Immunomodulation et sepsis – Impact de l’agent pathogène

Infection begins when micro-organisms overcome host barriers and multiply within host tissue. To contain infection, the host stages an inflammatory reaction to mobilize defence systems and kill the invading micro-organisms. In most cases, the activated defence mechanisms lead to eradication of infection throught a localized inflammatory reaction. However, when the infectious stimulus cannot be contained within tissues, infectious agents, their toxins, and host-derived mediators are released into the circulation leading to a systemic inflammatory response syndrome and remote organ dysfunction. It appears that microbial organisms have coevolved with their hosts to overcome protective host barriers and in selected cases, actually take advantage of innate host responses. Many microbial pathogens avoid host responses recognition or dampen the subsequent immune activation through sophisticated interactions with host responses, but some pathogens benefit from the stimulation if inflammatory reactions. The pathogenesis of sepsis assumes that host are capable to generate unique common responses to any pathogen but also exhibit different pathogen-specific immune responses. Determining whether the unique responses are advantageous to the pathogen or to the host is essential for understanding host-pathogen interactions. In this review, we will discuss how pathogens interfere with innate and adaptative immune responses in order to evade the immune response.     

Patients’ perspective on surgical intervention for Dupuytren’s disease – experiences,expectations and appraisal of results

Purpose: To explore patients’ perspectives on surgical intervention for Dupuytren’s disease (DD), focusing on patients’ appraisal of results, involving previous experiences, expectations and patient characters.

Method: The participants were 21 men, mean age 66 years, scheduled for DD surgery. Qualitative interviews were conducted 2–4 weeks before surgery and 6–8 months after surgery. The model of the Patient Evaluation Process was used as theoretical framework. Data were analyzed using problem-driven content analysis.

Results: Five categories are described: previous experiences, expectations before surgery, appraisal of results, expectations of the future and patient character. Previous experiences influenced participants’ expectations, and these were used along with other aspects as references for appraisal of results. Participants’ appraisal of results concerned perceived changes in hand function, care process, competency and organization, and could vary in relation to patient character. The appraisal of results influenced participants’ expectations of future hand function, health and care.

Conclusions: Patients’ appraisal of results involved multidimensional reasoning reflecting on hand function, interaction with staff and organizational matters. Thus, it is not enough to evaluate results after DD surgery only by health outcomes as this provides only a limited perspective. Rather, evaluation of results should also cover process and structure aspects of care.

• Implications for Rehabilitation

• To improve health care services, it is important to be aware of the role played by patient’s previous experiences, expectations as well as staff and organizational aspects of care.

• Knowledge about patients’ experience and view of the results from surgery and rehabilitation should be established by assessment of care effects on health as well as structure and process aspects of care.

• Evaluation of structure and process aspects of care can be done by using questions about if the patient felt listened to, received clear information and explanations, was included in decision-making, and their view of waiting time or continuity of care.

• Improving health care services means not only providing the best treatment method available but also developing individualized care by ensuring good interaction with the patient, providing accurate information, and working to improve the structure of the care process.

• Before treatment, health care providers should have a dialogue with the patient and consider previous experiences and expectations in order to ensure the patient has balanced expectations of the outcome.

     

“Staying safe” – a narrative review of falls prevention in people with Parkinson’s – “PDSAFE”

Abstract

Background: Parkinson’s disease demonstrates a spectrum of motor and non-motor symptoms. Falling is common and disabling. Current medical management shows minimal impact to reduce falls or fall-related risk factors, such as deficits in gait, strength, and postural instability. Despite evidence supporting rehabilitation in reducing fall risk factors, the most appropriate intervention to reduce overall fall rate remains inconclusive. This article aims to 1) synthesise current evidence and conceptual models of falls rehabilitation in Parkinson’s in a narrative review; and based on this evidence, 2) introduce the treatment protocol used in the falls prevention and multi-centre clinical trial “PDSAFE”.

Method: Search of four bibliographic databases using the terms “Parkinson*” and “Fall*” combined with each of the following; “Rehab*, Balanc*, Strength*, Strateg*and Exercis*” and a framework for narrative review was followed. A total of 3557 papers were identified, 416 were selected for review. The majority report the impact of rehabilitation on isolated fall risk factors. Twelve directly measure the impact on overall fall rate.

