Two-year outcome of an observe-and-plan regimen for neovascular age-related macular degeneration: how to alleviate the clinical burden with maintained functional results.

PurposeThe purpose of this study was to report the 2-year outcome of an individually tailored 'observe-and-plan' treatment regimen for neovascular age-related macular degeneration (nAMD), and to investigate its clinical value in terms of functional outcome. This regimen aimed to reduce the clinical burden (visits) by employing individually fixed injection intervals, based on the predictability of an individual's need for retreatment.MethodsThis prospective case series included 104 patients (115 eyes) with nAMD. Following three loading doses of ranibizumab, the disease recurrence interval was determined in monthly observation visits. Retreatment was applied in a series of three injections with individually fixed intervals (2 weeks shorter than the recurrence interval), combined with periodic adjustment of the intervals. The allowed injection intervals in treatment plans ranged from 1 to 3 months. If there was no recurrence at 3 months, the patient could change to monitoring alone.ResultsMean visual acuity (VA) improved by 8.7, 9.7, and 9.2 letters at months 3, 12, and 24, respectively. The mean number of injections was 7.8 and 5.8 during years 1 and 2, respectively, whereas the mean number of ophthalmic examinations was 4.0 and 2.9, respectively. The mean treatment interval (after the loading doses) was 2.0 months during year 1, and 2.2 months during year 2.ConclusionThe observe-and-plan regimen significantly improved and maintained VA over the course of 2 years. This favourable functional outcome was achieved with fewer clinic visits compared with other regimens. Therefore, this observe-and-plan regimen has the potential to alleviate the clinical burden of nAMD treatment.

Delivery Chain Management in the Elevator Industry

Tämän työn tarkoituksena oli kehittää toimintamalli, joka yhdenmukaistaisi Kone Elevators:in modernisointiliikealueen logistiset käytännöt. Toimintamalli luotiin kartoittamalla euroopan maayksiköiden nykyisiä logistisia käytäntöjä sekä perehtymällä asiaankuuluvaan kirjallisuuteen, case study:ihin sekä sähköisiin artikkeleihin. Tärkeää osaa työssä esittivät maayksiköiden sekä Koneen toimittajayksiköiden edustajien haastattelut. Haastatteluiden tuloksia vertailtiin ja analysoitiin. Niiden pohjalta huomattiin, että logistiset toimintatavat vaihtelevat maittain. Ongelmat ovat kuitenkin hyvin samanlaisia; tiedonkulun katkot toimitusprosessin aikana. Muiden Koneen liikealueiden toimintatapoja tutkimalla, haastattelujen tuloksia käyttämällä sekä kirjallisuustutkimuksen pohjalta muodostettiin näkemys parhaasta toimintatapamallista. Modernisointiliikealueen toimitusprosessi tullee perustumaan keskitettyyn ohjaukseen, mutta paikalliseen koordinointiin. Se tullee hyväksikäyttämään ulkoistetun logistiikan tarjoamia mahdollisuuksia sekä sähköistä tiedonsiirtoa. Fyysiselle siirrolle tarjotaan kolmea vaihtoehtoa, joista maayksiköt voivat valita tilanteeseen parhaiten sopivan.

Impact on costs of a case management intervention for emergency department frequent users

Background: In most of the emergency departments (ED) in developed countries, a subset of patients visits the ED frequently. Despite their small numbers, these patients are the source of a disproportionally high number of all ED visits, and use a significant proportion of healthcare resources. They place a heavy economic burden on hospital and healthcare system budgets overall. In order to improve the management of these patients, the University hospital of Lausanne, Switzerland implemented a case management intervention (CM) between May 2012 and July 2013. In this randomized controlled trial, 250 frequent ED users (visits>5 during previous 12 months) were allocated to either the CM group or the standard ED care (SC) group and followed up for 12 months. The first result of the CM was to reduce significantly the ED visits. The present study examined whether the CM intervention also reduced the costs generated by the ED frequent users not only from the hospital perspective, but also from the healthcare system perspective. Methods: Cost data were obtained from the hospital's analytical accounting system and from health insurances. Multivariate linear models including a fixed effect "group" and socio-demographic characteristics and health-related variables were run.

