BackgroundElderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable.MethodsSystematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract.ResultsSeventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital.ConclusionsThe definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.Electronic supplementary materialThe online version of this article (10.1186/s12877-019-1028-z) contains supplementary material, which is available to authorized users.

IntroductionInformal caregivers are important resources for community-dwelling frail elderly. But caring can be challenging. To be able to provide long-term care to the elderly, informal caregivers need to be supported as well. The aim of this study is to review the current best evidence on the effectiveness of different types of support services targeting informal caregivers of community-dwelling frail elderly.MethodsA systematic literature search was performed in Medline, PsychINFO, Ovid Nursing Database, Cinahl, Embase, Cochrane Central Register of Controlled Trials and British Nursing Index in september 2010.ResultsOverall, the effect of caregiver support interventions is small and also inconsistent between studies. Respite care can be helpful in reducing depression, burden and anger. Interventions at the individual caregivers’ level can be beneficial in reducing or stabilizing depression, burden, stress and role strain. Group support has a positive effect on caregivers’ coping ability, knowledge, social support and reducing depression. Technology-based interventions can reduce caregiver burden, depression, anxiety and stress and improve the caregiver’s coping ability.ConclusionIntegrated support packages where the content of the package is tailored to the individual caregivers’ physical, psychological and social needs should be preferred when supporting informal caregivers of frail elderly. It requires an intense collaboration and coordination between all parties involved.

Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.

Background: Metabolic syndrome (MetS) comprises a spectrum of clinical phenotypes in which dyslipidemia, dysglycemia and hypertension are clustered and where all share a high level of oxidative stress and an increased risk of cardiovascular disease. This study examines the effect of a nutritional supplement combining red yeast rice and olive fruit extract on the lipid profile and on oxidative stress in a population of patients with MetS. Methods: In a double blind placebo controlled randomized trial, 50 persons with MetS, as defined by the ATPIII criteria, received the study product or placebo for 8 weeks. The study product contained 10.82 mg of monacolins and 9,32 mg of hydroxytyrosol per capsule, and is commercialized as Cholesfytol plus. The primary outcome measure was the difference in LDL reduction between intervention and control groups. Furthermore, differences in changes of CH, HDL, ApoA1, ApoB, HbA1c and oxLDL were measured, as well as side-effects, CK elevation, changes in clinical parameters and in cardiovascular risk. Results: In the intervention group, LDL cholesterol was lowered by 24% whereas it increased by 1% in the control group (p < 0.001). Other effects observed were a change in total cholesterol (−17% in the intervention group vs +2% in the control group, p < 0.001), apolipoprotein B (−15% vs +6%, p < 0.001), and TG (−9% vs + 16%, p = 0.02). Oxidized LDL decreased by 20% vs an increase of 5% in the control group (p < 0.001). Systolic and diastolic arterial blood pressure decreased significantly by 10 mmHg (vs 0% in the control group, p = 0.001) and 7 mmHg (vs 0% in the control group, p = 0.05) respectively. One person in the intervention group, who suffered from Segawa's syndrome, dropped out because of severe muscle ache. Conclusions:The combination of active products in this study may be an alternative approach to statins in people who do not need, or cannot or do not want to be treated with chemical statins. Side effects, effects on oxidative stress and on glucose metabolism need to be examined more thoroughly.Trial registration: Clinicaltrials.gov NCT02065180 (February 2014).

BackgroundIn recent years, red yeast rice (RYR) supplements have been marketed aggressively as a natural way to lower cholesterol; however, the large majority of commercially available products have not been studied according to current research standards.MethodsIn a double blind placebo controlled randomized trial, 52 physicians and their spouses with a total cholesterol level of > 200 mg/dL were randomly allocated to receive a RYR extract or placebo for 8 weeks. As a primary outcome measure, we compared the before-after difference in lipid levels between both groups. As secondary outcome measures we looked at side-effects, CK elevation and a change in cardiovascular risk.ResultsLDL (low density lipoprotein) cholesterol was lowered with 36 mg/dL (22%) and total cholesterol with 37 mg/dL (15%) in the intervention group. This result was statistically significant as compared to the control group, in which no reduction in total cholesterol and LDL was observed (p < 0.001). There was no marked difference in CK (creatine kinase)-elevation or reported side-effects between study groups. In 5/31 participants in the intervention group, the lipid lowering effect resulted in lower cardiovascular risk as measured with SCORE (Systematic COronary Risk Evaluation).ConclusionsThe RYR formulation under study was effective in lowering cholesterol and LDL cholesterol in this study population. RYR therapy may be an attractive and relatively well studied alternative in patients who are intolerant for statins or who have objections against pharmacological lipid lowering. However, consumers need to be warned that the actual content of commercially available preparations is not assured by governmental regulations, which raises effectiveness and safety issues.Trial registrationClinicaltrials.gov, nr: NCT01558050

