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BMC Medicine Jan 2019Recently, studies have examined the underlying patient and practice factors for missed appointments, but less is known about the impact on patient health. People with...
BACKGROUND
Recently, studies have examined the underlying patient and practice factors for missed appointments, but less is known about the impact on patient health. People with one or more long-term conditions who fail to attend appointments may be at risk of premature death. This is the first study to examine the effect of missed primary healthcare appointments on all-cause mortality in those with long-term mental and physical health conditions.
METHODS
We used a large, nationwide retrospective cohort (n = 824,374) extracted from routinely collected general practice data across Scotland over a 3-year period from September 2013 until September 2016. This data encompasses appointment history for approximately 15% of the Scottish population, and was linked to Scottish deaths records for patients who had died within a 16-month follow-up period. We generated appointment attendance history, number of long-term conditions and prescriptions data for patients. These factors were used in negative binomial and Cox's proportional hazards modelling to examine the risk of missing appointments and all-cause mortality.
RESULTS
Patients with a greater number of long-term conditions had an increased risk of missing general practice appointments despite controlling for number of appointments made, particularly among patients with mental health conditions. These patients were at significantly greater risk of all-cause mortality, and showed a dose-based response with increasing number of missed appointments. Patients with long-term mental health conditions who missed more than two appointments per year had a greater than 8-fold increase in risk of all-cause mortality compared with those who missed no appointments. These patients died prematurely, commonly from non-natural external factors such as suicide.
CONCLUSIONS
Missed appointments represent a significant risk marker for all-cause mortality, particularly in patients with mental health conditions. For these patients, existing primary healthcare appointment systems are ineffective. Future interventions should be developed with a particular focus on increasing attendance by these patients.
Topics: Adolescent; Adult; Appointments and Schedules; Chronic Disease; Cohort Studies; Female; Humans; Male; Mental Disorders; Middle Aged; Patient Compliance; Retrospective Studies; Scotland
PubMed: 30630493
DOI: 10.1186/s12916-018-1234-0 -
Tropical Medicine and Infectious Disease Oct 2023The persistent burden of chronic hepatitis B among ≤5-year-old children in Africa suggests missed opportunities for controlling mother-to-child transmission (MTCT) of... (Review)
Review
The persistent burden of chronic hepatitis B among ≤5-year-old children in Africa suggests missed opportunities for controlling mother-to-child transmission (MTCT) of the hepatitis B virus (HBV). This scoping review maps the evidence base on the risk of HBV MTCT, the status of HBV MTCT mitigation strategies including hepatitis B birth-dose vaccination, and the role of systems complexity on the suboptimal adoption and performance of hepatitis B birth-dose vaccination programs in Africa. Overall, 88 peer-reviewed and grey literature sources published between 2000-2022 were included in this review. The growing evidence base consistently argues for a heightened risk of HBV MTCT amidst the HIV co-epidemic in the region. Without universal HBV screening programs integrated within broader antenatal care services, current selective hepatitis B birth-dose vaccination is unlikely to effectively interrupt HBV MTCT. We underscore critical health systems-related barriers to universal adoption and optimal performance of hepatitis B birth-dose vaccination programs in the region. To better conceptualize the role of complexity and system-wide effects on the observed performance of the program, we propose an adapted systems-based logic model. Ultimately, exploring contextualized complex systems approaches to scaling-up universal hepatitis B birth-dose vaccination programs should form an integral part of the regional research agenda.
PubMed: 37888602
DOI: 10.3390/tropicalmed8100474 -
Journal of Gastric Cancer Dec 2020Selective accumulation of a photosensitizer and the subsequent response in only the light-irradiated target are advantages of photodynamic diagnosis and therapy. The... (Review)
Review
Selective accumulation of a photosensitizer and the subsequent response in only the light-irradiated target are advantages of photodynamic diagnosis and therapy. The limited depth of the therapeutic effect is a positive characteristic when treating surface malignancies, such as peritoneal carcinomatosis. For photodynamic diagnosis (PDD), adjunctive use of aminolevulinic acid- protoporphyrin IX-guided fluorescence imaging detects cancer nodules, which would have been missed during assessment using white light visualization only. Furthermore, since few side effects have been reported, this has the potential to become a vital component of diagnostic laparoscopy. A variety of photosensitizers have been examined for photodynamic therapy (PDT), and treatment protocols are heterogeneous in terms of photosensitizer type and dose, photosensitizer-light time interval, and light source wavelength, dose, and dose rate. Although several studies have suggested that PDT has favorable effects in peritoneal carcinomatosis, clinical trials in more homogenous patient groups are required to identify the true benefits. In addition, major complications, such as bowel perforation and capillary leak syndrome, need to be reduced. In the long term, PDD and PDT are likely to be successful therapeutic options for patients with peritoneal carcinomatosis, with several options to optimize the photosensitizer and light delivery parameters to improve safety and efficacy.
