What are the positive outcomes of this trend? What are the negative outcomes of this trend? How may these negative outcomes be minimized?Deinstitutionalization and outpatient care for those with severe psychological problems Prevention programs and positive psychology

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What are the positive outcomes of this trend? What are the negative outcomes of this trend? How may these negative outcomes be minimized?Deinstitutionalization and outpatient care for those with severe psychological problems
Prevention programs and positive psychology

 

There are currently several trends in the treatment of psychological disorders, including the following:

The use of psychotropic medications
Deinstitutionalization and outpatient care for those with severe psychological problems
Prevention programs and positive psychology
Insurance coverage and managed care programs

Choose one of these current trends listed above and address the following questions: What are the positive outcomes of this trend? What are the negative outcomes of this trend? How may these negative outcomes be minimized? Respond to a classmate who chose a different trend by suggesting additional positive or negative aspects of that trend, or discussing how to minimize the negative effects of that trend.

Fluid Resuscitation in the Prehospital Trauma Patient

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Antony Nguyen


Abstract


Introduction:

Patients with traumatic acute blood loss from injury lead to a lack of perfusion in systemic and cerebral circulations. Without treatment these organ become acidosis and fail. The fundamental process of restoring, maintenance and treatment of haemorrhagic shock involving fluid resuscitation. Although minimal amount of evidence supports this practice, it is common in trauma patients in a prehospital environment intravenous are fluid administration.


Method:

A comprehensive literature review was conducted using the Ovid and CINAHL databases. The information retrieved was related to clinical portfolios and medical students in an undergraduate and clinical setting.


Results:

Electronic searches yielded 57 citations. A further three citations were obtained by hand searching of reference lists. With much refining, of the 57studies, only 12 articles met the inclusion criteria and were included in our review.


Conclusion:

This review has shown that the common belief in regards with a trauma victim prehospital intravenous access and fluid resuscitation is the ‘standard of care’. Although there is some information on fluid resuscitation there an inadequate amount. Furthermore, the data is consistently changing and hence consequences may be detrimental. Areas that should be focused in dealing with a trauma patient is the mechanism of injury, severity of the injury, anatomic immersion and the volume of fluid required for these patients.


Keywords:

head injury; injury; haemorrhage; resuscitation; intravenous fluid; venous accesses; prehospital; trauma; haemorrhagic shock; shock.


Introduction

Worldwide, injury kills more than five million people each year, which accounts for nearly 1 of every 10 deaths globally


2


. Internationally, 50% of the world’s injury-related deaths, which accounts for almost are related between the ages of 15 and 44 years


1-3


. In addition, due to injury, tens of millions of individuals visit emergency departments


2


. One leading factor is haemorrhagic shock which associates with one third of injury deaths


1


.

Patients with traumatic acute blood loss from injury lead to a lack of perfusion in systemic and cerebral circulations. When prolonged a reduction in tissue perfusion and tissue oxygen delivery causes these victims often become acidosis and impels to organ failure


1


. The fundamental component of the restoration, maintenance and management of haemorrhagic shock comprises of preserving blood pressure and tissue perfusion by resuscitation fluids


3


.

Prehospital intravenous fluid replacement is an extensively implemented advanced life support (ALS) procedure in trauma management


4


. In spite of an absence of evidence demonstrating assistance to prehospital fluid therapy, this method is taken into account to be standard of care


1



,



2



,



4



,



5


. Additionally, the type of fluid, the suitable rate of administration, and therefore the “resuscitations themselves remain unguided and unsupervised”


5


. This review will evaluate the research regarding the volumes of fluid resuscitation in the trauma patient population in an ambulance service context.


Methodology

This study is a review of the clinical reviews to evaluate the volumes of fluid when dealing with resuscitation in a range of medical and research electronic databases.

An in-depth search strategy was established to consist of both the peer-reviewed and non-peer reviewed literature, of the clinical practice related electronic search engines was commenced utilising the Ovid Medline available through the Monash University library.

In addition to a search of electronic databases, were three databases; Cumulative Index for Nursing and Allied Health Literature (CINAHL Plus), Google Scholar and Monash University Library were carried out from database inception to end of September 2013.

A majority of the articles were included if they contained data relating to fluid resuscitation and trauma victims in a prehospital environment. Some of the data extracted from included studies were appropriate for statistical analysis (i.e., Dunham 1991 and Dutton 2002).


Results

The initial search strategy generated 57 potentially relevant documents were found across the range of searches. A further three citations were attained by hand searching of reference lists. After eliminating duplicate articles and screened the titles and abstracts and full texts, 22 of these articles were considered relevant to assist in answering the research question. After reviewing the twenty two studies included in this analysis, only 12 articles met the inclusion criteria was considered relevant provided and sufficient information about the best fluid revitalisation regime for the trauma patient in the prehospital phase


3



,



6-11


.

The remaining twelve articles which lacked information therefore the articles was excluded due to trial design or failure to report outcome variables of interest and failed to meet the criteria. As would be expected of the fluid resuscitation to trauma patients in a prehospital setting, studies reported positive effects involving different amounts of fluid bought more closely together and thus could enhance clinical practice and allowed additional learning opportunities


4



,



7


.

Dunham 1991

This trail was a comparison conventional fluid administration procedure and using fluid administration using the rapid infusion system in trauma patients during the first 24 hours of admission (results as shown in table 1).

Out of the trauma participants, those who received a greater amount of fluids administered had a mortality rate of 5/20 (25%), as correlated to 5/16 (31%) who obtained a smaller amounts of fluids administered by the rapid infusion system. Thus, the relative danger for death is 0.80 (95% CI 0.28−2.29)


1


.

Dutton 2002

Dutton’s trail was randomised and had consisted of a broad spectrum of injury such as blunt and penetrating (refer to Table 2).

The results stated the larger volume administered the rate of mortality 4/55 (7.3%) while the group that had been given smaller doses 4/55 (7.3%). The relative danger for death is 1.00 (95% CI 0.26−3.81)


1


.

Furthermore randomised controlled trials are vital to analyse the best effective approaches for the fluid treatment of haemorrhage trauma patients


1



,



3


.


Discussion

This review established inadequate evidence for or against the utilisation of small or larger volume intravenous fluid administration in management of uncontrolled haemorrhage. However, in some victims, vigorous fluid resuscitation could further beneficially, the results from clinical trials are inconclusive


4



,



5



,



9



,



12



,



13


. The leading factors that need to be contemplated when addressing fluid replacement for the trauma patient is the assessment of hypovolaemia, when to administer fluid, which type of fluid, and the volume to administer.

The utmost applicable prehospital approach to resuscitative fluid intervention for trauma patients comprises of classifying anatomic involvement (i.e., head injury versus chest injury); identifying the mechanism of injury (i.e. penetrating versus blunt versus specific injuries); and the present physiological responses (i.e., heart rate, blood pressure, oxygen saturation, respiratory rate, skin perfusion, and conscious state)


6



,



7



,



9


. Unfortunately, vital signs and haemorrhage are not as reliable as is generally assumed


3



,



13


.

Fundamentally, there are different responses when dealing with haemorrhage and injury. Bradycardia is a common response to pure haemorrhage


11


. Tachycardia and increased blood pressure often presents itself in trauma patients which related by the feedback of the injury to compensate


11


. Nevertheless, in the incidence of substantial tissue damage, bradycardia could transpire.

