Is on‐demand treatment effective in patients with severe haemophilia?

Summary. On‐demand therapy enables stopping haemorrhages rapidly, reducing joint pain and restoring joint mobility, but does not prevent the beginning and subsequent development of haemophilic arthropathy. The main objective of this study was to identify the clinical and orthopaedic status of severe haemophilic patients with bleeding phenotype receiving on‐demand treatment in Spain. We conducted an epidemiological, observational, retrospective study, recruiting 167 patients from 36 centres (92% of them with haemophilia A), median age at enrolment of 35 years. Forty per cent of the patients received a combination of on‐demand and short‐term prophylaxis regimen; the rest was under on‐demand treatment. One hundred and forty‐five patients (87%) reported at least one bleeding episode and 22 (13%) of the biologically severe patients had no bleeding phenotype. Seventy‐one per cent of the studied population presented established haemophilic arthropathy, reaching 80% if we exclude patients without bleeding phenotype. Forty‐three per cent of these patients had one or two joints affected, 28% of them had three or four affected joints, 20% reported five or six affected joints and 9% more than six injured joints. An increase in established haemophilic arthropathy with age was observed. Forty‐six patients underwent orthopaedic surgery at least once. These data show that on‐demand therapy is not effective in preventing the development of haemophilic arthropathy in severe haemophilic population with bleeding phenotype. Therefore, we suggest that the optimal treatment in these patients should be based on prophylaxis. We recommend analysing the reasons for ending prophylaxis, in case its reinstatement should be necessary.     

The economics of inpatient on‐demand treatment for haemophilia with high‐responding inhibitors: a US retrospective data analysis

Summary. Inpatient costs comprise >50% of annual healthcare costs for haemophilia patients with inhibitors but no reports exist on inpatient resource use and costs at a US national level. To quantify inpatient resource use and costs for on‐demand treatment of bleeds of US haemophilia patients with inhibitors and compare costs and treatment duration between Factor VIII bypassing agents (BAs). Stays with haemophilia A from 2003–2008 were identified from inpatient billing records. Presence of inhibitors was inferred through use of BA; recombinant activated Factor VII and plasma‐derived activated prothrombin complex concentrate. Duration and number of infusions of BA, length of stay, use of opioid‐containing analgesics and costs were assessed and compared. Among 1322 stays mean BA treatment duration was 4.6 days with 4.9 infusions, 6.1 nights spent in hospital, and 58% administered opioid‐containing analgesics. In unadjusted analyses there were significant differences in the above mentioned outcomes by BA use, reflecting underlying differences between the two patient populations. Average inpatient costs were $82 911. In adjusted analyses, African‐American race, greater disease severity, hospital region outside the southern US and older age (cost model only) were significant predictors of longer BA treatment duration and higher costs. The economic burden of inpatient on‐demand treatment of haemophilia with inhibitors is substantial and is associated with lengthy stays, high costs and inadequate pain relief. Availability of more effective BAs could reduce the need for re‐treatment, reducing treatment costs and other medical costs, while improving health related quality of life.     

Treatment trends for haemophilia A and haemophilia B in the United States: results from the 2010 practice patterns survey

Frequent evaluation of haemophilia treatment is necessary to improve patient care. The 2010 Practice Patterns Survey (PPS) investigated current trends in haemophilia treatment in the United States, as reported by nurses. The aim was to document practice patterns for haemophilia A and haemophilia B Survey questionnaires were sent to nurses at haemophilia treatment centres (HTCs) across the United States. Seventy-one of 126 HTCs (56%) responded to the survey. Factor dosage across treatment modalities ranged from 20 to 50 IU kg(-1) for severe haemophilia A. Dosage for severe haemophilia B was more variable (<40 to >100 IU kg(-1)). On-demand dosing regimens were inconsistent for haemophilia A and more so for haemophilia B. Rates of adherence to prescribed treatment were similar for both haemophilia types (～80%). The main barrier to adherence was identified as inconvenience. More bleeding episodes occurred in adults (16.6 bleeding episodes per year) with severe haemophilia A than in younger patients (11.3 bleeding episodes per year) before switching patients to prophylaxis. For both haemophilia types, most patients who switched from prophylaxis to on-demand treatment were aged 13-24 years; these patients also had the lowest adherence (60-71%). More paediatric patients with severe haemophilia A and inhibitors (53%) received prophylactic bypassing therapy than their haemophilia B counterparts (38%). Adults with severe haemophilia A faced challenges in relation to co-morbidities and long-term care. This PPS provides insights into previously unexplored aspects of haemophilia care that will serve to increase awareness and promote discussion of current issues affecting haemophilia patient care.     

