Nurse care coordination in community-based long-term care. Prevention of intravascular catheter-related infection with newer chlorhexidine-silver sulfadiazine-coated catheters: a randomized controlled trial Interrater agreement with a standard scheme for classifying medication errors. Effect of anticysticercal treatment on the prognosis of epilepsy in neurocysticercosis: a pilot trial. Efficacy of Buffered Hypertonic Saline Nasal Irrigation for Nasal Symptoms in Children with Seasonal Allergic Rhinitis: A Randomized Controlled Trial Acute effects of prolonged intermittent low-intensity isometric warm-up schemes on jump, sprint, and agility performance in collegiate soccer players The relationship between myofascial trigger points of gastrocnemius muscle and nocturnal calf cramps. Assessment of Blood Tumor Mutational Burden as a Potential Biomarker for Immunotherapy in Patients With Non–Small Cell Lung Cancer With Use of a Next-Generation Sequencing Cancer Gene Panel Supporting Diabetes Self-Care in Underserved Populations Epilepsy and neurocysticercosis in an Andean community. Effect of a nurse-coordinated prevention programme on cardiovascular risk after an acute coronary syndrome: main results of the RESPONSE randomised trial Seizures associated with solitary cysticercus granuloma: antiepileptic drugs for how long? Integrating Web‐based Computer Cases into a Required Clerkship: Development and Evaluation Significance of serum tumor markers in monitoring advanced breast cancer patients treated with systemic therapy: A prospective study Multi-dimensional nursing form: a novel means of approaching nurse-led secondary cardiology prevention. A Highly Predictive Risk Model for Pacemaker Implantation After TAVR. The SPHERE Study. Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411] Community-Based Lifestyle Intervention in Patients With Coronary Artery Disease: The RESPONSE-2 Trial. Community-based comprehensive lifestyle programs in patients with coronary artery disease: Objectives, design and expected results of Randomized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 trial (RESPONSE 2). Effectiveness of a shared team approach between nurses and doctors for improved risk factor management in survivors of stroke: a cluster randomized controlled trial An integrated chronic care program for patients with atrial fibrillation: study protocol and methodology for an ongoing prospective randomised controlled trial. Improving patient adherence to lifestyle advice (IMPALA): a cluster-randomised controlled trial on the implementation of a nurse-led intervention for cardiovascular risk management in primary care (protocol) The SAFE or SORRY? programme. part II: effect on preventive care. Choice of secondary prevention improves risk factors after acute coronary syndrome: 1-year follow-up of the CHOICE (Choice of Health Options In prevention of Cardiovascular Events) randomised controlled trial Nurse-coordinated multidisciplinary, family-based cardiovascular disease prevention programme (EUROACTION) for patients with coronary heart disease and asymptomatic individuals at high risk of cardiovascular disease: a paired, cluster-randomised controlled trial
PURPOSE To evaluate the clinical outcomes of a nurse care coordination program for people receiving services from a state-funded home and community-based waiver program called Missouri Care Options ( MCO ) . DESIGN A quasi-experimental design was used to compare 55 MCO clients who received nurse care coordination ( NCC ) and 30 clients who received MCO services but no nurse care coordination .  METHODS Nurse care coordination consists of the assignment of a  registered nurse who provides home care services for both the MCO program and Medicare home health services .  Two st and ardized data sets , the Minimum Data Set ( MDS ) for resident care and planning and the Outcome Assessment Instrument and Data Set ( OASIS ) were collected at baseline , 6 months , and 12 months on both groups . Cognition was measured with the MDS Cognitive Performance Scale ( CPS ) , activities of daily living ( ADL ) as the sum of five MDS ADL items , depression with the MDS-Depression Rating Scale , and incontinence and pressure ulcers with specific MDS items . Three OASIS items were used to measure pain , dyspnea , and medication management . The Cochran-Mantel-Haenszel ( CMH ) method was used to test the association between the NCC intervention and clinical outcomes . FINDINGS At 12 months the NCC group scored significantly better statistically in the clinical outcomes of pain , dyspnea , and ADLs . No significant differences between groups were found in eight clinical outcome measures at 6 months . CONCLUSIONS Use of nurse care coordination for acute and chronic home care warrants further evaluation as a treatment approach for chronically ill older adults Background The indication of antiseptic-coated catheters remains debated . Objective To test the ability of the new generation of chlorhexidine-silver and sulfadiazine-coated catheters , with enhanced antiseptic coating , to reduce the risk of central venous catheter (CVC)-related infection in ICU patients . Design Multicentre r and omized double-blind trial . Patients and setting A total of 397 patients from 14 ICUs of university hospitals in France . Intervention Patients were r and omized to receive an antiseptic-coated catheter ( ACC ) or a st and ard non-coated catheter ( NCC ) . Measurements Incidence of CVC-related infection . Results Of 367 patients having a successful catheter insertion , 363 were analysed ( 175 NCC and 188 ACC ) . Patients had one ( NCC=162 , ACC=180 ) or more ( NCC=13 , ACC=11 ) CVC inserted . The two groups were similar for insertion site [ subclavian ( 64 vs 69 ) ] or jugular ( 36 vs 31 % ) ] , and type of catheters ( single-lumen 18 vs 18 % ; double-lumen 82 vs 82 % ) , and mean ( median ) duration of catheterisation [ 12.0±11.7 ( 9 ) vs 10.5±8.8 ( 8) days in the NCC and ACC groups , respectively ] . Significant colonisation of the catheter occurred in 23 ( 13.1 % ) and 7 ( 3.7 % ) patients , respectively , in the NCC and ACC groups ( 11 vs 3.6 per 1000 catheter-days ; p=0.01 ) ; CVC-related infection ( bloodstream infection ) occurred in 10 ( 5 ) and 4 ( 3 ) patients in the NCC and CC groups , respectively ( 5.2 vs 2 per 1000 catheter days ; p=0.10 ) . Conclusions In the context of a low baseline infection rate , ACC were associated with a significant reduction of catheter colonisation and a trend to reduction of infection episodes , but not of bloodstream infection PURPOSE The interrater agreement for and