the national clinical audit of adult inflammatory bowel disease (IBD) inpatient care in the UK published earlier this year by UK's Royal College of Physicians and mentioned in the Lancet in March 20121 report improvements in the quality of care (QoC) of patients with IBD since audits began in 2006 but also list improvements yet to be achieved. Importantly, optimising the quality of life (QoL) of sufferers was indicated as deserving greater attention as part of the global approach to improved QoC.

When continuity of care breaks down: a systems failure in identification of osteoporosis risk in older patients treated for minimal trauma fractures

OBJECTIVE: Minimal trauma fractures may be the first indication of osteoporosis. Our aim was to determine the proportion of patients who underwent bone density testing for osteoporosis of those with a minimal trauma wrist fracture treated in the emergency department (ED).

DESIGN: This observational retrospective cohort study used explicit medical record review and scripted telephone interviews.

SETTING: EDs of three metropolitan hospitals in Melbourne in 2006.

PARTICIPANTS: Patients aged 50 years and over who were treated for wrist fracture due to minimal trauma. Data collected included demographic details, fracture details, causes of injury, any bone density testing and any osteoporosis-related medication change.

MAIN OUTCOME MEASURE: The proportion of patients who underwent bone density testing in the follow-up period.

RESULTS: 131 patients were studied; 83% were female, and the median age was 71 years. No patient was referred by an ED or fracture clinic for bone density testing (95% CI, 0-3.5%). Telephone follow-up data were obtained from 91 patients. Of these, 28 reported having bone density testing after their fracture, of whom 14 (50%; 95% CI, 32%-67%) were found to have osteoporosis. Seven were treated with a bisphosphonate and one with a selective oestrogen-receptor modulator.

CONCLUSION: Follow-up of patients suffering minimal trauma wrist fractures treated in the ED is poor. Systems to improve the identification and treatment of osteoporosis in this group are needed if future osteoporotic fractures and their consequences are to be avoided.

An integrated model of care for inflammatory bowel disease sufferers in Australia: development and the effects of its implementation.

BACKGROUND: Psychological comorbidities are associated with poor outcome and increased healthcare utilization in patients with inflammatory bowel disease (IBD). However, a model of care addressing the biopsychosocial dimension of disease is not routinely applied in IBD. This review describes the development of such a model and the effects of its implementation in a hospital-based cohort of patients with IBD. METHODS: Three different approaches were used: 1) collecting baseline epidemiological data on mental health comorbidities; 2) raising awareness of and targeting mental health problems; 3) examining the effects of the model implementation. RESULTS: High rates of anxiety and depressive symptoms (36% and 13%, respectively) that are maintained over time were identified in IBD patients presenting at a metropolitan teaching hospital. Patients with documented psychological comorbidities were more likely to be hospitalized than those without (odds ratio [OR] = 4.13, 95% confidence interval [CI]: 1.25, 13.61). Improvements in disease activity, anxiety, depression, quality of life, and coping have been noted when cognitive-behavioral therapy (CBT) was provided to patients. A drop in the use of opiates (P = 0.037) and hospitalization rates (from 48% to 30%) in IBD patients has been noted as a result of introduction of the changed model of care. In addition, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 [US$15,236.79] vs. US$ 30,467.78 [US$ 53,760.20], P = 0.005). CONCLUSION: Our data to date suggest that an integrated model of care for patients with IBD may yield superior long-term outcomes in terms of medication use and hospitalization rates and reduce healthcare costs.

When a Change in Level of Care Results in a Transfer Between Programs

This project was chosen to investigate the criteria, process, procedures and policies in place for transferring patients of the Charleston Dorchester Mental Health Center between programs due to a change in their level of care in efforts to make the process more consistent and prevent or reduce gaps in care for patients.