Provider-initiated HIV testing and counseling (PITC) is recommended to reduce late HIV diagnoses, common among Sub-Saharan African migrants (SAM) residing in Europe. Primary care represents an ideal entry point for PITC. To support Flemish general practitioners (GPs), we developed a culturally sensitive PITC tool. Over a 12-week period, 65 GPs implemented PITC to assess acceptability and feasibility of PITC. The qualitative evaluation showed high acceptability among physicians. Routine PITC was challenged by physicians' personal discomfort, assumptions of patients' sexual risk, perceived incoherence with reasons for consultation, and time pressure. The best opportunity for PITC was an indicated blood analysis for other medical reasons. Counseling skills improved during the implementation, but participants still advocated for reduced counseling requirements. PITC proved to be feasible in primary care settings, but the up-scaling requires a reformulation of counseling guidelines, a policy stipulating the role of GPs in the prevention-care continuum, and an investment in (continuous) training.

In the past decade the advent of target therapy has led to a silent revolution in the treatment of lung cancer. Thanks to the specificity of their target, new tailored drugs are able to achieve a larger benefit and lower toxicity and provide better quality of life than cytotoxic drugs in a limited number of patients, selected by molecular profile. Nowadays, the epidermal growth factor receptor tyrosine kinase inhibitors erlotinib and gefitinib, and the anaplastic lymphoma kinase inhibitor crizotinib, are targeted agents approved for treatment of non-small-cell lung cancer. The past decade has witnessed a silent revolution in the war against cancer, thanks to the advent of new therapies, which target specific mutations related to cancer cell proliferation and survival in different types of tumors. Among all cancers, lung cancer remains the leading cause of cancer-related death in most countries, with 159,260 expected deaths in the United States in 2014. Lung cancer occurs predominately in people between 50 and 70 years old, but the risk of developing this cancer reaches a peak in people older than 70 years. Lung cancer incidence decreased in the past two decades in several countries, including the United States, following a decreased rate of smoking. At the same time, the incidence among women, including former or never smokers, is rapidly increasing.1 The discovery of "oncogenic driver mutations" and the subsequent development of tailored agents has radically changed the treatment of lung cancer in ten years, leading to the development of personalized strategies. 2,3 Non-small-cell lung cancer (NSCLC) was traditionally classified, based on histologic features, as adenocarcinoma, squamous cell carcinoma, and other nonspecified subtypes, which represent about 55%, 35%, and 10% of all NSCLC cases, respectively. In the early 1990s treatment approaches available for patients with lung cancer were poor, with a median survival of 2 to 4This article was externally peer reviewed.

Background: Many people with mental health problems do not receive appropriate mental health care, resulting in a considerable level of unmet mental health needs. Epidemiological research has shown that some people are at increased risk for unmet mental health needs and has identified both structural and attitudinal barriers to mental health care. However, epidemiological studies may not provide the complete picture and qualitative research about unmet mental health needs is scarce. This study aimed to explore unmet mental health needs in the general population from the perspectives of professionals working with vulnerable groups.Methods: Four focus group discussions and two interviews were held with a total of 34 social work, mental health and primary care professionals in one rural and one urban primary care zone in the province of Antwerp, Belgium. All transcripts were thematically analyzed.Results: Five themes emerged: (1) socio-demographic determinants and mental disorder characteristics associated with unmet mental health needs; (2) attitudinal barriers; (3) structural barriers; (4) consequences of unmet mental health needs; and (5) recommendations for meeting unmet mental health needs.Conclusions: Finding suggest that unmet mental needs are associated with socio-demographic and mental disorder characteristics, and attitudinal and structural barriers. For example, professionals mentioned care-avoiders and difficult access for complex cases due to strict criteria. The high level of unmet need results in feelings of burden and powerlessness among professionals. Professionals discussed good practices and recommendations for optimal and more equitable mental health care provision, which should ideally be targeted at those in the greatest need.