A network-based rehabilitation model for frail elderly people: development and assessment of a new model

INTRODUCTION AND PURPOSE: Living independently at home promotes the well-being of people aged 65 and over. In Finland, the municipalities are responsible for providing social and health services, including rehabilitation of the elderly. Rehabilitation is in practice carried out by independent rehabilitation centres. The Social Insurance Institution of Finland is a national agency responsible for financing and developing rehabilitation. Combining the efforts of these three agencies, a new network-based inpatient rehabilitation model was established to support the community living of frail elderly persons at high risk of institutionalization. This article describes the new model and evaluates the cooperation within the rehabilitation network, as well as the contents of the rehabilitation. MATERIAL AND METHODS: The new model was evaluated in two phases using diverse methods. First, the networks were assessed as they were being established in 2000, and secondly, when they were operational in 2002. The first phase involved 53 networks operating in 46 municipalities and 12 rehabilitation centres, and the second 44 networks in 41 municipalities and seven rehabilitation centres. The data were collected by questionnaires, interviews and reports. RESULTS: The rehabilitation networks were functional, although constant development and search for better working practices was time consuming. Two different approaches in the networks were found: the 'networks of creators' were able to carry out the new tasks highly successfully, while the 'networks of followers' only managed to do the minimum as instructed. Motivated network members and adequate resources appeared to be essential for a successful rehabilitation process. CONCLUSIONS: It is possible to create a functional rehabilitation network involving different agencies. Further development work is necessary to make the network-based rehabilitation model more efficient.     

The impact of arthritis on daily life with the patient perspective in focus

BACKGROUND: Rheumatoid arthritis (RA) often has a major impact on many areas of an individuals' life. The unpredictability of the prognosis as well as the day-to-day symptoms make it impossible to plan ahead. The aim of this study was to identify the domains of concern in the early course of RA. METHODS: Interviews were carried out according to the focus group method. Twenty-three patients with RA, aged between 27 and 67 years and with a disease duration ranging from 1 to 5 years, were included. Four groups were established, the composition of which was based on age, gender and social situation. RESULTS: Arthritis had a major impact on daily life of the patients, especially on the way they performed activities. It also strongly influenced their mood and social life. The participants tried to cope by 'dosing their activities', 'using new strategies' or to 'stretching their limits'. Their sense of helplessness and uncertainty led to both 'anger' and 'depression'. When activities could no longer be maintained, the role positioning in the family also changed. CONCLUSION: The results of this study support the view that more psychosocial support is required to encourage the recently diagnosed RA patient in the new situation of having a chronic disease.     

Effect of manual therapy and stretching on neck muscle strength and mobility in chronic neck pain.

OBJECTIVE: To study the effect of manual therapy and stretching on neck function in women with chronic neck pain. METHODS: A total of 125 women were randomized into 2 groups. Group 1 received manual therapy twice a week for 4 weeks followed by stretching exercises. Group 2 performed stretching 5 times a week for 4 weeks followed by manual therapy. Neck function was assessed by isometric neck strength and mobility measurements, and spontaneous neck pain during the past week and strain-evoked pain during the neck strength trials using a visual analogue scale. RESULTS: Both neck muscle strength (11-14%) and mobility (7-15%) improved similarly in both groups, with the exception of greater passive flexion-extension mobility (p = 0.019) in group 1 at week 4. Pain during the neck strength trials decreased from the baseline to week 4 by 26-35% and to week 12 by 39-61% similarly in both groups. Average neck pain during the past week decreased by 64% and 53% in groups 1 and 2, respectively, during the first 4 weeks, remaining rather stable thereafter. The decreases in neck pain during both the past week and strength trials showed association with the changes in neck strength results (r = 0.20-0.29). CONCLUSION: Both manual therapy and stretching were effective short-term treatments for reducing both spontaneous and strain-evoked pain in patients with chronic neck pain. It is possible that the decrease in pain reduced inhibition of the motor system and in part improved neck function. However, the changes in neck muscle strength were minor, showing that these treatments alone are not effective in improving muscle strength.     

