In‐depth descriptive analysis of trends in prevalence of long‐term care in Japan

Background: Long‐term care (LTC) insurance was introduced in Japan in 2000. Herein, we describe the trends in demand for LTC, using age‐standardized and level‐specific rates of entitlement and utilization of LTC at national and prefectural levels. Methods: We analyzed LTC data from 2002–2005 to examine: (i) the influence of population aging, calculating crude and age‐standardized entitlement and utilization rates; (ii) the relation between baseline entitlement rate and increase in the rate over this 3‐year period; and (iii) differences in increases in entitlement rate between low and high care levels. Results: The entitlement and utilization rates increased even after adjustment for age; approximately two‐thirds of the increase was not due to population aging. Variations in the entitlement rates among prefectures did not decrease (coefficient of variance was 0.12 in 2002 and 0.11 in 2005), and there was no significant correlation between baseline entitlement rates and the later increases among prefectures (r = ?0.20, P = 0.19). The increase in entitlement rate was larger for low than for high care levels (31% vs 6%), and those for low and high care levels were weakly correlated. Conclusion: This study suggested that a large part of the increase in LTC demand could not be explained by population aging, and the increase did not result from equalization of LTC services across the country. In addition, it seems that the demands of low and high care levels depend on different factors. The increase in LTC demand should be monitored carefully to identify underlying factors and to ensure sustainability of the system.     

Long‐term macrolides for non‐cystic fibrosis bronchiectasis: A systematic review and meta‐analysis

Long‐term macrolides are increasingly being prescribed for stable bronchiectasis. This meta‐analysis assessed the clinical effect of this treatment in bronchiectasis. A systematic review and meta‐analysis were carried out. All randomized, controlled trials (RCT) comparing long‐term macrolides with placebo and/or usual medical care, with outcome measures relating to efficacy and safety were selected. Nine RCT recruiting 530 patients were included. Compared with placebo and/or usual medical care, long‐term macrolides significantly reduced the risk of the exacerbations (number of participants with exacerbations (relative risk = 0.70, 95% confidence interval (CI) 0.60–0.82, P < 0.00001); average exacerbations per participant (weighted mean difference = ?1.01, 95% CI ?1.35 to ?0.67, P < 0.00001)), the St George's Respiratory Questionnaire total scores (weighted mean difference = ?5.39 95% CI ?9.89 to ?0.88, P = 0.02), dyspnoea scale (weighted mean difference = ?0.31 95% CI ?0.42 to ?0.20, P < 0.00001), 24‐h sputum volume (P < 0.00001), and attenuated the decline of forced expiratory volume in 1 s (weighted mean difference 0.02 L, 95% CI 0.00–0.04, P = 0.01). Eradication of pathogens (P = 0.06), overall rate of adverse events (P = 0.61), and emergence of new pathogens (P = 0.61) were not elevated, while gastrointestinal events increased significantly with macrolides (P = 0.0001). Macrolide resistance increased, but a meta‐analysis was not possible due to the diversity of parameters. Long‐term use of macrolides appears to be a treatment option for stable bronchiectasis. The results of this review justify further investigation about adding this intervention to the treatment regimens of bronchiectasis.     

A long‐term comparison of pioglitazone and gliclazide in patients with Type 2 diabetes mellitus: a randomized,double‐blind,parallel‐group comparison trial

Aims This study compared the effects of pioglitazone and gliclazide on metabolic control in drug‐naïve patients with Type 2 diabetes mellitus. Methods A total of 1270 patients with Type 2 diabetes were randomized in a parallel‐group, double‐dummy, double‐blind study. Patients with poorly controlled Type 2 diabetes (HbA_1c 7.5–11%), despite dietary advice, received either pioglitazone up to 45 mg once daily or gliclazide up to 160 mg two times daily. Primary efficacy endpoint was change in HbA_1c from baseline to the end of the study. Secondary efficacy endpoints included change in fasting plasma glucose, fasting plasma insulin and plasma lipids. At selected centres, oral glucose tolerance tests were performed and C‐peptide and pro‐insulin levels were measured. Results Mean HbA_1c values decreased by the same amount in the two treatment groups from baseline to week 52 [pioglitazone: ?1.4%; gliclazide: ?1.4%; (90% CI: ?0.18 to 0.02)]. A significantly greater mean reduction in fasting plasma glucose was observed in the pioglitazone group (2.4 mmol/l) than in the gliclazide group [2.0 mmol/l; treatment difference ?0.4 mmol/l in favour of pioglitazone; P = 0.002; (95% CI: ?0.7 to ?0.1)]. Improvements in high‐density lipoprotein cholesterol (HDL‐C) and total cholesterol/HDL‐C were greater with pioglitazone than with gliclazide (P < 0.001). The frequencies of adverse events were comparable between the two treatment groups, but more hypoglycaemic events were reported for gliclazide, whereas twice as many patients reported oedema with pioglitazone than with gliclazide. Conclusions Pioglitazone monotherapy was equivalent to gliclazide in reducing HbA_1c, with specific differences between treatments in terms of mechanism of action, plasma lipids and adverse events.     

