Telemonitoring in-home complex chronic patients from primary care in routine clinical practice: Impact on healthcare resources use

Background: Recent evidence indicates that home telemonitoring of chronic patients reduces the use of healthcare resources. However, further studies exploring this issue are needed in primary care.

Objectives: To assess the impact of a primary care-based home telemonitoring intervention for highly unstable chronic patients on the use of healthcare resources.

Methods: A one-year follow-up before and after exploratory study, without control group, was conducted. Housebound patients with heart failure or chronic lung disease, with recurrent hospital admissions, were included. The intervention consisted of patient’s self-measurements and responses to a health status questionnaire, sent daily from smartphones to a web-platform (aided by an alert system) reviewed by healthcare professionals. The primary outcome measure was the number of hospital admissions occurring 12 months before and after the intervention. Secondary outcomes were length of hospital stay and number of emergency department attendances. Primary care nurses were mainly in charge of the telemonitoring process and were assisted by the general practitioners when required.

Results: For the 28 patients who completed the follow-up (out of 42 included, 13 patients died and 1 discontinued the intervention), a significant reduction in hospitalizations, from 2.6 admissions/patient in the previous year (standard deviation, SD: 1.6) to 1.1 (SD: 1.5) during the one-year telemonitoring follow-up (P?<0.001), and emergency department attendances, from 4.2 (SD: 2.6) to 2.1 (SD: 2.6) (P?<0.001) was observed. The length of hospital stay was reduced non-significantly from 11.4 to 7.9 days.

Conclusion: In this small exploratory study, the primary care-based telemonitoring intervention seemed to have a positive impact decreasing the number of hospital admissions and emergency department attendances.     

Specific Formulation of Camellia sinensis Prevents Cold and Flu Symptoms and Enhances γδ T Cell Function: A Randomized,Double-Blind,Placebo-Controlled Study

Objective: Determine if a specific formulation of Camellia sinensis (CSF) can prevent illness and symptoms due to cold and flu, and enhance γδ T cell function

Methods: Design: Randomized, double-blind, placebo-controlled study. Subjects: Healthy adults 18–70 years old. Intervention: Proprietary formulation of Camellia sinensis (green tea) capsules, or a placebo, twice a day, for 3 months. Measures of Outcome: As assessed by daily symptom logs, percentage of subjects experiencing cold and flu symptoms, number of days subjects experienced symptoms, and percentage of subjects seeking medical treatment. Mean in vivo and ex vivo proliferative and interferon gamma responses of subjects’ peripheral blood mononuclear cells to γδ T cell antigen stimulation.

Results: Among subjects taking CSF there were 32.1% fewer subjects with symptoms (P = 0.035), 22.9% fewer overall illnesses of at least 2 days duration (P = 0.092), and 35.6% fewer symptom days (P < 0.002), compared to subjects taking placebo. γδ T cells from subjects taking CSF proliferated 28% more (P = 0.017) and secreted 26% more IFN-γ (P = 0.046) in response to γδ T cell antigens, as compared to γδ T cells from subjects taking placebo. CSF was well-tolerated.

Conclusions: This proprietary formulation of CSF is a safe and effective dietary supplement for preventing cold and flu symptoms, and for enhancing γδ T cell function.     

‘An end has a start’1

Abstract

Background: Disease management programmes (DMPs) improve quality of care for patients with heart failure (HF). However, only a limited number of trials have studied the efficacy of such programmes for patients with heart failure with preserved ejection fraction (HFPEF). Objective: To estimate the impact of a structured, nurse-led patient education programme and care plan in general practice on outcome parameters and events in patients with HFPEF. Methods: Single blinded randomized clinical trial with an intervention over six months and a follow-up during 12 additional months. In the control group, the patients (n = 41) were managed according to Russian national guidelines. Patients in the intervention group (n = 44) received education on individual lifestyle changes and modifications of cardiovascular disease (CVD) risk factors, home-based exercise training and weekly nurse consultations in addition to usual care. Results: Six months after their inclusion, patients in the intervention group significantly improved body mass index, waist circumference, six-min walk test distance, total cholesterol, low-density lipoprotein, left ventricular end-diastolic volume index, quality of life and level of anxiety. After 18 months, there were 11 deaths (25%) or hospitalizations in the intervention group and 12 (29%) in the control group (P = 0.134). Cardiovascular mortality and readmission rate were not reduced significantly after six months of follow-up: the hazard ratio was 0.47 (95% CI: 0.17–1.28; P = 0.197). After 18 months, this was 0.85 (0.42–1.73; P = 0.658).

