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JAMA Internal Medicine Jan 2022Systemic corticosteroids are commonly used in treating severe COVID-19. However, the role of inhaled corticosteroids in the treatment of patients with mild to moderate... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Systemic corticosteroids are commonly used in treating severe COVID-19. However, the role of inhaled corticosteroids in the treatment of patients with mild to moderate disease is less clear.
OBJECTIVE
To determine the efficacy of the inhaled steroid ciclesonide in reducing the time to alleviation of all COVID-19-related symptoms among nonhospitalized participants with symptomatic COVID-19 infection.
DESIGN, SETTING, AND PARTICIPANTS
This phase 3, multicenter, double-blind, randomized clinical trial was conducted at 10 centers throughout the US and assessed the safety and efficacy of a ciclesonide metered-dose inhaler (MDI) for treating nonhospitalized participants with symptomatic COVID-19 infection who were screened from June 11, 2020, to November 3, 2020.
INTERVENTIONS
Participants were randomly assigned to receive ciclesonide MDI, 160 μg per actuation, for a total of 2 actuations twice a day (total daily dose, 640 μg) or placebo for 30 days.
MAIN OUTCOMES AND MEASURES
The primary end point was time to alleviation of all COVID-19-related symptoms (cough, dyspnea, chills, feeling feverish, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell) by day 30. Secondary end points included subsequent emergency department visits or hospital admissions for reasons attributable to COVID-19.
RESULTS
A total of 413 participants were screened and 400 (96.9%) were enrolled and randomized (197 [49.3%] in the ciclesonide arm and 203 [50.7%] in the placebo arm; mean [SD] age, 43.3 [16.9] years; 221 [55.3%] female; 2 [0.5%] Asian, 47 [11.8%] Black or African American, 3 [0.8%] Native Hawaiian or other Pacific Islander, 345 [86.3%] White, and 1 multiracial individuals [0.3%]; 172 Hispanic or Latino individuals [43.0%]). The median time to alleviation of all COVID-19-related symptoms was 19.0 days (95% CI, 14.0-21.0) in the ciclesonide arm and 19.0 days (95% CI, 16.0-23.0) in the placebo arm. There was no difference in resolution of all symptoms by day 30 (odds ratio, 1.28; 95% CI, 0.84-1.97). Participants who were treated with ciclesonide had fewer subsequent emergency department visits or hospital admissions for reasons related to COVID-19 (odds ratio, 0.18; 95% CI, 0.04-0.85). No participants died during the study.
CONCLUSIONS AND RELEVANCE
The results of this randomized clinical trial demonstrated that ciclesonide did not achieve the primary efficacy end point of reduced time to alleviation of all COVID-19-related symptoms.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT04377711.
Topics: Administration, Inhalation; Adolescent; Adult; Ambulatory Care Facilities; COVID-19; Double-Blind Method; Female; Glucocorticoids; Humans; Male; Metered Dose Inhalers; Middle Aged; Outpatients; Pregnenediones; COVID-19 Drug Treatment
PubMed: 34807241
DOI: 10.1001/jamainternmed.2021.6759 -
Journal of General Internal Medicine Jul 2018
Topics: Ambulatory Care Facilities; Attitude to Death; Humans; Medicine in Literature; Physician's Role
PubMed: 29687434
DOI: 10.1007/s11606-018-4420-z -
Reumatologia Clinica 2016In recent years, outpatient clinics have undergone extensive development. At present, patients with rheumatic diseases are mainly assisted in this area. However, the...
INTRODUCTION
In recent years, outpatient clinics have undergone extensive development. At present, patients with rheumatic diseases are mainly assisted in this area. However, the quality standards of care are poorly documented.
OBJECTIVE
To develop specific quality criteria and standards for an outpatient rheumatology clinic.
METHOD
The project was based on the two-round Delphi method. The following groups of participants took part: scientific committee (13 rheumatologists), five nominal groups (45 rheumatologists and 12 nurses) and a group of discussion formed by 9 patients. Different drafts were consecutively generated until a final document was obtained that included the standards that received a punctuation equal or over 7 in at least 70% of the participants.
RESULTS
148 standards were developed, grouped into the following 9 dimensions: a) structure (22), b) clinical activity and relationship with the patients (34), c) planning (7), d) levels of priority (5), e) relations with primary care physicians, with Emergency Department and with other clinical departments, f) process (26), g) nursing (13), h) teaching and research (13) and i) activity measures (8).
CONCLUSION
This study established specific quality standards for rheumatology outpatient clinic. It can be a useful tool for organising this area in the Rheumatology Department and as a reference when proposing improvement measures to health administrators.