International comparison of long‐term care resident dependency across four countries (1998–2009): A descriptive study

Aim: To describe an international comparison of dependency of long‐term care residents. Methods: All Auckland aged care residents were surveyed in 1998 and 2008 using the ‘Long‐Term Care in Auckland’ instrument. A large provider of residential aged care, Bupa‐UK, performed a similar but separate functional survey in 2003, again in 2006 (including UK Residential Nursing Home Association facilities), and in 2009 which included Bupa facilities in Spain, New Zealand and Australia. The survey questionnaires were reconciled and functional impairment rates compared. Results: Of almost 90 000 residents, prevalence of dependent mobility ranged from 27 to 47%; chronic confusion, 46 to 75%; and double incontinence, 29 to 49%. Continence trends over time were mixed, chronic confusion increased, and challenging behaviour decreased. Conclusion: Overall functional dependency for residents is high and comparable internationally. Available trends over time indicate increasing resident dependency signifying care required for this population is considerable and possibly increasing.     

A comparison of the long‐term durability of nevirapine,efavirenz and lopinavir in routine clinical practice in Europe: a EuroSIDA study

Objectives

The durability of combination antiretroviral therapy (cART) regimens can be measured as time to discontinuation because of toxicity or treatment failure, development of clinical disease or serious long‐term adverse events. The aim of this analysis was to compare the durability of nevirapine, efavirenz and lopinavir regimens based on these measures.

Methods

Patients starting a nevirapine, efavirenz or lopinavir‐based cART regimen for the first time after 1 January 2000 were included in the analysis. Follow‐up started ≥3 months after initiation of treatment if viral load was <500 HIV‐1 RNA copies/mL. Durability was measured as discontinuation rate or development/worsening of clinical markers.

Results

A total of 603 patients (21%) started nevirapine‐based cART, 1465 (51%) efavirenz, and 818 (28%) lopinavir. After adjustment there was no significant difference in the risk of discontinuation for any reason between the groups on nevirapine and efavirenz (P=0.43) or lopinavir (P=0.13). Compared with the nevirapine group, those on efavirenz had a 48% (P=0.0002) and those on lopinavir a 63% (P<0.0001) lower risk of discontinuation because of treatment failure and a 31% (P=0.01) and 66% (P<.0001) higher risk, respectively, of discontinuation because of toxicities or patient/physician choice. There were no significant differences in the incidence of non‐AIDS‐related events, worsening anaemia, severe weight loss, increased aspartate aminotransferase (AST)/alanine aminotransferase (ALT) levels or increased total cholesterol. Compared with patients on nevirapine, those on lopinavir had an 80% higher incidence of high‐density lipoprotein (HDL) cholesterol decreasing below 0.9 mmol/L (P=0.003), but there was no significant difference in this variable between those on nevirapine and those on efavirenz (P=0.39).

Conclusions

The long‐term durability of nevirapine‐based cART, based on risk of all‐cause discontinuation and development of long‐term adverse events, was comparable to that of efavirenz or lopinavir, in patients in routine clinical practice across Europe who initially tolerated and virologically responded to their regimen.     

Direct costs of acute respiratory infections in a pediatric long‐term care facility

Acute respiratory tract infections (ARI) are a major burden in pediatric long‐term care. We analyzed the financial impact of ARI in 2012–2013. Costs associated with ARI during the respiratory viral season were ten times greater than during the non‐respiratory viral season, $31 224 and $3242 per 1000 patient‐days, respectively (P < 0·001). ARI are burdensome for pediatric long‐term care facilities not only because of the associated morbidity and mortality, but also due to the great financial costs of prevention.     

Prognostic Significance of Electrocardiographic Abnormalities in Diphtheritic Myocarditis After Hospital Discharge: A Long‐Term Follow‐Up Study

Objective: We aimed to investigate the long‐term cardiac mortality and the relationship between cardiac mortality and electrocardiographic abnormalities in patients with diphtheritic myocarditis who survived after hospital discharge. Materials and Methods: Between 1991 and 1996, 32 patients (all males, mean age 21.00 ± 3.77 years) surviving diphtheritic myocarditis were included in the study and they were followed up for an average of 16.3 months (range 10.3–26.8 months) after hospital discharge. Clinical evaluation, ECG, and echocardiography were performed on admission, daily while in hospital and at the time of discharge. ECG changes were permanent during the follow‐up period. The causes of death of the patients during follow‐up period were inferred from the death records of the patients and talking to the people witnessing cardiac arrest. Results: We observed that the patients with left bundle branch block (LBBB) and T wave inversion at hospital discharge had lower survival rates than that of the patients without these ECG changes in the long term. Although univariate Cox regression analysis identified LBBB (P = 0.001) and T wave inversion (P = 0.014) as the predictors of survival, only LBBB was an independent predictor of survival in multivariate Cox regression analysis. Adjusted hazard ratio was calculated as 13.67 for LBBB (P = 0.001; CI = 2.81–66.28). Conclusion: Diphtheritic myocarditis does not only demonstrate a malignant clinical course during acute phase of the disease, but also during the long‐term follow‐up period, especially in patients with LBBB and T wave inversion. Besides, T wave inversion and LBBB can help us to predict survival rate of the patients in long term. Moreover, LBBB is an independent predictor of long‐term survival in diphtheritic myocarditis.