In higher social-economic countries, a growing number of paramedics receive training on advance life support in regards with intravenous cannulation, intubation, and the administration of intravenous fluids


6


. In earlier stages of shock, it is easier for a placement of a venous line before hypovolaemia has progressed and compensatory mechanisms such as peripheral vasoconstriction have befallen


9



,



12



,



13


. As a result, paramedics will engage and be encouraged to use specified skills in trauma.

In a prehospital setting, a study shows that paramedics attend a minor fraction of trauma patients that require intubation (1%), while but a greater fraction (18%) are given intravenous fluids


1


. The quandary that paramedics every so often face when challenged with a hypovolemic trauma patient is basically the balance between:

• administering fluid; thus increases the lag when transferring, possible rebleeding, and increased haemorrhage or

• withholding fluid; thus allowing the possibility organ ischemia and death from the decreased blood volume and plasma to the organ, before arrival to the hospital


6


.

The appropriate interventions when attending a trauma patient at a scene is to start rapid fluid infusion as soon possible to restore and maintain adequate perfusion quickly


11



,



12


. However, the efforts to replace fluid could delay the time taken to hospital. Although a prompt successful cannulation can save time once patients arrive to hospital it is also clear that repetitive unsuccessful tries will impede the progress at the same time. Time is of an essential in a prehospital trauma related incident, a method to balance the benefits to be enlarged by gaining venous is to undertake cannulation en route


1



,



3



,



10



,



11



,



13


. Furthermore, under certain conditions, increasing the patient’s blood pressure via fluid resuscitation before controlling of haemorrhage may have negative outcomes.

In today’s ever-growing practice of paramedicine, the management for prehospital fluid therapy for trauma patients is consistently been updated. When cannulation and fluid administration takes priority rather than “loading and going”, it further delays the conveyance of reliable care in hospital


7


. One rule to note is trauma patients with severe head injury and with minimal or no prehospital fluid resuscitation is expected to have escalated morbidity and mortality rates


7


. Hypotension head injury patients must be treated as soon as possible to preserve and re-establish an adequate cerebral and systematic perfusion.

The detailed study of 235 trauma patients (blunt and penetrating), Dalton calculated the benefits of prehospital venous access and fluid administration


4


. The review of article stated that 80% of patients were given less than 600 ml of fluid in the prehospital environment, irrespective of hypotension en route, scene embranglement or mechanism of injury


4


. Overall, the final result was indistinct as the investigation was incompetent to recognize such benefits from fluid therapy and suggested withholding fluid administration


1



,



4


.

In the prehospital phase of patient care, it is important that “strategies are straightforward, reflecting the difficulties of treating trauma victims on scene and in transit, without detailed diagnostic information”


6


. Excessive or abusive fluid administration causes injury to patients and one method to reduce this risk is to administer limited boluses of fluid at an interval


11


. Ambulance Victoria Clinical Practice Guidelines states that patients with isolated neurogenic shock may be given up to 500 ml Normal Saline to correct hypotension


14


. However, is there risk to patients? AV suggests up to 40 ml/kg when a patient’s blood pressure remains under 100 mmHg. A majority of the articles suggested starting at a 250 ml boluses and then reassessing to ensure management of the hypotension is accomplished


1



,



3



,



6



,



7



,



10



,



13


. This indicates the mean arterial pressure (MAP) of as a minimum 90 mmHg. However in a backdated case matched reviewed of severe trauma patients, 217 patients who had been treated with fluid replacement were far worse, in terms of mortality, than who did not obtain fluid


1


.

In prospective of deficiency of information whether or not the effectiveness of existing resuscitation guidelines and the latent for harm. Thus further investigation is essential in a prehospital setting as fluid administration perhaps could be identified as a risk factor.


Conclusion

Regardless of the commonly belief that prehospital intravenous access and fluid resuscitation is the ‘standard of care’, there is insufficient information to upkeep this discipline. This is due to the indefinite benefits and possible threats of prehospital cannulation and fluid administration as well as the time spent on scene and applicable volumes of replaced. Thus these trauma patients are not a standardized group but should be individualised rendered to the mechanism of injury, severity of the injury, anatomic immersion, particular patient features and the estimated transport period to conclusive medical intervention at hospital.


References



1.Kwan I, Bunn F, Roberts I. Timing and volume of fluid administration for patients with bleeding. The Cochrane database of systematic reviews. 2003(3):CD002245. Epub 2003/08/15.



2.Organization WH. New publications show injuries kill more than five million people a year 2003; Available from:

http://www.who.int/mediacentre/news/releases/2003/pr40/en/

.



3.S.G. Kulkarni SG, G. Sundaram. Pre-hospital fluid therapy in the critically injured patient -a clinical update. N Engl J Med 2004. 2005(36):1001-10.



4.Dalton AM. Prehospital intravenous fluid replacement in trauma: an outmoded concept? Journal of the Royal Society of Medicine. 1995;88(4):213P-6P. Epub 1995/04/01.



5.Cotton BA, Jerome R, Collier BR, Khetarpal S, Holevar M, Tucker B, et al. Guidelines for prehospital fluid resuscitation in the injured patient. Journal of Trauma. 2009;67(2):389-402.



6.Revell M, Porter K, Greaves I. Fluid resuscitation in prehospital trauma care: a consensus view. Emergency Medicine Journal. 2002;19(6):494-8.



7.Cade JA, Truesdale M. Preferences of critical care registrars in fluid resuscitation of major trauma patients: concordance with current guidelines. Anaesthesia and Intensive Care. 2011;39(2):262+.



8.Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, et al. Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis. Annals of surgery. 2011;253(2):371-7. Epub 2010/12/24.



9.Pepe PE, Mosesso VN, Jr., Falk JL. Prehospital fluid rsuscitation of the patient with major trauma. Prehospital Emergency Care. 2002;6(1):81.



10.Bickell WH, Wall MJ, Pepe PE, Martin RR, Ginger VF, Allen MK, et al. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. New England Journal of Medicine. 1994;331(17):1105-9.



11.Nolan J. Fluid resuscitation for the trauma patient. Resuscitation. 2001;48(1):57-69.



12.Pepe PE, Dutton RP, Fowler RL. Preoperative resuscitation of the trauma patient. Current Opinion in Anesthesiology. 2008;21(2):216-21 10.1097/ACO.0b013e3282f60a46.



13.Napolitano LM. Resuscitation Endpoints in Trauma. Transfusion Alternatives in Transfusion Medicine. 2005;6(4):6-14.



14.Victoria A. Ambulance Victoria Clinical Practice Guidelines for Ambulance and MICA Paramedics 2012.

TEACH-BACK METHOD, PAIN & HCAHPS

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TEACH-BACK METHOD, PAIN & HCAHPS

Teach-back Method, Pain & HCAHPS
Topic of Paper: Can the implementation of a multifaceted, 4 week (28 day) pain management protocol pilot improve Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) pain scores in adult patients hospitalized in the Progressive Care Unit (PCU) at ******* Hospital compared to no pain management protocol usage?