L'insuffisance rénale chronique: quelle est la diète optimale

The optimal diet for chronic kidney disease (CKD) is an issue frequently brought up by patients and/or their relatives during outpatient visits. For patients without malnutrition who are motivated and supported by an experienced multidisciplinary team, the optimal protein intake of 0,6 g/kg of ideal body weight/day is recommended to halt the progression of CKD. A calorie intake of 30 to 35 kcal/kg of ideal body weight/day is necessary to reduce the risk of malnutrition from a low protein diet and to maintain a neutral nitrogen balance. A low-salt diet, namely 5 to 6 g/d, is useful to optimize the treatment of hypertension associated with CKD and to limit fluid overload. At the advanced stage of CKD, it is also necessary to restrict the intake of phosphorus and sometimes potassium. Given the complexity of optimal renal diet, coordination between general practitioners, nephrologists and dietitians is essential to foster optimal care.

Clinically meaningful parameters of progression and long-term outcome of Parkinson disease: An international consensus statement.

Parkinson disease (PD) is associated with a clinical course of variable duration, severity, and a combination of motor and non-motor features. Recent PD research has focused primarily on etiology rather than clinical progression and long-term outcomes. For the PD patient, caregivers, and clinicians, information on expected clinical progression and long-term outcomes is of great importance. Today, it remains largely unknown what factors influence long-term clinical progression and outcomes in PD; recent data indicate that the factors that increase the risk to develop PD differ, at least partly, from those that accelerate clinical progression and lead to worse outcomes. Prospective studies will be required to identify factors that influence progression and outcome. We suggest that data for such studies is collected during routine office visits in order to guarantee high external validity of such research. We report here the results of a consensus meeting of international movement disorder experts from the Genetic Epidemiology of Parkinson's Disease (GEO-PD) consortium, who convened to define which long-term outcomes are of interest to patients, caregivers and clinicians, and what is presently known about environmental or genetic factors influencing clinical progression or long-term outcomes in PD. We propose a panel of rating scales that collects a significant amount of phenotypic information, can be performed in the routine office visit and allows international standardization. Research into the progression and long-term outcomes of PD aims at providing individual prognostic information early, adapting treatment choices, and taking specific measures to provide care optimized to the individual patient's needs.

Frequency of and Risk Factors for Depression among Participants in the Swiss HIV Cohort Study (SHCS).

OBJECTIVES: We studied the incidence and prevalence of, and co-factors for depression in the Swiss HIV Cohort Study. METHODS: Depression-specific items were introduced in 2010 and prospectively collected at semiannual cohort visits. Clinical, laboratory and behavioral co-factors of incident depression among participants free of depression at the first two visits in 2010 or thereafter were analyzed with Poisson regression. Cumulative prevalence of depression at the last visit was analyzed with logistic regression. RESULTS: Among 4,422 participants without a history of psychiatric disorders or depression at baseline, 360 developed depression during 9,348 person-years (PY) of follow-up, resulting in an incidence rate of 3.9 per 100 PY (95% confidence interval (CI) 3.5-4.3). Cumulative prevalence of depression during follow-up was recorded for 1,937/6,756 (28.7%) participants. Incidence and cumulative prevalence were higher in injection drug users (IDU) and women. Older age, preserved work ability and higher physical activity were associated with less depression episodes. Mortality (0.96 per 100 PY, 95% CI 0.83-1.11) based upon 193 deaths over 20,102 PY was higher among male IDU (2.34, 1.78-3.09), female IDU (2.33, 1.59-3.39) and white heterosexual men (1.32, 0.94-1.84) compared to white heterosexual women and homosexual men (0.53, 0.29-0.95; and 0.71, 0.55-0.92). Compared to participants free of depression, mortality was slightly elevated among participants with a history of depression (1.17, 0.94-1.45 vs. 0.86, 0.71-1.03, P = 0.033). Suicides (n = 18) did not differ between HIV transmission groups (P = 0.50), but were more frequent among participants with a prior diagnosis of depression (0.18 per 100 PY, 95%CI 0.10-0.31; vs. 0.04, 0.02-0.10; P = 0.003). CONCLUSIONS: Depression is a frequent co-morbidity among HIV-infected persons, and thus an important focus of care.

Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.

OBJECTIVE: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. DESIGN: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. SETTING: General practices in metropolitan and rural Victoria, Australia. PARTICIPANTS: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. INTERVENTION: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. OUTCOME MEASURES: Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. RESULTS: 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0·52, CI 0·28 to 0·96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0·66, CI 0·46 to 0·96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0·40, CI 0·20 to 0·80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. CONCLUSIONS: A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. TRIAL REGISTRATION: ISRCTN.com ISRCTN16059206.