reliability of the National Coordinating Council for Medication Error Reporting and Prevention ( NCC MERP ) index for categorizing medication errors were determined . METHODS A letter was sent by the U.S. Pharmacopeia to all 550 contacts in the MEDMARX system user data base . Participants were asked to categorize 27 medication scenarios using the NCC MERP index  and were r and omly assigned to one of three tools ( the index alone , a paper-based algorithm , or a computer-based algorithm ) to assist in categorization . Because the NCC MERP index accounts for harm and cost , and because categories could be interpreted as substantially similar , study results were analyzed after the nine error categories were collapsed to six . The interrater agreement was measured using Cohen 's kappa value . RESULTS Of 119 positive responses , 101 completed surveys were returned for a response rate of 85 % . There were no significant differences in baseline demographics among the three groups . The overall interrater agreement for the participants , regardless of group assignment , was substantial at 0.61 ( 95 % confidence interval [ CI ] , 0.41 - 0.81 ) . There was no difference among the kappa values of the three study groups and the tools used to aid in medication error classification . When the index was condensed from nine categories to six , the interrater agreement increased with a kappa value of 0.74 ( 95 % CI , 0.56 - 0.90 ) . CONCLUSION Overall interrater agreement for the NCC MERP index for categorizing medication errors was substantial . The tool provided to assist with categorization did not influence overall categorization . Further refining of the scale could improve the usefulness and validity of medication error categorization Epilepsy secondary to active or inactive neurocysticercosis ( NCC ) is a major public health problem in Latin American countries . In an open-label pilot trial , we evaluated and followed ( mean = 13 months ) 16 patients with epilepsy result ing from active NCC which was treated with anticisticercal ( ACC ) drugs .  These patients were aged 12 - 68 years with confirmed active NCC and seizures not controlled by adequate antiepileptic drug ( AED ) therapy .  Patients were treated with albendazole or praziquantel ( ALB and PZQ , ACC drugs ) and AED monotherapy . The number of NCC cysts was markedly reduced by ACC therapy .  Thirteen patients remained seizure-free and 2 had only one seizure during follow-up . Our data suggest a positive effect of ACC treatment on the prognosis of epilepsy caused by active NCC , but a prospect i ve , double-blind , controlled study with long-term follow-up must be performed to determine whether ACC therapy improves long-term seizure control Background : Saline nasal irrigation is labelled as an add-on treatment in patients with allergic rhinitis ( AR ) . The primary aim of this study was to compare the efficacy of 21-day use of buffered hypertonic saline ( BHS ) versus normal saline solution ( NSS ) on reducing nasal symptoms in children with seasonal AR ( SAR ) . Comparing their efficacy on nasal cytology counts ( NCC ) , quality of life , and sleep quality was the secondary aim . Methods : In this 21-day , open-label , r and omized controlled study , 36 SAR children ( aged 6 - 13 years ) with a Total 5 Symptom Score ( T5SS ) ≥5 received twice-daily BHS  or  NSS  delivered through a nasal douche . Efficacy measures were least square mean changes ( LSmc ) in T5SS , NCC , Paediatric Rhinoconjunctivitis Quality of Life Question naire ( PRQLQ ) , and Pittsburgh Sleep Quality Index ( PSQI ) scores . Results : BHS improved the T5SS total score to a greater extent than NSS ( LSmc -6.45 vs. -5.45 , p < 0.001 ) . Concerning NCC , BHS significantly reduced the scores of neutrophils ( LSmc -0.76 , p = 0.004 ) and eosinophils ( LSmc -0.46 , p = 0.018 ) , while NSS did not . Similarly , only BHS yielded a significant improvement in the PRQLQ score ( LSmc -0.57 , p = 0.009 ) , whereas the improvement in PSQI score was comparable between the BHS ( LSmc -0.77 , p = 0.025 ) and NSS ( LSmc -1.39 , p < 0.001 ) groups . Overall , BHS was well tolerated . Conclusions : In children with SAR  , BHS is effective in improving nasal symptoms and NCC , with an associated beneficial effect on quality of life The aim of the present study was to compare the effects of different warm-up interventions on jump , sprint and agility performance in collegiate soccer players . Twenty-one healthy male college soccer players ( age : 20.14 ± 1.65 years ; body height : 179.9 ± 8.34 cm ; body mass : 74.4 ± 13.0 kg ; % body fat : 9.45 ± 4.8 ) participated in the study . Subjects underwent four different r and omized warm-up protocol s separated by at least 48 hours . The warm-up schemes were : 1 . no conditioning contraction protocol ( NCC ) ; 2 . dynamic stretching ( DS ) ; 3 . prolonged intermittent low-intensity isometric exercise ( ST ) ; and , 4 . ST with an additional external load equal to 30 % of body weight ( ST + 30 % BW ) . All interventions were preceded by a general warm-up . Results from one-way repeated measures ANOVA demonstrated a significant difference in countermovement jump ( CMJ ) at F(3,60 ) = 10.2 , ηρ2 = 0.337 , p < 0.01 . Post hoc analysis revealed a significant difference in CMJ performance in DS when compared to NCC and ST + 30 % BW . No significant difference in CMJ was observed between DS and ST . CMJ scores in NCC , ST , and ST + 30 % BW were non-significant . There was a significant difference in speed ; F(3 , 60 ) = 6.61 , ηρ2 = 0.248 , p < 0.01 . Post hoc analysis revealed significantly better time in DS than NCC and ST . However , no difference in speed was observed between DS and ST + 30 % BW . Similarly , speed was similar in NCC , ST and ST + 30 % BW . A significant difference in agility performance was also observed ; F(3 , 60 ) = 24.1 , ηρ2= 0.546 , p < 0.01 . Post hoc analysis revealed significantly greater performance gains in DS than NCC . No significant difference in agility was observed in DS , ST and ST + 30 % BW . In conclusion , a prolonged intermittent low-intensity isometric protocol using bodyweight only showed similar benefits with dynamic stretching in countermovement jump performance . When the same isometric condition with additional load equal to 30 % of bodyweight was applied , effects in speed and agility were similar to dynamic stretching To support that myofascial pain syndrome ( MPS ) of gastrocnemius muscle is one cause of nocturnal calf cramps , quantitative assessment of the efficacy of trigger point ( TrP ) injection compared with oral quinine in