Paper Must Include the Following Two Sections:

I. Significance of the Practice Problem (3 Pages)

Provide pain statistics for United States. Describe how not treating or under treating pain in hospitalized patients can negatively impact patient satisfaction (HCAHPS) score. Describe the difficulties healthcare providers and organizations have in properly managing patients’ pain. Describe the consequences of not properly managing patients’ pain (e.g. decreased reimbursement rates, poor public perception of the healthcare provider/hospital, fines, regulatory accreditation issues, etc.).

II. Synthesis of the Literature (7 Pages)

Conduct a focused systematic review of scholarly literature (see the articles I uploaded) related to the practice problem and the effectiveness of the selected Intervention to the desired outcome in the selected population and setting; effectively synthesize and concisely summarize the reviewed scholarly literature related to the practice problem.
Background Information: The pilot pain management protocol uses the following interventions:

-A three-part online education module for nurses on use of the teach-back method and pain management. A pre and post-education quiz will be completed by each nurse online and the scores will be collected in the online learning management system

-Nurses will be expected to utilize the teach-back method when delivering patient education

-Nurses will be expected to use the white board in each patient’s room to identify the pain management plan of care (i.e. current pain score, goal pain score, pharmacological and non-pharmacological pain management intervention and a listing of when pain interventions are next available). Nursing leadership will be validating (with a simple validation tool) that the white board is updated every shift and that patients understand their pain related plan of care.

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Concept Synthesis Paper on Personal Nursing Philosophy.

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Concept Synthesis Paper on Personal Nursing Philosophy.

A scholarly paper in which you will identify, describe, research, and apply the concepts that underlie your personal philosophy for professional nursing practice. I have included several attachments to help with direction and instructions. Please review the highlighted area.

Good Hand Hygiene practices prevent cross infections

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Within the essay I am going to discuss whether good hand hygiene practices are the single most important factor in preventing cross infection. Some may argue for this statement others against. Jeanes A (2005) refers to the NMC code of professional conduct (2004) who state that you must act to identify and minimise risk to patients and clients.

Hand hygiene is everybody’s job, including the patients. Linda Pearson (2006) refers to AL Damouk et al (2004) who suggests that inviting patients to become partners in their care maybe an appropriate response to reports of the rising incidence of healthcare associated infections and difficulties with ensuring healthcare staff was their hands effectively and at appropriate times. From previous work on the ward, implications were in place whereby patients were encouraged to wash their hands before and after meal times , after elimination or at any point they felt their cleanliness was been jeopardised. Matron carried out weekly audits and noted how many individuals successfully used the hand gel and soap provided at the appropriate times. However some individuals failed to follow protocol. Gould D (1994) suggested that when it is performed it is not always at the most appropriate times and the technique used does not always result in effective cleansing of all hand surfaces.

Hospital acquired infections can be a result of bad hand hygiene. Methicillin-resistant staphylococcus aureus (MRSA) is one of the hospital infections that can be picked up from the hospital environment, mainly because patients’ defence systems are low. Platt AT (2001) states that MRSA is becoming more prevalent, especially in intensive care environments. Transmission can be prevented by all patients and healthcare workers following the same infection control procedures. Present on my ward was the regime of asking every person on entering and leaving the ward to wash their hands with the alcohol gel provided. Linda Bissett (2007) refers to Widmer (2000) who says that a ‘a thorough hand wash takes approximately one minute and yet research indicates that conformity to hand hygiene guidelines rarely exceed 40%.

Hand hygiene protocols are easy to follow. Firstly is palm to palm, secondly right palm over left dorsum and vice versa, thirdly palm to palm however this time fingers interlaced, fourthly backs of fingers to opposing palms with fingers interlaced, fifthly rotational rubbing of the right thumb clasped in left palm and vice versa, then lastly backwards and forwards with clasped fingers of right hand in the palm and vice versa. It is essential that you are thorough when following protocol, after this your hands should be fully decontaminated. Gould D, Drey N (2008) states that thoroughness is encouraged using ultraviolet lights, you wash your hands in a fluorescent solution which on exposure to the light reveals the skin that has escaped the soap, thus enabling staff to identify areas of weakness. This procedure was shown to me during Mandatory training within the NHS by the infection control team and I believe that it is an effective way of showing how important it is to employers and employees of the NHS with regards to preventing cross infection.

It’s perfectly ok washing our hands but equally important is drying our hands. Often on the ward environment paper towels were not readily available and patients were seen to be patting their hands on their clothes. Its good practice for staff to pat their hands dry on paper towels rather than rubbing them dry as this helps to reduce damage to the skin Bissett L (2007). Following hand decontamination and drying , ‘all staff should use a good quality, aqueous based hand cream to protect their skin from damage’ Linda Bissett L (2007).

Preventing cross infection is essential for nurses in everyday practice. However hand hygiene may not be the only best way to prevent this. The use of aprons within direct nursing care can also prevent cross infection. Candlin J, Stark S (2005) refers to Nicol et al (2001) who states that nurses when working directly with patients and body fluids should wear protective aprons. Relating back to my previous work I noted that it was essential that nurses wore aprons during patient care, ensuring that they discarded of them after patient contact. Not only does wearing an apron act as a barrier it is also recognised as a type of PPC (Personal protective clothing). Cadlin J, Stark S (2005) suggests that the Health and Safety Executive (HSE) (1991, 1992) says ‘Health and Safety Regulations require that all healthcare employees are provided with personal protective clothing’. However McCullough (1998) suggests that nurses’ uniforms are not considered protective clothing and that protection within the NHS is provided by the use of disposable aprons. Surprisingly some healthcare workers and qualified nurses were not discarding aprons after patient contact, not only is this bad practice but it increases the risk of cross infection between patients. Babb et al (1983) within Candlin J, Stark S (2005) article found that ‘although micro-organisms can survive for varying lengths of time and adhere to plastic aprons, they do not multiply and are difficult to redistribute’.

Gloves are another form of PPC that can help to prevent cross infection. On the ward where I worked gloves came in different sizes and various types. To adhere to allergies some gloves where latex free or nitrile gloves. Nitrile gloves are used mainly for activities dealing with body fluid or blood. Within Chalmers C, Straub M (2006) article Korniewicz et al (1990) states that ‘vinyl gloves are looser fitting and, although reported to be more likely to develop holes than latex, this is only with prolonged use’. Some individuals tend to wear gloves instead of adhering to hand washing protocols. Gloves should not be considered as an alternative to hand decontamination hands must be cleaned before and after use Damani (2003).

Some may argue that there are other factors that influence the significant role of hand decontamination within the NHS. Chalmers C, Straub M (2006) state that Wilson (2001) believes that factors that affect hand decontamination include workload, staff shortage, poor facilities and lack of knowledge. Working in the hospital myself I noticed that the staff to patient ratio was inadequate and that the skills mix between healthcare workers and staff was disjointed thus affecting the team work present on the ward. Broken taps in side rooms or bays meant that hot water wasn’t readily available for patients and staff to use. Ward D (2003) refers to Meyres and King (2000) who ‘distributed a hand washing questionnaire to 33 patients with such diseases, with a 91% response rate, the results highlighted that a high proportion of those who participated were always offered hand washing facilities after using the toilet or commode however, problems identified included tap water being too hot, hand basins being too small, difficulties operating taps and paper towel and soap dispensers, and inability to reach soap’.