Lifestyle of the Elderly Receiving Home Care in Spain

The aim of this study is to examine the lifestyle characteristics and health status of the elderly in order to identify aspects that might help promote active ageing. Participants were 26 elderly citizens aged 75 or over who were the recipients of home care services in Vilafranca del Penedès (Barcelona, Spain). They were recruited by means of convenience sampling, and a case study approach was adopted. Fieldwork was conducted in April 2007, with a specially designed questionnaire administered in the context of an in-depth interview. Quantitative data were analyzed with SPSS 15, while qualitative data were analysed and grouped by category. The results indicated that 53.8% of the elderly interviewees perceived their health status as being regular, most did not have adequate nutrition and hydration, while 42.3% had chewing problems and 65.3% presented slight dependence. Most of them received visits at home, but did not go on leisure outings. The only exercise they took was walking. These findings highlight the need to promote and strengthen activities for healthy ageing, and to ensure that people over 75 receive adequate care. Programmes should be implemented to improve those aspects that are currently under-addressed.

Lifestyle of the Elderly Receiving Home Care in Spain

The aim of this study is to examine the lifestyle characteristics and health status of the elderly in order to identify aspects that might help promote active ageing. Participants were 26 elderly citizens aged 75 or over who were the recipients of home care services in Vilafranca del Penedès (Barcelona, Spain). They were recruited by means of convenience sampling, and a case study approach was adopted. Fieldwork was conducted in April 2007, with a specially designed questionnaire administered in the context of an in-depth interview. Quantitative data were analyzed with SPSS 15, while qualitative data were analysed and grouped by category. The results indicated that 53.8% of the elderly interviewees perceived their health status as being regular, most did not have adequate nutrition and hydration, while 42.3% had chewing problems and 65.3% presented slight dependence. Most of them received visits at home, but did not go on leisure outings. The only exercise they took was walking. These findings highlight the need to promote and strengthen activities for healthy ageing, and to ensure that people over 75 receive adequate care. Programmes should be implemented to improve those aspects that are currently under-addressed.

Lifestyle of the Elderly Receiving Home Care in Spain

The aim of this study is to examine the lifestyle characteristics and health status of the elderly in order to identify aspects that might help promote active ageing. Participants were 26 elderly citizens aged 75 or over who were the recipients of home care services in Vilafranca del Penedès (Barcelona, Spain). They were recruited by means of convenience sampling, and a case study approach was adopted. Fieldwork was conducted in April 2007, with a specially designed questionnaire administered in the context of an in-depth interview. Quantitative data were analyzed with SPSS 15, while qualitative data were analysed and grouped by category. The results indicated that 53.8% of the elderly interviewees perceived their health status as being regular, most did not have adequate nutrition and hydration, while 42.3% had chewing problems and 65.3% presented slight dependence. Most of them received visits at home, but did not go on leisure outings. The only exercise they took was walking. These findings highlight the need to promote and strengthen activities for healthy ageing, and to ensure that people over 75 receive adequate care. Programmes should be implemented to improve those aspects that are currently under-addressed.

Turvallisuuteen liittyvä riskianalyysi metsäteollisuusyrityksessä

Diplomityön päätavoitteena oli määrittää yhdenmukainen käytäntö koskien turvallisuuteen liittyviä järjestelmiä metsäteollisuudessa. Työn tarkoituksena oli esittää erilaisia aihepiiriin liittyviä ohjeistuksia, joiden avulla tulevat hankkeet ja muutosprojektit ovat samalla lähtöviivalla niiden alkaessa. Teoreettinen osuus on työssä laaja, koska sen tavoitteena on toimia aihepiirin kokoavana käsikirjana kohdeyritykselle. Teorian tavoitteena on käsitellä aihepiiriä mahdollisimman monesta eri näkökulmasta. Työn käytännön osuuteen kerättiin materiaalia vierailemalla neljässä UPM:n yksikössä, joilla oli kokemuksia liittyen työn aihepiiriin. Tarkoituksena oli löytää hyväksi havaittuja käytäntöjä sekä kehityskohteita, joiden perusteella työssä esitetyt ohjeet toteutettaisiin. Lisäksi käytännön osuudessa verrataan työssä toteutettua ohjeistavaa mallia teollisuudessa esitettyihin malleihin. Työn tuloksena UPM:lle muodostettiin yhteiset riskiparametrit riskien arviointiin ja turvallisuuden eheystasotarkasteluihin. Tulevissa projekteissa näitä parametreja käyttäen päästään lähemmäksi yhdenmukaista käytäntöä. Tämän lisäksi diplomityö esittää ohjeen koskien vanhojen laitosten eheystasotarkasteluja sekä sanallisen arvion turvallisuuteen liittyvien järjestelmien kustannustekijöistä niiden elinkaaren aikana.