Conclusion: This primary care based DMP for patients with HFPEF improved the patients’ emotional status and quality of life, positively influenced body weight, functional capacity and lipid profile, and attenuated heart remodelling.     

老年心力衰竭313例诱因分析

目的探讨老年心力衰竭(CHF)的病因、发病诱因,为提高老年CHF防治水平提供临床依据。方法对我院近5年老年心力衰竭患者资料进行回顾性总结分析。结果老年心衰病人发病季节特点为冬季占全年41.5%,春季占21.4%,夏季11.5%,秋季25.6%;老年人心力衰竭临床诱因特点为感染81例(26.0%),心肌缺血73例(23.4%),劳累59例(18.7%),情绪激动25例(8.0%),输液过快15例(8.0%)。结论老年CHF发病时间存在明显的季节差异,表现为冬高夏低。老年人心衰临床主要诱因为感染、心肌缺血、心律失常。     

Factors associated with low health-related quality of life among younger and older Thai patients with non-valvular atrial fibrillation

Purpose

The aim of this study was to investigate the factors associated with low health-related quality of life (HRQoL) compared between younger and older Thai patients with non-valvular atrial fibrillation (NVAF).

Methods

This is a cross-sectional analysis of baseline data from a prospective NVAF registry from 24 hospitals located across Thailand. Patient demographic, clinical, lifestyle, and medication data were collected at baseline. EuroQOL/EQ-5D-3L was used to assess HRQoL. Health utility was calculated for the entire study population, and low HRQoL was defined as the lowest quartile. Multivariate logistic regression was used to identify factors that significantly predict low HRQoL among younger and older (≥?65 years) patients with NVAF.

Results

Among the 3218 participants that were enrolled, 61.0% were aged older than 65 years. Mean HRQoL was lower in older than in younger patients (0.72?±?0.26 vs. 0.84?±?0.20; p?<?0.001). Factors associated with low HRQoL among younger NVAF patients were the treatment-related factors bleeding history (p?=?0.006) and taking warfarin (p?=?0.001). Among older patients, the NVAF-related complications ischemic stroke or TIA, heart failure (HF), and dementia (all p?<?0.001) were all significantly associated with low HRQoL. Dementia is the factor that most adversely influences low HRQoL among older NVAF. Interestingly, symptomatic NVAF was found to be a protective factor for low HRQoL (p?<?0.001).

Conclusions

Bleeding history and taking warfarin among younger patients, and ischemic stroke/TIA, HF, and dementia among older patients are significant predictors of low HRQoL. These factors should be taken into consideration when selecting treatment options for patients with NVAF.

     

Mini Nutritional Assessment in patients with Parkinson's disease: correlation between worsening of the malnutrition and increasing number of disease-years

Abstract

Objective: To monitor the nutritional status of patients with Parkinson's disease using the Mini Nutritional Assessment (MNA) questionnaire.

Patients and methods: This was a 3-year longitudinal study conducted in a national referral centre for Parkinson's disease and other movement disorders. The cohort included 61 Parkinson's disease patients, 37 men and 24 women, mean age of 70.5 ± 5.5 years, mean duration of disease 9 ± 6.3 years; 35 patients were followed-up after 3 years.

Results: MNA score diminished from 24.9 ± 1.6 to 24 ± 2.5 (P = 0.02); the proportion of patients at risk of malnutrition increased from 22.9% to 34.3%. A linear correlation was observed between MNA score and the duration of disease (P = 0.0096). The dietary assessment subscore significantly diminished (8.6 versus 8.1; P = 0.0009) as did body mass index (25.9 ± 3.5 kg/m² versus 27.1 ± 3.1 kg/m²; P = 0.001).

