Evaluation of first nonfebrile seizures

Nonfebrile seizures may indicate underlying disease or epilepsy. The patient history can often distinguish epileptic seizures from nonepileptic disorders by identifying the events directly preceding the convulsion, associated conditions, and details of the seizure, including triggers, length, and type of movements. Laboratory testing, lumbar puncture, and neuroimaging may be indicated depending on the presentation, suspected etiology, and patient's age. Electroencephalography should be performed 24 to 48 hours after a first seizure because of its substantial yield and ability to predict recurrence. Neuroimaging is recommended for adults, infants, and children who have cognitive or motor developmental delay or a focal seizure. Neuroimaging may be scheduled on an outpatient basis for patients with stable vital signs who are awake and have returned to neurologic baseline. Emergent neuroimaging should be performed in patients with persistent decreased mental status or a new focal neurologic abnormality. Although magnetic resonance imaging is generally preferred to head computed tomography because of its greater sensitivity for intracranial pathology, computed tomography should be performed if intracranial bleeding is suspected because of recent head trauma, coagulopathy, or severe headache. Treatment with an antiepileptic drug after a first seizure does not prevent epilepsy in the long term, but it decreases the short-term likelihood of a second seizure. Adults with an unremarkable neurologic examination, no comorbidities, and no known structural brain disease who have returned to neurologic baseline do not need to be started on antiepileptic therapy. Treatment decisions should weigh the benefit of decreased short-term risk of recurrence against the potential adverse effects of antiepileptic drugs.     

Schmerzdiagnostik und -therapie in der Geriatrie

The geriatric pain patient is a frail patient at risk of losing the ability to take care of him/herself and, therefore, at risk of losing personal independence. There is a growing probability of comorbidity and of cognitive impairment with increasing age. One of the main objectives of geriatrics is the preservation and promotion of the capacity to perform everyday tasks (activity) and to participate in social life (participation). Comorbidity impacts on disability to a higher degree than pain does. Cognitive restrictions contribute to a decreased validity of the assessment instruments. For these reasons, geriatric assessment has to be multidimensional and has to take into account the patient's psychological and social situation in addition to the pain and physical status. In geriatrics, a set of standardized instruments is used to accomplish this task. It may not be practical to handle the whole set in the practice of the pain specialist; nevertheless, some simple measures for the assessment of functional as well as cognitive status should be incorporated into the diagnostic procedure for the elderly pain patient. Written questionnaires should not be used in cases of sensory or cognitive impairment of the patient. The adequate tool for these patients is a structured pain interview.     

Nutritional therapy in advanced cancer. Setting realistic goals

Cancer cachexia is a complex syndrome resulting from metabolic disturbances, mechanical obstacles, and behavioral alterations. Assessments of the potential benefits of nutritional support for an individual patient must reflect the cancer stage and prognosis, the patient's expressed wishes, and the impact of treatment on the family unit. Enteral or parenteral alimentation may preserve body mass during aggressive, potentially curative therapy of early cancer. Palliation may be provided for the more advanced patient whose major problem is not being able to eat. In terminal illness, feeding may no longer be therapeutic--it may briefly prolong life with considerable morbidity and expense. At each stage, decisions should be based on realistic assessments of possible gains and losses to the patient's life and overall well-being.     

Perceptions of family participation among parents of children with cerebral palsy followed from infancy to toddler hood

Background.?Little is known about the way parents of children with cerebral palsy (CP) perceive their involvement in family and personal life situations, also called ‘family participation’.

Purpose.?To investigate the perception of family participation among parents of preschool children with CP.

Method.?Semi-structured interviews were used to describe how parents (n = 53) of children with CP (aged 18 months) perceive participation with respect to family activities and their personal activities. In addition, using a combined score of family and personal activities, we investigated the changes of parental (n = 36) perceived family participation over time (followed from 18 months onwards until 42 months of age).

Results.?At the child's age of 18 months, a substantial percentage of parents expressed a feeling of being restricted in their family activities (45%) or personal activities (53%). The longitudinal data show that over the 24-month follow-up significant more parents perceived to be restricted in family participation (p = 0.008; Cochran's Q test).

Conclusions.?A child with CP in a family may lead to parents perceiving restrictions in family participation. These restrictions arise early in the life of a child with CP and may become more prominent as the child grows older.     

