The Norwegian General Practice – Nursing Home criteria (NORGEP-NH) for potentially inappropriate medication use: A web-based Delphi study

Objective. To develop a set of explicit criteria for pharmacologically inappropriate medication use in nursing homes. Design. In an expert panel, a three-round Delphi consensus process was conducted via survey software. Setting. Norway. Subjects. Altogether 80 participants – specialists in geriatrics or clinical pharmacology, physicians in nursing homes and experienced pharmacists – agreed to participate in the survey. Of these, 62 completed the first round, and 49 panellists completed all three rounds (75.4% of those ultimately entering the survey). Main outcome measures. The authors developed a list of 27 criteria based on the Norwegian General Practice (NORGEP) criteria, literature, and clinical experience. The main outcome measure was the panellists’ evaluation of the clinical relevance of each suggested criterion on a digital Likert scale from 1 (no clinical relevance) to 10. In the first round panellists could also suggest new criteria to be included in the process. For each criterion, degree of consensus was based on the average Likert score and corresponding standard deviation (SD). Results. A list of 34 explicit criteria for potentially inappropriate medication use in nursing homes was developed through a three-round web-based Delphi consensus process. Degree of consensus increased with each round. No criterion was voted out. Suggestions from the panel led to the inclusion of seven additional criteria in round two. Implications. The NORGEP-NH list may serve as a tool in the prescribing process and in medication list reviews and may also be used in quality assessment and for research purposes.     

Serological response to tick-borne encephalitis (TBE) vaccination in the elderly – results from an observational study

Background: In the elderly, the incidence of tick-borne encephalitis (TBE) is higher than in younger individuals. At the same time, the responsiveness of the elderly to vaccination may be decreased. Product information for TBE vaccines therefore recommends determining antibody response after two of the three doses required for primary immunization in persons over 60. Objective: To determine the proportion of persons aged 60 years or older with insufficient antibody response after administration of two doses of TBE vaccine. Methods: A retrospective analysis of TBE-specific antibody levels as determined by Immunozym^® ELISA in serum samples of 185 vaccinees > 60 years of age after the first two of the three vaccinations required for primary immunisation. Patients received either FSME-IMMUN Adult or Encepur^® Adults at one vaccination centre in the Czech Republic. In a subset of 80 vaccinees, two additional ELISAs and a neutralization test (NT) were performed. Results: Overall, 33 of the 185 individuals (18%) included in the Immunozym analysis had antibody concentrations below putative protective levels after two doses. Geometric mean concentrations and seropositivity rates were higher in individuals vaccinated with FSME-IMMUN than in those vaccinated with Encepur^®. While the differences in mean antibody levels and/or seropositivity rates in ELISAs for the Neudörfl strain (used in FSME-IMMUN) were significant, no significant differences were obtained for Enzygnost, which uses the Karlsruhe strain (used in Encepur). Conclusions: After two doses of TBE vaccine, one in five persons aged 60 years or older may be without protective antibodies, confirming the importance of testing the antibody response after the second vaccination and administering an additional dose in the event of insufficient response.     

Are triptans with enhanced lipophilicity used for the acute treatment of migraine associated with an increased consulting rate for depressive illness?

1997, sumatriptan-treated migraineurs had significantly higher depression PCRs (22.3%) compared with non-triptan users (19.3%), a difference of 6.4% (95% confidence interval (CI) 4.6-8.4%, P < 0.001). In the year (April 1997 to March 1998) following the launch of the TELs, depression PCRs were significantly higher among patients using these compounds compared with sumatriptan-treated patients (5.1%, CI 1.8-12.0%, P < 0.05). However, after taking account of prior depression (odds ratio (OR) 6.45, 95% CI 3.63-11.43), TELs were not significantly associated with depression (OR 0.27, 95% CI 0.03-2.13). Furthermore, rates of newly diagnosed depression after treatment were similar in the two triptan groups (sumatriptan 4.2%; TELs 3.9%). Although, the TELs are being prescribed to patients with higher pre-existing rates of depression, they are not associated with subsequently increased consulting for depressive illness compared with patients taking sumatriptan. This study highlights the potential to use GPRD to test targeted hypotheses exploring pharmacovigilance issues for patients using new medicines.     

Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms – A prospective observational study

BackgroundAn immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms.MethodsAll patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient’s ECG. The main study outcome was the diagnosis of an acute cardiovascular event.ResultsOf the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse–physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712 and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001).ConclusionsECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.     

Is albumin administration in the acutely ill associated with increased mortality? Results of the SOAP study

Introduction  

Albumin administration in the critically ill has been the subject of some controversy. We investigated the use of albumin solutions in European intensive care units (ICUs) and its relationship to outcome.     