Topics: Ambulatory Care Facilities; Delphi Technique; Humans; Quality of Health Care; Rheumatic Diseases; Rheumatology; Spain
PubMed: 26775226
DOI: 10.1016/j.reuma.2015.11.004 -
Nephrology, Dialysis, Transplantation :... Mar 2020People with advanced chronic kidney disease and evidence of progression have a high risk of renal replacement therapy. Specialized transition clinics could offer a... (Review)
Review
People with advanced chronic kidney disease and evidence of progression have a high risk of renal replacement therapy. Specialized transition clinics could offer a better option for preparing these patients for dialysis, transplantation or conservative care. This review focuses on the different aspects of such transition clinics. We discuss which patients should be referred to these units and when referral should take place. Patient involvement in the decision-making process is important and requires unbiased patient education. There are many themes, both patient-centred and within the healthcare structure, that will influence the process of shared decision-making and the modality choice. Aspects of placing an access for haemodialysis and peritoneal dialysis are reviewed. Finally, we discuss the importance of pre-emptive transplantation and a planned dialysis start, all with a focus on multidisciplinary collaboration at the transition clinic.
Topics: Ambulatory Care Facilities; Delivery of Health Care; Disease Progression; Humans; Patient Participation; Renal Dialysis; Renal Insufficiency, Chronic; Renal Replacement Therapy
PubMed: 32162667
DOI: 10.1093/ndt/gfaa022 -
Revista de NeurologiaThe current level of technological progress in the methods of diagnosis and treatment of epilepsies requires certain resources to be concentrated in so-called epilepsy... (Review)
Review
AIMS
The current level of technological progress in the methods of diagnosis and treatment of epilepsies requires certain resources to be concentrated in so-called epilepsy clinics (EC) or centres.
DEVELOPMENT
Although many epileptic patients can be diagnosed and treated by clinicians who are not specialized in epilepsies, those whose diagnosis is not totally sure and those who do not have their seizures completely controlled should be referred to an EC. EC are stratified according to the degree of complexity of the studies and therapeutic measures carried out there, the most important being video-EEG monitoring and epilepsy surgery. Moreover, they can be both medical and medical-surgical EC, and may be basic or a reference in their field. If they are properly adapted to a certain volume of population by gradually meeting the local medical and social requirements until they reach an optimum level of development, they can be extremely effective and efficient. The different regional EC must be connected to one another and cooperate with common guidelines for action that have been commonly agreed to by all the centres. They must also allow a bidirectional flow of patients. Every EC must fulfil certain minimum requirements to guarantee the quality of the health care offered there.
CONCLUSIONS
Doctors who attend people with epilepsy, with the support of the health authorities, must promote the setting up and development of EC, in order to achieve the maximum possible control over the seizures and a better quality of life for the epileptic patient.
Topics: Ambulatory Care Facilities; Anticonvulsants; Electroencephalography; Epilepsy; Humans; Neurology; Videotape Recording
PubMed: 14593643
DOI: No ID Found -
Physical Therapy Sep 2008
Topics: Ambulatory Care Facilities; Humans; Low Back Pain; Outcome and Process Assessment, Health Care; Physical Therapy Modalities; Physical Therapy Specialty; Quality of Health Care; Workforce
PubMed: 18757442
DOI: 10.2522/ptj.20070110.ic1 -
Annals of African Medicine 2020It is now known that thrombotic disorders such as venous thromboembolism, ischemic stroke, and myocardial infarction contribute significantly to global morbidity and... (Review)
Review
It is now known that thrombotic disorders such as venous thromboembolism, ischemic stroke, and myocardial infarction contribute significantly to global morbidity and mortality. Anticoagulation service must respond to this new development. Warfarin has continued to provide the backbone for anticoagulation service for decades but with considerable drawbacks. The introduction of nonVitamin K oral anticoagulants (NOACs) has created new challenges. This article seeks to discuss how the establishment of appropriate models of anticoagulation could contain the draw backs of the old anticoagulants and improve on the compliance, availability, affordability, and accessibility of newer anticoagulants. Successful anticoagulation has always been defined by a scientific balancing of the risk of thrombosis and the complication of hemorrhage. To be able to maintain such optimal anticoagulation requires rational drug prescription (physician factor), institutelization of monitoring of therapy (anticoagulation clinic factor) as well as active participation of patients receiving therapy (patient factor). New models of service can be created out of this triad in a bid to replace the old routine medical care model. New models of anticoagulation service should include appropriately trained professionals such as Physicians, Pharmacists, Clinical Pharmacologists, Nurses, and Laboratory Scientists who are knowledgeable in diagnostic, management, and monitoring of anticoagulation. The different models of anticoagulation service discussed in this article clearly demonstrate the need for restructuring of this life saving service particularly in the era of NOAC. Newer models of care that should provide safe, efficacious, and cost-effective services are needed.
