Gestational Diabetes and Subsequent Metabolic Dysfunction: An National Health and Nutrition Examination Survey Analysis (2011-2018)

Background: Gestational diabetes mellitus (GDM) complicates ∼10% of pregnancies, with the highest rates among Asian women. Evidence suggests that GDM is associated with an increased risk for future chronic health conditions, yet data for Asian women are sparse. We explored the association between prior GDM and metabolic dysfunction with nationally representative data to obtain Asian-specific estimates. Methods: For this cross-sectional study, data were drawn from the National Health and Nutrition Examination Survey for 7195 women with a prior pregnancy. GDM (yes/no) was defined using the question "During pregnancy, were you ever told by a doctor or other health professional that you had diabetes, sugar diabetes, or gestational diabetes?." Current metabolic dysfunction (yes/no) was based on having at least one of four indicators: systolic blood pressure (SBP, ≥130 mmHg), waist circumference (≥88 cm), high-density lipoprotein (HDL) cholesterol (<50 mg/dL), and glycosylated hemoglobin (HbA1c) (≥6.5%). Logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between prior GDM and metabolic outcomes, overall and by race. Models included sampling weights and demographic and behavioral factors. Results: Overall, women with prior GDM had 46% greater odds of high waist circumference (OR: 1.5; 95% CI: 1.1-2.0) and 200% greater odds (OR: 3.0; 95% CI: 2.1-4.2) of high HbA1c. Prior GDM was not associated with high blood pressure or low HDL cholesterol. In race-specific analyses, prior GDM was associated with increased risk of elevated HbA1c among Asian (OR: 6.6; 95% CI: 2.5-17.2), Mexican American (OR: 3.0; 95% CI: 1.5-5.8), Black (OR: 3.0; 95% CI: 1.7-5.5), and White (OR: 2.6; 95% CI: 1.5-4.6) women. Prior GDM was associated with elevated SBP among Mexican American women and low HDL among Black women. Discussion: Prior GDM is associated with elevated HbA1c among all women, yet is a stronger predictor of elevated HbA1c among Asian women than other women. Race-specific associations between prior GDM and metabolic dysfunction were observed among Mexican American and Black women. Further research is warranted to understand the observed race/ethnic-specific associations.

Veterinary and Pharmacy Students' Expectations Before and Experiences After Participating in an Interdisciplinary Access to Care Veterinary Clinic, WisCARES

This pilot survey study describes student expectations and experiences at WisCARES, a low-cost veterinary medical teaching clinic where students from multiple disciplines collaborate. We hypothesized that prior to the workday, students would describe different expectations of working in an interdisciplinary access to care clinic than what they ultimately experienced. We surveyed 62 students from the School of Veterinary Medicine (46) and pharmacy (16) who spent a clinic day at WisCARES. Before introductory rounds, students completed a short survey consisting of four open-ended questions about their learning expectations; at the end of the day, they reviewed their initial responses and added what they actually learned. Qualitative information was categorized and analyzed using descriptive statistics. Thirteen major themes emerged: diversity, confidence, communication, case lead/case management, financial experience, helping people, teamwork, technical skills, inter-professional experience, mentoring, non-specific positive regard, appreciation for resources, and rounds. Students reported improved confidence in managing and leading cases with specific positive outcomes in communicating with clients, particularly regarding leading financial conversations. Developing greater insight into diversity was a common theme expressed in students' expectations but was less frequently noted as an end-of-day outcome. Veterinary students less frequently described the value of the inter-professional environment and collaboration, but this was a major theme noted among pharmacy students. Student feedback was positive overall. The current study is useful in identifying areas for improving collaborative instruction and access to care professional student learning opportunities.

The earliest known reported occurrence of dentigerous cyst in a six-month-old child

The earliest reported case of the occurrence of a dentigerous cyst is described; the cyst surrounded an unerupted permanent tooth bud in a 6-month-old infant. Most commonly these lesions present between the second and third decades of life. They rarely occur before 10 years of age and have not been documented prior to 1 year of age. In the case reported here, the treatment instituted was extraction of the adjacent deciduous tooth and enucleation of the cyst along with the permanent molar tooth bud. Clinicians should be aware of the potential for this lesion to occur across a wide range of ages and the importance of prompt diagnosis and treatment to prevent complications and reduce morbidity.