Methodology of Care Humanitude in Promoting Self-care in Dependent People: An Integrative Review

Abstract. The aging of the population has led to an increase in the prevalence of chronic degenerative diseases and dependence. We need to implement humanized health care that will improve the quality of life and well-being of these people and help maintain their autonomy and self-care. Objective: To identify the implications of the caring in Humanitude in promoting self-care in the dependent person. Methods: Integrative review of the literature of the period between 2007 and 2015, using the databases Medline, EBSCO and Google Scholar. In using the PI[C]OD methodology and criteria for inclusion and exclusion, we obtained 54 items where 7 were selected for analysis. Results: There are several health benefits in the promotion of self-care, by ap-plying the Humanitude caring philosophy, mainly regarding the relationship be-tween the nurse and the patient. Conclusions: It is essential to develop further studies focused on the implications of caring in Humanitude in self-care in the dependent person.

Behaviour disorders and teacher negligence

The purpose of this paper is to examine the legal implications of the continuing rise in the number of school children diagnosed with behaviour disorders. Not only are teachers now subject to a dense grid of legal regulation, they are also increasingly vulnerable to actions in tort. It will be argued here that as more and more children are labelled ‘disordered’, the duty of care become more onerous, and hence harder for teachers to meet. As a consequence, teachers are more likely to face claims of negligence. It is concluded that while the schooling system needs to retain a healthy scepticism about each new pathologising disorder that seeks special status for its sufferers, it also needs to provide greater training and resources for teachers regarding disorder management. It is also concluded that recent changes to negligence law regarding the issue of ‘reasonable foreseeability’ within breach of duty of care, may not be as significant as might have been hoped by the teaching community. Indeed, the elevated standard of care required by the increasing numbers of disordered pupils, places teachers in an ever more difficult legal position.

Behaviour disorders and the negligent teacher

The purpose of this paper is to examine the legal implications of the continuing rise in the number of school children diagnosed with behaviour disorders. Not only are teachers now subject to a dense grid of legal regulation, they are also increasingly vulnerable to actions in tort. It will be argued here that as more and more children are labelled ‘disordered’, then the concomitant duty of care requirements for teachers becomes more onerous. As a consequence, teachers are less likely to be able to defend themselves against claims of negligence. It is concluded that while the schooling system needs to retain a healthy scepticism about each new pathologising disorder that seeks special status for its sufferers, it also needs to provide greater training and resources for teachers regarding disorder management. It is also concluded that recent changes to negligence law regarding the issue of ‘reasonable foreseeability’ within breach of duty of care, may not be as significant as might have been hoped by the teaching community. Indeed, the elevated standard of care, as required by increasing numbers of disordered pupils, place teachers in an ever more difficult legal position.

XIAP downregulation accompanies mebendazole growth inhibition in melanoma xenografts

Mebendazole (MBZ) was identified as a promising therapeutic on the basis of its ability to induce apoptosis in melanoma cell lines through a B-cell lymphoma 2 (BCL2)-dependent mechanism. We now show that in a human xenograft melanoma model, oral MBZ is as effective as the current standard of care temozolomide in reducing tumor growth. Inhibition of melanoma growth in vivo is accompanied by phosphorylation of BCL2 and decreased levels of X-linked inhibitor of apoptosis (XIAP). Reduced expression of XIAP on treatment with MBZ is partially mediated by its proteasomal degradation. Furthermore, exposure of melanoma cells to MBZ promotes the interaction of SMAC/DIABLO with XIAP, thereby alleviating XIAP's inhibition on apoptosis. XIAP expression on exposure to MBZ is indicative of sensitivity to MBZ as MBZ-resistant cells do not show reduced levels of XIAP after treatment. Resistance to MBZ can be reversed partially by siRNA knockdown of cellular levels of XIAP. Our data indicate that MBZ is a promising antimelanoma agent on the basis of its effects on key antiapoptotic proteins.