Topics: Administration, Oral; Ambulatory Care Facilities; Anticoagulants; Drug Prescriptions; Humans; Quality of Health Care; Thromboembolism; Treatment Outcome; Warfarin
PubMed: 32820726
DOI: 10.4103/aam.aam_30_19 -
Diabetes Care May 2019Group clinics are becoming popular as a new care model in diabetes care. This evidence synthesis, using realist review methodology, examined the role of group clinics in... (Review)
Review
Group clinics are becoming popular as a new care model in diabetes care. This evidence synthesis, using realist review methodology, examined the role of group clinics in meeting the complex needs of young people living with diabetes. Following Realist And Meta-narrative Evidence Synthesis-Evolving Standards (RAMESES) quality standards, we conducted a systematic search across 10 databases. A total of 131 articles met inclusion criteria and were analyzed to develop theoretically informed explanations of how and why group clinics could work (or not) for young people with diabetes. Models of group-based care in the literature varied significantly and incorporated different degrees of clinical and educational content. Our analysis identified four overarching principles that can be applied in different contexts to drive sustained engagement of young people in group clinics: ) emphasizing self-management as practical knowledge; ) developing a sense of affinity between patients; ) providing safe, developmentally appropriate care; and ) balancing group and individual needs. Implementation of group clinics was not always straightforward; numerous adjustments to operational and clinical processes were required to establish and deliver high-quality care. Group clinics for young people with diabetes offer the potential to complement individualized care but are not a panacea and may generate as well as solve problems.
Topics: Adolescent; Age Factors; Age of Onset; Ambulatory Care Facilities; Diabetes Mellitus; Health Services Accessibility; Health Services Needs and Demand; Humans; Self-Management; Young Adult
PubMed: 31010940
DOI: 10.2337/dc18-2005 -
Current Oncology (Toronto, Ont.) May 2022Ambulatory cancer centers face a fluctuating patient demand and deploy specialized personnel who have variable availability. This undermines operational stability...
Ambulatory cancer centers face a fluctuating patient demand and deploy specialized personnel who have variable availability. This undermines operational stability through the misalignment of resources to patient needs, resulting in overscheduled clinics, budget deficits, and wait times exceeding provincial targets. We describe the deployment of a Learning Health System framework for operational improvements within the entire ambulatory center. Known methods of value stream mapping, operations research and statistical process control were applied to achieve organizational high performance that is data-informed, agile and adaptive. We transitioned from a fixed template model by an individual physician to a caseload management by disease site model that is realigned quarterly. We adapted a block schedule model for the ambulatory oncology clinic to align the regional demand for specialized services with optimized human and physical resources. We demonstrated an improved utilization of clinical space, increased weekly consistency and improved distribution of activity across the workweek. The increased value, represented as the ratio of monthly encounters per nursing worked hours, and the increased percentage of services delivered by full-time nurses were benefits realized in our cancer system. The creation of a data-informed demand capacity model enables the application of predictive analytics and business intelligence tools that will further enhance clinical responsiveness.
Topics: Ambulatory Care Facilities; Humans; Neoplasms
PubMed: 35735427
DOI: 10.3390/curroncol29060318 -
Clinical Journal of the American... May 2015Infections continue to be a major cause of disease and contributor to death in patients on dialysis. Despite our knowledge and acceptance that hemodialysis catheters... (Review)
Review
Infections continue to be a major cause of disease and contributor to death in patients on dialysis. Despite our knowledge and acceptance that hemodialysis catheters should be avoided and eliminated, most patients who begin dialysis initiate treatment through a central vein hemodialysis catheter. Dialysis Medical Directors must be the instrument through which our industry changes. We must lead the charge to educate our dialysis staff and our dialysis patients. We must also educate ourselves so that we not only know that our facility policies are consistent with the best evidence available, but we must also know where local and federal regulations differ. When these differences impact on patient care, we must speak out and have these regulations changed. But it is not enough to know the rules and write them. We must lead by example and show our patients, our nephrology colleagues and our dialysis staff that we always follow these same policies. We need to practice what we preach and be willing and available to redirect those individuals who have difficulty following the rules. In order to effectively change process meaningful data must be collected, analyzed and acted upon. Dialysis Medical Directors must direct and lead the quality improvement process. We hope this review provides Dialysis Medical Directors with the necessary tools to effectively drive this process and improve care.
Topics: Ambulatory Care Facilities; Catheter-Related Infections; Equipment Contamination; Hand Hygiene; Humans; Infection Control; Leadership; Organizational Policy; Patient Education as Topic; Physician Executives; Renal Dialysis; Vaccination
PubMed: 25710803
DOI: 10.2215/CJN.06050614