The use of a Swedish telephone medical advice service by the elderly – a population-based study

Objective: The present study aimed to describe contact made by the elderly to Sweden’s nationwide medical helpline, Healthcare Guide 1177 by Phone (HGP). Other objectives were to study potential gender differences and the association between different HGP referral levels and acute visits to hospital-based emergency departments and acute visits to primary care centres.

Design: De-identified data from recorded calls to HGP was extracted for analysis (n?=?7477 for the oldest age group). Information about acute visits to emergency departments and to primary care reception was extracted from the patient administration system.

Setting: Västerbotten County, Sweden.

Subjects: Patients over 80 years.

Main outcome measures: Calling and visiting frequencies for different age groups as well as reasons for contact and individual recommendations.

Results: The utilisation rate of the telephone advice service for the oldest age group was high, with an incidence rate of 533 per 1000 person-years. Women had a 1.17 times higher incidence rate compared with men. The most common reason for contact was drug-related questions (17% of all contacts). Calls that were recommended to care by a medical specialist correlated with total emergency department visits (r?=?0.30, p?r?=?0.38, p?=?0.005).

Conclusion: The high utilisation of the telephone advice service by the elderly gives the telephone advice service a unique ability to function as a gatekeeper to further healthcare. Our data suggest that with the telephone advice service’s present guidelines, a significant proportion of all calls are being directed to further medical help. The high frequency of drug-related questions raises concerns about the elderly’s medication regimens.

• Key points

• Patients over 80 years of age had a high utilisation of the telephone medical advice service compared with other age groups.

• Drug-related questions were the most common reason for contact.

• A significant proportion of all calls made resulted in further heatlhcare contacts.

     

Is the introduction of a student-centred, problem-based curriculum associated with improvements in student nurse well-being and performance? An observational study of effect

AIMS: To explore the impact of curriculum redesign and innovation on student well-being and performance, including essay and examination marks and sickness absence. BACKGROUND: While the emotional impact of preparing to be a health professional can be reduced by helping students to adapt, the positive effect of curriculum innovation and redesign is rarely evaluated. DESIGN, SAMPLE AND METHODS: Student nurse well-being and performance was compared at weeks 24/25 and 40/50 following course entry between comparable independent cohorts of students undertaking a traditional programme (N=406, 83% return rate) with those on an innovative, student-centred, problem-based educational programme (N=447, 79% return rate). The setting was a School of Nursing and Midwifery in the North-East of Scotland. Measures included stress and mental health outcomes and measures of performance including academic marks and sickness absence. RESULTS: At week 25 into the course students on the innovative course had fewer academic, clinical and personal worries than students in the previous more traditional programme and were more likely to report using adaptive direct, problem-solving coping at week 50. While students on the innovative course reported less distress in their first year of the course, they scored less well on comparable essay assignments and had reliably greater sickness absence totals than those educated by traditional methods. CONCLUSION: In this setting, curriculum innovation was associated with positive changes in student well-being but not on performance.     

Knee crepitus is not associated with the occurrence of total knee replacement in knee osteoarthritis – a longitudinal study with data from the Osteoarthritis Initiative

Objective(s)To investigate whether the presence of knee crepitus is associated with the occurrence of total knee replacement (TKR), quality of life and deficits in physical function at long-term.MethodsSetting – This observational study uses longitudinal data (up to 4-year follow-up) from the Osteoarthritis Initiative (OAI). Participants – 4566 participants. Main Outcome Measure(s) – Logistic regression models were used to test if baseline knee crepitus is associated with the occurrence of TKR. Linear mixed models with adjustment for confounding variables (age, gender, BMI and Kellgren–Lawrence grade) were used to test the association between baseline knee crepitus and longitudinal changes in the pain, self-reported physical function, quality of life and performance-based function.ResultsThe presence of knee crepitus at baseline does not predict the occurrence of TKR at 36 months (p = 0.58 and 0.67 for right and left knees, respectively). The crepitus group presented a slightly knee extension strength decline from baseline to 48 months (p = 0.03 for the right and 0.01 for the left knee; between group difference = 2% for both right [95%CI = −0.12; −0.01] and left knees [95%CI = −0.13; −0.02]).ConclusionThe presence of knee crepitus is not associated with the occurrence of TKR in the following three years. Knee crepitus is associated with slightly declines in knee extension strength, but this does not seem to affect physical function and quality of life at long-term.     