Conclusions: The evaluation of nutritional status should be part of the routine work-up of a Parkinson's disease patient. Dietary education should be included amongst the therapeutic measures designed to improve the general conditions in Parkinson's disease.     

Case in Point

Abstract

Epidemiologic and clinical trial data suggest that blood pressure in patients with hypertension who are at high risk for cardiovascular events because of coronary artery disease, diabetes, chronic kidney disease, stroke, or heart failure should be reduced to < 140/90 mm Hg in patients aged < 80 years, and that systolic blood pressure should be reduced to 140 to 145 mm Hg, if tolerated, in patients aged ≥ 80 years. Studies on patients with coronary artery disease, diabetes, chronic kidney disease, stroke, and heart failure are discussed, supporting a blood pressure goal of < 140/90 mm Hg in patients aged < 80 years who are at high risk for cardiovascular events.     

Chest pain in primary care: Epidemiology and pre-work-up probabilities

Abstract

Background/objective: Chest pain is a common complaint and reason for consultation. We aimed to study the epidemiology of chest pain with respect to underlying aetiologies and to establish pre-work-up probabilities for the primary care setting. Methods: We included 1212 consecutive patients with chest pain, aged 35 years and older, attending 74 general practitioners (GPs). GPs recorded symptoms and findings of each patient and provided follow-up information. An independent interdisciplinary reference panel reviewed clinical data of every patient and decided on the aetiology of chest pain at the time of patient recruitment. Results: The prevalence of chest pain among all attending patients was 0.7%. The majority (55.9%) of patients were women. Mean age was 59 (35–93) years. Of these patients, 53.2% had chest pains at the time of consultation and 29.6% presented with acute (<48 hours’ duration) chest pain. Pain originating from the chest wall was diagnosed in 46.6% of all patients, stable ischaemic heart disease (IHD) in 11.1%, and psychogenic disorders in 9.5%; 3.6% had acute coronary syndrome (ACS).

Conclusion: The study adds important information about the epidemiology of chest pain as a frequent reason for consulting primary care practitioners. We provide updated pre-work-up probabilities for IHD for each age and sex category.     

Intensive support to improve clinical decision making in cardiovascular care: a randomised controlled trial in general practice

Objective: To evaluate the effects of feedback reports combined with outreach visits from trained non-physicians on the clinical decision making of general practitioners (GPs) in cardiovascular care.

Design: Pragmatic cluster controlled trial with randomisation of practices to support (intervention group) or no special attention (control group); analysis after 2 years.

Setting: 124 general practices in The Netherlands.

Participants: 185 GPs.

Main outcome measures: Compliance rates for 12 evidence-based indicators for the management of patients with hypertension, hypercholesterolaemia, angina pectoris, or heart failure. The evaluation relied on the prospective recording of patient encounters by the participating GPs.

Results: The GPs reported 30 101 clinical decisions at baseline and 22 454 decisions after the intervention. A significant improvement was seen for five of the 12 indicators: assessment of risk factors in patients with hypercholesterolaemia (odds ratio 2.04; 95% CI 1.44 to 2.88) or angina pectoris (3.07; 1.08 to 8.79), provision of information and advice to patients with hypercholesterolaemia (1.58, 1.17 to 2.13) or hypertension (1.55, 1.35 to 1.77), and checking for clinical signs of deterioration in patients with heart failure (4.11, 2.17 to 7.77). Single handed practices, non-training practices, and practices with older GPs gained particular benefit from the intervention.

Conclusions: Intensive support from trained non-physicians can alter certain aspects of the clinical decision making of GPs in cardiovascular care. The effect is small and the strategy needs further development.