the treatment of nocturnal calf cramps ( NCC ) associated with MPS of gastrocnemius muscle was design ed . Twenty four subjects with NCC and gastrocnemius TrPs were r and omly divided into two groups of twelve for each treatment . Patients in group 1 were treated with xylocaine injection at the gastrocnemius TrP , and 300 mg of quinine sulfate p.o . was prescribed for patients of group 2 . The treatment period was four weeks with a follow-up 4 weeks later . Cramps were assessed quantitatively ( in terms of frequency , duration , pain intensity , cramp index , and pain threshold of the gastrocnemius TrPs ) before treatment , after treatment and at the end of the follow-up respectively . The outcome of treatment in both groups showed a statistically significant reduction in all quantitative aspects of cramps ( 95 % confidence interval ) . Also the pain threshold of the gastrocnemius TrP was significantly increased in group 1 only when comparing the pre-treatment and at the end of follow-up . In comparing the two groups we found no statistical difference during the period of treatment . The benefit of both strategies lasted up to four weeks following cessation of the treatment but the outcome of all measures ( except pain threshold ) were found to be significantly better in the group treated with TrP injection . The results of this study support that gastrocnemius trigger point is one cause of NCC and show that the TrP injection strategy for NCC associated with myofascial pain is not only as effective as oral quinine during the treatment period but also better in the prolonged effect at follow-up Importance Tumor mutational burden ( TMB ) , as measured by whole-exome sequencing ( WES ) or a cancer gene panel ( CGP ) , is associated with immunotherapy responses . However , whether TMB estimated by circulating tumor DNA in blood ( bTMB ) is associated with clinical outcomes of immunotherapy remains to be explored . Objectives To explore the optimal gene panel size and algorithm to design a CGP for TMB estimation , evaluate the panel reliability , and further vali date the feasibility of bTMB as a clinical actionable biomarker for immunotherapy . Design , Setting , and Participants In this cohort study , a CGP named NCC-GP150 was design ed and virtually vali date d using The Cancer Genome Atlas data base . The correlation between bTMB estimated by NCC-GP150 and tissue TMB ( tTMB ) measured by WES was evaluated in matched blood and tissue sample s from 48 patients with advanced NSCLC . An independent cohort of 50 patients with advanced NSCLC was used to identify the utility of bTMB estimated by NCC-GP150 in distinguishing patients who would benefit from anti – programmed cell death 1 ( anti – PD-1 ) and anti – programmed cell death lig and 1 ( anti – PD-L1 ) therapy .  The study was performed from July 19 , 2016 , to April 20 , 2018 . Main Outcomes and Measures Assessment of the Spearman correlation coefficient between bTMB estimated by NCC-GP150 and tTMB calculated by WES . Evaluation of the association of bTMB level with progression-free survival and response to anti – PD-1 and anti – PD-L1 therapy . Results This study used 2 independent cohorts of patients with NSCLC ( cohort 1 : 48 patients ; mean [ SD ] age , 60 [ 13 ] years ; 15 [ 31.2 % ] female ; cohort 2 : 50 patients ; mean [ SD ] age , 58 [ 8 ] years ; 15 [ 30.0 % ] female ) . A CGP , including 150 genes , demonstrated stable correlations with WES for TMB estimation ( median r2 = 0.91 ; interquartile range , 0.89 - 0.92 ) , especially when synonymous mutations were included ( median r2 = 0.92 ; interquartile range , 0.91 - 0.93 ) , whereas TMB estimated by the NCC-GP150 panel found higher correlations with TMB estimated by WES than most of the r and omly sample d 150-gene panels . Blood TMB estimated by NCC-GP150 correlated well with the matched tTMB calculated by WES ( Spearman correlation = 0.62 ) . In the anti – PD-1 and anti – PD-L1 treatment cohort , a bTMB of 6 or higher was associated with superior progression-free survival ( hazard ratio , 0.39 ; 95 % CI , 0.18 - 0.84 ; log-rank P = .01 ) and objective response rates ( bTMB ≥6 : 39.3 % ; 95 % CI , 23.9%-56.5 % ; bTMB < 6 : 9.1 % ; 95 % CI , 1.6%-25.9 % ; P = .02 ) . Conclusions and Relevance The findings suggest that established NCC-GP150 with an optimized gene panel size and algorithm is feasible for bTMB estimation , which may serve as a potential biomarker of clinical benefit in patients with NSCLC treated with anti – PD-1 and anti – PD-L1 agents Purpose The purpose of this study was to evaluate the impact of an innovative intervention that utilized a certified medical assistant with specific diabetes training to work with a multidisciplinary diabetes care team to help provide basic diabetes education and self-care support in low-income minority population s with type 2 diabetes . Methods Enrolled participants were r and omized to either the medical assistant coaching ( MAC ) group ( N = 25 ) or the treatment as usual ( TAU ) group ( N = 25 ) . Deidentified data was obtained on a matched no contact control ( NCC ) group ( N = 50 ) . Results Analysis of covariance ( ANCOVA ) comparisons revealed no significant differences between the 3 groups on A1C , but a trend was observed . A1Cs decreased across time for the MAC group , while increasing for the TAU and NCC groups . ANCOVA comparisons also indicated that the MAC group experienced significantly greater increases in perceived empowerment and a larger , although non-significant , reduction in perceived diabetes related problems than the TAU group . Conclusions This r and omized controlled pilot study suggests that the inclusion of a medical assistant self-care coach as part of the diabetes care team holds promise in improving outcomes and should be further examined in a large-scale study BACKGROUND Taenia solium neurocysticercosis ( NCC ) has been documented as one of the major causes of epilepsy in developing countries . However , method ological limitations have hindered the evaluation of the epidemiological relationship between cysticercosis and epilepsy at the community level . METHODS We used the WHO protocol for epidemiological evaluation of neurological disorders to conduct a door-to-door survey among 2723 residents of San Pablo del Lago , an Ecuadorean rural community in which T. solium taeniasis/cysticercosis was known to be endemic . The WHO protocol was complemented by neuroimaging and immunological tests to confirm the diagnosis of this infection . RESULTS In all 31 people suffering from active epilepsy were detected ( prevalence 11.4 per 