Participation in People Living With Spinal Cord Injury in Switzerland: Degree and Associated Factors

ObjectiveTo describe different domains of participation such as productive, leisure and social activities and describe sociodemographic and spinal cord injury (SCI)-related characteristics that are associated with participation in these domains in a large sample of community-dwelling individuals with SCI in Switzerland.DesignCross-sectional population-based survey within the Swiss Spinal Cord Injury Cohort Study. Participation in major life domains was measured by the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-Participation). Univariable unconditional analysis and unbiased recursive partitioning were used to identify the predominant associations of sociodemographic and SCI-related characteristics with multiple dimensions of participation.SettingCommunity.ParticipantsSwiss residents aged 16 years or older and living with traumatic or nontraumatic SCI (N=1549).InterventionsNot applicable.Main Outcome MeasureThe USER-Participation, a 32-item self-report questionnaire with 3 scales (Frequency, Restrictions, and Satisfaction) to assess key domains of participation (productive, leisure, social).ResultsFrequency (median 34.5 out of 100) in productive, outdoor leisure, and social activities was reduced with distinctive perceived restrictions in work and education, sports, and partner relationships. Domestic leisure activities (65.4%) and maintaining social relationships (76.1%) were those activities most often performed and with least perceived restrictions. Participants were generally satisfied with their current daily life activities. Lower scores across all participation scales were associated with more severe SCI, higher age, being female, not having a partner, and lower level of education.ConclusionsThis study provides a thorough analysis of participation in major life domains of individuals with SCI in Switzerland. Different risk groups for reduced levels in participation in productive, leisure, and social activities were identified. This population-based evidence is instrumental to the better targeting of rehabilitation and policy interventions that aim to improve community participation.     

Amyotrophic lateral sclerosis: comprehensive management.

The cause of amyotrophic lateral sclerosis remains unknown, and no curative treatment is available. From a rehabilitation perspective, however, comprehensive management and symptomatic treatment can minimize complications, increase function and improve the patient's quality of life. Quinine, diazepam (Valium) and phenytoin (Dilantin) may relieve muscle cramps, and orthoses may permit greater participation in daily activities. Problems with respiration and swallowing may require surgical procedures and the use of feeding tubes. Decisions regarding surgical intervention must be made in the context of the patient's overall status.     

Visitation policies in the ICU: a time for change

The belief that visitation restrictions in the ICU are for the patient's good is not fully supported by research. However, there are no firm conclusions regarding how visitation decisions should be made. This paper suggests that decisional control over visitation be given to the patient and that, with the nurse functioning as a patient advocate, individualization of visitation be practiced. It is up to nursing to institute changes in visitation of the critical care patient.     

Participation of the elderly after vision loss

Purpose.?To assess the degree of participation of the visually impaired elderly and to make a comparison with population-based reference data.

Method.?This cross-sectional study included visually impaired elderly persons (≥55 years; n?=?173) who were referred to a low-vision rehabilitation centre. Based on the International Classification of Functioning, Disability and Health (ICF) participation in: (1) domestic life, (2) interpersonal interactions and relationships, (3) major life areas, and (4) community, social and civic life was assessed by means of telephone interviews. In addition, we assessed perceived participation restrictions.

Results.?Comparison with reference data of the elderly showed that visually impaired elderly persons participated less in heavy household activities, recreational activities and sports activities. No differences were found for the interpersonal interactions and relationships domain. Participants experienced restrictions in household activities (84%), socializing (53%), paid or voluntary work (92%), and leisure activities (88%).

Conclusions.?Visually impaired elderly persons participate in society, but they participate less than their peers. They experience restrictions as a result of vision loss. These findings are relevant, since participation is an indicator for successful aging and has a positive influence on health and subjective well-being.     

Patient participation in decision making at the end of life as seen by a close relative

The aim of the present study was to describe variations in patient participation in decisions about care planning during the final phase of life for a group of gravely ill patients, and how the different actors' manner of acting promotes or impedes patient participation. Thirty-seven qualitative research interviews were conducted with relatives of the patients. The patients' participation in the decisions could be categorized into four variations: self-determination, co-determination, delegation and nonparticipation. The manner in which patients, relatives and caregivers acted differed in the respective variations; this seemed either to promote or to impede the patients' opportunities of participating in the decision making. The possibility for participation seems to be context dependent and affected by many factors such as the dying patient's personality, the social network, the availability of different forms of care, cultural values, and the extent to which nurses and other caregivers of the different forms of care can and want to support the wishes of the patients and relatives in the decision-making process.     