Outcomes in gastric and junctional cancer using neoadjuvant and adjuvant chemotherapy (epirubicin, oxaliplatin, and capecitabine) and radical surgery

Background The MAGIC/UK Medical Research Council (MRC) trial set the standard of care for treatment of resectable gastric and junctional adenocarcinoma, demonstrating that perioperative chemotherapy with epirubicin, cisplatin and 5-fluorouracil (ECF) confers a survival benefit over surgery alone. The randomized ECF for advanced and locally advanced esophagogastric cancer (REAL-2) trial showed that, in the metastatic setting, the EOX regimen (epirubicin, oxaliplatin and capecitabine) is as effective as ECF, with a favourable toxicity profile. Methods Consecutive patients with resectable gastric or junctional adenocarcinoma treated with perioperative EOX, between 2007 and 2012, were retrospectively analysed. Results Fifty-nine patients (12 female, 47 male), commenced EOX therapy; 47 underwent surgery. A good pathological response was seen in 34 %, (16/47). Disease recurrence occurred in 19 patients (19/47, 40 %). Median overall survival was 22 months, with 4-year survival of 47 %. Chemotoxicities were consistent with those previously reported for this regimen. Conclusion This study in a high-volume centre demonstrates that EOX in resectable gastric and junctional adenocarcinoma is associated with a reasonable safety profile, and efficacy consistent with that reported for ECF.

Gliptins - do they increase cardiovascular risk or benefit?

INTRODUCTION: In 2008, the US FDA required all new glucose-lowering therapies to show cardiovascular safety, and this applies to the dipeptidyl peptidase-4 inhibitors ('gliptins'). AREAS COVERED: The cardiovascular safety trials of saxagliptin and alogliptin have recently been published and are the subject of this evaluation. EXPERT OPINION: The Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus - Thrombolysis in Myocardial Infarction 53 trial and Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care were both multicentre, randomised, double-blind, placebo-controlled, Phase IV clinical trials. These trials showed that saxagliptin and alogliptin did not increase the primary end point, which was a composite of cardiovascular outcomes that did not include hospitalisations for heart failure. However, saxagliptin significantly increased hospitalisation for heart failure, which was a component of the secondary end point. The effect of alogliptin on hospitalisations for heart failure has not been reported. Neither agent improved cardiovascular outcomes. As there is no published evidence of improved outcomes with gliptins, it is unclear to us why these agents are so widely available for use. We suggest that the use of gliptins be restricted to Phase IV clinical trials until such time as cardiovascular safety and benefits/superiority are clearly established

KAT5 (Tip60) is a potential therapeutic target in malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rare aggressive cancer of the pleura. Asbestos exposure (through inhalation) is the most well established risk factor for mesothelioma. The current standard of care for patients suffering from MPM is a combination of cisplatin and pemetrexed (or alternatively cisplatin and raltitrexed). Most patients, however, die within 24 months of diagnosis. New therapies are therefore urgently required for this disease. Lysine acetyltransferases (KATs) including KAT5 have been linked with the development of cisplatin resistance. This gene may therefore be altered in MPM and could represent a novel candidate target for intervention. Using RT-PCR screening the expression of all known KAT5 variants was found to be markedly increased in malignant tumors compared to benign pleura. When separated according to histological subtype, KAT5 was significantly overexpressed in both the sarcomatoid and biphasic subgroups for all transcript variants. A panel of MPM cell lines including the normal pleural cells LP9 and Met5A was screened for expression of KAT5 variants. Treatment of cells with a small molecule inhibitor of KAT5 (MG-149) caused significant inhibition of cellular proliferation (p<0.0001), induction of apoptosis and was accompanied by significant induction of pro-inflammatory cytokines/chemokines.

Ribavirin-Induced Anemia in Hepatitis C Virus Patients Undergoing Combination Therapy