POS1202 B-CELL RECONSTITUTION IS STRONGLY ASSOCIATED WITH A POSITIVE SEROLOGIC RESPONSE TO THE COVID-19 BOOSTER VACCINE IN PREVIOUSLY SEROLOGICALLY UNRESPONSIVE RITUXIMAB TREATED RHEUMATIC DISEASE PATIENTS

Background

Booster doses of SARS-CoV-2 vaccines have emerged as an important strategy for containing the pandemic and may be especially important to rituximab treated patients. B-cell depletion has been associated with worse outcomes from COVID-19 infection, and many rituximab treated patients demonstrate an inadequate serologic response to the initial vaccine series (1). Strategies to optimize serologic response to COVID-19 vaccine boosters in previously serologically unresponsive patients is, therefore, of particular relevance.

Objectives

To assess factors associated with serologic response to COVID-19 booster vaccines in rituximab treated patients previously serologically unresponsive to the initial vaccine series.

Methods

A retrospective chart review of rituximab treated patients who failed to demonstrate a serologic response to the first SARS-CoV-2 vaccination series and subsequently received an mRNA vaccine booster was performed. Serologic response four weeks or more after the booster was the primary outcome. T-tests, Fisher’s exact tests, and Wilcoxon rank sum tests were used for comparisons. Box and whisker plots were constructed to visualize differences between serologic response.

Results

In 31 rituximab treated patients who were seronegative following the initial vaccine series, demographic characteristics, concurrent therapies, rheumatologic diagnosis, and vaccine type were not associated with serologic positivity to the booster vaccine (Table 1). B-cell reconstitution was significantly different between those with positive (median, IQR 1.785 (0.65, 3)) and negative (median, IQR 0 (0,0)) serologic responses to the booster (p-value<0.001) as was time from last rituximab exposure (p-value = 0.030) (Figure 1). Positive predictive value of B-cell presence was 90.9% (95% CI: 70.8%, 98.9%) and negative predictive value was 100% (95% CI: 59%, 100%) for serologic response to the mRNA booster. Positive predictive value of time >6 months from last rituximab to the booster was 78.3% (95% CI 56.3%, 92.5%) and the negative predictive value was 62.5% (95% CI 24.5%, 91.5%).

Table 1.

Bivariate comparisons between seronegative and seropositive patients to the COVID-19 booster vaccine by patient characteristics and demographics

FactorValueNegativePositivep-valueaN311021Age, median (IQR)64 (51, 72)63 (51, 69)65 (51, 73)0.75Sex1.00 Female23 (74%)7 (70%)16 (76%) Male8 (26%)3 (30%)5 (24%)Any immunosuppressantb9 (29%)3 (30%)6 (29%)1.00Corticosteroid5 (16%)1 (10%)4 (19%)1.003rdVaccine dose type0.24 Pfizer19 (61%)8 (80%)11 (52%) Moderna12 (39%)2 (20%)10 (48%)Dichotomous B-cell status around booster dose<0.001 No detectable B-cells7 (23%)7 (70%)0 (0%) Detectable B-cells22 (71%)2 (20%)20 (95%) Missing2 (6%)1 (10%)1 (5%)Time from last RTX infusion to booster, median (IQR)260 (216, 379)188 (169, 245)301 (251, 368)0.030Time from last RTX infusion to booster dose0.10 <6months8 (25.81%)5 (50%)3 (14%) 6-12 months15 (48.39%)3 (30%)12 (57%) >12 months8 (25.81%)2 (20%)6 (29%)

aP-values are from Fisher’s exact test, Student’s T-test and Wilcoxon rank sum tests

bImmunosuppressants included Leflunomide, Azathioprine, Methotrexate, Mycophenolate Mofetil, and Tocilizumab

IQR= Interquartile range

Conclusion

Presence of detectable B-cells and longer time from last rituximab were associated with the development of SARS-CoV-2 spike protein antibodies following the booster vaccine. These factors should be considered in timing of administration of booster vaccine doses in previously unresponsive rituximab treated patients.