1000 , 95 % CI:7.7 - 15.4 ) ; 26 agreed to undergo a computer tomography ( CT ) examination , and 28 agreed to have blood drawn for serodiagnosis . Fourteen of the 26 ( 53.8 % ) had CT changes compatible with NCC and six of the 28 ( 21.4 % ) tested positive in the enzyme-linked immunoelectro-transfer blot ( EITB ) assay . In a seizure-free r and om sample of this population , 17 of 118 ( 144 per 1000 ) subjects examined by CT and 10 out of 96 ( 104 per 1000 ) examined by EITB had evidence of this infection . The differences between the epilepsy group and the r and om sample of the population were statistically significant ( OR = 6.93 , 95 % CI : 2.7 - 17.5 , P < 0.001 ) for CT diagnosis , but not for EITB results ( OR = 2.75 , 95 % CI : 0.8 - 7.1 , P > 0.12 , NS ) . CONCLUSIONS These findings confirm that T. solium NCC is a significant cause of epilepsy at the community level in And ean villages of Ecuador . It is important to initiate effective public health interventions to eliminate this infection , which may be responsible for at least half of the cases of reported epilepsy in Ecuador Objective To quantify the impact of a practical , hospital-based nurse-coordinated prevention programme on cardiovascular risk , integrated into the routine clinical care of patients discharged after an acute coronary syndrome , as compared with usual care only . Design RESPONSE ( R and omised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists ) was a r and omised clinical trial . Setting Multicentre trial in secondary and tertiary healthcare setting s. Participants 754 patients admitted for acute coronary syndrome . Intervention A nurse-coordinated prevention programme , consisting of four outpatient nurse clinic visits , focusing on healthy lifestyles , biometric risk factors and medication adherence , in addition to usual care . Main outcome measures The main outcome was 10-year cardiovascular mortality risk as estimated by Systematic Coronary Risk Evaluation at 12 months follow-up . Secondary outcomes included Framingham Coronary Risk Score at 12 months , in addition to changes in individual risk factors . Risk factor control was classified as ‘ poor ’ if 0 to 3 factors were on target , ‘ fair ’ if 4 to 6 factors were on target , and ‘ good ’ if 7 to 9 were on target . Results The mean Systematic Coronary Risk Evaluation at 12 months was 4.4 per cent ( SD 4.5 ) in the intervention group and 5.4 per cent ( SD 6.2 ) in the control group ( p=0.021 ) , representing a 17.4 % relative risk reduction . At 12 months , risk factor control classified as ‘ good ’ was achieved in 35 % of patients in the intervention group compared with 25 % in the control group ( p=0.003 ) . Attendance to the nurse-coordinated prevention programme was 92 % . In the intervention group , 86 rehospitalisations were observed against 132 in the control group ( relative risk reduction 34.8 % , p=0.023 ) . Conclusions The nurse-coordinated hospital-based prevention programme in addition to usual care is a practical , yet effective method for reduction of cardiovascular risk in patients with coronary disease . Our data suggest that the counselling component of the programme may lead to a reduction in hospital readmissions . Trial Registration trialregister.nl Identifier TC1290 In human brain parenchyma , the larval form of Taenia solium undergoes four stages of evolution , vesicular , colloidal , granularnodular and calcification . The term , cysticercus granuloma is used broadly to parasites in the colloidal or the granular-nodular stages and these two stages are together considered as transitional or degenerative phase of the disease process . Seizures associated with transitional phase of neurocysticercosis ( NCC ) are a consequence of inflammation around a cyst and these seizures as such may be categorized under acute symptomatic or provoked seizures . In developing countries transitional phase of NCC is probably the most common cause of acute symptomatic seizure(s ) . Multiple cysts , parenchymal and extraparenchymal , are more commonly reported in Latin American countries , where as there is an over abundance of reports of solitary cysticercus granulomas ( SCG ) from India . More than 90 percent of patients with SCG , the presenting feature is seizures . In our study of acute symptomatic seizures , NCC in transitional phase , was the etiological factor in 66 percent of the patients . Neurocysticercosis accounted for 10 percent of patients with seizures who presented to an emergency department in Los Angeles and 6 percent of such patients in New Mexico . Acute symptomatic seizures generally tend not to recur and usually long-term antiepileptic drug ( AED ) treatment is not necessary . Even if AEDs are used to suppress recurrence of seizures , they generally do not need to be continued after the patient has recovered form the primary illness . These concepts are based on the basic assumption that acute symptomatic seizures presumably cease with the resolution of the precipitating cause or illness . Patients with SCG with seizure(s ) provide a good model to study this concept . There are no guidelines regarding the duration for which AED should be continued in patients with SCG . This is largely because of two factors : ( i ) variable seizure recurrence rate after the initial seizure and ( ii ) variable natural history of SCG . Seizure recurrence in patients with SCG rate is high after a first seizure . In a prospect i ve study of 77 patients with a first seizure and active or transitional NCC ( this included 60 percent patients with SCG ) , 40.3 percent of patients experienced seizure recurrence . Kaplan-Meier estimated recurrence was 22 percent at 6 months , 32 percent at 12 months , 39 percent at 24 months and 49 percent at 48 and 84 months . The risk of seizure recurrence in patients with SCG is related to persistence of brain lesion . The natural history of SCG can take one of the two courses : ( i ) it resolves entirely or ( ii ) it leaves a punctate calcification as residue . In some patients magnetization transfer magnetic resonance imaging ( MRI ) has shown presence of gliotic changes at the site of a healed granuloma . The duration or time of resolution of the lesion is quite variable . In a prospect i ve study of 210 patients with SCG presenting with seizures , 18.8 percent of granulomas resolved at 3 months , 36.4 percent at 6 months and 62.5 percent at 1 year . Our long-term follow-up study has shown that seizures associated with SCG have good prognosis and AEDs can safely be withdrawn with the resolution CT lesion . Other authors have also