While it is important to educate the staff as well as patients on the theoretical and practical aspects of the significance of hand hygiene, education is not the sole barrier of compliance Storr J, Clayton-Kent S (2004).The information and education given within the hospital where I worked was very minimal, in fact hand hygiene was mentioned briefly in mandatory training. To gain more compliance within this subject, education and information present for staff, relatives and patients should be more substantial. Storr J, Clayton-kent (2004) refers to Colombo et all (2002), Jenner et all (2002) and O’Boyle (2001) who say that ‘teaching interventions can improve compliance but this must be underpinned by other strategies that address the lack of reinforcement of the behaviours in real life situations in the health service.

In conclusion I believe that good hand hygiene practices are not the single most important factor in preventing cross infection. My essay indicates that there are other factors that affect prevention of cross infection. Hand hygiene is an important aspect within the NHS and practitioners as well as patients and relatives need to be aware of that. Good role models, management and organisational support will allow an increase in compliance towards hand hygiene. Peoples’ attitudes and behaviour towards the importance of hand hygiene may influence how others view its importance.

Inter Professional Practice In Health Nursing Essay

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Inter-professional practice includes benefits that help to improve the provisions of health and social care services. One of these benefits that derive from inter-professional practice is that it increases the number of professions, which means that all aspects of service users who have multiple needs requiring different specialists are taken into consideration rather than neglecting some aspects. E.g. an individual who was a victim of domestic violence and had sustained physical injuries would not only receive treatment for the physical injuries but also receive counselling for their emotional needs so that they are healed holistically.

By increasing the number of professions also allows health and social services to be able to deal with complexity. This is because of the different qualifications, skills, knowledge and expertises each professional has which not only reduces workload creating less stress but make difficult tasks achievable. Likewise errors made by some professionals can be quickly identified and rectified by others reducing risks towards patients/users e.g. a physiotherapist may fail to provide treatment to a patient which a nurse can pick up on.

Professional roles in relation to health and social care provision entail the responsibilities and duties of a professional towards their patients/users. This includes jobs that they have to perform that fits into the specific professions that they have been qualified to do. E.g. the role of a nurse is to provide care for their patients.

Professional principles are the rules and regulations that act as a guideline by defining the boundaries/perimeters of what is inclusive and expected of professionals due to the nature of their work, which in terms of the health and social care provision is to provide patients/users the best quality care/services they need to function properly.

It also stresses out the legal requirements these professionals need to have in order for them to carry out practice such as the type of qualifications that they need. These principles are set out by professional bodies within certain organisations to act as a guideline in order to maintain the high standing of the profession. E.g. the Nursing and Midwifery council (NMC) regulates nurses and midwives by having codes of conduct which informs nurses and midwives on how to care for their patients by treating them as individuals, giving equal opportunities regardless of their gender, race etc.

Professionals within health and social care services use inter-professional working to improve the quality of care that they provide which in turn enhances patient/users’ experience as their level of trust increases, restoring their confidence further motivating them into using their health and social care services.

For example, if it was just one professional available to care for a patient/user with needs that goes beyond the expertise of their profession, the patient/user wouldn’t want to use that service as they feel that the professional is incapable of providing the necessary care that they need. However if they know that other professionals can be involve in their care, they are empowered to use the service and get the help that they need.

With the level of trust and confidence patients/users develop in their care services due to inter-professional, this enables professionals to creates alliances with their patients/users as these patients/users know that for the professionals to be collaborating, they are being put at the centre of service provision to ensure that they receive a high standard of care.

Taylor (2000) defined reflection as “throwing back of thoughts and memories, in cognitive acts such as thinking, contemplation, mediation and any other form of attentive consideration, in order to make sense of them, and to make contextually appropriate changes if they are required”. This help us to think critically of situations where we might find ourselves in enabling us to make the changes needed to improve certain aspects of ourselves especially in our professional life as it helps to maintain a high standard of work.

Reflection also helps us to pick up on errors and ensure that they do not reoccur e.g. a nurse who might not have used effective communication with one of their patient, such as not letting the patient know that they were about to give them an injection. Through reflection, the nurse would know where they went wrong and make certain that they use effective communication which is informing the patient before carrying out any procedure.

In this reflection, I’ll be referring to the Marks-Maran & Rose’s Reflective Cycle (1997) to explore and highlight areas within a specific event for me to make any required changes. The cycle consists of an explanation of the event, my thoughts arising from the situation, how it relates to theory and how it can be applied into practice.

The inter-professional learning is based on a session which I (a student nurse) took part in with my student peers from different professions consisting of a student; social worker, physiotherapist, radiotherapist, pharmacist and three other student nurses. The session was based on a case study about a girl named Millie, who has Downs Syndrome and also a long term boyfriend and wanted to go on the Contraceptive Pill. We had to debate about whether it was in her best interest to start taking the pills or not. My team had to debate against Millie going on the pill, for this my team and I used different skills such as communication, listening, information gathering and teamwork skills in order to achieve the main aim of the task.

I made use of my communication skill by interacting with my student peers within my team and the opposing team to discuss about the evidence gathered and our own view of the situation. Communication involves a ‘reciprocal process of sending and receiving message between two or more persons’. Sellman and Snelling (2010). For the other opposing team to hear our side of the debate we had to be clear, precise and concise so that they are able to give feedback to show that they understood our arguments. I made sure I used the right tone of voice by sounding calm and collected in the manner in which I delivered my speech, by keeping the pitch of my voice moderately loud enough for others to hear me without sounding aggressive, even though at some points of the debate the level of my voice was slightly high when some members of the opposing team became hostile by shouting over my team.

I felt that this skill was used appropriately and effectively even though there were times were it lacked consistency. This is because I have learnt that communication does not only involve using words, signs, language, tone, speech etc, it also consists of body language e.g. how you face an individual during a conversation. I also noticed that others in my team positioned their body away from the rest of the group which looked like they weren’t interested or wanted to be part of the team. This has made me more conscious of my body language when communicating with people so that I don’t give the wrong impressions.

This skill would be beneficial when applied into practice, importantly in inter-professional working as my role of a nurse involves working collaboratively with other professionals to provide care for certain patients e.g. working with dieticians, radiotherapists, radiologists etc. With effective communication, service users are safeguarded and protected against potential risks they may be exposed to by reducing the number of errors that may occur. For instance, a GP might have prescribed the wrong dosage of medication to an individual, the pharmacist is able to pick up on this and get in contact with the GP.

Active listening was shown through feedbacks and contributions which also showed my level of understanding and that of my team members, however if going through what the opposing team had said did not make sense we asked them to repeat themselves. In support to this, Hoppe (2006) suggested that “reflecting the other person’s information, perspective, and feelings is a way to indicate that you hear and understand.” This helped lessen the level of confusion through misinterpretations which the opposing team seem to have had a problem with, as a member of their team kept answering their question that was meant for our team or our questions were not being answered.

I have learnt that it is important to actively listen to people as it is the key to effective communication in receiving information, which in turn enables individuals to grasp hold of messages immediately rather than allowing the other person involved to keep on repeating themselves delaying response or action.

