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Developing and Validating High-Value Patient Digital Follow-Up Services: a Pilot Study in Cardiac Surgery
No full textBackground: The existing digital healthcare solutions demand a service development approach that assesses needs, experience, and outcomes, to develop high-value digital healthcare services. The objective of this study was to develop a digital transformation of the patients' follow-up service after cardiac surgery, based on a remote patient monitoring service that would respond to the real context challenges.
Methods: The study followed the Design Science Research methodology framework and incorporated concepts from the Lean startup method to start designing a minimal viable product (MVP) from the available resources. The service was implemented in a pilot study with 29 patients in 4 iterative develop-test-learn cycles, with the engagement of developers, researchers, clinical teams, and patients.
Results: Patients reported outcomes daily for 30 days after surgery through Internet-of-Things (IoT) devices and a mobile app. The service's evaluation considered experience, feasibility, and effectiveness. It generated high satisfaction and high adherence among users, fewer readmissions, with an average of 7 ± 4.5 clinical actions per patient, primarily due to abnormal systolic blood pressure or wound-related issues.
Conclusions: We propose a 6-step methodology to design and validate a high-value digital health care service based on collaborative learning, real-time development, iterative testing, and value assessment.info:eu-repo/semantics/publishedVersio
Magnetic Resonance Imaging Target Fusion Biopsy vs. Transrectal Ultrasound-Guided Biopsy - A Comparative Study of ISUP Score Upgrading Risk in the Final Radical Prostatectomy Specimen
No full textObjectives: The aim of this study was to com-pare the risk of International Society of Urological Pathology (ISUP) score upgrading between magnetic resonance imaging targeted fusion biopsy (MRI-TB) and tran-srectal ultrasound-guided biopsy (TRUS-B) in the final radical prostatectomy (RP) specimen pathological report.
Materials and methods: This retrospective single center study included 51 patients with prostate cancer (PCa) diagnosed with MRI-TB and 83 patients diagnosed with TRUS-B between October/2019 and July/2021. We compared the rates of ISUP score upgrading between both groups after robotic-assisted radi-cal prostatectomy (RARP) and the specific transition of each ISUP score based on biopsy modality. The rate of ISUP score concordance and downgrading were also assessed. To define the intra and interobserver concordance for each ISUP score in biopsy and RP specimen for each biopsy modality, the Cohen's Kappa coefficient was calculated. ISUP scores and biopsy modal-ity were selected for multivariate analysis and a logistic regres-sion model was built to provide independent risk factors of ISUP score upgrading.
Results: The difference of the rate of upgrading between MRI-TB group and TRUS-B group was statistically significant (p = 0.007) with 42.2% of patients of TRUS-B group experiencing an upgrade in their ISUP score while only 19.6% in MRI-TB group. Concordance and downgrading rates did not statistically differ between the two groups. Strength of concordance using Cohen's Kappa coefficient was fair in both groups but higher in MRI-TB group (TRUS-B group k = 0.230; p < 0.001; concordance: 47%vs. MRI/TB group k = 0.438; p < 0.001; concordance: 62.7%). Biopsy modality and ISUP 1 on biopsy were independent predic-tors of ISUP upgrading after RP.