PubMed: 33425438
DOI: 10.5230/jgc.2020.20.e39 -
Annals of the American Thoracic Society Apr 2020Tuberculosis treatment lasts for 6 months or more. Treatment adherence is critical; regimen length, among other factors, makes this challenging. Globally, analyses...
Tuberculosis treatment lasts for 6 months or more. Treatment adherence is critical; regimen length, among other factors, makes this challenging. Globally, analyses mapping common types of nonadherence are lacking. For example, is there a greater challenge resulting from early treatment cessation (discontinuation) or intermittent missed doses (suboptimal dosing implementation)? This is essential knowledge for the development of effective interventions and more "forgiving" regimens, as well as to direct national tuberculosis programs. To granularly describe how patients take their tuberculosis medication and the temporal factors associated with missed doses. The present study included patients with pulmonary tuberculosis enrolled in the control arm of a pragmatic, cluster-randomized trial in China of electronic reminders to improve treatment adherence. Treatment was the standard 6-month course (180 d), dosed every other day (90 doses). Medication monitor boxes recorded adherence (box opening) without prompting reminders. Patterns of adherence were visualized and described. Mixed-effects logistic regression models examined the temporal factors associated with per-dose suboptimal dosing implementation, adjusting for clustering within a participant. Cox regression models were used to examine the association between early suboptimal dosing implementation and permanent discontinuation. Across 780 patients, 16,794 (23.9%) of 70,200 doses were missed, 9,487 of which were from suboptimal dosing implementation (56.5%). By 60 days, 5.1% of participants had discontinued, and 14.4% had discontinued by 120 days. Most participants (95.9%) missed at least one dose. The majority of gaps were of a single dose (71.4%), although 22.6% of participants had at least one gap of 2 weeks or more. In adjusted models, the initiation-continuation phase transition (odds ratio, 3.07 [95% confidence interval, 2.68-3.51]) and national holidays (1.52 [1.39-1.65]) were associated with increased odds of suboptimal dosing implementation. Early-stage suboptimal dosing implementation was associated with increased discontinuation rates. Digital tools provide an unprecedented step change in describing and addressing nonadherence. In our setting, nonadherence was common; patients displayed a complex range of patterns. Dividing nonadherence into suboptimal dosing implementation and discontinuation, we found that both increased over time. Discontinuation was associated with early suboptimal dosing implementation. These apparent causal associations between temporal factors and nonadherence present opportunities for targeted interventions.Clinical trial registered with the ISRCTN Registry (ISRCTN46846388).
Topics: Adult; Antitubercular Agents; China; Female; Humans; Logistic Models; Male; Medication Adherence; Middle Aged; Proportional Hazards Models; Reminder Systems; Text Messaging; Tuberculosis, Pulmonary
PubMed: 31860328
DOI: 10.1513/AnnalsATS.201905-394OC -
Radiation Protection Dosimetry Sep 2023Biomarkers for ionising radiation exposure have great utility in scenarios where there has been a potential exposure and physical dosimetry is missing or in dispute,...
Biomarkers for ionising radiation exposure have great utility in scenarios where there has been a potential exposure and physical dosimetry is missing or in dispute, such as for occupational and accidental exposures. Biomarkers that respond as a function of dose are particularly useful as biodosemeters to determine the dose of radiation to which an individual has been exposed. These dose measurements can also be used in medical scenarios to track doses from medical exposures and even have the potential to identify an individual's response to radiation exposure that could help tailor treatments. The measurement of biomarkers of exposure in medicine and for accidents, where a larger number of samples would be required, is limited by the throughput of analysis (i.e. the number of samples that could be processed and analysed), particularly for microscope-based methods, which tend to be labour-intensive. Rapid analysis in an emergency scenario, such as a large-scale accident, would provide dose estimates to medical practitioners, allowing timely administration of the appropriate medical countermeasures to help mitigate the effects of radiation exposure. In order to improve sample throughput for biomarker analysis, much effort has been devoted to automating the process from sample preparation through automated image analysis. This paper will focus mainly on biological endpoints traditionally analysed by microscopy, specifically dicentric chromosomes, micronuclei and gamma-H2AX. These endpoints provide examples where sample throughput has been improved through automated image acquisition, analysis of images acquired by microscopy, as well as methods that have been developed for analysis using imaging flow cytometry.