Feasibility study of the BrightBrainer™ integrative cognitive rehabilitation system for elderly with dementia

Purpose: To describe the development of BrightBrainer? integrative cognitive rehabilitation system and determine clinical feasibility with nursing home-bound dementia patients. Method: BrightBrainer cognitive rehabilitation simulations were first played uni-manually, then bimanually. Participants sat in front of a laptop and interacted through a game controller that measured hand movements in 3D, as well as flexion of both index fingers. Interactive serious games were designed to improve basic and complex attention (concentration, short-term memory, dual tasking), memory recall, executive functioning and emotional well-being. Individual simulations adapted automatically to each participant’s level of motor functioning. The system underwent feasibility trials spanning 16 sessions over 8 weeks. Participants were evaluated pre- and post-intervention, using standardized neuropsychological measures. Computerized measures of movement repetitions and task performance were stored on a remote server. Results: Group analysis for 10 participants showed statistically significant improvement in decision making (p?p?p?p?p?Conclusions: Preliminary findings demonstrate utility within an advanced dementia population, suggesting that it will be beneficial to evaluate BrightBrainer through controlled clinical trials and to investigate its application in other clinical populations.

• Implications for Rehabilitation

• It is possible to improve cognitive function in older low-functioning patients. Integrative rehabilitation through games combining cognitive (memory, focusing, executive function) and physical (bimanual whole arm movement, grasping, task sequencing) elements is enjoyable for this population.

• The severity of depression in these elderly can be reduced through virtual reality bimanual games.

• The number of upper extremity active repetitions performed in the process of solving cognitive problems with the BrightBrainer? system is 600. This number is 18 times (1875%) larger than those observed by other researchers in conventional physical or occupational rehabilitation sessions.

     

I’ve changed,but I’m not less happy: Interview study among nonclinical relatives of long-term missing persons

Twenty-three nonclinical relatives of long-term missing persons were interviewed. Patterns of functioning over time were studied retrospectively by instructing participants to draw a graph that best described their pattern. Patterns most frequently drawn were a recovery and resilient/stable pattern. Participants were also asked to select 5 out of 15 cards referring to coping strategies, which they considered most helpful in dealing with the disappearance. Acceptance, emotional social support, mental disengagement, and venting emotions were most frequently chosen. This study provided some indication of coping strategies that could be strengthened in treatment for those in need of support.     

Actual use of and satisfaction associated with rollators and “shopping carts” among frail elderly Japanese people using day-service facilities

Purpose This study aimed at clarifying the actual use of and satisfaction with rollators and “shopping carts” (wheeled walkers with storage) among frail elderly people, who were certified by a long-term care insurance system as users of facilities that provide day-service nursing care and rehabilitation. Methods We identified 1247 frail elderly people who used day-service facilities, and evaluated their actual use of, and satisfaction with, rollators and shopping carts. Results Forty-four (3.5%) individuals used rollators, and 53 (4.3%) used shopping carts. The shopping cart group contained more individuals who were certified as care level 1 (26.4%), than the rollator group (20.5%), and 52.8% of the shopping cart group was certified as care levels 1–3. The scores for “repairs and services” and “follow-up” from the Quebec User Evaluation of Satisfaction with assistive Technology second version (QUEST 2.0) survey were significantly higher in the rollator group than in the shopping cart group. Conclusions The QUEST 2.0 scores revealed that shopping cart users exhibit insufficient “repairs and services” and “follow-up” scores. As frail elderly people with poor care status accounted for?>50% of the shopping cart group, these individuals urgently need walking aids that are tailored to their care status.

• Implications for Rehabilitation

• We conclude that walking aid fitting must be tailored to each persons care status, and suggest that a system should be established to allow occupational or physical therapists to provide this fitting

• Moreover, our analysis of the QUEST2.0 service scores revealed that repairs, services, and follow-up are insufficient to meet the needs of shopping cart users.

     

High levels of education are associated with an increased risk of latent autoimmune diabetes in adults: results from the Nord-Trøndelag health study

OBJECTIVE

To investigate whether the risk for autoimmune diabetes in adults differs between socioeconomic groups and to compare such risk with that for type 2 diabetes.

RESEARCH DESIGN AND METHODS

The inhabitants of the Norwegian county of Nord-Trøndelag were investigated by questionnaires and clinical examinations on three occasions during 1984–2008. We used information from a subset consisting of 56,296 subjects (participating in at least two surveys), including 122 incident cases of autoimmune diabetes in adults (aged ≥35 and anti-GAD positive) and 1,555 cases of type 2 diabetes (aged ≥35 and anti-GAD negative). Hazard ratios (HRs) of diabetes associated with self-reported education and occupation were estimated by Cox proportional hazards models.