     

Social support and health-related quality of life in chronic heart failure patients

Objectives: Objectives of this study were to: (1) describe perceived social support during a baseline hospitalization and 12 months later among heart failure patients; (2) examine differences in social support as a function of gender and age (less than 65 and 65 years or older); and (3) examine social support as a predictor of health-related quality of life. Background: Social support is a predictor of well-being and mortality, but little is known about support patterns among heart failure patients and how they influence quality of life. Methods: The sample included 227 hospitalized patients with heart failure who completed the Social Support Survey and the Chronic Heart Failure Questionnaire at baseline; 147 patients completed these questionnaires again 12 months after baseline. Results: Mean baseline and 12-month total support scores were 56 and 53, respectively, with a score of 76 indicating the most positive perceptions of support. The ANOVA indicated significant interactions of gender by age for total (F = 5.04; p = 0.03) and emotional/informational support (F = 4.87; p = 0.03) and for positive social interactions (F = 4.43; p = 0.04), with men under age 65 perceiving less support than men aged 65 and older and women in either age group. Baseline support did not predict 12-month health-related quality of life, but changes in social support significantly predicted changes in health-related quality of life (R ² = 0.14). Conclusions: Overall, perceptions of support were moderate to high, but there was wide variation in perceptions over time. Men under age 65 reported less support than other groups of patients. Importantly, changes in social support were significant predictors of changes in health-related quality of life. This revised version was published online in June 2006 with corrections to the Cover Date.     

The impact of the modified Atkins diet on lipid profiles in adults with epilepsy

Objectives: The modified Atkins diet (MAD) is a high fat, low carbohydrate ketogenic diet used to treat intractable seizures in children and adults. The long-term impact on fasting lipid profiles (FLPs) remains unknown. This study was designed to detect significant lipid changes in adults on MAD.

Methods: Patients were observed prospectively. A FLP was obtained in all patients at the first visit then serially. Patients were started on a 20?g per day net carbohydrate limit MAD. They were screened for risk for coronary heart disease and counseled to reduce saturated fats by a registered dietitian if deemed at risk. Patients that remained on MAD for 3 or more months with one or more follow-up FLP were included.

Results: Thirty-seven patients (14 male), mean age 33 years (SD 13, range 18–59) met study criteria. Median diet duration was 16 months (range 3–41). Total cholesterol and low-density lipoprotein (LDL) increased significantly over the first 3 months of MAD (P?=?0.01 and 0.008, respectively), but were not significantly different from baseline after 1 year of treatment (P?=?0.2 and P?=?0.5, respectively). High-density lipoprotein levels trended upward in the first 3 months (P?=?0.05) and triglycerides remained unchanged (P?=?0.5). In 12 patients followed for 3 or more years, no cardiovascular or cerebrovascular events were reported.

Discussion: Although total cholesterol and LDL increased over the first 3 months of the MAD, these values normalized within a year of treatment, including in patients treated with MAD for more than 3 years.     

苏州市2007－2013年2岁以下儿童住院肠套叠流行特征

目的 了解苏州市<2岁儿童住院肠套叠流行状况及临床特征。方法 回顾性收集苏州大学附属儿童医院2007年1月1日至2013年8月31日<2岁儿童住院肠套叠病例,采用描述性流行病学方法分析住院肠套叠发病率、病例年龄和季节分布及其临床特点等。采用Wilcoxon秩和检验比较年龄;采用简单线性回归分析发病年龄M和发病率的变化趋势;利用Origin 8.0软件对年龄和季节分布进行多项式拟合。结果 共纳入<2岁儿童住院肠套叠594例,无死亡病例。平均年发病率为57.3(95%CI:52.8~62.1)/10万,其中<1岁儿童为100.6(95%CI:92.1~109.8)/10万。病例男女性别比为1.90 : 1,男性高于女性。<1岁病例占85.4%(507/594),且多集中于3~8月龄(66.2%,393/594),发病高峰为5~8月龄。发病年龄(M)为6.8(4.4)月龄,且由2007年的6.3(4.2)月龄增高至2013年的7.3(4.0)月龄,发病年龄M呈逐年增高趋势。住院病例中未观察到有明显的季节分布。主要临床表现为呕吐(83.2%,494/594),腹部包块(81.1%,482/594),血便(64.5%,383/594)。腹部超声检查(98.7%,586/594)为主要影像学诊断方法。手术为主要治疗方法(86.2%,512/594)。肠套叠发生部位以回-结肠型(34.5%,183/530)、回肠型(30.8%,163/530)或回-回-结肠型(27.9%,148/530)多见。结论 苏州市<2岁肠套叠儿童病例发病率较高,应建立主动监测系统。     