Topics: Humans; Flow Cytometry; Health Personnel; Image Processing, Computer-Assisted; Medicine; Microscopy
PubMed: 37721060
DOI: 10.1093/rpd/ncad060 -
Public Health Reports (Washington, D.C.... 2015We evaluated the extent to which children and adolescents were not vaccinated against measles ("unvaccinated"), clustering within U.S. counties, and factors associated...
OBJECTIVE
We evaluated the extent to which children and adolescents were not vaccinated against measles ("unvaccinated"), clustering within U.S. counties, and factors associated with unvaccination, including parents' vaccine-related beliefs and missed opportunities.
METHODS
We analyzed data from the 2010-2013 National Immunization Survey (NIS) and NIS-Teen Survey of households with 19- to 35-month-old children and 13- to 17-year-old adolescents, respectively. We used provider-reported vaccination histories to assess measles vaccination status.
RESULTS
In 2013, 7.5% of children and 4.5% of adolescents were unvaccinated against measles. Four-fifths (80.0%) of unvaccinated children lived in counties containing 41.9% of the nation's children, and 80.0% of unvaccinated adolescents lived in counties containing 30.4% of the nation's adolescents. Multivariable statistical analyses found that 74.6% of children who were unvaccinated against measles missed being vaccinated for reasons other than parents' negative vaccine-related beliefs, and 89.6% could be deemed as having at least one missed opportunity for being vaccinated against measles because they were administered at least one dose of other recommended vaccines after 12 months of age. Among adolescents, multivariable analyses found that only demographic factors, not vaccine-related parental beliefs, were independently associated with being unvaccinated.
CONCLUSIONS
Reasons other than negative vaccine-related beliefs, including missed opportunities, accounted for the vast majority of unvaccinated children and adolescents.
Topics: Adolescent; Analysis of Variance; Child, Preschool; Cluster Analysis; Disease Eradication; Disease Outbreaks; Emigrants and Immigrants; Ethnicity; Family Characteristics; Female; Geography; Health Care Surveys; Health Knowledge, Attitudes, Practice; Humans; Infant; Male; Measles; Measles Vaccine; Medically Uninsured; Parents; Social Class; United States
PubMed: 26327727
DOI: 10.1177/003335491513000512 -
Journal of Applied Clinical Medical... Sep 2018Head and neck cancers are commonly treated with radiation therapy, but due to possible volume changes, plan adaptation may be required during the course of treatment....
BACKGROUND
Head and neck cancers are commonly treated with radiation therapy, but due to possible volume changes, plan adaptation may be required during the course of treatment. Currently, plan adaptations consume significant clinical resources. Existing methods to evaluate the need for plan adaptation requires deformable image registration (DIR) to a new CT simulation or daily cone beam CT (CBCT) images and the recalculation of the dose distribution. In this study, we explore a tool to assist the decision for plan adaptation using a CBCT without re-computation of dose, allowing for rapid online assessment.
METHODS
This study involved 18 head and neck cancer patients treated with CBCT image guidance who had their treatment plan modified based on a new CT simulation (ReCT). Dose changes were estimated using different methods and compared to the current gold standard of using DIR between the planning CT scan (PCT) and ReCT with recomputed dose. The first and second methods used DIR between the PCT and daily CBCT with the planned dose or recalculated dose from the ReCT respectively, with the dose transferred to the CBCT using rigid registration. The necessity of plan adaptation was assessed by the change in dose to 95% of the planning target volume (D95) and mean dose to the parotids.
RESULTS
The treatment plans were adapted clinically for all 18 patients but only 7 actually needed an adaptation yielding 11 unnecessary adaptations. Applying a method using the daily CBCT with the planned dose distribution would have yielded only four unnecessary adaptations and no missed adaptations: a significant improvement from that done clinically.
CONCLUSION
Using the DIR between the planning CT and daily CBCT can flag cases for plan adaptation before every fraction while not requiring a new re-planning CT scan and dose recalculation.
Topics: Cone-Beam Computed Tomography; Head and Neck Neoplasms; Humans; Phantoms, Imaging; Radiotherapy Dosage; Radiotherapy Planning, Computer-Assisted; Radiotherapy, Intensity-Modulated
PubMed: 30084159
DOI: 10.1002/acm2.12432 -
Journal of Radiological Protection :... Dec 2021The potential for unintended and adverse radiation exposure in radiotherapy (RT) is real and should be studied because RT is a highly complex, multistep process, which...