Computer-assisted instruction: design and content in neuroscience nursing

Computer-assisted instruction (CAI) includes games, tutorials, simulations, and drills. Computer simulation exercises can be used to simulate patient care and promote diagnostic reasoning skills in nursing. Computer simulation exercises (CSEs) based on case studies of patients with head injury, spinal cord injury, epilepsy, febrile seizures and meningitis have been developed and implemented at the University of Washington School of Nursing, Department of Physiological Nursing, in conjunction with the Health Sciences Center for Educational Resources. These simulations provide a realistic, constantly changing scenerio in which the nurse-learner collects data, analyzes it, and makes decisions about the patient's nursing care. The patient's condition may change dramatically as a result of the decisions made by the nurse-learner.     

The complexity of participation in daily life: a qualitative study of the experiences of persons with acquired brain injury

OBJECTIVE: To describe and enhance the understanding of how adults with acquired brain injury experience participation in daily life. PATIENTS AND METHODS: Qualitative interviews with 11 persons of working age with acquired brain injuries were analysed using qualitative content analysis. RESULTS: The informants' experiences formed 5 categories: "Performing tasks"; "Making decisions and exerting influence"; "Being engaged in meaningful activities"; "Doing things for others"; and "Belonging". The categories that needed to be present for the informants to experience a feeling of participation varied according to their individual daily life situations. In addition, their experiences showed that a variety of conditions, related to each of the 5 categories, influenced their participation. Individuals adopted a variety of strategies to enhance their experience of participation. CONCLUSION: The meaning of participation and the conditions and strategies influencing participation are complex. Many of the categories identified for participation can be understood only through subjective experience and cannot be captured by professionals' observation of the performance of activities. These results emphasize the importance of considering clients' unique experiences of participation when designing individually tailored rehabilitation programmes intended to enhance participation.     

Aging and Down syndrome: implications for physical therapy

The number of people over the age of 60 years with lifelong developmental delays is predicted to double by 2030. Down syndrome (DS) is the most frequent chromosomal cause of developmental delays. As the life expectancy of people with DS increases, changes in body function and structure secondary to aging have the potential to lead to activity limitations and participation restrictions for this population. The purpose of this update is to: (1) provide an overview of the common body function and structure changes that occur in adults with DS as they age (thyroid dysfunction, cardiovascular disorders, obesity, musculoskeletal disorders, Alzheimer disease, depression) and (2) apply current research on exercise to the prevention of activity limitations and participation restrictions. As individuals with DS age, a shift in emphasis from disability prevention to the prevention of conditions that lead to activity and participation limitations must occur. Exercise programs appear to have potential to positively affect the overall health of adults with DS, thereby increasing the quality of life and years of healthy life for these individuals.     

Evaluation and improvement of QOL among IBD patients

This article provided a short review on the assessment of quality of life (QOL) among patients with ulcerative colitis. Quantitative approach with psychometric measures has empirically showed that psycho-social aspects of patient's QOL are often affected by her clinical, psychological, and social conditions. Although the control of disease activities plays a pivotal role for improving patient's QOL, more holistic approach such as psychoeducational intervention should also be considered to enhance patient's self-efficacy and sense of control. Besides, qualitative research suggests that helping patient's narrative reconstruction through enhanced communication with the physician may be the most powerful tool that the physician can provide for improving patient's QOL.     

Integration of critical care and palliative care at end of life

End-of-life care in the critical care environment suffers from a lack of clarity and uncertainty. Critical care nurses may often feel torn between wanting to do everything possible to sustain a patient's life and wanting to do what is in the patient's best interests. Reframing the focus of care from cure to comfort can be an uncomfortable shift for nurses, who may not be in control of when the change of goals takes place. Good end-of-life care should be a core competency for all nurses and it is our responsibility to ensure that decisions to forgo life-sustaining treatment in critical care are appropriate and timely. Futility, conflict and resources all factor in such decisions. Nurses must ensure the transition from cure to comfort does not emphasize a dichotomy between palliative care and critical care but instead focuses on the provision of the best possible end-of-life care.     