Early recognition of heart failure in patients with diabetes type 2 in primary care. A prospective diagnostic efficiency study. (UHFO-DM2)

Background  

We hypothesize that the prevalence of unknown heart failure in diabetic patients aged 60 years and over is relatively high (15% or more) and that a cost-effective strategy can be developed to detect heart failure in these patients. The strategy is expected to include some signs and symptoms (such as dyspnoea, orthopnoea, pulmonary crepitations and laterally displaced apical beat), natriuretic peptide measurements (Amino-terminal B-type natriuretic peptide) and possibly electrocardiography. In a subset of patients straightforward echocardiography may show to be cost-effective. With information from our study the detection of previously unknown heart failure in diabetic patients could be improved and enable the physician to initiate beneficial morbidity and mortality reducing heart failure treatment more timely.     

Associations of smoking with cardiometabolic profile and renal function in a Romanian population-based sample from the PREDATORR cross-sectional study

Background: The impact of smoking on morbidity is well known, but in Romania, limited data are available regarding the smoking prevalence and relationship with cardiometabolic profile and kidney function.

Objectives: To assess the association of smoking with cardiometabolic traits and kidney function, in a Romanian population-based sample from the PREDATORR study.

Methods: PREDATORR was an epidemiological cross-sectional study. Between 2012 and 2014, participants were randomly selected from the lists of general practitioners and enrolled if they were aged 20 to 79 years, born and living in the past 10 years in Romania. Sociodemographic and lifestyle characteristics were collected through interviewer-administered questionnaires.

Results: Overall, 2704 participants were included in the analysis, 18% of them being current smokers and 30.8% former smokers. Current smokers compared to non-smokers had higher total cholesterol (220.6?±?50.4 versus 213.9?±?86.8?mg/dl, P?=?0.017), LDL-cholesterol (137.8?±?45.2 versus 130.7?±?83.7?mg/dl, P?=?0.004) and glomerular filtration rate (96.9?±?16.8 versus 90.7?±?19.1?ml/min/1.73?m², P?<0.001) in women and higher triglycerides (170.7?±?129.8 versus 144.3?±?94.2?mg/dl, P?=?0.007), glomerular filtration rate (97.6?±?17 versus 90.3?±?18?ml/min/1.73?m², P?P?=?0.002) in men. Active smoking was associated with hypercholesterolaemia [OR: 1.40 (95% CI: 1.01–1.96), P?=?0.04] and low HDL-cholesterolaemia [OR: 1.39 (95% CI: 1.01–1.91), P?=?0.04] and negatively associated with overweight/obesity [OR: 0.67 (95% CI: 0.48–0.94), P?=?0.02]. Male former smokers had higher prevalence of abdominal obesity (82.4% versus 76.4%, P?=?0.02), hypertriglyceridaemia (43.6% versus 35.6%, P?=?0.01), hypertension (64% versus 56.4%, P?=?0.01) and ischaemic vascular disease (40.5% versus 30.9%, P?=?0.003) than male non-smokers.

Conclusion: The PREDATORR study showed a high prevalence of smoking in the adult Romanian population providing data on the association of smoking with cardiometabolic traits.     

Experienced continuity of care in patients at risk for depression in primary care

Background: Existing studies about continuity of care focus on patients with a severe mental illness.

Objectives: Explore the level of experienced continuity of care of patients at risk for depression in primary care, and compare these to those of patients with heart failure.

Methods: Explorative study comparing patients at risk for depression with chronic heart failure patients. Continuity of care was measured using a patient questionnaire and defined as () number of care providers contacted (personal continuity); () collaboration between care providers in general practice (team continuity) (six items, score 1–5); and () collaboration between GPs and care providers outside general practice (cross-boundary continuity) (four items, score 1–5).