In practice, this skill would help me to understand patients clearly as it will allow me to pick up on underlying issues which may go unnoticed, for this “you must listen to the people in your care and respond to their concerns and preferences” (UK Nursing and Midwifery Council 2008). This helps to reduce the likelihood of incidents occurring especially in healthcare such as sending a patient home when they tell you that they are unwell and when they do go back home they are found unconscious or dead.

Information gathering was used in this session as we were asked to conduct a research about literatures that were against the contraceptive pill and those that supported it. Because information gathering is also known as research which “seeks to make known something about a field of practice or activity which is currently unknown to the researcher” (Brown and Dowling 1998), so by looking at various sources; journals, books and the Web rather than focusing on one source for information. This allowed my team and I to collect a wide range of information that targeted different areas of the topic, such as the effect of the pill on a Down syndrome woman and her mental capacity in relation to the Mental Capacity Act 2005 which tries “to empower and protect vulnerable people who are unable to make their own decisions” (UK Department of Health 2005) and it seemed like Millie was not in the position to make rational decisions due to her disability as one of the symptoms of Downs syndrome is the difficulty to understand why they have made certain choices.

This skill would be useful in the health and social care sector where me as a health practitioner would need to be able to gather information on services users’ background on past medical histories by knowing how to source them electronically via the computer, folders and even the patients themselves so that me and those involve in the professionals have an idea of how best to provide effective care.

Teamwork involves a group of people working together towards an aim, in my group we supported each other by reading out our literatures based on our research such as statistics and government Acts if we thought that they needed help so that we come out stronger in the debate. Because of lack of teamwork the other team seemed to have struggled for their members were left on their own to argue our points without any input from the rest of their team.

I think that this skill is one of the attribute a professional need to have when working collaboratively with other professionals; this means professionals helping each other especially in areas that others may lack in knowledge, understanding or unable to cope by themselves. In health, this ensures that patients/users needs are not neglected by making sure that they are at the centre of service provision by everyone working together as a team.

With this skill I have learnt that in order for one to become successful in their work, they have to work with others as “effective teamwork is being dependent on each team member being able to anticipate the needs of others” (Alonso and Dunleavy 2012) for them to successfully achieve their goals. This is because everyone has weaknesses which may pose as an obstacle preventing them from achieving their goals, but with the help of others barriers are minimised as all the people involved work towards the same goal. For example a social worker might seek the assistance of a nurse to identify their needs such as they might need carers, go into a home that caters to their needs due to the patient’s medical condition(s).

Teamwork can be applied in practice by collaborating with others in a professional manner by contributing, showing support to others and having an understanding of what my role and others roles are within the team as a way to reduce misunderstanding and enable us to work efficiently.

In terms of reflection, it helps an individual get a broaden outlook on how they have performed, which for a professional enables them to identify where they might have gone wrong within their practice which they can learn from and assist them in becoming a competent professional.

Critique (and rewrite) the following definition for the industry in

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Critique (and REWRITE) the following definition for the industry in which the University of Scranton operates:The college industry is made up of institutions which provide post-high school education. Included in this industry are colleges that have bachelors and masters programs.  (40% of post grade)2. List three specific parts of the industry section (pages 18-29 only) that you had the most difficulty understanding. Describe your current understanding of these parts. (60% of post grade)

A nursing phenomenon of interest (POI) can be defined as any factor that influences health status and is relevant to nursing. These phenomena relate to all the different aspects of human behavior and functioning; the phenomena can relate to an individual patient, the family unit, the community, or an entire population.

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A nursing phenomenon of interest (POI) can be defined as any factor that influences health status and is relevant to nursing. These phenomena relate to all the different aspects of human behavior and functioning; the phenomena can relate to an individual patient, the family unit, the community, or an entire population.

The student should consider their own area of expertise and practice when selecting a POI; the selected phenomena should come from an observed practice “problem” that has importance to the student.

Within the scholarly paper assignment you will identify a POI that has significance to your area of practice. You will explain why you think this POI is significant- this section of the paper should be supported with peer reviewed evidence from the literature available on the subject. The evidence should be current-no older than 5-7 years at most.

Next, you will discuss your basic philosophic approach to your life and work. Please refer to the Keynote and Resources provided earlier in this Unit for further details on what type of information will be expected in this section of the assignment. Please provide discussion detailing how your philosophic viewpoint impacts how you view the chosen POI and how it impacts the way you search for the “truth” about this issue.

Next, you will discuss the opposing philosophical viewpoint as it relates to your practice and your POI. If your viewpoint is primarily Analytical, you will discuss the merits of Continental philosophy; if your primary viewpoint is Continental, you will discuss the merits of an Analytical viewpoint. Please note that references regarding Philosophy, Theory, etc may be older than 5-7 years…these are considered to be “classic” articles and are acceptable to use for this purpose.

Finally, you will summarize the four ways of knowing identified by Carper and provide a discussion about how these different ways of knowing will impact your advanced nursing practice role. This section should be well supported by current peer reviewed references.

This assignment is a scholarly paper and should be written in a formal style. The length of this assignment should be between 6-8 pages excluding the title page and Reference list. This assignment will be submitted to Turnitin before you submit it to the assignment section. You are responsible for viewing your Turnitin score and making revisions to your paper if necessary prior to your final submission. You are required to merge a copy of your Turnitin digital originality report to the end of your paper prior to submission for faculty review.

Strategies to Decrease Healthcare Costs in Texas

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To: Texas State Senator Lois Kolkhorst – Chair of the Senate Committee on Health and Human Services

From: Ian Anderson

Problem Statement

Health care costs in Texas continue to rise at rates that will lead to painful cuts to health care or discretionary spending. These expenditures are costing Texas $42.9 billion per year, around 43% of the state’s budget (Hegar, 2017). Drug costs are among the largest drivers of this increase (TMC, 2018).  What can Senator Kolkhorst do to decrease health care costs in Texas?

Background

Drug prices for state funded health insurance plans are rising at a far greater rate than inflation or population growth (Hegar, 2017). Drug prices are some of the largest drivers of cost increases and in many cases, it is due to a small number of new or specialty drugs (Hegar, 2017).

Options

Option 1 – Implementation of value-based contracts for pharmaceuticals.

Drug prices are having a significant financial impact on health insurance funded by the state. Value-based contracts allow for the state and pharmaceutical companies to negotiate drug prices (Reck, 2018). CMS has approved this plan in Oklahoma (Reck, 2018). While this type of state-wide drug negotiation has not been attempted on a large scale, Texas needs to act to bring down drug prices. This option may be more popular politically at it may lead to cost savings and will not require a narrowing of Medicaid eligibility.

Option 2 –   State and federal drug price coordination.

Other government entities such as the Department of Veterans Affairs and Department of Defense have negotiated lower drug rebates than Medicaid has (Blumenthal, 2016). By obtaining similar rebates for drug prices in Texas, it would lead to significant savings. This will be a politically difficult solution. The pharmaceutical industry will likely mount a strong lobbying campaign to defeat this attempt. A similar attempt in Ohio and California were put to the ballot but was defeated (Young & Garfield, 2018).

Recommendation

Option 1 – Implementation of value-based contracts for pharmaceuticals.