suggested that AEDs can safely be withdrawn once the follow-up CT shows the resolution of the lesion . However patients with more than two seizures and those with breakthrough seizures need to be caution ed after AED withdrawal as some of these patients are at a risk of seizure recurrence . Where as the seizures associated with calcific stage of NCC are to be considered under unprovoked seizures and should be treated like any other remote symptomatic epilepsy . In conclusion the present evidence suggests that patients with acute symptomatic seizure(s ) associated with SCG should be treated with AEDs for two reasons : ( i ) seizures are likely to recur as long as the lesion persist and ( ii ) the time period for the resolution of the CT lesion is quite variable . The present evidence also suggests that AEDs can safely be withdrawn once the followup scan shows resolution of the lesion . Most often , good seizure control can be achieved with a single conventional AED ( monotherapy ) . Dr S and eep Kaushal and his colleagues in their article published in this issue have suggested that clobazam can be an alternative . In their study clobazam was well tolerated , safe and effective in the treatment of seizures associated with SCG . Uncontrolled observations have also shown good efficacy Purpose To evaluate a five-year experience ( 1995–2000 ) developing and integrating computer cases into a required clerkship . Method In Study 1 , 54 volunteer students were r and omly assigned to study articles , a paper case  , or a  computer case on low back pain/kidney stones . Students were given an exam immediately after the exercise and one week later . In Study 2 , 325 clerkship students were asked to select and complete two computer cases or to prepare assignments on unrelated topics . Among the cases offered were two test cases on low back pain/kidney stones and pneumonia . Questions specific to the computer test cases ( CC ) and other noncomputer cases ( NCC ) were in the final exam . Exam scores related to CC questions and NCC questions were compared between the groups of students who did and did not complete the computer cases . Students also rated the  computer cases  on a question naire . Results In Study 1 , reading articles required the most time and received the most negative comments . The students who completed the computer case scored the best on the exam one week later . In Study 2 , the students who completed the two computer cases scored significantly higher on the CC questions than did students who studied only one or none of the computer cases ( p < .001 ) . There was no difference among groups for the NCC scores ( p = .76 ) . Students rated the computer cases  with a mean of 6 on a seven-point scale ( 7 = strongly agree ) . Conclusion Computer cases are effective learning tools , are well-received by students , and can be successfully integrated into existing clerkships Objective The significance of serum tumor markers in monitoring advanced breast cancer patients is still controversial . To clarify this issue , the Tumor Marker Study Group of the Japanese Breast Cancer Society conducted a prospect i ve study . Methods Patients with advanced breast cancer who were treated with systemic therapy between January and December 2002 were recruited from five collaborative institutes in Japan . The patients were monitored every four weeks using three serum tumor markers , CEA , CA 15 - 3 and NCC-ST-439 during the therapy . Results Findings from 108 eligible patients were analyzed . The pretreatment positivity rates were 51.9 % for CEA , 50 % for CA 15 - 3 , and 34.3 % for NCC-ST-439 . The changes in each marker level at 8 and 12 weeks but not at 4 weeks after the start of therapy seemed to correlate with the response to therapy in pretreatment marker-positive patients but not in negative patients . The Cox proportional hazard model revealed a greater than 20 % reduction in CEA , CA 15 - 3 or NCC-ST-439 levels at 4 , 8 and /or 12 weeks after the start of therapy to be an independent predictive factor for longer time-to-progression ( TTP ) in pretreatment marker-positive patients . Conclusion This prospect i ve study supported the findings obtained from our previous retrospective study that in pretreatment marker-positive patients 1 ) the changes in serum tumor marker levels after the start of therapy correlate with the response to therapy ; and 2 ) a greater than 20 % reduction in the tumor marker levels was a favorable predictive factor for TTP during systemic therapy . When the pretreatment serum level of these markers is over the respective cut-off value , sequential measurement of them may be useful for evaluating the efficacy of treatment as well as monitoring the outcome of patients with advanced breast cancer BACKGROUND AND AIM  Secondary prevention  after an acute coronary syndrome ( ACS ) has proved to be effective in patients with coronary heart disease , and is strongly recommended by the international guidelines . However , there is a lack of widespread secondary preventive programmes in real-world clinical practice , even though it has been shown that these can be successfully conducted by nurses . METHOD AND RESULTS We have design ed a multicentre r and omised trial involving patients with ACS in which nurses will fully coordinate secondary prevention  in the intervention arm using a multidimensional nursing form after attending ad hoc teaching sessions OBJECTIVES This study sought to develop a robust and definitive risk model for new permanent pacemaker implantation ( PPMI ) after SAPIEN 3 ( third generation balloon exp and able valve )  ( Edwards Lifesciences , Irvine , California ) transcatheter aortic valve replacement ( third generation balloon exp and able valve TAVR ) , including calcification in the aortic-valvular complex ( AVC ) . BACKGROUND The association between calcium in the AVC and need for PPMI is poorly delineated after third generation balloon exp and able valve TAVR . METHODS At Cedars-Sinai Heart Institute in Los Angeles , California , a total of 240 patients with severe aortic stenosis underwent third generation balloon exp and able valve TAVR and had contrast computed tomography .  