Results: Most patients at risk for depression contacted several care providers throughout the care spectrum in the past year. They experienced high team continuity and low cross-boundary continuity. In their general practice, they contacted more different care providers for their illness than heart failure patients did (P < 0.01). Patients at risk for depression experienced a slightly better collaboration between these care providers in their practice: a mean score of 4.3 per item compared to 4.0 for heart failure patients (P = 0.03). The perceived cross-boundary continuity, however, was reversed: a mean score of 3.5 per item for patients at risk for depression, compared to 4.0 for heart failure patients (P = 0.01).

Conclusion: The explorative comparison between patients at risk for depression and heart failure patients shows small differences in experienced continuity of care. This should be analysed further in a more robust study.     

Financial burden of heart failure in a developing country: cost analysis from Manipal Heart Failure Registry,India

Aim

To estimate the comprehensive healthcare costs of heart failure (HF) and determine the utilization of healthcare resources (HRU) for 2 years following index hospitalization.

Subjects and methods

The Manipal Heart Failure Registry (MHFR) is a prospective registry analyzing the financial burden and HRU in 610 patients with HF. Costs incurred by patients during 2 years following index hospitalization were estimated, and their association with socio-demographic and clinical factors were calculated. After 54 (8.8%) in-hospital mortalities, 556 patients were followed up for 2 years.

Results

The mean age of the study cohort was 65.08?±?13.6 years, and 245 (40.2%) were females. Based on the ejection fraction (EF), 506 (82.9%) patients were diagnosed as having HF with reduced EF. Average hospital stay during index admission was 5.3?±?2.9 days. Total expenditure during index hospitalization was INR 36.3 million and during 2-year follow-up was INR 45.2 million. Average total expenditure per patient was INR 133,663. The average out-of-pocket expense was INR 82,766 and average health insurance coverage was INR 50,896. Difference in expenditure was significant (P?<?0.05) between specific groups, i.e., etiologies, genders, HF phenotypes, age groups, and healthcare insurance types.

Conclusion

Healthcare expenditure of patients with HF in India is much lower than for the western counterparts. Higher utilization of healthcare resources in HF patients with ischemic etiology, non-compliant to medications, and elderly (age?>?60 years) was associated with increased expenses. Interventional procedures and implantations account for the bulk of the expenses in ischemic HF patients.

Trial registration number

Clinical Trial Registry of India: CTRI/2017/11/010395; National Institute of Health (NIH) clinical trial no.: NCT03157219.

     

A 9 year prospective cohort study of endoscoped patients with upper gastrointestinal symptoms

Despite the high prevalence of upper gastrointestinal symptoms and associated costs of diagnosis and management, evidence regarding long-term outcomes is scant. We studied symptom outcomes 18 months (FU1) and 8/9 years (FU2) post-index endoscopy to identify demographic, diagnostic and treatment factors associated with outcomes. A retrospective review of medical records at two Australian teaching hospitals identified a cohort of 302 patients who had an index endoscopy (performed by 23 endoscopists) 18 months previously. Patients were interviewed at FU1 and FU2. In total 34% (95%CI: 29.0--39.8) of patients were asymptomatic at FU1 and 41% (95%CI: 35.6--46.6) at FU2. For 63%, outcomes at FU1 predicted long-term outcome, with 19% (95%CI: 14.6--23.4) asymptomatic and 44% (95%CI: 38.4--50.0) symptomatic at both times. Those whose symptom status changed were as likely to deteriorate as improve (p > 0.05). Number and severity of presenting symptoms (F = 3.3, df = 3,277, p < 0.05) and older age (F = 2.8, df = 2,301, p < 0.05) were associated with poorer outcomes. Long-term outcome was unrelated to endoscopic diagnosis. Those symptomatic were significantly more likely to be on proton pump inhibitors (PPIs) or Histamine₂ Receptor Antagonists (H2RAs) than those who were asymptomatic. Use of PPIs at FU2 was associated with a significantly better outcome than use of H2RAs. However this impact was relatively small, with 69% of patients on PPIs and 84% on H2RAs symptomatic at FU2. Upper gastrointestinal symptoms prompting endoscopy are chronic for the majority of patients regardless of diagnosis. Endoscopic diagnosis is of limited value in predicting long-term outcomes. The association between poor outcome and use of H2RAs and PPIs challenges views about their long-term effectiveness in symptom control.     