This option has already been approved by CMS for Oklahoma. This should help the approval process for Texas. Using value-based contracts for drug prices will help to bring down costs for the most expensive drugs. The plan also benefits from its limited scope. Adopting this will not lead to immediate or wholesale change to health care services in the state. It will involve careful planning, negotiation, and will only apply, at the early stages, to a few drugs. More contracts can be added if there are cost savings. Conversely, if the contracts are not providing cost savings, they can be terminated or allowed to expire and return to the current system of drug payment.

Federal law limits other drug control strategies such as restricting access to FDA approved drugs. This option gets around that problem by allowing all drugs to be prescribed, but by stating the state’s preference to which should be prescribed. Other drugs may be given but may require approval before prescription. This will help to control costs while still allowing Texas residents to receive the treatment they need.

To: Texas State Senator Lois Kolkhorst – Chair of the Senate Committee on Health and Human Services

From: Ian Anderson

Problem Statement

Health care costs in Texas continue to rise at rates that will lead to painful cuts to health care or discretionary spending. These expenditures are costing Texas $42.9 billion per year, around 43% of the state’s budget (Hegar, 2017). Drug costs are among the largest drivers of this increase (TMC, 2018).  What can Senator Kolkhorst do to decrease health care costs in Texas?

Background

Raising health care costs are not limited to Texas, the United States has experienced unprecedent health care cost growth (TMC, 2018). These costs are increasingly putting a strain on the Texas budget. In state health care costs increased by almost 20% from 2011 to 2015, outstripping population growth and inflation (Hegar, 2017). With 43% of the budget going to fund various health care costs in the state, it accounts for 12% of gross state product (TMC, 2018). This is squeezing the state and limiting its ability to fund other necessary initiatives.

State managed Medicaid coverage accounts for almost 60% of that cost (Hegar, 2017). Significant federal support for Texas health care is provided, but as fixed percentages, it does not reduce Texas’ financial burden. Current Medicaid federal reimbursement to Texas is 58% or around $16 billion. Another $2 billion is provided by the federal government to supplement other programs such as state employees’ health insurance and psychiatric and public health services (Hegar, 2017).

Drug prices are one of the largest drivers of raising health care costs for Texas (Hegar, 2017). A dramatic increase in the use of specialty drugs and price increases on existing drugs by manufacturers has been the largest driver of cost growth (Frakt, 2018). This is occurring while use of generic drugs is around 84%, higher than most other industrialized countries (Papanicolas, Woskie, & Jha, 2018). Federal law currently prohibits states from restricting FDA approved drugs to Medicaid recipients, this limits the state’s ability to reduce drug costs (Young & Garfield, 2018). Systems that do restrict drug access are called closed formularies and are allowed for the Department of Veterans Affairs, but this is unlikely to approved at the state level (Blumenthal, 2016).

Options

Option 1 – Implementation of value-based contracts for pharmaceuticals.

Value-based contracting was recently approved by CMS in Oklahoma to help the state deal with high drug costs (Reck, 2018). This approach works by securing contracts with drug companies for specific drugs. The contract will make the drug a preferred treatment for a condition, in exchange the drug company will guarantee better prices to the state (Reck, 2018). If drug usage costs the state more than anticipated, the company will be required to provide rebates to the state for the exceeded amount (Reck, 2018).

This could have a major impact on state drug costs. This should insulate the state from random price increases such as was seen with Mylan’s Epipen, a drug which experienced a 400% price increase (Lazarus, 2018). This has been occurring regularly even with common drugs as pharmaceutical companies look to increase profit margins. Difficulty with this proposal will stem from the work needed to create a contract and maintain ongoing evaluation. Texas should be in a strong position to negotiate due to the size of its Medicaid population and the possible benefit to the pharmaceutical companies in terms of increased sales.

Political feasibility is good. Any reduction in government spending will be seen by Republican lawmakers as a positive result and continuing access to drugs for Medicaid beneficiaries will be the same for Democratic lawmakers. It will also likely not be met with resistance from state residents. Since the use of these contracts will be limited to some of the least used and expensive drugs and every drug will still be available, the public should see the need for this type of cost saving effort.

Since the use of value-based contracts has only been approved within the last 12 months, there has not been significant research into the possible costs savings with the program. The benefit is that value-based contracting does not become mandatory for all drugs. This can be used on a select number of the costliest drugs with limited impact on the Medicaid population. If a contract costs more than estimated or there are other problems, the contract can be terminated, and the state will return to the current system.

Option 2 – State and federal drug price coordination.

Specialty drugs have been the largest driver of health care costs in Texas (Hegar, 2017). These drugs accounted for 32% of total drug costs for the state while being prescribed less than 1% of the time (Hegar, 2017). Medicaid rules do not allow the banning of drugs so other strategies must be used to better mange how and when it can be prescribed (Young & Garfield, 2018). Luckily the program allows states to have some control of specialty drug utilization.

Currently, each state must negotiate Medicaid drug rebates. This increases each state’s Medicaid bureaucracy while limiting its ability to negotiate rebates. Coordinating with other states or the federal government to negotiate drug rebates would help to lessen the state’s financial burden. Trying to align drug rebates with that of the Department of Veterans Affairs or the Department of Defense would lead to significant reductions in Texas’ drug cost burden. Both of those agencies have negotiated lower drug rebates of 24%, about 0.9% lower than Medicaid (Blumenthal, 2016).

It should be noted that both agencies have significantly different health care goals and populations than the general public and are a fraction of the size. Companies may be more willing to offer these rebates but would hesitate for a larger blanket rebate for Medicaid. Attempts in Ohio and California were put on ballot initiatives in the respective states and were voted down after heavy lobbying (Young & Garfield, 2018). This must be taken into consideration as any attempt to decrease reimbursement rates for drugs will face push back.

The budgetary results would be immediate. Any reduction in drug prices would have a major impact on all parts of state funded health care. Beyond cost saving for Medicaid, it could be applied to other state funded health care such as for state employees, teachers, and retirees (Hegar, 2017).

Politically this is a feasible solution. It would result in drug cost reductions while not excluding any current beneficiaries. It is likely that many residents who have Medicaid would not be aware of the change, as the largest impact will be on the costs paid by the state and not the individual. The largest difficulty will be in partnering with another state or with the federal government to receive the better rebates. This has not been attempted and would likely need the approval of CMS and Congress itself. While this option may provide the most consistent cost saving if fully implemented, it is likely the most difficult to achieve.

Recommendation

Option 1 – Implementation of value-based contracts for pharmaceuticals.

The first option provides an achievable goal of reducing drug prices for the state of Texas. Value-based contracting for drug prices has been approved by CMS in Oklahoma already and there would be little reason to assume that it would not be approved for Texas.

The political outlook for this plan is good. Members of both parties are looking for ways to decrease drug prices and implementation of this would add another tool for Texas HHS. Since approval in mid-2018, Oklahoma has entered into several contracts with drug companies (Reck, 2018). This is a positive sign for the quick implementation in Texas. Since Oklahoma is the first state to begin this process, any positive outcomes in terms of cost savings are unknown. This will be the largest sticking point with lawmakers in getting this approved. These concerns should be dealt with by explaining that approval of value-based contracting will not radically change the Medicaid system.