An overview of assistive technology for persons with multiple sclerosis

Multiple sclerosis (MS) is a progressive neurologic disease clinically characterized by episodes of focal disorder of the cranial nerves, spinal cord, and the brain. MS affects a significant number of young adults, and they most often face a future of progressive functional losses as more of their central nervous system and cranial nerves are affected. As the disease progresses, they have new impairments with accompanying limitations in activities, restrictions to their participation in life, and compromised quality of life. Assistive technology includes any item that is used to maintain or improve functional capabilities. The rehabilitation healthcare provider has many opportunities to intervene with assistive technologies to decrease activity limitations and participation restrictions. The purpose of this article is to (1) review the impairments and associated activity limitations and participations restrictions experienced by persons with MS, (2) provide an overview of high- and low-tech assistive technologies appropriate for persons with MS, (3) discuss funding opportunities for assistive technologies, (4) review current studies of assistive technology used for persons with MS and discuss future research directions, and (5) consider assistive technology as an intervention for disability prevention.     

Are contextual factors associated with activities and participation after total hip arthroplasty? A systematic review

ObjectivesAfter total hip arthroplasty (THA), over 30% of individuals report activity limitations and participation restrictions. This systematic review aimed to determine the association between contextual factors and outcomes in the activity and participation domain after THA for hip osteoarthritis (OA).MethodsThis systematic review was developed according to the PRISMA guidelines for systematic reviews. PubMed, Web of Science, Embase and Scopus were searched until August 2022. Risk of bias was assessed with the Quality in Prognosis Studies tool (QUIPS).ResultsTwenty-nine articles were included. Eighteen had a high risk of bias, 3 had a low risk of bias, and 8 had a moderate risk of bias. Anxiety was only investigated in studies with high risk of bias but showed a consistent negative association with activities and participation after THA across multiple studies. Evidence was inconsistent regarding the associations between depression, trait anxiety, sense of coherence, big 5 personality traits, educational level, marital status, employment status, job position, expectations and social support, and the activity and participation domain. Optimism, general self-efficacy, cognitive appraisal processes, illness perception, ethnicity, and positive life events were associated with activities and participation but were only investigated in 1 study. No associations were identified across multiple studies for living or smoking status. Control beliefs, kinesiophobia, race, discharge location, level of poverty in neighbourhood, negative life events and occupational factors, were not associated with the activity and participation domain but were only investigated in 1 study.ConclusionMethodological quality of the included studies was low. Anxiety was the only factor consistently associated with worse outcomes in the activity and participation domain after THA but was only investigated in studies with high risk of bias. Further research is needed to confirm relationships between other contextual factors and activities and participation after THA.RegistrationPROSPERO CRD42020199070     

In refractory temporal lobe epilepsy,consider surgery sooner

Despite evidence that surgery for temporal lobe epilepsy is safe and effective, physicians continue to view it as a last resort in people who do not respond to medical therapy. A randomized study in Canada has demonstrated significantly higher rates of freedom from seizures in patients who underwent surgery rather than medical therapy. If we wait too long to rule a patient's epilepsy medically refractory, we increase the patient's risk of morbidity and death, and we miss a window of opportunity to eliminate seizures and permit the patient a full and productive life.     

Attitudes towards do-not-resuscitate decisions: differences among health professionals in a Portuguese hospital

OBJECTIVES: Implementation of an in-hospital cardiopulmonary resuscitation (CPR) program stresses the need to discuss do-not-resuscitate (DNR) orders, as CPR may not be desirable in some terminally ill patients. Ethical, social, educational, and professional issues may influence these decisions. This study was designed to evaluate attitudes among four categories of healthcare professionals. DESIGN AND SETTING: Survey in a tertiary hospital in Portugal. METHODS: An anonymous self-completed questionnaire was distributed to 825 staff members, 527 of whom responded (20% physicians, 44% nurses, 20% health technicians, 16% healthcare domestic staff). Responses were compared between the various health professional groups. RESULTS: The level of medical/health training was positively related to the frequency of DNR decisions (physicians and nurses could foresee more circumstances warranting DNR decisions than technical/administrator or domestic staff) and negatively related to the willingness to include the patient's family in the DNR decision (physicians and nurses saw less need for the family's participation than technical/administrator or domestic staff). Significant differences were also found between professional groups regarding the physician's responsibility and the nurses' participation in DNR decisions. There was no difference between the professional groups regarding the need to note the DNR decision in clinical charts. CONCLUSION: Health professionals differ in their attitudes concerning DNR decisions. In particular, the level of medical/health training and/or degree of involvement with the patient's daily care may play an important role in DNR decisions.