Rate responsive pacing using transthoracic impedance minute ventilation sensors: a multicenter study on calibration stability

Previous studies showed that transthoracic impedance minute ventilation (IMV), as measured by a pacemaker sensor, is closely correlated to actual minute ventilation (VE) determined by standard methods. The aim of this study was to analyze the changes in the calibration between IMV and VE at rest and during exercise over time. Fifteen patients (age 60 +/- 13 years) with Medtronic Kappa 400 pacemakers completed a baseline visit followed by two visits separated by 1 month and 1 week, respectively. In each patient, VE (L/min) was monitored at rest in the supine and sitting positions and during graded bicycle ergometer exercise using a standard cardiopulmonary metabolic gas analysis system with simultaneous recording of IMV (omega/min) using DR-180 extended telemetry monitors. Calibration at rest was defined as the ratio of IMV to VE, calculated from 1-minute average values in the supine and sitting positions. Calibration during bicycle exercise was defined as intercept (IMV value at VE = 10 L/min-typical VE value at beginning of exercise), and slope of the IMV/VE regression line. The calibration of IMV showed individual variability over time. The magnitude (absolute value) of observed fractional changes in calibration at 1 month was 0.23 +/- 0.20 (rest-supine), 0.20 +/- 0.15 (rest-sitting), 0.18 +/- 0.19 (exercise-intercept), 0.28 +/- 0.35 (exercise-slope), and 0.18 +/- 0.15, 0.15 +/- 0.09, 0.28 +/- 0.39, and 0.27 +/- 0.15, respectively, at 1 week. The magnitude of change at 1 month was not statistically different from the magnitude of change at 1 week. In conclusion, the calibration of IMV, as measured by a pacemaker sensor, versus actual VE may demonstrate variability. However, this study also suggests that the observed changes are not cumulative over time. These results have implications for patient monitoring applications using these sensors and for development of future pacemaker rate response algorithms.     

Splanchnic Secretion Rates of Plasma Triglycerides and Total and Splanchnic Turnover of Plasma Free Fatty Acids in Men with Normo- and Hypertriglyceridaemia

Abstract. Plasma triglyceride (TG) “turnover rates” were estimated in the fasting state in three different ways: splanchnic chemical TG secretion, splanchnic isotope TG secretion and plasma TG clearance. Forty-two men with a wide range of fasting plasma TG concentrations, from 0.53 to 16.50 mmol/l were investigated. A constant intravenous infusion of albumin-bound ³H-labelled palmitate was given and blood was simultaneously sampled from the hepatic vein and an artery for determination of hepatic venous-arterial differences of labelled and unlabelled plasma TG. In addition total and splanchnic turnovers of plasma FFA were measured. Similar values were obtained for plasma TG “turnover rate” by the splanchnic chemical TG secretion and the plasma TG clearance method. The values for these two methods varied between 3 and 74 μmol/min. and m² body surface area, except for two cases who had considerably higher values. The splanchnic isotope TG secretion method gave lower values varying from 1 to 34 μmol/min. and m² body surface area. This method probably measures only that fraction of the splanchnic TG secretion which is derived from plasma FFA. No correlations were found among normotriglyceridaemic subjects between plasma total TG or VLDL-TG concentrations and plasma TG “turnover rates” measured by any of the three methods. For patients with hypertriglyceridaemia significant positive correlations were found between plasma VLDL-TG concentrations and plasma “turnover rates”. The “fractional turnover rate” decreased with increasing TG levels in an apparently hyperbolic fashion. The results suggest an impaired plasma TG removal capacity in patients with hypertriglyceridaemia. In 7 out of 14 patients the plasma TG “turnover rates” were in the upper part of the normal range and seemed to have contributed to the hypertriglyceridaemia in these patients. Plasma FFA turnover rate ranged between 102 and 439 μmol/min. and m² body surface area. On the average splanchnic FFA mobilization and uptake were about 30 and 60 per cent respectively of total FFA turnover rate. Significant positive correlations were found for the interrelationships between the three plasma FFA total and splanchnic transport parameters. Significant positive correlations were found between the three plasma TG “turnover rates” and total and splanchnic turnover of plasma FFA in subjects with normal plasma TG concentrations. Some patients with hypertriglyceridaemia fell outside the intervals of 99 per cent confidence of the regression analyses for the normo-triglyceridaemic subjects. This group had higher TG “turnover rates” than “expected” from plasma FFA turnover rates and may represent a distinctive group of hypertriglyceridaemia from the point of view of pathogenesis. It was concluded that all patients with hypertriglyceridaemia who were investigated had decreased “fractional turnover rates” of plasma TG indicating a decreased removal capacity which might be a primary cause of the hypertriglyceridaemia although inflow of plasma TG seemed to be an essential contributing factor in half the number of patients.     

Age-Dependent Fracture Risk in Hip Revisions With Radial Impaction Grafting Technique : A 5–10 Year Medium-Term Follow-Up Study

Radial impaction grafting (RIG) potentially improves the durability and reliability of cementing the femoral components in revision total hip arthroplasty (THA). In this multicenter, prospective study, 88 revision THAs (87 patients) with RIG technique were performed. The average follow-up time was 7.0 years (range, 5.0–10.2). There were 14 femur fractures: 2 intraoperative, 5 within 3 months after surgery, and 7 later in the postoperative stage (range, 5–84 months). Sixteen patients were lost to follow-up and 20 died without stem re-revision. None of the patients have been re-revised for any reason during follow-up. Age was observed to be a significant factor for determining fracture risk. In conclusion, RIG can be considered a reliable surgical technique, especially for younger patients.     

