Health Care Costs in End-of-Life and Palliative Care
Mary Beth Morrissey, Bruce Jennings in Partners in Palliative Care, 2013
Advances in medicine and technology have diluted distinctions between disease modifying therapy and therapies with a palliative intent. Therefore it is common now for dying patients to seek both types of care. Hospice as it is presently financed and organized is not well-designed to meet these needs and interests (Peres, 2011). Some hospices are now adopting and implementing “open access” policies that permit certain curative treatments such as chemotherapy at the same time as comfort care; this is not the general rule. As one response to this problem, the Affordable Care Act mandates demonstration projects in multiple sites that will test the effect of allowing concurrent hospice and conventional care on both quality and cost (MedPAC, 2011). Oncology is a good example of a medical specialty where perverse incentives driving physician practice and increasing costs may remain, however. The research evidence is that there may be a need for increasing collaboration between hospice and oncology in defining the goals of care for patients at the end of life (Harrington & Smith, 2008).
Clinical pharmacology: principles of analgesic drug management
Nigel Sykes, Michael I Bennett, Chun-Su Yuan in Clinical Pain Management, 2008
Frequent reassessment ensures that correct diagnoses are made and that goals are being reached. The adequacy of the management plan should be assessed by discussion with the patient in terms of the original goals of therapy, function, and quality of life; review of the number of rescue doses required per day; recording pain severity and excluding significant side effects. If treatment is not providing adequate pain relief then the analgesic regime or the original diagnoses should be reviewed, remembering that a patient may have more than one source of pain. Patient review must also be frequent enough to detect and manage side effects, while continuing to tailor the analgesic regime. Modification of the analgesic prescription may be required on average every two weeks.14 [V] There is often a need to change therapy due to the nature of changing disease: either progression of malignancy, imminent death, or response to disease-modifying treatment such as chemotherapy or radiotherapy.
Haemopoietic Stem Cell Transplantation for Rheumatoid Arthritis—World Experience and Future Trials
Richard K. Burt, Alberto M. Marmont in Stem Cell Therapy for Autoimmune Disease, 2019
The study continued as an Australian multicentre trial in which patients were randomised to either unmanipulated or CD34+ selected grafts.38 The trial recruited 33 patients who had failed therapy with methotrexate and at least one other disease modifying agent. Patients received high dose immunosuppression with cyclophosphamide 200 mg/kg followed by randomised rescue with unmanipulated or CD34 selected cells. Thirty-one patients proceeded to transplant. There were no deaths and no major unexpected toxicities. On an intention to treat basis (including 2 patients who failed to mobilise stem cells), ACR 20, 50, and 70 responses were achieved in 70%, 45% and 39% of patients. There were no significant differences between the unmanipulated and the CD34 selected groups in terms of response and time to relapse and re-introduction of disease modifying therapy. Although not part of the trial, a minority of patients were observed closely after re-introduction of disease modifying therapy. Responses, some as profound as ACR 70, were observed in two thirds of the patients followed up, supporting the hypothesis that the transplant procedure provides disease debulking such that subsequent control is possible with low dose agents.
The use of nasal allergen vs allergen exposure chambers to evaluate allergen immunotherapy
Published in Expert Review of Clinical Immunology, 2021
Lubnaa Hossenbaccus, Anne K Ellis
Allergic rhinitis (AR) is an immunoglobulin (Ig) E-mediated, type 2 inflammatory disease of the nasal mucosa [1]. Triggered by allergen exposure, AR manifests clinically as sneezing, rhinorrhea, nasal congestion, and nasal itching [2]. It is a disease that impacts a quarter of the population in the United States (USA) and has an increasing worldwide incidence [3]. AR has a significant burden on quality of life as it negatively affects sleep, work, and school [4]. The treatment algorithm for AR begins with allergen avoidance, as precautionary measures to reduce exposure to allergens may improve symptoms. Persistent symptoms can be addressed with pharmacologic therapies, including oral antihistamines, intranasal corticosteroids, and combination therapies [5]. If patients’ symptoms are ill-controlled by conventional treatments, allergen-specific immunotherapy (AIT) is recommended. It is the only disease-modifying treatment and has been seen to provide long-lasting symptom improvement [6]. AIT can be administered subcutaneously (SCIT) or sublingually (SLIT). The nasal allergen challenge and allergen exposure chamber (NAC and AEC, respectively) are models of AR that can also be used to evaluate the properties and efficacy of AIT. Here we have assessed peer-reviewed articles from the PubMed, EMBASE, and OVID Medline databases published mainly between 2010 and 2020 evaluating AIT using AEC or NAC models. This review will evaluate the use of the NAC compared to established AEC methodologies in the study of AIT, in efforts to guide future clinical evaluations.
Impact of high-intensity concurrent training on cardiovascular risk factors in persons with multiple sclerosis – pilot study
Published in Disability and Rehabilitation, 2019
Charly Keytsman, Dominique Hansen, Inez Wens, Bert O. Eijnde
Following local advertisement and written informed consent, 16 persons with MS (mean Expanded Disability Status Scale; EDSS 2.6 ± 0.2) were included. Subjects were excluded if they were pregnant, aged <18 years, participated in another study, experienced an acute exacerbation 6 months prior to the start of the study, had contraindications to perform physical exercise or had an EDSS score >6. Use of disease-modifying therapy and other medication intake was inventoried. Subjects were asked to maintain their usual medication intake constant throughout the study course. All data were collected at the Rehabilitation Research Centre of Hasselt University. The study was approved by the local Ethical Committee of the Jessa hospital and Hasselt University and was performed in accordance with the Declaration of Helsinki of 1975. This study was registered at ClinicalTrials.gov (NCT02466165).
Hereditary transthyretin amyloidosis in Sweden: Comparisons between a non-endemic and an endemic region
Published in Amyloid, 2022
Kristin Samuelsson, Ana Jovanovic, Karl Egervall, Intissar Anan, Jonas Wixner, Rayomand Press
Treatment data was available for all 21 Stockholm patients and 128 of 134 patients in Västerbotten. All 21 Stockholm patients and 124 of 128 patients in Västerbotten had received disease-modifying treatment over the course of disease. Many patients were treated with more than one type of disease-modifying treatment over the years. The types of therapy used in Stockholm and Västerbotten patients are shown in Figure 8. The proportion of patients treated with diflunisal was higher in Stockholm (15 of 21, 71%), vs Västerbotten (59 of 124, 46%), but no significant differences were seen for other agents (Figure 8). The median time between the onset of symptoms and initiation of first disease-modifying therapy did not differ between Stockholm (4.2 years) and Västerbotten (4.9 years), as seen in Table 1. Nor did the time from diagnosis to initiation of first disease-modifying therapy differ between Stockholm (121 days) and Västerbotten (135 days), as shown in Table 1.
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