References

[1]Levavi H, Lancman G, Gabriolove J. Impact of rituximab on COVID-19 outcomes. Ann Hematol 2021;100:2805-12.

Disclosure of Interests

Kaitlin Schultz: None declared, Deanna Jannat-Khah Shareholder of: Cytodyn, Astrazeneca, Walgreens, Robert Spiera Consultant of: AbbVie, Regeneron, Sanofi, Chemomab, Formation Biologics, GSK, Janssen Pharmaceuticals, Chemocentryx, Grant/research support from: GSK, Boehringer Ingelheim Pharmaceuticals, Corbus Pharmaceuticals, Formation Biologics, InflaRx, Kadmon, Astrazeneca, AbbVie, Sanofi, Genentech/Roche, Principia, Novartis

The aquaculture supply chain in the time of covid-19 pandemic: Vulnerability, resilience, solutions and priorities at the global scale

The COVID-19 global pandemic has had severe, unpredictable and synchronous impacts on all levels of perishable food supply chains (PFSC), across multiple sectors and spatial scales. Aquaculture plays a vital and rapidly expanding role in food security, in some cases overtaking wild caught fisheries in the production of high-quality animal protein in this PFSC. We performed a rapid global assessment to evaluate the effects of the COVID-19 pandemic and related emerging control measures on the aquaculture supply chain. Socio-economic effects of the pandemic were analysed by surveying the perceptions of stakeholders, who were asked to describe potential supply-side disruption, vulnerabilities and resilience patterns along the production pipeline with four main supply chain components: a) hatchery, b) production/processing, c) distribution/logistics and d) market. We also assessed different farming strategies, comparing land- vs. sea-based systems; extensive vs. intensive methods; and with and without integrated multi-trophic aquaculture, IMTA. In addition to evaluating levels and sources of economic distress, interviewees were asked to identify mitigation solutions adopted at local / internal (i.e., farm-site) scales, and to express their preference on national / external scale mitigation measures among a set of a priori options. Survey responses identified the potential causes of disruption, ripple effects, sources of food insecurity, and socio-economic conflicts. They also pointed to various levels of mitigation strategies. The collated evidence represents a first baseline useful to address future disaster-driven responses, to reinforce the resilience of the sector and to facilitate the design reconstruction plans and mitigation measures, such as financial aid strategies.

The Epidemiology of Operative Pediatric Hand Trauma: A Retrospective Chart Review

Background: Hand injuries are common in the pediatric population with a wide spectrum of morbidity that can occur. Simple injuries are distinguished from complex injuries by the number of fingers/systems that are involved. The epidemiology of simple and complex operative hand trauma in the pediatric population has not yet been defined. Methods: A retrospective review was performed of all pediatric patients requiring operative intervention for hand trauma at a major children's hospital over a 3-year period (2015-2017). Data pertaining to demographics, mechanism, severity, type of surgery, and other factors related to hand trauma were then analyzed and interpreted. Results: Three hundred seventy-one pediatric hand injuries over a 3-year period required surgical intervention, with 19.2% being classified as complex. The average patient age was 11.0 years. A total of 68.7% of patients were men. Bony injuries made up 86.3% of simple injuries, with the proximal phalanx being the most commonly fractured bone. Complex injuries occurred more frequently in men and required a greater number of surgeries (1.6 vs 1.0). Of the complex injuries, only major injuries (severity score >100) required a significantly greater number of surgeries. Major hand injuries were mostly caused by motorized vehicles and required a significantly greater number of surgeries (3.8), compared with other causes of injuries. Conclusions: Operative hand injuries occur along a spectrum of morbidity in the pediatric population. While most of the injuries are simple and require only 1 procedure, more complex injuries can also occur and deserve a higher level of care and attention.