AVC was characterized precisely by leaflet sector and region . RESULTS The total new PPMI rate was 14.6 % . On multivariate analysis for predictors of PPMI , pre-procedure third generation balloon exp and able valve TAVR , right bundle branch block ( RBBB ) , shorter membranous septum ( MS ) length , and noncoronary cusp device-l and ing zone calcium volume ( NCC-DLZ CA ) were included . Predictive probabilities were generated using this logistic regression model . If 3 pre-procedural risk factors were present , the c-statistic of the model for PPMI was area under the curve of 0.88 , sensitivity of 77.1 % , and specificity of 87.1 % ; this risk model had high negative predictive value ( 95.7 % ) . The addition of the procedural factor of device depth to the model , with the parameter of difference between implantation depth and MS length , combined with RBBB and NCC-DLZ CA increased the c-statistic to 0.92 , sensitivity to 94.3 % , specificity to 83.8 % , and negative predictive value to 98.8 % CONCLUSIONS : By using a precise characterization of distribution of calcification in the AVC in a single-center , retrospective study , NCC-DLZ CA was found to be an independent predictor of new PPMI post-third generation balloon exp and able valve TAVR . The findings also reinforce the importance of short MS length , pre-existing RBBB , and ventricular implantation depth as important synergistic PPMI risk factors . This risk model will need validation by future prospect i ve multicenter studies Background The aim of the SPHERE study is to design , implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease ( CHD ) in general practice across two different health systems on the isl and of Irel and .CHD is a common cause of death and a significant cause of morbidity in Irel and . Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives . Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the isl and of Irel and . The review literature recommends structured programmes with continued support and follow-up of patients ; the provision of training , tailored to practice needs of access to evidence of effectiveness of secondary prevention ; structured recall programmes that also take account of individual practice needs ; and patient-centred consultations accompanied by attention to disease management guidelines . Methods SPHERE is a cluster r and omised controlled trial , with practice -level r and omisation to intervention and control groups , recruiting 960 patients from 48 practice s in three study centres ( Belfast , Dublin and Galway ) . Primary outcomes are blood pressure , total cholesterol , physical and mental health status ( SF-12 ) and hospital re-admissions . The intervention takes place over two years and data is collected at baseline , one-year and two-year follow-up . Data is obtained from medical charts , consultations with practitioners , and patient postal question naires . The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice . It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients . General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD . Patients are invited to attend regular four-monthly consultations over two years , during which targets and goals for secondary prevention are set and review ed . The analysis will be strengthened by economic , policy and qualitative components BACKGROUND Among patients with coronary artery disease ( CAD ) , improvement of lifestyle-related risk factors ( LRFs ) reduces cardiovascular morbidity and mortality . However , modification of LRFs is highly challenging . OBJECTIVES This study sought to evaluate the impact of combining community-based lifestyle programs with regular hospital-based secondary prevention . METHODS The authors performed a r and omized controlled trial of nurse-coordinated referral of patients and their partners to 3 widely available community-based lifestyle programs , in 15 hospitals in the Netherl and s. Patients admitted for acute coronary syndrome and /or revascularization , with ≥1 LRF ( body mass index > 27 kg/m2 , self-reported physical inactivity , and /or smoking ) were included . All patients received guideline -based usual care . The intervention was based on 3 lifestyle programs for weight reduction , increasing physical activity , and smoking cessation . The primary outcome was the proportion of success at 12 months , defined as improvement in ≥1 qualifying LRF using weight ( ≥5 % reduction ) , 6-min-walking distance ( ≥10 % improvement ) , and urinary cotinine ( 200 ng/ml detection limit ) without deterioration in the other 2 . RESULTS The authors r and omized 824 patients . Complete data on the primary outcome were available in 711 patients .  The proportion of successful patients in the intervention group was 37 % ( 133 of 360 ) compared with 26 % ( 91 of 351 ) in the control group ( p = 0.002 ; risk ratio : 1.43 ; 95 % confidence interval : 1.14 to 1.78 ) . In the intervention group , partner participation was associated with a significantly greater success rate ( 46 % vs. 34 % ; p = 0.03 ) . CONCLUSIONS Among patients with coronary artery disease , nurse-coordinated referral to a comprehensive set of community-based , widely available lifestyle interventions , with optional partner participation , leads to significant improvements in LRFs . ( RESPONSE-2 : R and omised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists 2 ; NTR3937 ) UNLABELLED Patients with coronary artery disease ( CAD ) are at high risk of recurrent events . A healthy lifestyle can significantly reduce this risk . A previous trial , R and omized Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists ( RESPONSE ) , demonstrated that nurse-coordinated outpatient clinics improve drug treatment of cardiovascular risk factors . However , lifestyle-related risk factors , including smoking , overweight , and physical inactivity , were common and remained largely unchanged at follow-up in most patients ( 66 % ) . The aim of the current study is to evaluate the impact of 3 community-based lifestyle programs in patients after hospitalization for CAD . We are conducting a multicenter ( n = 15 ) , r and omized trial that will recruit 800 patients to test the efficacy of up to 3 widely available commercial lifestyle programs , aim ed at patients and their partners , on top of usual care . These programs are aim ed at smoking cessation ( Luchtsignaal ( ® ) ) , weight loss ( Weight Watchers ( ® ) ) , and improving physical activity ( Philips DirectLife ( ® ) ) . OUTCOMES The primary outcome at 12months is the proportion of patients in whom at least 1 lifestyle risk factor is improved without deterioration in any of the other 2 , and a relative increase of at least 30 % in this proportion is considered clinical ly relevant BACKGROUND AND PURPOSE Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack . The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high-risk population was determined . METHODS This was a prospect i ve , multicentre , cluster-r and