RESULTS

High levels of education (university versus primary school) were associated with an increased risk of autoimmune diabetes (HR 1.98 [95% CI 1.21–3.26]), after adjustment for BMI, lifestyle factors, and family history of diabetes. Case subjects with high levels of education had lower levels of C-peptide, tended to have higher levels of anti-GAD, and were more often treated with insulin. Conversely, these subjects had a reduced risk of type 2 diabetes (HR 0.69 [95% CI 0.57–0.82]), a risk that was partly explained by lower BMI and more physical activity (adjusted HR 0.89 [95% CI 0.74–1.06]).

CONCLUSIONS

High levels of education are associated with an increased risk of autoimmune diabetes in adults, a finding that may be mediated by effects on autoimmune activity. Because the association is not explained by traditional risk factors, other, currently unidentified, environmental factors are likely to be involved.There is some evidence indicating that socioeconomic conditions during early life can affect the incidence of autoimmune diabetes. Lower rates of childhood diabetes have been reported in more materially deprived areas, and children in families with a high socioeconomic position seem more prone to develop type 1 diabetes (1–3). It has been hypothesized that these associations result from differences in environmental factors, such as feeding patterns, hygiene standards, and lack of infections in early life, conditions that may affect the immune system and trigger an autoimmune reaction (4,5). Whether socioeconomic factors associate with autoimmune diabetes that develops at adult age is, however, not known. Contrasting with data on childhood type 1 diabetes, the risk of developing type 2 diabetes is more pronounced in lower socioeconomic groups (6–8). This association can be explained, at least in part, by traditional risk factors such as overweight and physical inactivity (9).Autoimmune diabetes in adults comprises latent autoimmune diabetes in adults (LADA) as well as “classical” type 1 diabetes. Autoimmunity is indicated by the presence of antibodies against β-cell–associated antigens, such as GAD (10). LADA is by far the most common form of adult-onset autoimmune diabetes and is estimated to account for 2–12% of all diabetes cases (11). As indicated by the name, onset of LADA is slower than type 1 diabetes, and insulin treatment is typically not required at the time of diagnoses. Even though it is characterized by autoimmunity, LADA patients also display features of type 2 diabetes with risk associations to being overweight and physical inactivity (12).The aim of this study was to investigate whether the risk of developing autoimmune diabetes in adults differs between socioeconomic groups and to compare such risk with that for type 2 diabetes. Furthermore, we aimed to analyze whether evidence could be found for a role of autoimmunity and whether associations found could be explained by traditional risk factors for type 2 diabetes, such as family history of diabetes, being overweight, physical inactivity, or smoking.     

A pilot study – the potential value of an activity-based feedback system for treatment of individuals with chronic lower back pain

Abstract

Purpose: The aim of this pilot study was to evaluate the potential value of a new personalized activity-based feedback treatment. Method: A prognostic cohort study was carried out in the daily environment of the patients. Seventeen individuals with chronic lower back pain (CLBP) symptoms for >3 months were included. Patients were from the Netherlands, aged 18–65 years. Patients wore an accelerometer and a Personal Digital Assistant (PDA) for 15?d. Patients received continuous and time-related personalized feedback and were instructed to follow the activity pattern as displayed on the PDA. Technical performance and compliance with the system were rated. Objective and subjective activity scores were compared for exploring awareness. The absolute difference between the activity pattern of the patient and the norm value used was calculated and expressed as mean difference. Pain intensity was measured using the VAS. Results: The technical performance and compliance with the system were rated moderate. More than half of the patients were aware of their activity level during the feedback days (67%). A positive effect of the feedback was seen in a trend which showed a decrease in the absolute difference between the activity pattern of the patient and the norm value (p?=?0.149) and a significant decrease in pain intensity levels (p?=?0.005). Conclusions: This pilot study suggested that an individual-tailored feedback system that focuses on the activity behavior of the patient has potential as the treatment of individuals with CLBP.

• Implications for Rehabilitation

• Activity-based feedback for individuals with chronic low back pain:

• Many patients are not aware of their activity patterns.

• The activity patterns of patients differ from those of healthy controls.

• It is important to make patients aware of their activity patterns in order to change activity behavior.

• An individual-tailored feedback system seems promising in decreasing pain intensity levels for a subgroup of patients.