Discussion: Results were used to construct a narrative review with conceptual discussion based on the “International Classification of Functioning”, leading to presentation of the “PDSAFE” intervention protocol.

Conclusions: Evidence suggests training single, fall risk factors may not affect overall fall rate. Combining with behavioural and strategy training in a functional, personalised multi-dimensional model, addressing all components of the “International Classification of Functioning” is likely to provide a greater influence on falls reduction. “PDSAFE” is a multi-dimensional, physiotherapist delivered, individually tailored, progressive, home-based programme. It is designed with a strong evidence-based approach and illustrates a model for the clinical delivery of the conceptual theory discussed.

• Implications for Rehabilitation

• Parkinson’s disease demonstrates a spectrum of motor and non-motor symptoms, where falling is common and disabling.

• Current medical and surgical management have minimal impact on falls, rehabilitation of falls risk factors has strong evidence but the most appropriate intervention to reduce overall fall rate remains inconclusive.

• Addressing all components of the International Classification of Function in a multifactorial model when designing falls rehabilitation interventions may be more effective at reducing fall rates in people with Parkinson’s than treating isolated risk factors.

• The clinical model for falls rehabilitation in people with Parkinson’s should be multi-dimensional.

     

Gut function in the intensive care unit – What is ‘normal’?

BackgroundManagement of gut function in the intensive care unit (ICU) is often protocol-driven. Protocols for enteral feeding or bowel management are based on assumptions about what is ‘normal’ gastrointestinal motility during critical illness or in the early postoperative period, although ‘normal’ has not been well described in this group.ObjectivesThis study aimed to describe aspects of gut function based on an audit of current ICU patients.MethodsA retrospective medical audit of 100 recent consecutive ICU patients was conducted to obtain data on gut function parameters in the critically ill or postoperative population.ResultsThe audit indicated that delayed gastric emptying is common in the ICU. Regardless of the definition volume used, large gastric aspirates occurred in most enterally fed patients. Patient positioning was a significant influence, with a bed angle <30° associated with increased gastric aspirates (p = 0.0002). Constipation was more common among enterally fed patients than among orally fed ones (p = 0.001) and was associated with opioids (p = 0.009). Diarrhoea was associated with antibiotic use (p = 0.047). For enterally fed patients, the first bowel motion in the ICU occurred on average day 4.60 (standard deviation, 2.78), compared to day 2.72 (standard deviation, 1.67) for orally fed patients (p = 0.0001).ConclusionAlteration of upper and lower gastrointestinal motility is common in critically ill and early postoperative patients. Care should be taken in interpreting protocols that relate to gut function to avoid unnecessary interventions or interruptions to nutritional therapy.     

Evaluation of a part-time adult diploma nursing programme – ‘Tailor-made’ provision?

Part-time pre-registration nursing programmes aim to widen participation to female mature students and to reduce tension between domestic and study roles by 'tailoring' provision to the perceived needs of this group but there is little evidence of whether these aims are achieved. Findings are presented from an evaluation of a part-time pre-registration adult diploma nursing programme which suggest that this programme was successful in widening participation to female mature students but did not succeed in reducing role conflict for female mature students. The authors relate these findings to the literature and conclude that that this second aspect of tailoring may be difficult to achieve due to socio-economic changes, particularly increased female participation in the workforce.     

Patient participation in emergency care – A phenomenographic study based on patients’ lived experience

International guidelines promote patient participation in health care. When patients participate in their care they experience greater satisfaction. Studies have shown that patients in emergency departments express dissatisfaction with their care, and it was therefore important to study how patients understand and conceptualize their participation. The aim of this study was to describe patients’ qualitatively different conceptions of patient participation in their care in an emergency department. Based on a lifeworld perspective, nine interviews were performed with patients in an emergency department. The phenomenographic analysis shows that participation by patients means contact with the emergency department staff in three categories of conceptions: being acknowledged; struggling to become involved; and having a clear space. The different conceptions of patient participation give us a deeper understanding of how patients may experience their care, and this result may provide a foundation for developing nursing practice and the quality of health care in line with international guidelines.     

Communicating with your colleagues and your clients – remember the Seven C’s!