Age-related pulmonary crackles (rales) in asymptomatic cardiovascular patients

PURPOSE The presence of age-related pulmonary crackles (rales) might interfere with a physician’s clinical management of patients with suspected heart failure. We examined the characteristics of pulmonary crackles among patients with stage A cardiovascular disease (American College of Cardiology/American Heart Association heart failure staging criteria), stratiffed by decade, because little is known about these issues in such patients at high risk for congestive heart failure who have no structural heart disease or acute heart failure symptoms.METHODS After exclusion of comorbid pulmonary and other critical diseases, 274 participants, in whom the heart was structurally (based on Doppler echocardiography) and functionally (B-type natriuretic peptide <80 pg/mL) normal and the lung (X-ray evaluation) was normal, were eligible for the analysis.RESULTS There was a significant difference in the prevalence of crackles among patients in the low (45–64 years; n = 97; 11%; 95% CI, 5%–18%), medium (65–79 years; n = 121; 34%; 95% CI, 27%–40%), and high (80–95 years; n = 56; 70%; 95% CI, 58%–82%) age-groups (P <.001). The risk for audible crackles increased approximately threefold every 10 years after 45 years of age. During a mean follow-up of 11 ± 2.3 months (n = 255), the short-term (≤3 months) reproducibility of crackles was 87%. The occurrence of cardiopulmonary disease during follow-up included cardiovascular disease in 5 patients and pulmonary disease in 6.CONCLUSIONS Recognition of age-related pulmonary crackles (rales) is important because such clinically unimportant crackles are so common among elderly patients that, without knowledge of this phenomenon, their existence might interfere with the physician’s management of cardiopulmonary patients.     

Dietary intake among paediatric HIV-positive patients initiating antiretroviral therapy in Johannesburg,South Africa

ABSTRACT

In South Africa, prevention of mother to child transmission (PMTCT) has reduced MTCT from 3.6% in 2011 to 1.3% in 2017. However, there are challenges in reaching vulnerable HIV-positive children; those at increased risk of malnutrition or present late with advanced disease. Macro – and micronutrient deficiencies, common in HIV, may accelerate disease progression. This was a prospective cohort study of paediatric patients (aged 1–10 years) initiating ART between 08/2014 and 09/2016 at a public health facility in Johannesburg, South Africa. Trained clinic staff collected anthropometric indices and dietary intake at ART initiation and at one and three months post initiation. A blood sample was collected at ART initiation and at six months post initiation for biochemistry. We describe demographics, anthropometry, dietary intake, dietary diversity at enrolment and changes in anthropometry and biochemistry from ART initiation until six months for paediatric HIV-positive patients initiating antiretroviral therapy (ART).

Twenty-seven patients were enrolled. The World Health Organization dietary intake recommendations for children were not met for the majority of nutrients including energy, fats, iron, calcium and Vitamin A at ART initiation. At least 40% of patients were receiving less than four of the main food groups. At initiation, 18.5% of children presented with severe acute malnutrition (MUAC <11cm), 14.3% were underweight (weight-for-age Z score <-2SD), 19.1% stunted (height-for-age Z score <-2SD) and 33.4% were wasted (weight-for-height <-2SD). At six months, there was a general increase in WHZ (<5 years), BMI (≥5 years), C-reactive protein, iron and albumin but a significant increase in Vitamin A.

The results highlight the need for dietary counselling and provision of nutritional supplementation at ART initiation for paediatric patients. Adequate nutrition should be established early at initiation, to improve growth, development and health outcomes.