Conclusions: MRI-TB is highly accurate with lower risk of PCa upgrading after RP than TRUS-B. Patients with ISUP 1 on biopsy have greater susceptibility to upgrading their ISUP score.info:eu-repo/semantics/publishedVersio
Recurrent Pyogenic Infections Caused by a Movel Gln1420* Mutation in the C3 Gene
No full textC3 is a crucial protein of the complement system. Congenital C3 deficiency is extremely rare and manifests through recurrent, severe infections and should always be considered as a differential diagnosis of recurrent pyogenic infections. We report a case of a patient with a novel C3 gene mutation, responsible for complete C3 deficiency with impaired complement system activation and recurrent infections.info:eu-repo/semantics/publishedVersio
Informal Caregivers’ Health Literacy in Lisbon, Portugal: A Profile for Health Promotion Prioritization
No full textHealth literacy (HL) allows people to access, understand and evaluate health information. Informal caregivers' levels of HL may impact long-term care outcomes. 'Informal caregivers' profile in Lisbon county: a health community approach' is a nurse-led research project aiming to assess informal caregivers' health literacy and associated factors in Lisbon county, as well as to foster the development of a local-specific health literacy strategy. A survey to identify a health/social caregiver profile, including questions about HL (HLS-EU-PT), was submitted to a representative sample of carers. Descriptive and bivariate inferential analysis was developed. Informal caregivers' level of HL was mostly sufficient (n = 99, 38%). More than 60% of caregivers have limited HL regarding health promotion. 'Access', 'Appraisal' and 'Use' are the information processing stages with lower mean scores of HL. Carers with low HL levels appear to be older and to have less education, low knowledge of community resources and decreased wellbeing (p < 0.05). A strategy focused on health promotion-related HL through primary care resources can potentially improve caregivers' knowledge, competencies and motivation, as well as health system sustainability. Reported HLS-EU-PT scores deserve special attention. Future work should emphasize the role of HL-associated factors and health outcomes for caregivers and cared-for persons.info:eu-repo/semantics/publishedVersio
Monitoração Remota versus Seguimento Hospitalar Presencial em Portadores de Cardioversor-Desfibrilhador: Resultados dum Estudo Randomizado em Portugal
No full textIntroduction: Remote monitoring (RM) is a safe and effective alternative to in-office conventional follow-up.
Objective: We aimed to evaluate patient satisfaction with RM and its impact on healthcare resources in a population with cardiac implantable electronic devices.
Methods: Randomized, pragmatic, open-label controlled trial, with adult wearers of implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with ICD (CRT-D), eligible for the CareLink® system. Patients newly implanted or with previous conventional follow-up were randomized to RM or conventional follow-up (control), and followed for 12 months, according to the centers' practice. The number of in-office visits and adverse events were compared between groups. Patient and healthcare professionals' satisfaction with RM were described.
Results: Of the 134 randomized patients (69 RM; 65 control, aged 60±13 years), 80% were male, 23% employed, 72% ICD wearers and 54% newly implanted. Most patients (70%) reported travel costs less than 15€/visit, and 46% daily routine interference with in-office visits. Median physician/technician time with patient was 15 min/15 min, per in-office visit. Excluding baseline and final visits, control patients had more in-office visits in total: median 1 vs. 0, p<0.001. In 81% of the in-office visits, no clinical measures were taken. There were 10 adverse events, with no differences between groups. At the final visit, 95% of RM patients considered RM easy/very easy to use, and would all prefer to maintain RM and recommend it to others. All professionals found the CareLink website easy/very easy to use and were satisfied with transmission data.
Conclusions: In a Portuguese population with ICD and CRT-D, RM safely reduced the burden of in-office visits, with high levels of satisfaction among patients and healthcare professionals.info:eu-repo/semantics/publishedVersio
Using Patient-Reported Outcome Measures to Evaluate Care for Patients With Inflammatory Chronic Rheumatic Disease
No full textObjectives: Few countries integrate patient-reported outcome measures (PROMs) in routine performance assessment and those that do focus on elective surgery. This study addresses the challenges of using PROMs to evaluate care in chronic conditions. We set out a modeling strategy to assess the extent to which changes over time in self-reported health status by patients with inflammatory chronic rheumatic disease are related to their biological drug therapy and rheumatology center primarily responsible for their care.
Methods: Using data from the Portuguese Register of Rheumatic Diseases, we assess health status using the Health Assessment Questionnaire-Disability Index for rheumatic patients receiving biological drugs between 2000 and 2017. We specify a fixed-effects model using the least squares dummy variables estimator.
Results: Patients receiving infliximab or rituximab report lower health status than those on etanercept (the most common therapy) and patients in 4 of the 26 rheumatology centers report higher health status than those at other centers.