The many faces of preparatory control in task switching: Reviewing a decade of fMRI research

A large body of behavioural research has used the cued task‐switching paradigm to characterize the nature of trial‐by‐trial preparatory adjustments that enable fluent task implementation when demands on cognitive flexibility are high. This work reviews the growing number of fMRI studies on the same topic, mostly focusing on the central hypothesis that preparatory adjustments should be indicated by enhanced prefrontal and parietal BOLD activation in task switch when compared with task repeat trials under conditions that enable advance task preparation. The evaluation of this straight‐forward hypothesis reveals surprisingly heterogeneous results regarding both the precise localization and the very existence of switch‐related preparatory activation. Explanations for these inconsistencies are considered on two levels. First, we discuss methodological issues regarding (i) the possible impact of different fMRI‐specific experimental design modifications and (ii) statistical uncertainty in the context of massively multivariate imaging data. Second, we discuss explanations related to the multidimensional nature of task preparation itself. Specifically, the precise localization and the size of switch‐related preparatory activation might depend on the differential interplay of hierarchical control via abstract task goals and attentional versus action‐directed preparatory processes. We argue that different preparatory modes can be adopted relying either on advance goal activation alone or on the advance resolution of competition within action sets or attentional sets. Importantly, while either mode can result in a reduction of behavioral switch cost, only the latter two are supposed to be associated with enhanced switch versus repeat BOLD activation in prepared trial conditions. Hum Brain Mapp, 2013. © 2011 Wiley Periodicals, Inc.     

Quality assurance in drug demand reduction in European countries: an overview

Background: The EMCDDA, through its network of National Focal Points, collects information on the quality assurance systems for drugs-related interventions across European countries. European National Drug Strategies include recommendations for systems and approaches for the assurance of the quality of interventions.

Methods: We searched National Drug Strategies for elements related to quality assurance in drug demand reduction and summarised information through questionnaires administered to the EMCDDA Network of National Focal Points.

Results: In total, 15 National Drug Strategies and 60 questionnaires were analysed. Almost all the strategies include quality-related topics. Frequently, the Ministry of Health leads quality assurance although sometimes jointly with the Ministries of Education, Labour, Family and Social Welfare. Accreditation systems are common, but implemented in different ways. Training and education are widely provided, for the vast majority of countries, consisting of short-term training to keep professionals updated. Guidelines and Standards are gathering momentum as the major tools for the implementation of evidence-based recommendations and are usually available across countries.

Conclusions: Although the evidence base for interventions in drug demand reduction is becoming available and accepted, attention needs to be given to implementation issues. The European countries are rapidly moving towards paying greater attention to the quality of interventions.     

某院护士药学服务能力、认知与需求的调查分析

目的 了解护士药学服务能力、认知与需求,为提高药学服务水平和护理质量提供建议.方法 采用方便抽样法,于2016年7—8月,选取成都医学院第一附属医院护士180人,采用自行设计的问卷进行调查.结果 护士药学服务能力平均得分为(9.87±1.27)分,理论知识平均得分为(2.94±0.691)分.护士对药学服务持肯定态度.护士对药师服务的需求度较高.结论 必须加强护理相关药学服务教育,药师必须帮助护理人员提高药学服务所需的知识与技能,计算机技术也可以用于辅助护士药学服务,从而提高药学服务的整体水平.     