ABSTRACT:

Communication is a vital part of patient care and client relationship in today’s veterinary practice. Reviewing communication from the aspects of context, content, complexity, concentration, courtesy, consistency, and compassion, the article suggests ways the veterinary nurse can improve how they talk to their clients in the consult room or other areas of interaction. Improving communication directly affects client compliance, customer experience, and so leads to improved animal welfare.     

Migraine – more than a headache: women’s experiences of living with migraine

Purpose: In this qualitative study the aim was to explore the meaning of living with migraine. Methods: In-depth interviews were conducted with ten women about their experience of living with migraine. Halfway through the interview, the women drew a picture of what living with migraine is like, and the interview continued with the conversation being guided by the picture. The interviews were analyzed using a hermeneutic phenomenological method inspired by van Manen. Results: The analysis revealed an essence “Being obliged to endure a life accompanied by an unpredictable and invisible disorder” and three themes “Being besieged by an attack”, “Struggling in a life characterized by uncertainty” and “Living with an invisible disorder.” Conclusions: Migraine is a debilitating disorder which accompanies life in the sense that it or the threat of its return is always present, and yet invisible to others. The struggle of enduring life with migraine is worsened by the feeling of having an invisible disorder and of being doubted. There is a need to increase the knowledge among healthcare professionals about what it means to live with migraine, something this qualitative study offers.

Implications for Rehabilitation

• The meaning of living with migraine is experienced as having a debilitating disorder which accompanies life in the sense that it or the threat of its return is always present, and yet invisible to others.

• There is a need for healthcare professionals to increase their awareness of the meaning of living with migraine, to enable them to meet the needs of each person with migraine.

     

From resistance to rescue – patients’ shifting attitudes to antihypertensives: A qualitative study

Objective. The objective of this study was to gain a deeper knowledge and understanding of experiences of antihypertensive drug treatment. Design. Interview study. Setting. A primary health care centre in western Sweden. Method. Qualitative interviews and analyses through systematic text condensation described by Malterud. Subjects. Ten informants in pharmacological treatment for high blood pressure (six men and four women). Main outcome measure. Experiences of hypertension drug treatment. Results. The findings revealed a process starting with resistance to drug treatment related to lack of control, side effects, and unwanted awareness of impaired health. These negative feelings then changed into a positive desire for lifestyle changes caused by a fear of cardiovascular disease which in turn changed the attitude towards drugs into seeing them as a rescue remedy and something normal and this then evoked health care trust. Conclusion. Despite initial resistance to treatment, the experience of antihypertensive drug treatment became more positive with time. Confidence in the health care system is important for adherence to treatment. General practitioners have a key role in this regard.Key Words: Attitude to health, health behaviour, hypertension, patient acceptance of health care, patient compliance, process, general practice, Sweden

• Hypertension is common and a well-known risk factor for diseases such as myocardial infarction or stroke.
• Initially, most patients are resistant to antihypertensives but attitudes change if they are well informed and if they have confidence in the health care system.
• Before treatment is started the individual''s gain in risk reduction for serious events should be considered.

     

Blowin’ in the Wind – Another Study Reporting Shortfalls in Caring for Our Transgender Patients

The factors that contribute to persistent health disparities faced by the transgender community, such as lack of practitioner training and electronic health record deficiencies, are well documented. Yet, health-care leaders across settings and disciplines have not enacted the guidance provided almost a decade ago by organizations such as The Joint Commission to address the issues. This article summarizes a recent survey conducted by Goldberg, Moy, and Rosenkrantz (2018) which reported on policies and practices at breast-imaging facilities across the United States. In addition to summarizing the article that was published in the Journal of the American College of Radiology, this article discusses the relevance of Goldberg et al.’s findings. This commentary calls on health-care leaders to take action to address the festering shortfalls in care which contribute to the health disparities faced by the transgender community across all settings including radiology practices.     