Asymmetrical nature of the Trollius-Chiastocheta interaction: insights into the evolution of nursery pollination systems

The mutualistic versus antagonistic nature of an interaction is defined by costs and benefits of each partner, which may vary depending on the environment. Contrasting with this dynamic view, several pollination interactions are considered as strictly obligate and mutualistic. Here, we focus on the interaction between Trollius europaeus and Chiastocheta flies, considered as a specialized and obligate nursery pollination system - the flies are thought to be exclusive pollinators of the plant and their larvae develop only in T.europaeus fruits. In this system, features such as the globelike flower shape are claimed to have evolved in a coevolutionary context. We examine the specificity of this pollination system and measure traits related to offspring fitness in isolated T.europaeus populations, in some of which Chiastocheta flies have gone extinct. We hypothesize that if this interaction is specific and obligate, the plant should experience dramatic drop in its relative fitness in the absence of Chiastocheta. Contrasting with this hypothesis, T.europaeus populations without flies demonstrate a similar relative fitness to those with the flies present, contradicting the putative obligatory nature of this pollination system. It also agrees with our observation that many other insects also visit and carry pollen among T.europaeus flowers. We propose that the interaction could have evolved through maximization of by-product benefits of the Chiastocheta visits, through the male flower function, and selection on floral traits by the most effective pollinator. We argue this mechanism is also central in the evolution of other nursery pollination systems.

A qualitative study of adolescents with medically unexplained symptoms and their parents. Part 2: How is healthcare perceived?

Medically unexplained symptoms (MUS) are common among adolescents and an important cause of clinical visits. This study sought to understand the experiences with, and perceptions of, the healthcare of adolescents who have MUS and their parents. Using a qualitative approach, six focus groups and two individual interviews were conducted with a total of ten adolescents and sixteen parents. The participants were recruited in a university hospital in Switzerland. A thematic analysis was conducted in accordance with the Grounded Theory. Six main themes emerged: needing a label for the symptoms, seeking an etiology to explain the symptoms, negotiating the medical system, medication and treatments, interactions with doctors, and the inclusion of parents during consultations. Transcending these themes, however, was the need for good communication between the adolescents, their parents and the clinicians. When explaining the symptoms, clinicians should make sure to discuss the results, investigations and lack of organic origin.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study.

BACKGROUND: Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability. METHODS: A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used. RESULTS: We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2). CONCLUSIONS: Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.

Screening of mental health and substance users in frequent users of a general Swiss emergency department.

BACKGROUND: The objectives of this study were to determine the proportions of psychiatric and substance use disorders suffered by emergency departments' (EDs') frequent users compared to the mainstream ED population, to evaluate how effectively these disorders were diagnosed in both groups of patients by ED physicians, and to determine if these disorders were predictive of a frequent use of ED services. METHODS: This study is a cross-sectional study with concurrent and retrospective data collection. Between November 2009 and June 2010, patients' mental health and substance use disorders were identified prospectively in face-to-face research interviews using a screening questionnaire (i.e. researcher screening). These data were compared to the data obtained from a retrospective medical chart review performed in August 2011, searching for mental health and substance use disorders diagnosed by ED physicians and recorded in the patients' ED medical files (i.e. ED physician diagnosis). The sample consisted of 399 eligible adult patients (≥18 years old) admitted to the urban, general ED of a University Hospital. Among them, 389 patients completed the researcher screening. Two hundred and twenty frequent users defined by >4 ED visits in the previous twelve months were included and compared to 169 patients with ≤4 ED visits in the same period (control group). RESULTS: Researcher screening showed that ED frequent users were more likely than members of the control group to have an anxiety, depressive disorder, post-traumatic stress disorder (PTSD), or suffer from alcohol, illicit drug abuse/addiction. Reviewing the ED physician diagnosis, we found that the proportions of mental health and substance use disorders diagnosed by ED physicians were low both among ED frequent users and in the control group. Using multiple logistic regression analyses to predict frequent ED use, we found that ED patients who screened positive for psychiatric disorders only and those who screened positive for both psychiatric and substance use disorders were more likely to be ED frequent users compared to ED patients with no disorder. CONCLUSIONS: This study found high proportions of screened mental health and/or substance use disorders in ED frequent users, but it showed low rates of detection of such disorders in day-to-day ED activities which can be a cause for concern. Active screening for these disorders in this population, followed by an intervention and/or a referral for treatment by a case-management team may constitute a relevant intervention for integration into a general ED setting.