三甲医院病人分级护理服务需求影响因素及对策研究

目的通过对病人分级护理服务现状的调查,分析病人分级护理服务需求的影响因素。方法对6家三甲医院主管临床护理的管理者进行分级护理方面的调研,对6家三甲医院的病人进行病人分级护理服务需求问卷调查。结果不同职业、文化程度、自理能力、护理等级的护理服务需求比较,差异有统计学意义(P<0.05)。0.004%的病人暂时尚无分级护理服务需求。在7 911名有分级护理服务需求的病人中,97.5%的病人希望有基本治疗服务,95.9%的病人希望有病情观察服务,95.7%的病人希望有健康教育服务,87.5%的病人希望有清洁服务,36.8%的病人希望有帮助活动服务,26.1%的病人希望有饮食指导服务,22.7%的病人希望有帮助排泄服务。相关性分析结果显示,经济状况与文化程度有关(r=0.288,P<0.01),年龄和病人自理能力有关(r=0.266,P<0.01)。多因素logistic回归分析结果显示,自理能力、护理等级是分级护理服务需求的影响因素(P<0.05)。结论自理能力越差,护理等级越高,病人分级护理服务需求度越高。社会与政府应当重视病人的分级护理,明确等级划分标准,规范分级护理服务内容,加强分级护理服务建设。     

农村在校留守与非留守儿童心理健康服务获取现状及需求比较

目的了解农村留守与非留守儿童心理健康服务获取现状、需求以及2者的差异,为留守儿童心理服务体系的建立提供参考。方法于2018年4—7月,采用分层整群抽样法抽取四川、安徽、河南省共14所农村中小学四到九年级学生3 456人,通过自编农村留守儿童心理健康服务现状及需求问卷进行调查。结果农村留守与非留守儿童接受心理健康服务比率分别为27.9%和27.0%,2者无统计学差异;农村留守与非留守儿童获取心理健康服务途径及引带者、心理健康服务的效果评价、希望接受心理健康服务途径与方式等也均无统计学差异(P> 0.05);留守与非留守儿童希望获取心理健康服务的比率分别为63.0%和57.2%,2者差异有统计学意义(P=0.001);留守与非留守儿童在改善抑郁、焦虑等不舒服的感觉,克服回答问题或与陌生人交谈时紧张、面红心跳、流汗、口吃等现象,能够改变自己对事物的消极看法,肯定自己的价值,让自己内心强大,免于被欺凌,应对压力或其他不好事情的方式6个心理健康服务内容的需求条目上差异均有统计学意义(均P <0.05)。结论留守儿童已获取的心理健康服务比率、途径与其希望得到的服务情况有较大差距;与非留守儿童相比,留守儿童更需要心理健康服务,并且矫正性目标相关的需求更明显。     

Demand-oriented and demand-driven health care: the development of a typology

In most European countries, there is an increasing demand for demand-oriented and demand-driven approaches in the development of health care policy and the organization of health care services. Both approaches, in which the main focus is on 'the demand', are seen as counterparts of the supply-oriented approach, that has 'the supply' as point of departure. However, there is much confusion about the definition of the concepts. To identify the different views, and to examine to what extent there is consensus in the Netherlands about the concepts of demand-orientation and demand-driven care, a Delphi study was done among 26 experts; scientists, health care insurance companies, health care suppliers, the government, independent advisory bodies and client interest groups. The study resulted in a typology. The similarities and differences between the two concepts were demonstrated in five dimensions; responsibility, control, need-determination, formal embedment of vision in organization and choice. Furthermore, the typology was used to identify existing types of services as being either demand-oriented or demand-driven services. The typology provides an understanding of the similarities and differences between the two concepts, and appears to be a useful tool in identifying services to the extent that they are demand oriented or demand driven.