The "can do, do do" concept in individuals with chronic obstructive pulmonary disease: an exploration of psychological mechanisms

Background

The “can do, do do” concept aims at identifying subgroups among persons with chronic obstructive pulmonary disease (COPD). Following a two-dimensional categorization, individuals are binarily classified with respect to their levels of physical capacity (“can’t do” or “can do”) and physical activity (“don’t do” or “do do”), resulting in four disjunct quadrants. The approach has been debated recently and the latest articles have concluded that the quadrants should be specifically examined in terms of psychological aspects of physical activity. Therefore, the goal of the present study was to explore the role of psychological variables in physical activity in the context of the “can do, do do” quadrant concept.

Methods

Within the scope of secondary data analyses of the “Stay Active After Rehabilitation” (STAR) randomized controlled trial, a total of 298 COPD rehabilitants of an inpatient pulmonary rehabilitation program were grouped into the suggested quadrants. We set fixed cut-offs at 70% of relative 6-min walking test performances for healthy individuals (physical capacity dimension) and 5.000 steps per day (physical activity dimension). Univariate and multivariate logistic regression analyses served to analyze whether depression scores, fear avoidance behaviors, disease-specific anxiety, self-concordance for physical activity, and five indicators of physical activity-related health competence (PAHCO) effectively discriminated between the “don’t do” and “do do” groups.

Results

Among persons with lower relative physical capacity, depression scores, fear avoidance behaviors, and disease-specific anxiety (univariate case) significantly differentiated between the more and the less active. Among persons with higher relative physical capacity, fear avoidance behaviors, disease-specific anxiety, as well as three PAHCO indicators (physical activity-specific self-efficacy, self-control, and affect regulation) significantly separated the more and the less active. In multivariate analyses, only fear avoidance behaviors and affect regulation discriminated among individuals with better relative physical capacity.

Conclusion

The findings identified important psychological and competence-oriented variables that explain discrepancies in the quadrant concept. Based on this, we discuss implications for physical activity promotion in individuals with COPD. Respiratory research can benefit from future studies complementing the quadrant concept through further behavioral analyses.

Trial registration Clinicaltrials.gov, ID: NCT02966561. Registered 17 November, 2016, https://clinicaltrials.gov/ct2/show/NCT02966561.

Association of routine school closures with child maltreatment reporting and substantiation in the United States; 2010-2017

BACKGROUND

There exists a presumption that school closures lead to a diminished capacity to detect child maltreatment, but empiric evidence is lacking.

OBJECTIVE

To determine if child maltreatment reporting and substantiation differ between periods when schools are routinely closed compared to in session.

PARTICIPANTS AND SETTING

Child maltreatment reporting and substantiation among all U.S. States and the District of Columbia from January 1, 2010 through December 31, 2017.

METHODS

Two-week intervals during periods of routine school closure (early January, June through mid-August, late November, and late December) were compared to all other 2-week intervals. Negative binomial generalized estimating equations compared rates of reporting and substantiation, resulting in incidence rate ratios (IRR) with 95% confidence intervals (CI).

RESULTS

Compared to when school was in session, reporting was 16.0% (IRR 0.84 [95% CI: 0.83, 0.85]) lower during school closures and substantiations were 12.3% (IRR 0.88 [95% CI: 0.86, 0.89]) lower. The largest reductions in reporting were observed among education personnel (-42.1%; IRR 0.58 [95% CI: 0.54, 0.62]), children aged 5-17 years (-18.6%; IRR 0.81 [95% CI: 0.80, 0.83), and for physical abuse (-19.6%; IRR 0.80 [95% CI: 0.79, 0.82]). Reductions during closure periods were not matched by increases during two-week intervals immediately following closure periods.

CONCLUSIONS

Results suggest that the detection of child maltreatment may be diminished during periods of routine school closure. Findings may inform prevention planning and risk-benefit analyses for future school closures. Further study should disentangle the issue of decreased detection versus decreased prevalence of maltreatment during school closures.