There will be difficulty in obtaining the contracts once the plan is approved. This will involve protracted negotiations with pharmaceutical companies, which will have to be repeated for every drug that HHS wants a cost reduction on. These contracts will likely also only be for a few years meaning that a permanent contracting department will need to be created. They will be responsible for evaluating and enforcing contract terms to ensure that Texas is being charged or reimbursed correctly. The increase to Texas’ health care bureaucracy will be offset even by small decreases in drug prices.

Another positive of value-based contracting is that it does not exclude drugs that are not under contract. All FDA approved drugs will be available for use but may require pre-authorization (Reck, 2018). The goal is to divert some percentage of Medicaid recipients to these contracted drugs to reduce costs.

Implementation of this policy will help to control prices for the most expensive drugs. As these are the largest drivers of drug costs across all health care funded by the state, targeting even a few of them will be beneficial. As time goes on and more drug contracts are initiated, these cost savings will become apparent. For the impact of this program to be determined, the state must be willing to continue the program for several years.

Failure to implement this or any other drug price control strategy will lead to unmanageable cost increases to the state over the next several years. As health care costs continue to increase either taxes will have to be increased or discretionary spending will have to be reduced. Neither of these are attractive options to the citizens or lawmakers of Texas. With each passing year, it becomes obvious that major changes must be made to Medicare management in the state. Federal law prohibits banning the use of any FDA approved pharmaceutical and cut backs to service would endanger federal reimbursement the state receives (Young & Garfield, 2018).

This program will require careful evaluation. Due to the limited number of states attempting this mode of drug price control, every effort must be made to ensure there are not unintended costs. As a large state with a large Medicaid population, Texas will be in a strong position to negotiate prices with pharmaceutical companies.

References

  • Blumenthal, D. (2016, May 10).

    Drug Price Control: How Some Government Programs Do It

    . Retrieved from The Commonwealth Fund: https://www.commonwealthfund.org/blog/2016/drug-price-control-how-some-government-programs-do-it
  • Frakt, A. (2018, November 12).

    Something Happened to U.S. Drug Costs in the 1990s

    . Retrieved from The New York Times: https://www.nytimes.com/2018/11/12/upshot/why-prescription-drug-spending-higher-in-the-us.html
  • Hegar, G. (2017).

    Texas Health Care Spending Report Fiscal 2015.

    Austin: Texas Comptroller of Public Accounts.
  • Lazarus, D. (2018, June 5).

    Always look on the bright side of life, says CEO who raised EpiPen price by more than 400%

    . Retrieved from Los Angeles Times: https://www.latimes.com/business/lazarus/la-fi-lazarus-mylan-epipen-drug-prices-20180605-story.html
  • Papanicolas, I., Woskie, L. R., & Jha, A. K. (2018, March 13). Health Care Spending in the United States and Other High-Income Countries.

    JAMA, 10

    , pp. 1024-1039.
  • Reck, J. (2018, September 25).

    Oklahoma Signs the Nation’s First State Medicaid Value-Based Contracts for Rx Drugs

    . Retrieved from National Academy for State Health Policy: https://nashp.org/oklahoma-signs-first-medicaid-value-based-contracts-for-rx-drugs/
  • Texas Comptroller. (2017).

    Texas Comptroller’s Office Releases Health Care Spending Report.

    Austin: Texas Comptroller.
  • TMC. (2018).

    Reducing the Cost of Health Care Current Innovations & Future Possibilities.

    Texas Medical Center Health Policy Institute.
  • Young, K., & Garfield, R. (2018, February 21).

    Snapshots of Recent State Initiatives in Medicaid Prescription Drug Cost Control

    . Retrieved from Kaiser Family Foundation: https://www.kff.org/medicaid/issue-brief/snapshots-of-recent-state-initiatives-in-medicaid-prescription-drug-cost-control/

Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection

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Introduction:

In the previous randomized control study, they calculated the risk probabilities and benefits chances of beginning antiretroviral in HIV-positive patients whom they have CD4+ counts of below 500 cells per cubic millimeters (cells/mm3). Conversely, the discoveries of earlier studies are inconsistent and did not emphasise the benefits probabilities such as virus suppressed and cd4 recover and goes up or risks chances of initiation therapy in patients with high CD4+ count above 500  cells/mm3 such as effect in kidney, liver, and others drugs side effects. Furthermore, the former recommendations of guidelines for curing positive HIV patients are varying and the baseline level of CD4+ to initiate and start antiretroviral therapy has been changed for various times. There is confirmed evidence to start antiretroviral when CD4+ count range 350 however it is generally originated only from the result as an observational study. Therefore, this Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection is undoubtedly statement and address focused matter and it is highly fundamental because it seals the gaps of evidence in the earlier reports and studies. using a randomized controlled trail designing in this study was appropriate. In addition, that study design is proper to uncover the study objective which is to determine the hazards and profits of fast starting of ARTs therapy in patients have asymptomatic human immunodeficiency virus (HIV) infection those who have a CD4+ counts excess of 500 cells/mm3. The question of the research was extremely valuable because the question looked for rising proportion of HIV-positive patients all around the world and attempted to downgrade the extreme risks and high mortalities that are generally correlated with HIV and significantly develop the patients’ health condition and considerably shrinkage the potential HIV spread.

Population:

This Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection study is a multicontinental study; where it is conducted in 35 countries involving low earnings incomes nations and great income countries in 215 sites and clinics. The people that have been reports in the research are from multicontinental and diverse continents (Asia, Africa, North and South America, Australia, Europe, middle east- Israel, and Mexico). In addition to, many different bac ground races and ethnicity. For example, (Blacks, Asians, Latinos, Whites, and others). The outcomes of this study connected to all of the world so, the findings may appropriate and valid for all the world people. But, to take into consideration almost  32% of the patients were smokers, and that may affect or fake the results outcomes. Moreover, both race background and ethnic groups background were not equal. In addition to,  the median ages of the contributors is 36 which means mostly only youthful young patients were tacked in consider in this study.

The comparator was given:

This Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection study compared amongst instant initiation or start of antiretroviral therapy in a positive HIV patients who have CD4+ counts upper than 500 with delayed start of antiretroviral until the CD4+ count ranges 350 cells/mm3 because of this CD4+ count (350) was the beginning or baseline to initiate antiretroviral in earlier time (WHO, 2008). Although, 21 patients which they are represent 4% in the postponed group introduced antiretroviral with a CD4+ cell counts beneath the deferred treatment baseline of 350 cells/mm3 and five primary main endpoints happen for them. The 21 patients as a number in this outsized sort of study not a significant number but they must consider it and make no hidden facts. That might shake the outcomes and contributes to escalation the percentages of the primary endpoints in a deferred or delayed initiation group.