omized controlled trial with blinded assessment of outcomes and intention-to-treat analysis . Patients hospitalized for stroke/transient ischaemic attack and aged ≥18 years were recruited from four hospitals . General practice s treating recruited patients were r and omized to provide either usual care or an individualized management programme comprising nurse-led education and review of care plans by stroke specialists in addition to usual care . The primary outcome was a change in cardiovascular Framingham Risk Score between baseline and 12 months . RESULTS From January 2010 to November 2013 , 156 general practice s ( 280 patients ) were r and omly assigned to usual care ( control ) and 159 ( 283 patients ) to the intervention . The median age was 70.1 years ; 65 % were male . Overall , > 80 % of participants were prescribed recommended secondary prevention therapies at baseline . The primary efficacy analysis comprised 533 participants , with 30 either dying or lost to follow-up . In adjusted analyses , no significant between-group difference was found in the cardiovascular risk score at 12 months ( 0.04 , 95 % confidence interval -1.7 , 1.8 ) . CONCLUSIONS The effectiveness of an organized secondary prevention programme for stroke may be limited in patients from high-performing hospitals with regular post-discharge follow-up and communication with general practice BACKGROUND Adherence to guidelines for the management of atrial fibrillation ( AF ) is often poor , although this is associated with improved morbidity and mortality in such patients . Increasing numbers of programs are design ed to enhance appropriate counselling , treatment and coordinated care delivery including the nurse-led , guidelines -based , software-supported integrated chronic care program ( ICCP ) for patients with AF reported here . OBJECTIVES This paper outlines the study protocol and methodology currently being used to evaluate the effectiveness of a newly developed nurse-led , guideline -based , software-supported ICCP for patients with AF . DESIGN AND METHODS Evaluation of the ICCP is currently being carried out in the outpatient care setting known as the AF-Clinic . A prospect i ve r and omised controlled trial is currently underway in the outpatient AF-Clinic of a University Hospital in the Netherl and s in cooperation with the collaborating university . The primary outcome measures are cardiovascular hospitalisation and /or death . Secondary outcome measures include guideline adherence , patient knowledge about their condition , quality of life , satisfaction and other outcome measurements such as cost-effectiveness . PARTICIPANTS It was calculated that 698 participants are needed to demonstrate discernible outcomes in relation to the primary endpoint ( 349 patients in each group ) with follow-up after 1 year . RESULTS The study started in January 2007 and the first results are expected in the beginning of 2010 . CONCLUSIONS It is hypothesised that the ICCP may contribute towards closing the gap between guideline recommendations and current practice in the management of atrial fibrillation . Furthermore , it is hypothesised that the program has the potential to optimise the management of AF patients and improve the efficiency and coordination of patient care . This may lead to better patient outcomes including improved quality of life and patient satisfaction in such patients Background Many patients at high risk of cardiovascular diseases are managed and monitored in general practice . Recommendations for cardiovascular risk management , including lifestyle change , are clearly described in the Dutch national guideline . Although lifestyle interventions , such as advice on diet , physical exercise , smoking and alcohol , have moderate , but potentially relevant effects in these patients , adherence to lifestyle advice in general practice is not optimal . The IMPALA study intends to improve adherence to lifestyle advice by involving patients in decision making on cardiovascular prevention by nurse-led clinics . The aim of this paper is to describe the design and methods of a study to evaluate an intervention aim ed at involving patients in cardiovascular risk management . Methods A cluster-r and omised controlled trial in 20 general practice s , 10 practice s in the intervention arm and 10 in the control arm , starting on October 2005 . A total of 720 patients without existing cardiovascular diseases but eligible for cardiovascular risk assessment will be recruited . In both arms , the general practitioners and nurses will be trained to apply the national guideline for cardiovascular risk management . Nurses in the intervention arm will receive an extended training in risk assessment , risk communication , the use of a decision aid and adapted motivational interviewing . This communication technique will be used to support the shared decision-making process about risk reduction . The intervention comprises 2 consultations and 1 follow-up telephone call . The nurses in the control arm will give usual care after the risk estimation , according to the national guideline . Primary outcome measures are self-reported adherence to lifestyle advice and drug treatment . Secondary outcome measures are the patients ' perception of risk and their motivation to change their behaviour . The measurements will take place at baseline and after 12 and 52 weeks . Clinical endpoints will not be measured , but the absolute 10-year risk of cardiovascular events will be estimated for each patient from medical records at baseline and after 1 year . Discussion The combined use of risk communication , a decision aid and motivational interviewing to enhance patient involvement in decision making is an innovative aspect of the intervention . Trial registration Current Controlled Trials IS RCT BACKGROUND Patient care guidelines are usually implemented one at a time , yet patients are at risk for multiple , often preventable , adverse events simultaneously . OBJECTIVE The SAFE or SORRY ? programme targeted three adverse events ( pressure ulcers , urinary tract infections and falls ) and was successful in reducing the incidence of these events . This article explores the process of change and describes the effect on the preventive care given . DESIGN Separate data on preventive care were collected along the cluster r and omised trial , which was conducted between September 2006 and November 2008 . SETTING S Ten hospital wards and ten nursing home wards . PARTICIPANTS We monitored nursing care given to adult patients with an expected length of stay of at least