[Guideline for the Diagnosis and Treatment of Asthma - Addendum 2020 - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]

The present addendum of the guideline for the diagnosis and treatment of asthma (2017) complements new insights into the diagnosis and management of asthma as well as for the newly approved drugs for the treatment of asthma. Current, evidence-based recommendations on diagnostic and therapeutic approaches are presented for children and adolescents as well as for adults with asthma.

[Group Training of Patients with Chronic Lung Diseases under Outpatient Conditions - Recommendations of the Working Group Lung Sports in Germany and the German Airways League]

To improve acceptance and use of physical training by patients with chronic lung diseases, recommendations for performing lung exercises on an outpatient basis in a group setting are given by experts in physical training, sports therapists and pulmonologists. The evidence-based positive effects of physical training were analyzed for asthma , COPD, interstitial lung diseases, cystic fibrosis, lung carcinoma, and pulmonary hypertension. The requirements for lung exercises in outpatient groups as well as compensation by care providers were given on the basis of legal regulations. Furthermore, the main items of the training units as well as supervision by specially trained group leaders in relation to the severity of the underlying lung disease are described. Finally, aspects of safety of the participating patients are discussed, including the prevention of infection with corona-2-virus.

[Recommendations from the German Respiratory Society for Pulmonary Rehabilitation in Patients with COVID-19]

Vor dem Hintergrund der Pandemie durch Infektionen mit dem SARS-CoV-2 hat die Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin (DGP e. V.) die Sektion 12 „Rehabilitation, Prävention und Tabakkontrolle“ beauftragt, Empfehlungen zur Umsetzung pneumologischer Rehabilitation bei Patienten nach COVID-19 zu erstellen. Dieses Positionspapier basiert auf dem momentanen aktuellen Wissen, das sich täglich weiterentwickelt. Neben einer Beschreibung der gesundheitlichen Folgen von COVID-19 wird die Indikationsstellung aufgezeigt. Rehabilitative Therapien bei COVID-19 sind bereits auf der Normalstation bzw. Intensivstation indiziert, setzen sich fort als pneumologische Frührehabilitation im Akutkrankenhaus und als Anschlussheilbehandlung oder Reha-Heilverfahren in pneumologischen Rehabilitationskliniken. Im Fokus dieses Positionspapiers stehen Empfehlungen zur inhaltlichen Durchführung einer multimodalen, interdisziplinären pneumologischen Rehabilitation bei COVID-19.

Assessing health status over time: impact of recall period and anchor question on the minimal clinically important difference of copd health status tools

Background

The Minimal Clinically Important Difference (MCID) assesses what change on a measurement tool can be considered minimal clinically relevant. Although the recall period can influence questionnaire scores, it is unclear if it influences the MCID. This study is the first to examine longitudinally the impact of the recall period of an anchor question and its design on the MCID of COPD health status tools using the COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ) and the St. George’s Respiratory Questionnaire (SGRQ).

Methods

Moderate to very severe COPD patients without respiratory co-morbidities were recruited during 3-week Pulmonary Rehabilitation (PR). CAT, CCQ and SGRQ were completed at baseline, discharge, 3, 6, 9 and 12 months. A 15-point Global Rating of Change scale (GRC) was completed at each follow-up. A five-point GRC was used as second anchor at 12 months. Mean change scores of a subset of patients indicating a minimal improvement on each of the anchor questions were considered the MCID. The MCID estimates over different time periods were compared with one another by evaluating the degree of overlap of Confidence Intervals (CI) adjusted for dependency.

Results

In total 451 patients were included (57.9 ± 6.6 years, 65% male, 50/39/11% GOLD II/III/IV), of which 309 completed follow-up. Baseline health status scores were 20.2 ± 7.3 (CAT), 2.9 ± 1.2 (CCQ) and 50.7 ± 17.3 (SGRQ). MCID estimates for improvement ranged − 3.1 to − 1.4 for CAT, − 0.6 to − 0.3 for CCQ, and − 10.3 to − 7.6 for SGRQ. Absolute higher – though not significant – MCIDs were observed for CAT and CCQ directly after PR. Significantly absolute lower MCID estimates were observed for CAT (difference − 1.4: CI -2.3 to − 0.5) and CCQ (difference − 0.2: CI -0.3 to −0.1) using a five-point GRC.