     

Toll‐like receptor 4 polymorphism is associated with coronary stenosis but not with the occurrence of acute or old myocardial infarctions

Objective. Atherosclerosis is considered to be a chronic inflammatory disease. Toll‐like receptor 4 (TLR‐4), a key mediator in activating inflammatory cascade, has an A‐to‐G functional polymorphism that changes aspartic acid to glycine at position 299. TLR‐4 is activated by, for example, lipopolysaccharides. The purpose of this study was to investigate the role of a common Asp299Gly polymorphism of the TLR‐4 gene in atherosclerosis. Material and methods. The study comprised autopsy material from 657 men (the Helsinki Sudden Death Study; mean age 53, range 33–70 years). Results. Fewer G‐allele carriers had 3‐vessel coronary artery disease compared with AA homozygotes (OR 0.32; 95?% CI, 0.12–0.88, p = 0.027), and they also had a lower mean value for maximal coronary stenosis (p = 0.019). TLR‐4 polymorphism was not significantly associated with the occurrence of acute or old myocardial infarction (MI). Conclusions. The G allele of the TLR‐4 gene, which is associated with a lower inflammation response, was associated with a lower risk of coronary stenosis but not with the occurrence of MI and hence is not a major factor in the development of coronary atherosclerosis.     

Is endoscopic balloon dilation for removal of bile duct stones associated with an increased risk for pancreatitis or a higher rate of hyperamylasemia?

BACKGROUND AND STUDY AIMS: We studied the rate of pancreatitis and asymptomatic hyperamylasemia after endoscopic balloon dilation (EBD) and endoscopic sphincterotomy (EST) for removal of bile duct stones. PATIENTS AND METHODS: Patients with bile duct stones of all sizes were randomly allocated to undergo EBD (8-mm dilation balloon) or EST. Pancreatitis was defined as epigastric pain combined with at least a threefold rise in serum amylase at 24 hours after the endoscopic retrograde cholangiopancreatography (ERCP). Asymptomatic hyperamylasemia was defined as a threefold rise in serum amylase without epigastric pain. RESULTS: There were 180 patients (67 men, 113 women; mean age 67, SD 16.2) available for analysis. Complete stone removal after a single ERCP was achieved in 82 (88%) of 93 EBD patients and in 81 (93%) of 87 EST patients (P = 0.38). Mechanical lithotripsy was used more frequently in the EBD group (31% vs. 13%, P = 0.005). Early complications occurred in 16 EBD patients (17%) and in 19 EST patients (22%) (P = 0.46). Pancreatitis was observed in seven patients in each group (8%). Logistic regression identified no significant predictors for the occurrence of pancreatitis. Asymptomatic hyperamylasemia occurred in 21 EBD patients (23%) vs seven EST patients (8%) (P = 0.008). Logistic regression identified EBD as the only significant predictor for asymptomatic hyperamylasemia: odds ratio 2.9 (95% confidence interval (CI) 1.1 to 7.3, R2 = 0.02). CONCLUSIONS: We did not observe a difference in the rate of pancreatitis between EBD and EST. Asymptomatic hyperamylasemia was observed more frequently after EBD. Although asymptomatic hyperamylasemia is not a clinical entity, this finding may indicate that EBD causes more irritation of the pancreas than EST.     

Vocational rehabilitation case manager factors associated with vocational rehabilitation service program outcomes for people with disabilities in Taiwan – an exploratory study

Purpose The aim of this study is to explore whether/which vocational rehabilitation case manager (VRCMer) factors were significantly associated with the vocational rehabilitation service (VRS) program outcomes in Taiwan. Method This study used the 2011 VRS Program for People with Disabilities Database in a metropolitan city in Taiwan (N?=?466) to do a secondary data analysis using hierarchical logistic regression. Results This study found that the employment rate and stable employment rate created by the 2011 VRS program in a metropolitan city in Taiwan were 48.7% and 42.1%, respectively. For the predictors of employment/stable employment, “occurrences of the services provided by the VRCMer” variable was definitely dominant. In addition, “level of the disability” was the second-ranking predictor, and was significantly negatively correlated with both employment and stable employment outcomes. Conclusions Vocational rehabilitation case manager factors in this study were significantly correlated with VRS program outcomes for people with disabilities in Taiwan after controlling for the clients’ socio-demographic variables. The results indicate that greater input by VRCMers for people with disabilities equates to better employment outcomes in metropolitan Taiwan.

• Implications for Rehabilitation

• This is the first study to build an inferential statistical model in attempt to explain and predict the association between vocational rehabilitation case manager factors and vocational rehabilitation service program outcomes for people with disabilities in Taiwan.

• In cases of severe disability, a vocational rehabilitation case manager should seek out more in-kind and in-cash resources, and choose a suitable job coach to cooperate in assisting the client to become employed.

• Based on the findings, government has to continue implementing opportunities for people with disabilities to attain higher and better quality educational levels, for increasing their employment rate.

• Vocational rehabilitation case managers should raise the referral rate and cooperation with job coaches as this directly affects the quality of services and clients’ employment rate.