five days . METHODS The SAFE or SORRY ? programme consisted of the essential recommendations of guidelines for pressure ulcers , urinary tract infections and falls . A multifaceted implementation strategy was used to implement this multiple guidelines programme . Data on preventive care given to patients were collected in line with these guidelines and the difference between the intervention and the usual care group at follow-up was analysed . RESULTS The study showed no overall difference in preventive pressure ulcer measures between the intervention and the usual care group in hospitals ( estimate=6 % , CI : -7 - 19 ) and nursing homes ( estimate=4 % , CI : -5 - 13 ) . For urinary tract infections , even statistically significantly fewer hospital patients at risk received preventive care ( estimate=19 % , CI : 17 - 21 ) . For falls in hospitals and nursing homes , no more patients at risk received preventive care . CONCLUSION Though the SAFE OR SORRY ? programme effectively reduced the number of adverse events , an increase in preventive care given to patients at risk was not demonstrated . These results seem to emphasise the difficulties in measuring the compliance to guidelines . More research is needed to explore the possibilities for measuring the implementation of multiple guidelines using process indicators Objective : To determine the effect of a new CHOICE ( Choice of Health Options In prevention of Cardiovascular Events ) programme on cardiovascular risk factors in acute coronary syndrome ( ACS ) survivors . Design : Single-blind r and omised controlled trial . Setting : Tertiary referral hospital in Sydney Australia . Patients : 144 ACS survivors who were not accessing st and ard cardiac rehabilitation .  Data were also collected on a further 64 ACS survivors attending st and ard cardiac rehabilitation . Intervention : The CHOICE group ( n = 72 ) participated in a brief , patient-centred , modular programme comprising a clinic visit plus telephone support , encompassing m and atory cholesterol lowering and tailored preferential risk modification . The control group ( n = 72 ) participated in continuing conventional care but no central ly coordinated secondary prevention . Main outcome measures : Values for total cholesterol , systolic blood pressure , smoking status and physical activity . Results : CHOICE and control groups were well matched at baseline . At 12 months , the CHOICE group ( n = 67 ) had significantly better risk factor levels than controls ( n = 69 ) for total cholesterol ( TC ) ( mean ( SEM ) 4.0 ( 0.1 ) vs 4.7 ( 0.1 ) mmol/l , p<0.001 ) , systolic blood pressure ( 131.6 ( 1.8 ) vs 143.9 ( 2.3 ) mm Hg , p<0.001 ) , body mass index ( 28.9 ( 0.7 ) vs 31.2 ( 0.7 ) kg/m2 , p = 0.025 ) and physical activity ( 1369.1 ( 167.2 ) vs 715.1 ( 103.5 ) METS/kg/min , p = 0.001 ) as well as a better knowledge of risk factor targets . Also at 1 year , fewer CHOICE participants ( 21 % ) had three or more risk factors above widely recommended levels then controls ( 72 % ) ( p<0.001 ) . Conclusions : Participation in a brief CHOICE programme significantly improved the modifiable risk profiles and risk factor knowledge of ACS survivors over 12 months . CHOICE is an effective alternative for dealing with the widespread underuse of existing secondary prevention programmes . Trial registration number : IS RCT BACKGROUND Our aim was to investigate whether a nurse-coordinated multidisciplinary , family-based preventive cardiology programme could improve st and ards of preventive care in routine clinical practice . METHODS In a matched , cluster-r and omised , controlled trial in eight European countries , six pairs of hospitals and six pairs of general practice s were assigned to an intervention programme ( INT ) or usual care ( UC ) for patients with coronary heart disease or those at high risk of developing cardiovascular disease . The primary endpoints-measured at 1 year-were family-based lifestyle change ; management of blood pressure , lipids , and blood glucose to target concentrations ; and prescription of cardioprotective drugs . Analysis was by intention to treat . The trial is registered as IS RCT N 71715857 . FINDINGS 1589 and 1499 patients with coronary heart disease in hospitals and 1189 and 1128 at high risk were assigned to INT and UC , respectively . In patients with coronary heart disease who smoked in the month before the event , 136 ( 58 % ) in the INT and 154 ( 47 % ) in the UC groups did not smoke 1 year afterwards ( difference in change 10.4 % , 95 % CI -0.3 to 21.2 , p=0.06 ) . Reduced consumption of saturated fat ( 196 [ 55 % ] vs 168 [ 40 % ] ; 17.3 % , 6.4 to 28.2 , p=0.009 ) , and increased consumption of fruit and vegetables  ( 680 [ 72 % ] vs 349 [ 35 % ] ; 37.3 % , 18.1 to 56.5 , p=0.004 ) , and  oily fish  ( 156 [ 17 % ] vs 81 [ 8 % ] ; 8.9 % , 0.3 to 17.5 , p=0.04 ) at 1 year were greatest in the INT group . High-risk individuals and partners showed changes only for fruit and vegetables ( p=0.005 ) . Blood-pressure target of less than 140/90 mm Hg was attained by both coronary ( 615 [ 65 % ] vs 547 [ 55 % ] ; 10.4 % , 0.6 to 20.2 , p=0.04 ) and high-risk ( 586 [ 58 % ] vs 407 [ 41 % ] ; 16.9 % , 2.0 to 31.8 , p=0.03 ) patients in the INT groups . Achievement of total cholesterol of less than 5 mmol/L did not differ between groups , but in high-risk patients the difference in change from baseline to 1 year was 12.7 % ( 2.4 to 23.0 , p=0.02 ) in favour of INT . In the hospital group , prescriptions for statins  were higher in the INT group ( 810 [ 86 % ] vs 794 [ 80 % ] ; 6.0 % , -0.5 to 11.5 , p=0.04 ) . In general practice s in the intervention groups ,  angiotensin-converting enzyme inhibitors  ( 297 [ 29 % ] INT vs 196 [ 20 % ] UC ; 8.5 % , 1.8 to 15.2 , p=0.02 ) and  statins  ( 381 [ 37 % ] INT vs 232 [ 22 % ] UC ; 14.6 % , 2.5 to 26.7 , p=0.03 ) were more frequently prescribed . INTERPRETATION To achieve the potential for cardiovascular prevention , we need local preventive cardiology programmes adapted to individual countries , which are accessible by all hospitals and general practice s caring for coronary and high-risk patients
NCC demonstrated to have an effect on a small number of outcomes .
NCC that incorporated blood pressure monitoring , cholesterol control and smoking cessation has an impact on the improvement of secondary prevention .
Current guidelines on secondary prevention of cardiovascular disease recommend nurse-coordinated care ( NCC ) as an effective intervention .
However , NCC programmes differ widely and the efficacy of NCC components has not been studied .