Assisted normality – a grounded theory of adolescent’s experiences of living with personal assistance

Purpose: The purpose of the study was to explore how adolescents with disabilities experience everyday life with personal assistants. Method: In this qualitative study, individual interviews were conducted at 35 occasions with 16 Swedish adolescents with disabilities, in the ages 16–21. Data were analyzed using grounded theory methodology. Results: The adolescents' main concern was to achieve normality, which is about doing rather than being normal. They try to resolve this by assisted normality utilizing personal assistance. Assisted normality can be obtained by the existing relationship, the cooperation between the assistant and the adolescent and the situational placement of the assistant. Normality is obstructed by physical, social and psychological barriers. Conclusion: This study is from the adolescents’ perspective and has implications for understanding the value of having access to personal assistance in order to achieve assisted normality and enable social interaction in everyday life.

• Implications for Rehabilitation

• Access to personal assistance is important to enable social interaction in everyday life.

• A good and functional relationship is enabled through the existing relation, co-operation and situational placement of the assistant.

• If the assistant is not properly sensitized, young people risk turning into objects of care.

• Access to personal assistants cannot compensate for disabling barriers in the society as for example lack of acceptance.

     

Patients’ experiences and actions when describing pain after surgery – A critical incident technique analysis

BackgroundPostoperative pain assessment remains a significant problem in clinical care despite patients wanting to describe their pain and be treated as unique individuals. Deeper knowledge about variations in patients’ experiences and actions could help healthcare professionals to improve pain management and could increase patients’ participation in pain assessments.ObjectiveThe aim of this study was, through an examination of critical incidents, to describe patients’ experiences and actions when needing to describe pain after surgery.MethodsAn explorative design involving the critical incident technique was used. Patients from one university and three county hospitals in both urban and rural areas were included. To ensure variation of patients a strategic sampling was made according to age, gender, education and surgery. A total of 25 patients who had undergone orthopaedic or general surgery was asked to participate in an interview, of whom three declined.FindingsPain experiences were described according to two main areas: “Patients’ resources when in need of pain assessment” and “Ward resources for performing pain assessments”. Patients were affected by their expectations and tolerance for pain. Ability to describe pain could be limited by a fear of coming into conflict with healthcare professionals or being perceived as whining. Furthermore, attitudes from healthcare professionals and their lack of adherence to procedures affected patients’ ability to describe pain. Two main areas regarding actions emerged: “Patients used active strategies when needing to describe pain” and “Patients used passive strategies when needing to describe pain”.Patients informed healthcare professionals about their pain and asked questions in order to make decisions about their pain situation. Selfcare was performed by distraction and avoiding pain or treating pain by themselves, while others were passive and endured pain or refrained from contact with healthcare professionals due to healthcare professionals’ large work load.     

Problem-solving in physiotherapy – physiotherapists’ talk about encounters with patients with non-specific low back pain

Purpose: To investigate how physiotherapists talk about the choice of intervention for patients with NSLBP, particularly how professionals manage clinical encounters that may be experienced as challenging. Method: Discourse analysis was performed of four focus groups’ talk. Twenty-one experienced physiotherapists working in primary health care in southern Sweden participated. Results: Four focal themes appeared: Responsibility for health and health-related problems; Normalization – what counts as a normal back pain problem in relation to living an ordinary life; Change process – how to lead one’s life; and Individualization of the intervention in relation to the individual patient but also from the physiotherapists’ point of view. The themes shape an over-arching pattern of Problem-solving – which concerned both the professional task and the back pain problem, and was related to varying case complexity. This may have implications for the intervention the individual patient will be offered and on outcome. Conclusions: Physiotherapists’ attitudes and approaches seem to entail components of professional and personal values which may influence patients’ access to health care, with a risk for unequal assessment and intervention as a consequence. We argue that enhanced physiotherapist-patient collaboration, including patient-led problem-investigation, is a prerequisite for improved outcome in terms of patient satisfaction, and for physiotherapy development. Future investigations of patients’ roles in specific face-to-face encounters are needed.

Implications for Rehabilitation

• Varying attitudes among professionals regarding responsibility for health and health-related problems may influence patients’ access to rehabilitation, with a risk for unequal assessment and intervention as a consequence.

• Professionals’ use of personal approaches indicates that interventions may be based on professional instead of patient preferences, with consequences on patient satisfaction and outcome.

• Enhanced professional-patient collaboration which thoroughly includes patient preferences seems to be a prerequisite for improved clinical outcome in terms of patient satisfaction, and for professional development.