A qualitative study of patient choices in using emergency health care for long-term conditions: The importance of candidacy and recursivity

Objective

We aimed to explore how patients with long-term conditions choose between available healthcare options during a health crisis.

Methods

Patients in North-West England with one or more of four long-term conditions were invited to take part in a questionnaire cohort study of healthcare use. Semi-structured interviews were conducted with a sub-sample of fifty consenting patients. Data were analysed qualitatively, using a framework approach.

Results

Patients described using emergency care only in response to perceived urgent need. Their judgements about urgency of need, and their choices about what services to use were guided by previous experiences of care, particularly how accessible services were and the perceived expertise of practitioners.

Conclusion

Recursivity and candidacy provide a framework for understanding patient decision-making around emergency care use. Patients were knowledgeable and discriminating users of services, drawing on experiential knowledge of healthcare to choose between services. Their sense of ‘candidacy’ for specific emergency care services, was recursively shaped by previous experiences.

Practice implications

Strategies that emphasise the need to educate patients about healthcare services use alone are unlikely to change care-seeking behaviour. Practitioners need to modify care experiences that recursively shape patients’ judgements of candidacy and their perceptions of accessible expertise in alternative services.     

Patients’ preferences for patient-centered communication: A survey from an outpatient department in rural Sierra Leone

Objectives

To investigate patients’ preferences for patient-centered communication (PCC) in the encounter with healthcare professionals in an outpatient department in rural Sierra Leone.

Methods

A survey was conducted using an adapted version of the Patient-Practitioner Orientation Scale (PPOS) as a structured interview guide. The study population was drawn from the population of all adults attending for treatment or treatment for their children.

Results

144 patients were included in the analysis. Factors, such as doctor's friendly approach, the interpersonal relationship and information-sharing were all scored high (patient-centered) on the PPOS. Factors associated with shared-decision making had a lower (doctor-centered) score. A high educational level was associated with a more patient-centered scoring, an association that was most pronounced in the female population.

Conclusion

The results provide an insight into the patients’ preferences for PCC. Patients expressed a patient-centered attitude toward certain areas of PCC, while other areas were less expressed. More research is needed in order to fully qualify the applicability of PCC in resource-poor settings.

Practice implications

Stakeholders and healthcare professionals should aim to strengthen healthcare practice by focusing on PCC in the medical encounter while taking into considerations the patients’ awareness and preferences for PCC.     

Exploring caregiver understanding of medications immediately after a pediatric primary care visit

Objective

Assess accuracy of caregiver understanding of children's prescribed medications and examine factors associated with accurate recall.

Methods

Cross-sectional, observational study of English- or Spanish-speaking caregivers of primary care patients aged 0–7 years. Child and visit characteristics and caregiver health literacy (Short Test of Health Literacy in Adults) were assessed. Post-visit, caregivers completed questionnaires on medications prescribed. Caregiver and medical record agreement on medication name and administration (dose and frequency) were examined using chi square and logistic regression.

Results

Analyses included 68 caregivers (28% low health literacy); 96% of children had public insurance. Caregivers indicated that the doctor provided clear medication information (100%) and they could follow instructions (98%). 101 medicines were prescribed; 6 were recalled by caregiver only. 71% of medications were accurately named; 37% of administration instructions were accurately recalled. Accurate naming was more often found for patients 3–7 years, without conditions requiring repeat visits, and new medications. Accurate administration responses were associated with having only 1 child at the visit.

Conclusion

Unperceived medication instruction understanding gaps exist at physician visits for caregivers of all literacy levels. Communication and care delivery practices need further evaluation.

Practice implications

Clinicians should be aware of the frequency of caregiver medication misunderstanding.     

Extending Physician ReACH: Influencing patient activation and behavior through multichannel physician communication

Objective

Despite evidence-based recommendations, physical activity as a self-management technique is underutilized. Many physical activity interventions require significant resources, ranging from repeated phone follow-up with nursing staff to intensive sessions with cooperating physical therapists. This intervention, Extending Physician ReACH (Relationship And Communication in Healthcare), examined physician to patient communication tactics for promoting walking exercise to patients with type 2 diabetes, using limited clinic time and financial resources.