BACKGROUND AND PURPOSE
The potential for unintended and adverse radiation exposure in radiotherapy (RT) is real and should be studied because RT is a highly complex, multistep process, which requires input from numerous individuals from different areas and steps of the RT workflow. The 'Incident' (I) is an event the consequence of which is not negligible from the point of view of protection or safety. A 'near miss' (NM) is defined as an event that is highly likely to happen but did not occur. The purpose of this work is to show that through systematic reporting and analysis of these adverse events, their occurrence can be reduced.
MATERIALS AND METHODS
Staff were trained to report every type of unintended and adverse radiation exposure and to provide a full description of it.
RESULTS
By 2018, 110 worksheets had been collected, with an average of 6.1 adverse events per year (with 780 patients treated per year, meaning an average incident rate of 0.78%). In 2001-2009, 37 events were registered (13 I and 24 NM), the majority of them were in the decision phase (12/37), while in 2010-2013, there were 42 (1 I and 41 NM) in both the dose-calculation and transfer phase (19/42). In 2014-2018, 31 events (1 I and 30 NM) were equally distributed across the phases of the RT process. In 9/15 cases of I, some checkpoint was introduced.
CONCLUSION
The complexity of the RT workflow is prone to errors, and this must be taken into account by encouraging a safety culture. The aim of this paper is to present the collected incidents and near misses and to show how organization and practice were modified by the acquired knowledge.
Topics: Humans; Medical Errors; Patient Safety; Radiation Oncology; Radiotherapy; Risk Management; Safety Management; Workflow
PubMed: 34134092
DOI: 10.1088/1361-6498/ac0c01 -
Indian Journal of Nuclear Medicine :... 2020Radioiodine (I) therapy is approved and well-accepted modality for the treatment of hyperthyroidism. The dosage of I for successful treatment is based on many factors;...
PURPOSE OF THE STUDY
Radioiodine (I) therapy is approved and well-accepted modality for the treatment of hyperthyroidism. The dosage of I for successful treatment is based on many factors; however, an objective tool to determine the dose was missing. In a retrospective study, we found that high I uptake values required more dose to achieve desirable results contrary to the belief.
MATERIALS AND METHODS
Clinically and scintigraphically proven Graves' disease patients with high I uptake (>50%) were accrued for this study and block randomized into low-dose (Group I) and high-dose (Group II) groups. Low activity (5 mCi) was administered in Group I and higher activity (10 mCi) in Group II. The patients were followed up after 3 months with thyroid function tests to determine the outcome.
RESULTS
A total of 344 patients were analyzed at the end of 3 months, with 174 in low-dose group and 170 in high-dose group. Euthyroidism/hypothyroidism was achieved in significantly higher number of patients as compared to the low-dose group.
CONCLUSION
The higher dose of I is required to achieve euthyroidism/hypothyroidism in patients with high I uptake.
PubMed: 31949364
DOI: 10.4103/ijnm.IJNM_158_19 -
AIDS Education and Prevention :... Aug 2018HIV pre-exposure prophylaxis (PrEP) is being adopted by members of key populations, such as gay and bisexual men (GBM). Since adherence to a daily PrEP regimen ensures a...
HIV pre-exposure prophylaxis (PrEP) is being adopted by members of key populations, such as gay and bisexual men (GBM). Since adherence to a daily PrEP regimen ensures a maximum protection, it is critical to understand GBM's behavioral responses to having missed PrEP doses. We report on qualitative interviews with GBM taking PrEP. We identified three behavioral responses: (1) 59% continued with their next scheduled dose; (2) 49% described "making up" for a missed dose by taking medication as soon as possible; and (3) 11% reported "doubling" the next PrEP dose. Participants provided potentially contradictory narratives about their sexual behavior after a missed dose: (1) 54% described making no changes; (2) 49% described adjusting their sexual behavior to reduce HIV risk; and (3) 10% said their decision would be contingent upon how many doses were missed. For PrEP prescribers, our data provide a useful lens to understand patients' lived experiences with PrEP.
Topics: Adult; Bisexuality; HIV Infections; Homosexuality, Male; Humans; Interviews as Topic; Male; Medication Adherence; New York City; Pre-Exposure Prophylaxis; Qualitative Research; Sexual Behavior
PubMed: 30148670
DOI: 10.1521/aeap.2018.30.4.275