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This randomized clinical trial evaluates the effectiveness of an intervention combining nicotine replacement with brief behavioral support in reducing cigarette use among adults with opioid dependency in Norway.
New England Journal of Medicine, Ahead of Print.
Ductal carcinoma in situ (DCIS) is considered a nonobligate precursor of invasive breast cancer. Surgery is thought to reduce this risk, as evidenced by studies demonstrating cause-specific survival of 97% to 98% after treatment with mastectomy or lumpectomy with or without radiotherapy. Invasive cancer is found at surgical excision in 26% of all women diagnosed with DCIS by core biopsy and in 20% of those with low- to intermediate-grade DCIS or lesions of 2 cm or smaller on mammography. Despite the apparent success of surgery, significant concerns about overtreatment of DCIS have been raised. The substantial increase in the detection of DCIS between 1992 and 2011 that coincided with the widespread adoption of screening mammography did not result in parallel reductions in invasive cancer detection or breast cancer mortality, suggesting that a proportion of the DCIS being identified would have never progressed to invasive cancer. The very high cause-specific survival after surgery and the limited knowledge of the evolution of untreated DCIS raises the possibility that similar excellent outcomes might be obtained with a less aggressive approach such as active monitoring, with surgery reserved for patients showing evidence of progression to invasive cancer; however, the safety of this approach is uncertain. Ideally, a subset of DCIS patients at low risk of progression to invasive cancer could be identified by molecular profiling, but at present, this goal remains aspirational.
Introduction
Ageing is often accompanied by chronic diseases, multimorbidity and frailty, increasing the need for clinical and social care to support healthy ageing and manage these conditions. We are currently in the UN Decade of Ageing, and there is a growing focus on the need to prevent or delay some of these conditions through the ‘Healthy Ageing’ initiative of the WHO. However, there are limited data available to inform prioritisation of interventions, particularly for countries in sub-Saharan Africa.
Methods and analysis
This study will use a mixed-methods, stepwise approach to identify the current needs for older people in Rwanda, health system capacity and possible solutions to unmet need. First, we will conduct a household survey in the City of Kigali (predominantly urban) and Northern Province Burera district (predominantly rural) to determine the burden of multimorbidity, frailty, access to care, and experiences and responsiveness of care in older people. This work will be supplemented by secondary analysis of data from the Rwandan STEPwise approach to non-communicable disease risk factor surveillance (STEPs) survey of 2021. Second, we will conduct a health facility readiness assessment and healthcare provider survey to assess health system capacity and gaps to deliver effective primary care to older people in Rwanda. Third, to capture the voices of older people, we will explore the quality of healthcare as experienced by them using in-depth interviews. Fourth, we will synthesise data using mixed methods to understand barriers to access to quality of care among people of older ages based on a Three Delays framework (seeking, reaching and receiving quality healthcare). Finally, the project will culminate in a stakeholder workshop to ensure results are contextually appropriate and disseminated, and gaps identified are prioritised to design novel interventions to promote healthy ageing in Rwanda and the region.
Ethics and dissemination
The study has received ethics approval from the Rwanda National Ethics Committee, Northwestern University, USA, and the University of Birmingham, UK. This study will deliver impactful research by using multiple methodologies and working with in-country partners to develop a deep knowledge and understanding of healthcare systems experienced by older people in Rwanda. It will also provide a framework for sustainable healthy ageing research and policy engagement to benefit older adults living in Rwanda and inform similar work in low- and middle-income countries during this Decade of Healthy Ageing and beyond.
Molecola agisce sulla neuroinfiammazione e rallenta la progressione della patologia. In Italia 50mila pazienti
Introduction
Postoperative delirium occurs in up to 40% of older surgical patients and has been associated with prolonged hospital stays, long-term cognitive impairment and increased 1-year postoperative mortality. Postoperative sleep disturbances may increase the risk of delirium, but studies investigating pharmacotherapies to improve postoperative sleep to prevent delirium remain limited. Suvorexant is a selective antagonist of orexin 1 and 2 receptors and is approved for insomnia pharmacotherapy by the Food and Drug Administration. It has the potential to improve postoperative sleep and reduce postoperative delirium rates, but randomised controlled trials (RCTs) are needed to determine the efficacy of postoperative suvorexant administration. The REPOSE study (reducing delirium by enhancing postoperative sleep with suvorexant) is a single-centre, randomised, double-blinded RCT that aims to evaluate the efficacy of suvorexant in increasing total sleep time (TST) and decreasing delirium severity in older patients undergoing non-cardiac surgery.