Methods

This was a single-site, six-month prospective intervention, which implemented theoretically driven, evidenced-based information factor strategies. Of the 128 volunteers who participated in the initial clinic visit, 67 patients with type 2 diabetes completed the six-month intervention.

Results

Significant intervention effects were detected risk perception, social norms, and patient activation.

Conclusions

This study was designed to identify information factors that could affect physician success in motivating patients with type 2 diabetes to enact the ADA physical activity recommendations.

Practice implications

The success of this intervention models a strategy through which clinicians can reach beyond “one-shot” persuasion without placing onerous time and resource demands on physicians.     

GENETIC CONTROL OF SUSCEPTIBILITY IN CLINICAL AND EXPERIMENTAL UVEITIS

Genetic association of some immune-mediated human uveitic diseases with histocompatibility antigens, ethnic origin, familial background, or gender have suggested the presence of a hereditary component in susceptibility to uveitis. Uveitis is a genetically complex disease, in which genes and environment contribute to the phenotype appearance. In complex traits, genotypes of particular sets of genes, together with environmental factors, alter the probability that an individual will express the characteristic, although each individual factor is typically insufficient to cause the disease. The main susceptibility genes for clinical and experimental uveitis seem to be located within the major histocompatibility complex (MHC) region, but genes possibly regulating responses to lymphokines, hypothalamic-adrenal-pituitary axis hormones, vascular effects, and possibly T cell repertoire and other pathways play a role to determine "permissiveness" or "nonpermissiveness" to the disease.     

Adjuvants for Enhancing the Immunogenicity of Whole Tumor Cell Vaccines

Whole tumor cell lysates can serve as excellent multivalent vaccines for priming tumor-specific CD8⁺ and CD4⁺ T cells. Whole cell vaccines can be prepared with hypochlorous acid oxidation, UVB-irradiation and repeat cycles of freeze and thaw. One major obstacle to successful immunotherapy is breaking self-tolerance to tumor antigens. Clinically approved adjuvants, including Montanide? ISA-51 and 720, and keyhole-limpet proteins can be used to enhance tumor cell immunogenicity by stimulating both humoral and cellular anti-tumor responses. Other potential adjuvants, such as Toll-like receptor agonists (e.g., CpG, MPLA and PolyI:C), and cytokines (e.g., granulocyte-macrophage colony stimulating factor), have also been investigated.     

Cancer Testis Antigens: Novel Biomarkers and Targetable Proteins for Ovarian Cancer

Ovarian cancer is the fifth leading cause of cancer death in women and the leading cause from gynecological malignancies. Despite the recently improved outcomes of new chemotherapeutical agents in the therapy of ovarian cancer and the increased 5-year survival rate, the mortality of this malignancy disease remains unchanged. Ovarian cancer therapy is often correlated to the stage of the tumor, but the first step is usually surgical treatment. Afterward, various courses of chemotherapy and radiation are suggested. Obviously, the higher the developmental stage of the tumor, the less the probability is in eradicating it surgically, especially in relation to metastasis. It is clear that an early diagnosis of ovarian cancer is important for the survival of these patients. In order to identify ovarian cancer patients in the early stages, a number of studies are focusing on a particular class of antigens called cancer testis antigens. These antigens display high expression in tumors of different histology, but are normally restricted to the testis and have low or no expression in normal tissues. The testes are an immunologically-privileged site due to the presence of tight junctions between adjacent Sertoli cells that constitute the blood-testis barrier, which prevents auto-immune reactions. In the past few years, some of these antigens were demonstrated to be very promising for the early diagnosis and development of vaccines for ovarian cancer. This review aims to underline the most reliable cancer testis antigens under investigation at this moment.     

Effect of shared care on blood pressure in patients with chronic kidney disease: a cluster randomised controlled trial

Background

Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients

Aim

To assess the effect of a shared care model in managing patients with CKD who also have diabetes or hypertension.

Design and setting

A cluster randomised controlled trial in nine general practices in The Netherlands.