Evaluation of a controlled,national collaboration study on a clinical pharmacy service of screening for risk medications

Background Risk medications are frequently associated with adverse events and hospitalisations. Objective To evaluate a risk medication screening service for in-patients at Danish hospitals. Setting Danish hospitals. Methods The study was designed as a controlled, prospective intervention study. Inpatients were screened for the use of five risk medications; anticoagulants, digoxin, methotrexate, NSAIDs and opioids, and during the intervention period recommendations were made by clinical pharmacists according to a standardized intervention scheme. The recommendations were discussed with the physician face-to-face. Main outcome measure Readmissions within 6 months after discharge. Results In total, 1,007 control and 775 intervention patients were included in the study. The study found that half of the patients (50 % during the control and 48 % during the intervention period) admitted to Danish hospitals were treated with at least one of the five selected risk medications, significantly more drug related problems (DRPs) were identified during the control period (1.7/patient during the control and 1.4/patient during the intervention period (p < 0.001)), and the acceptance rate of recommendations (62 %) was similar to medication management service studies in the literature (39–100 %). However, no impact on outcome measures was found. The majority (69 %) of the clinical pharmacists reported that they had increased their professional competences by participating in the study, and that a national clinical pharmacy study may be used in promoting and implementing a unique clinical pharmacy service throughout the country (67 %). Conclusion The study showed that a national screening service for risk medications could help identify and address DRPs. Despite no impact on the selected outcome measures, it is likely that the screening service could be included in a medication management review with further focus on the individual patient to ensure positive outcomes, or that the screening service should be delivered to selected patients groups, who might have maximum benefit of the service.     

Smoking,nicotine dependence and nicotine intake by socio-economic status and marital status

Introduction

Low socio-economic status (SES) is strongly related to smoking, but studies examining the association of SES with nicotine dependence (ND) are scarce. The aim of this study was to examine the associations of SES and marital status with smoking, multiple measures of ND, and cotinine as a nicotine intake biomarker.

Methods

The sample comprised 1746 ever smokers, sampled from the National FINRISK 2007 Study, who had completed a tobacco specific questionnaire in addition to the standard clinical examination. The Fagerström Test for Nicotine Dependence (FTND), the Heaviness of Smoking Index (HSI), the Nicotine Dependence Syndrome Scale (NDSS), and the Hooked On Nicotine Checklist (HONC) were assessed, while plasma cotinine was measured as a biomarker of nicotine exposure in daily smokers. Univariate and multivariate associations were assessed by linear regression and multinomial logistic regression.

Results

In multivariate models, lower education was associated with higher FTND and HSI, income with HSI, and occupation with HSI (men only), FTND, HONC and NDSS scores. Lower education was related to higher cotinine levels among daily smokers, although the association diminished slightly after adjusting for daily smoking amount. Living without a spouse was associated with daily smoking and higher ND.

Conclusion

In this cross-sectional study low SES was linked with higher ND among current smokers, while low SES was associated with higher cotinine levels among daily smokers. Living alone was linked with higher ND. Longitudinal studies are warranted to further explore these associations. As lower SES smokers are more addicted they may need more targeted cessation services to succeed in quitting smoking.     

Sleep–wake activity rhythm and health‐related quality of life among patients with coronary artery disease and in a population‐based sample—An actigraphy and questionnaire study

The aim of this study was to explore whether there are gender differences in sleep and health‐related quality of life in patients with coronary artery disease (CAD) and a matched population‐based sample and to see how subjectively rated sleep is associated with actigraphy. Secondly, to explore whether factors that predict patients' sleep quality could be identified. Fifty‐seven patients with stable CAD and 47 participants from a population‐based sample were included. All participants completed the Uppsala Sleep Inventory (USI), the Epworth Sleepiness Scale and the SF‐36. Actigraphy recordings and a sleep diary were performed for seven 24‐h periods. Multiple stepwise regression analysis showed that sleep duration, sleep onset latency, nocturnal awakenings, vitality (SF‐36) and body mass index explained 60% of the sleep quality outcome (USI). Sleep duration, sleep efficiency and fragmentation index assessed with actigraphy and sleep diary accounted for 36% of the sleep quality outcome (diary). The result can form the basis for a non‐pharmacological, self‐care programme supported and led by nurses.