Methods and analysis
REPOSE will enroll 130 patients (aged ≥65 years) undergoing non-cardiac surgery with a planned postoperative inpatient stay. Participants will be randomised to receive 20 mg oral suvorexant or placebo nightly on postoperative nights 0, 1 and 2. The primary endpoint is TST on the first postoperative night, as measured using an electroencephalography headband. The secondary endpoint is peak postoperative delirium severity as measured by the 3-minute diagnostic interview for the confusion assessment method severity scores. Primary endpoint data will be analysed with a two-sample t-test using an intent-to-treat approach to compare TST on the first night that a patient received a study drug dose. Secondary and exploratory endpoint data will be analysed using two-sample t-tests between groups.
Ethics and dissemination
Ethical approval was obtained from the Duke Institutional Review Board (protocol #00111869). Results of the REPOSE study will be published in a peer-reviewed journal and presented at academic conferences. Trial data will be deposited in ClinicalTrials.gov.
Trial registration number
NCT05733286.
Minore diffusione al Sud per la qualità di una molecola
WASH and nutrition interventions reduced pediatric antibiotic use through the prevention of enteric and respiratory infections in a rural, low-income population. Given that many of these infections are caused by viruses or parasites, WASH and nutrition interventions may help reduce inappropriate antibiotic use in similar settings.
Migliora capacità verbali e comportamento bimbi
Introduction
Benzodiazepine receptor agonists (BZRA) deprescribing interventions are needed to tackle high BZRA use in the older population. This study aims to assess the feasibility of the D-PRESCRIBE intervention, adapted from Canada to the Belgian community setting. This pharmacist-led intervention comprises a patient educational brochure and a pharmacist-to-prescriber communication tool.
Methods and analysis
We will conduct a feasibility study of a cluster randomised controlled trial involving 8–10 community pharmacies (clusters) and aiming to recruit 56–80 patients (≥65 years). Intervention pharmacies will deliver the adapted D-PRESCRIBE intervention and control pharmacies, usual care. Patients will be blinded to group allocation. Quantitative data will be collected at baseline, 3 months and 6 months through patients’ and pharmacists’ questionnaires, aiming: (1) to test the feasibility of the intervention, (2) to test the feasibility of the study design needed for its evaluation and (3) to perform an exploratory cost-effectiveness analysis. Hence, data about implementation outcomes, mechanisms of impact (ie, mechanisms through which the intervention is supposed to be effective) and contextual factors will be gathered. Patient-centred outcomes will also be collected as they would be in a full cost-effectiveness trial. The feasibility of the study design will be assessed through participation rate, completeness of the data and a satisfaction survey, sent to participants after the 6-month data collection. Data will be analysed using descriptive statistics. To gain a deeper understanding of pharmacists and patients’ experience with the intervention, interviews will be conducted after the 6-month data collection and the Theoretical Domains Framework will be used as a deductive framework for analysis.
Ethics and dissemination
This study was approved by the Ethics Committee of CHU UCL Namur (NUB: B0392023000036). Participants will receive a summary of the results. Results will also be disseminated through the organisation of a local symposium and a peer-reviewed publication.
Trial registration number
NCT05929417.
Objectives
Transient loss of consciousness (TLOC) is one of the most common neurological complaints in the Emergency Department (ED), but little is known about the patient perspective. We aimed to explore patient perceptions of diagnostic assessment for TLOC.
Setting
ED, Acute Medical Unit and Syncope and Neurology clinics in a single tertiary teaching hospital in the north of England.
Participants
20 adult patients (60% female, age range 17–90 years) attending or referred with a first presentation of TLOC.
Primary and secondary outcome measures
Exploratory thematic analysis of semistructured qualitative interviews.
Results
We identified three themes within the data: satisfaction with care, unanswered questions and being left in limbo/no man’s land. Participants explored these themes through four topics: communication; the role of investigations; the role of authority and the social context of care.
Conclusions
Communication (including differential diagnosis, significance of investigations and further assessments, and interim safety advice) is emphasised in supporting ongoing self-management, even before a definitive diagnosis is made.
Annals of Internal Medicine, Ahead of Print.
Annals of Internal Medicine, Ahead of Print.
Annals of Internal Medicine, Ahead of Print.
Annals of Internal Medicine, Ahead of Print.