Conclusions: PROMs can be used for those with chronic conditions to provide the patient's perspective about the impact on their health status of the choice of drug therapy and care provider. Care for chronic patients might be improved if healthcare organizations monitor PROMs and engage in performance assessment initiatives on a routine basis.info:eu-repo/semantics/publishedVersio
Secondary Adrenal Suppression Related to High Doses of Inhaled Corticosteroids in Patients with Severe Asthma
No full textinfo:eu-repo/semantics/publishedVersio
Primary Biliary Cholangitis: a Rare Diagnosis During Pregnancy
No full textPrimary biliary cholangitis is an autoimmune disease that mostly affects women. It is uncommon in women of childbearing age and the diagnosis during pregnancy is rare and can be challenging. Described here is a case of primary biliary cholangitis first manifesting during pregnancy, with the onset of pruritus, jaundice, biochemical liver abnormalities and positive antimitochondrial antibodies. Although treatment with ursodeoxycholic acid was started at the time of diagnosis, there was a progressive worsening of cholestatic biochemical markers throughout pregnancy. In addition, fasting hyperglycemia with polyhydramnios was diagnosed, consistent with gestational diabetes. She had a spontaneous preterm delivery at 31 weeks of gestation, of a newborn who was admitted to the neonatal intensive care unit but who subsequently had no long-term sequelae of preterm delivery. A maternal postpartum flare occurred. Treatment with ursodeoxycholic acid was well tolerated during pregnancy and lactation.info:eu-repo/semantics/publishedVersio
Presentations of Children to Emergency Departments Across Europe and the COVID-19 Pandemic: A Multinational Observational Study
No full textBackground: During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses.
Methods and findings: Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems.
Conclusions: Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell.info:eu-repo/semantics/publishedVersio
Stent Graft Explantation Following Endovascular Aortic Aneurysm Repair – a Case Series
No full textINTRODUCTION: Endovascular aneurysm repair (EVAR) offers signifcant advantages on aneurysm treatment.
However, the management of EVAR complications or failure often results in complex surgical approaches,
sometimes requiring graft explantation which remains a major challenge and one associated with a high
morbidity and mortality. The purpose of this study is to review our contemporary institutional experience with
EVAR explantation.
METHODS: An institutional administrative database was reviewed to identify patients who were subject of graft
explantation following standard infra-renal EVAR between 2011 and 2021. Follow-up was extracted from patient
charts. The primary endpoint was perioperative mortality (30-days or in-hospital). Demographics, indications for
explantation and procedure details were evaluated.
RESULTS: Over a 10-year period, between 2011 and 2021, there were 617 standard primary EVAR procedures
performed in our institution for infrarenal aortic aneurysms. During this period, we identifed 13 patients
submitted to EVAR explantation, two of which were referrals from other vascular centers. All patients were male
and mean age at explantation was 71 years (range 47-81). The primary EVAR procedure took place 29 months
(range 0-72) before explantation. The primary indication for EVAR was ruptured aortic aneurysm in seven patients.The majority of explantation operations were emergent (6/13, three due to unstable aorto-enteric fstula (AEF),three due to rupture) or urgent (4/13, two stable AEF, two graft infections). In 3 cases, explantation was elective(two type Ia endoleaks and one type II endoleak with sac expansion). None of the patients had been submitted to a previous attempt at endovascular salvage. All patients were submitted to transperitoneal approaches, and all required initial supracoeliac or suprarenal aortic clamping.
After explantation, in situ reconstruction was performed in eight patients, six of which with complete EVAR
explantation and two with partial EVAR explantation. Two in situ reconstructions were made using superfcial
femoral veins, and the remaining used prosthetic grafts. Aortic ligation and extra-anatomic bypass were
performed in fve cases, The 30-day mortality was 54% (seven patients) with 33% of mortality for elective repair,
50% mortality for urgent repair, and 67% mortality for emergent repair. Mean hospital stay after surgery was 48
days for survivors. Mean survival after discharge was 10 months.
CONCLUSION: EVAR explantation is still a relatively rare and particularly complex procedure. When the reason for explantation is graft infection and AEF, and when performed in an emergent context, it is a particularly morbid procedure with a dismal prognosis. As the number of endovascular aneurysm repairs increase, our global experience will become increasingly important in bettering our surgical and clinical outcomes.info:eu-repo/semantics/publishedVersio