Method

Five practices were allocated to the shared care model and four practices to usual care for 1 year. Primary outcome was the achievement of blood pressure targets (130/80 mmHg) and lowering of blood pressure in patients with diabetes mellitus or hypertension and an estimated glomerular filtration rate (eGFR)<60ml/min/1.73m².

Results

Data of 90 intervention and 74 control patients could be analysed. Blood pressure in the intervention group decreased with 8.1 (95% CI = 4.8 to 11.3)/1.1 (95% CI = −1.0 to 3.2) compared to −0.2 (95% CI = −3.8 to 3.3)/−0.5 (95% CI = −2.9 to 1.8) in the control group. Use of lipid-lowering drugs, angiotensin-system inhibitors and vitamin D was higher in the intervention group than in the control group (73% versus 51%, 81% versus 64%, and 15% versus 1%, respectively, [P = 0.004, P = 0.01, and P = 0.002]).

Conclusion

A shared care model between GP, nurse practitioner and nephrologist is beneficial in reducing systolic blood pressure in patients with CKD in primary care.     

Pro-caspase-3 is constitutively expressed in luteinized granulosa cells from women undergoing controlled ovarian stimulation for in vitro fertilization

Apoptosis regulation in luteinized granulosa cells (LGC) during assisted reproduction procedures is still controversial. Caspase-3 is a major apoptosis mediator encoded by CASP3 and formed through cleavage of its precursor pro-caspase-3. The aim of this study was to investigate the expression patterns of pro-caspase-3 (mRNA and protein) and cleaved caspase-3 in human LGC. Thirty-five women undergoing controlled ovarian stimulation for in vitro fertilization were prospectively enrolled in the study. LGC were isolated from follicular fluid during oocyte pickup and evaluated by immunocytochemistry for pro-caspase-3 and cleaved caspase-3, and by real-time PCR for CASP3 mRNA expression. We found a positive staining of pro-caspase-3 in 77 % of the LGC (95 % confidence interval [CI] 60%–84%), whereas cleaved caspase-3 was found in only 4% of the cells (95 % CI 3%–6%). The abundance of cells expressing pro-caspase-3 was independent from CASP3 mRNA levels (r = 0.24, p = 0.255) and did not correlate with the amount of cleaved caspase-3 (r = -0.24, p = 0.186). Multivariable logistic regression showed that pro-caspase-3 positivity was not influenced by clinical characteristics such as age, cause or length of infertility, antral follicle count or hormonal drugs used to induce ovulation. These findings suggest that pro-caspase-3 is constitutively expressed in LGC, allowing quick cleavage into active caspase-3 and apoptosis triggering whenever needed in the course of gonadotropin-induced follicular development.     

Next-generation sequencing for inborn errors of immunity

Inborn errors of immunity (IEIs) include several hundred gene defects affecting various components of the immune system. As with other constitutional disorders, next-generation sequencing (NGS) is a powerful tool for the diagnosis of these diseases. While NGS can provide molecular confirmation of disease in a patient with a suspected or classic phenotype, it can also identify new molecular defects of the immune system, expand gene-disease phenotypes, clarify mechanism of disease, pattern of inheritance or identify new gene-disease associations. Multiple clinical specialties are involved in the diagnosis and management of patients with IEI, and most have no formal genetic training or expertise. To effectively utilize NGS tools and data in clinical practice, it is relevant and pragmatic to obtain a modicum of knowledge about genetic terminology, the variety of platforms and tools available for high-throughput genomic analysis, the interpretation and implementation of such data in clinical practice. There is considerable variability not only in the technologies and analytical tools used for NGS but in the bioinformatics approach to variant identification and interpretation. The ability to provide a molecular basis for disease has the potential to alter therapeutic management and longer-term treatment of the disease, including developing personalized approaches with molecularly targeted therapies. This review is intended for the clinical specialist or diagnostic immunologist who works in the area of inborn errors of immunity, and provides an overview of the need for genetic testing in these patients (the “why” aspect), the various technologies and analytical approaches, bioinformatics tools, resources, and challenges (the “how” aspect), and the clinical evidence for identifying which patients might be best served by such testing (the “when” aspect).