Conclusions

The recall period of a 15-point anchor question seemed to have limited impact on the MCID for improvement of CAT, CCQ and SGRQ during PR; although a 3-week MCID estimate directly after PR might lead to absolute higher values. However, the design of the anchor question was likely to influence the MCID of CAT and CCQ.

Trial registration

RIMTCORE trial #DRKS00004609 and #12107 (Ethik-Kommission der Bayerischen Landesärztekammer).

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0950-7) contains supplementary material, which is available to authorized users.

[Guideline for the Diagnosis and Treatment of Asthma - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]

The present guideline is a new version and an update of the guideline for the diagnosis and treatment of asthma, which replaces the previous version for german speaking countries from the year 2006. The wealth of new data on the pathophysiology and the phenotypes of asthma, and the expanded spectrum of diagnostic and therapeutic options necessitated a new version and an update. This guideline presents the current, evidence-based recommendations for the diagnosis and treatment of asthma, for children and adolescents as well as for adults with asthma.

Newborn Ear Deformities: Early Recognition and Novel Nonoperative Techniques

Congenital auricular anomalies are common sources of aesthetic concern and psychosocial distress for both children and their parents. Only one-third of these anomalies self-correct, leaving a large need for acceptable corrective methods. Otoplasty is often the standard treatment; however, newer nonsurgical methods, including splinting and molding in the neonatal period, have shown favorable results without the complications of surgical intervention and with the advantage of early intervention. These treatment options have not yet been widely adopted in Western countries due to delayed diagnosis of auricular deformities and confusion regarding treatment indications and technique.

Frontal Sinus Fractures

The frontal bone serves a protective role, representing the transition between the facial skeleton and the cranium. Within its enclosure, the frontal sinus lies adjacent to many important intracranial structures, and injury to this region has severe complications if not properly managed. Historically, the goals of frontal sinus fracture management have been to best prevent intracranial complications with invasive procedures, but a recent shift favoring conservative management now aims to preserve the form and function of the frontal sinus and its outflow tract. With the advancement of endoscopic techniques and the development of new technologies, many alternatives to aggressive surgical management are available.

Flight-Test of a Tactile Situational Awareness System in a Land-based Deck Landing Task

The National Research Council of Canada and Defence Research and Development Canada flight-tested the U.S. Naval Aerospace Medical Research Laboratory's Tactile Situational Awareness System (TSAS) in a dynamic task. The TSAS vest uses small pneumatic actuators or ‘tactors’ to transmit information to the pilot. Eleven pilots used the TSAS to cue horizontal axis performance in a land-based deck landing task flown in the NRC Bell 205 helicopter. Pilots tracked a vertically moving target with and without the TSAS in good and degraded visual conditions. The TSAS effectively cued longitudinal fore/aft drifts and reduced RMS error. It had less effect on lateral positioning error, possibly due to the presence of strong visual cues. Pilot situational awareness during degraded visual environment conditions in high sea states was significantly improved by the TSAS, as measured by the China Lake situational awareness rating scale. No change in workload, as measured by Modified Cooper Harper Workload Scale, was attributable to the TSAS use. The improvements in situational awareness and the reduction in longitudinal error suggest that the TSAS would be beneficial for helicopter ship deck landing.