The current standard of care for hepatitis C virus (HCV) infection - combination therapy with pegylated interferon and ribavirin - elicits sustained responses in only similar to 50% of the patients treated. No alternatives exist for patients who do not respond to combination therapy. Addition of ribavirin substantially improves response rates to interferon and lowers relapse rates following the cessation of therapy, suggesting that increasing ribavirin exposure may further improve treatment response. A key limitation, however, is the toxic side-effect of ribavirin, hemolytic anemia, which often necessitates a reduction of ribavirin dosage and compromises treatment response. Maximizing treatment response thus requires striking a balance between the antiviral and hemolytic activities of ribavirin. Current models of viral kinetics describe the enhancement of treatment response due to ribavirin. Ribavirin-induced anemia, however, remains poorly understood and precludes rational optimization of combination therapy. Here, we develop a new mathematical model of the population dynamics of erythrocytes that quantitatively describes ribavirin-induced anemia in HCV patients. Based on the assumption that ribavirin accumulation decreases erythrocyte lifespan in a dose-dependent manner, model predictions capture several independent experimental observations of the accumulation of ribavirin in erythrocytes and the resulting decline of hemoglobin in HCV patients undergoing combination therapy, estimate the reduced erythrocyte lifespan during therapy, and describe inter-patient variations in the severity of ribavirin-induced anemia. Further, model predictions estimate the threshold ribavirin exposure beyond which anemia becomes intolerable and suggest guidelines for the usage of growth hormones, such as erythropoietin, that stimulate erythrocyte production and avert the reduction of ribavirin dosage, thereby improving treatment response. Our model thus facilitates, in conjunction with models of viral kinetics, the rational identification of treatment protocols that maximize treatment response while curtailing side effects.

Highlights from the 13th St Gallen International Breast Cancer Conference 2013. Access to innovation for patients with breast cancer: how to speed it up?

The recognition that early breast cancer is a spectrum of diseases each requiring a specific systemic therapy guided the 13th St Gallen International Breast Cancer Consensus Conference [1]. The meeting assembled 3600 participants from nearly 90 countries worldwide. Educational content has been centred on the primary and multidisciplinary treatment approach of early breast cancer. The meeting culminated on the final day, with the St Gallen Breast Cancer Treatment Consensus, established by 40-50 of the world's most experienced opinion leaders in the field of breast cancer treatment. The major issue that arose during the consensus conference was the increasing gap between what is theoretically feasible in patient risk stratification, in treatment, and in daily practice management. We need to find new paths to access innovations to clinical research and daily practice. To ensure that continued innovation meets the needs of patients, the therapeutic alliance between patients and academic-led research should to be extended to include relevant pharmaceutical companies and drug regulators with a unique effort to bring innovation into clinical practice. We need to bring together major players from the world of breast cancer research to map out a coordinated strategy on an international scale, to address the disease fragmentation, to share financial resources, and to integrate scientific data. The final goal will be to improve access to an affordable, best standard of care for all patients in each country.

Communication practices in physician decision-making for an unstable critically ill patient with end-stage cancer.

BACKGROUND: Shared decision-making has become the standard of care for most medical treatments. However, little is known about physician communication practices in the decision making for unstable critically ill patients with known end-stage disease. OBJECTIVE: To describe communication practices of physicians making treatment decisions for unstable critically ill patients with end-stage cancer, using the framework of shared decision-making. DESIGN: Analysis of audiotaped encounters between physicians and a standardized patient, in a high-fidelity simulation scenario, to identify best practice communication behaviors. The simulation depicted a 78-year-old man with metastatic gastric cancer, life-threatening hypoxia, and stable preferences to avoid intensive care unit (ICU) admission and intubation. Blinded coders assessed the encounters for verbal communication behaviors associated with handling emotions and discussion of end-of-life goals. We calculated a score for skill at handling emotions (0-6) and at discussing end of life goals (0-16). SUBJECTS: Twenty-seven hospital-based physicians. RESULTS: Independent variables included physician demographics and communication behaviors. We used treatment decisions (ICU admission and initiation of palliation) as a proxy for accurate identification of patient preferences. Eight physicians admitted the patient to the ICU, and 16 initiated palliation. Physicians varied, but on average demonstrated low skill at handling emotions (mean, 0.7) and moderate skill at discussing end-of-life goals (mean, 7.4). We found that skill at discussing end-of-life goals was associated with initiation of palliation (p = 0.04). CONCLUSIONS: It is possible to analyze the decision making of physicians managing unstable critically ill patients with end-stage cancer using the framework of shared decision-making.