The conclusions considered:

The endpoints purpose or design of this research was significantly applicable. This study or research considered multifactorial conclusions which involve two chief components. The first fundamental one was any serious AIDS-related incident, which involved mortality from AIDS or whichever AIDS-defining incident (established by the Centres for Disease Control and Prevention in 1993). The second important element was any serious non–AIDS-related incident, including mortality from reasons but AIDS.  The secondary endpoints stayed pre-specified in the study reports procedure and protocol, however, the sub-grouped did not specify because of the research built on the whole entire study people. The secondary endpoints incorporate severe AIDS-related cases, serious non–AIDS-related cases, mortality, and deaths for any reason, class 4 incidents, and unscheduled or rash hospital admissions for causes but AIDS incidents. However, unscheduled or suddenly hospital admissions did not define or state in the article clearly. Nevertheless, possibly unconnected incidents involved non-AIDS cancers. For example, prostate, bladder, gastric adenocarcinoma. Furthermore, death because of liver illness, diabetes, substance misuse, or suicide, which were more repeated in the deferred initiation group. In addition, the outcomes results reached established on countries with an elevated prevalence of tuberculosis which is the number one killer of AIDS patients in Africa and might not be straight applicable to the highly incomes countries.

Randomization:

How was the study carried out?

Appropriate applicants randomized in a 1:1 proportion either in the immediate antiretroviral therapy (ART) group or the deferred antiretroviral therapy (ART) group. Randomization stratified via the clinical sites. Positive HIV patients who were 18 years of age or oldest and who antiretroviral therapy ART naïve and without previous  history of AIDS, and were in over-all good suitable health were appropriate for the study research if patients had two CD4+ counts o excess of 500 cells/mm3 as a minimum 14 days apart within two months by  or before the enrollment for the study. But, individuals who are normally in good and suitable health conditions did not define in the study protocols. The females who are being pregnant or breastfeeding at screen phase were not eligible and not qualified; females who turn out to be pregnant during follow-up continued and remained in the study research. The other group of the patients which who has CD4+ count dropped to 350 cells/mm3or the progressive development of an AIDS-related incident or any other circumstance that needed the use of antiretroviral therapy ART. In general, both immediate initiation group and deferred initiation group were the same at the baseline and the randomization was satisfactory and appropriate to answer and response the study research question.

Entered patients and conclusion:

3.0 years was the mean follow-up time for Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection study, and  2.8 years was the median for this study. Nevertheless,  the time for follow up in the study research was considered to be a short time because it is not given sufficient time to show the side effects of antiretroviral therapy ART. That is because they reached the answer for the research fundamental question, they discontinued the study and most of the patients in the delayed or deferred initiation group straight start ART therapy. 23% only of the patients were followed and continued for 4 years and more. That could be reflected as one of the weaknesses points of this research study. The station with concern to unknown for the primary endpoint which was described as an absence of connection for at least 295 days for 93 patients which represent around 4.0% in the immediate-initiation group and 119 patients which represent  5.0% in the deferred-initiation group. That numbers of patients were not highly significant and might have no major effects on the outcomes.

Were they blind?

since of the surrounded environment and the nature of the study the investigator and patients were not blind to the treatment groups project. However,  the endpoints for that were reviewed as blind to the treatment group. The interim summary outcomes during the research study were not well-known by study researchers and the outcomes of interim studies were reviewed and examined by a liberated independent data and monitoring safety board.

Were the groups similar?

In this study, The two study groups were well equalized at same baseline they randomly assigned 4685 of patients. 2326 of the patients were received immediate therapy and 2359 of patients established deferred antiretroviral therapy. The median ages were 36 years old, and almost 27% of the contributors of every group were females. The CD4+ count was 651 cells/mm3 was The median. Nearly the social life’s for the patients in the groups were analogous because the social living might effect on the drug adherence for the patients. In lower social life societies, the drug adherence was significantly lower. Nevertheless, in this research the patient from Asia consider lower although Asia includes almost two-thirds of the earth people. The proportion of ladies consider a small because the high number of individuals living with HIV in 2013 was around 34.9 millions, 16.1 millions of them were females which represent 45,7. But, in Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection study, the percentage of women is ONLY 26.8 %. Furthermore, The 70%  which is 25 millions out of 36 millions individuals lives beside HIV are from Africa. In this study, only 21.2% of the patients at baseline was from Africa. Additionally, there are some countries shows the above representations.

Were the groups cured comparably brand or generic drug?

Medications that were primarily have been used for the initial treatments in the immediate-initiation group also the deferred-initiation group were 89% tenofovir in both groups), 89% and 88%, respectively were used emtricitabine, and efavirenz was representing 73.1% and 50.9%, respectively. However, still the question stand with no answer did the groups of patients used a similar brand of ARTs or generics since the drug bioavailability differs? that does not have a clear declaration in the study research. So that could affect and disturb the outcomes of the research question.

How great was the treatment medications effect?

The primary composite endpoint remained reported in 42 of the patients in the immediate-initiation group.In addition to, in 96 of the patients in deferred-initiation group.

How precise was the approximation of the medication outcome?

In the contrast among both groups which are the immediate-initiation group and the deferred-initiation group, the expected hazard or risk ratio was exactly 0.28 (95% CI, 0.15 to 0.50; P<0.001) for the serious AIDS-related incident and is considered as suitable or acceptable. 0.61 (95% CI, 0.38 to 0.97; P=0.04) was the estimated hazard ratio for the serious of non–AIDS-related incident, and for death because of any reasons was 0.59 (95% CI, 0.28 to 1.17; P=0.13. For the dual highest recurrent serious non–AIDS-related incidents which are non-AIDS cancer and cardiovascular disease, the predictable hazard or risk ratios were 0.49 which represent  95% CI, 0.22 to 1.11; P=0.09 and 0.85 which represent  95% CI, 0.39 to 1.81; P=0.65. The hazard proportion for the cancer patients for both combining the AIDS and the non-AIDS cancers was 0.37 (95% CI, 0.19 to 0.66; P=0.001). Nevertheless, in an interval of deaths and mortality from any reason and the non-AIDS cancers and cardiovascular CVS diseases are wide-ranging, which that means there are a slight precise and additional data are needed.

Is the result related in or to my context?

As a Student of pharmacy, this research can be considered as one of the most significant studies that ever  done before considering a time to start ARTs since it is connected straight to my area of work and might increase  and improve the well-being life qualities of HIV positive patients and downgrade the spread of this diseases since initial the ART prompt lower the probability of the transmission of HIV. Furthermore, the pharmacist’s performance the fundamental job in the treatment of HIV diseases.

Were all the clinical significant results considered?

the research study deliberated the results that the physicians and HIV patients are possible to view as principal serious AIDS-related incidents, serious non–AIDS-related incidents, or mortality for any reason. the study concludes founded on nations and countries alongside an extreme prevalence’s of TB could not be straight appropriate to the developed countries. In addition to, side effect of lifetime long treatments with the ART would be state and additional studies must be done on this since HIV positive patients will be associated in extended lifetime using this medications.

Are the cost of treatment and benefits worth this harms?

The benefits worth the risks and the costs since the outcomes of this research save countless life’s in compared to were still shadowing the former guideline (BHIVA)( and the outcomes of the study nowadays recommended via WHO besides the research appraised by high ranked journal and already published it.

Close:

This research transformation the overall practices to postpone or defer the initiation of antiretroviral therapy in asymptomatic patients alongside a CD4+ count exceeding a undeniable threshold levels and the most recognize origination all over the world currently indorse starting ARTs whatever of the number of CD4+ counts.

References:

  • Initiation of Antiretroviral Therapy in Early Asymptomatic HIV Infection. (2015). New England Journal of Medicine, 373(9), pp.795-807.