Complexity of gap junctions between horizontal cells of the carp retina

In the vertebrate retina, horizontal cells (HCs) reveal homologous coupling by gap junctions (gj), which are thought to consist of different connexins (Cx). However, recent studies in mouse, rabbit and zebrafish retina indicate that individual HCs express more than one connexin. To provide further insights into the composition of gj connecting HCs and to determine whether HCs express multiple connexins, we examined the molecular identity and distribution of gj between HCs of the carp retina. We have cloned four carp connexins designated Cx49.5, Cx55.5, Cx52.6 and Cx53.8 with a close relationship to connexins previously reported in HCs of mouse, rabbit and zebrafish, respectively. Using in situ hybridization, Cx49.5 expression was detected in different subpopulations of retinal neurons including HCs, whereas the Cx52.6 transcript was localized exclusively in HCs. Using specific antibodies, Cx55.5 and Cx53.8 were detected on dendrites of all four HC subtypes and axon terminals. Immunoelectron microscopy confirmed the presence of Cx55.5 and Cx53.8 in gap junctions between these processes and Cx55.5 was additionally observed in HC dendrites invaginating cone pedicles, suggesting its participation in the modulation of photoreceptor output in the carp retina. Furthermore, using single-cell RT-PCR, all four connexins were detected in different subtypes of HCs, suggesting overlapping expression patterns. Thus, the composition of gj mediating homologous coupling between subtypes of carp HCs appears to be more complex than expected. Moreover, BLAST searches of the preliminary carp genome, using novel sequences as query, suggest that most of the analyzed connexin genes are duplicated in carp.

Pilot study of incorporating a supportive care program into a small community oncology practice

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Background: Incorporation of supportive care has become standard of care in patients with advanced or metastatic cancer undergoing palliative chemotherapy. Implementation of a supportive care program is often difficult in a small community practice due to a multitude of factors. Methods: We piloted a supportive care program with the partnership of Sage Hospice & Palliative Care in which patients with advanced or metastatic cancer undergoing chemotherapy would be evaluated by a certified nurse practitioner (CNP). Patients were selected for evaluation based on age, stage of cancer, and likelihood of needing additional supportive measures during their oncologic treatment. Patients were enrolled in the program by seeing the CNP and being followed throughout their chemotherapy, or until their death. Home visits were done by the CNP after hours, on weekends, or during business hours if it was noted to be medically necessary. Results: Forty-four patients were enrolled in the supportive care program. All patients either had metastatic or advanced cancer that required chemotherapy. The most common diagnoses are breast, pancreatic, prostate and lung cancer. The average number of patient home visits was 3.35 visits. Interventions varied, but the most common tasks performed were IV hydration, pain control and symptom management. Of the 44 patients, only 7 required an inpatient stay (15.9%) and none of these patients required a second hospital stay or were noted to be a 30 day readmission. Ten patients were enrolled in hospice, and 7 of those patients died. Zero patients died while on treatment or died without being enrolled on hospice. Conclusions: Incorporation of a supportive care program is feasible in a small community practice. The benefits may include improved patient outcomes, decreased hospitalizations, and smoother transition to end of life care.

Stellenwert ambulanter, gerätegestützter Trainingstherapie bei Atemwegs- und Lungenkrankheiten

Die körperliche Trainingstherapie gilt als eine der wichtigsten Therapieoptionen für Patienten mit chronischen Atemwegs- und Lungenkrankheiten: Die Effekte des Ausdauer- und Krafttrainings auf Atemnot, körperliche Leistungsfähigkeit und Lebensqualität sind unbestritten. Dennoch wird die Trainingstherapie im ambulanten Bereich durch die Rahmenvereinbarungen der Bundesarbeitsgemeinschaft für Rehabilitation (BAR) limitiert: Nur der in Gruppen angeleitete Lungensport wird über längere Zeiträume von den Kostenträgern finanziert, das gerätegestützte Training bleibt ausgeschlossen, obwohl sich dessen herausragende Effizienz durch zahlreiche randomisiert kontrollierte Studien nachweisen lässt.

In diesem Übersichtsartikel werden neben der Methodik und den Effekten auch die aktuellen organisatorischen Strukturen einer ambulanten, gerätegestützten Trainingstherapie für Patienten mit chronischen Atemwegs- und Lungenkrankheiten in Deutschland aufgezeigt und kritisch diskutiert.