Towards interprofessional networking in medication management of the aged: current challenges and potential solutions in Finland

Objective: The Finnish Medicines Agency (Fimea) initiated a programme in 2012 for enhancing interprofessional networking in the medication management of the aged. The goal is to develop national guidelines for interprofessional collaboration with respect to medication management. This study aims to explore the challenges and potential solutions experienced by existing health care teams in managing medication of the aged: (1) at the individual and team level (micro level), (2) organisational level (meso level) and (3) structural level (macro level).

Design: Group discussions (n?=?10), pair (n?=?3) and individual interviews (n?=?2). Abductive content analysis combining data and theory was applied. Networking was used as a theoretical framework.

Setting: Meetings (n?=?15) organised by Fimea in the formation phase of the interprofessional network in 2012.

Subjects: Health care professionals (n?=?55).

Main outcome measures: Challenges and solutions in the medication management of the aged at the micro, meso and macro levels.

Results: Challenges in interprofessional collaboration, problems with patient record systems, and the organisation of work and lack of resources were present at all the levels contributing to patients’ medication problems. Participants suggested multiple potential solutions to improve interprofessional collaboration, sharing of tasks and responsibilities, better exploitation of pharmaceutical knowledge and developing tools as being the most commonly mentioned.

Conclusions: Optimising medication use of the aged requires new systemic solutions within and between different system levels. The main challenges can be solved by clarifying responsibilities, enhancing communication and applying operational models that involve pharmacists and the use of information technology in medication management.

• KEY POINTS

• An interprofessional team approach has been suggested as a solution to promote rational medicine use among the aged.

• Fragmented health care system and lack of coordinated patient care are reasons for medication related problems of the aged.

• Challenges in the implementation of interprofessional collaboration in medication management appear in legislation, information systems, operational models and individuals’ attitudes.

• Optimising medications requires better interprofessional networking and new systemic solutions within and between macro, meso and micro levels.

     

The quality of online antidepressant drug information: An evaluation of English and Finnish language Web sites

BackgroundThe Internet is a frequently used source of drug information, including among people with mental disorders. Online drug information may be narrow in scope, incomplete, and contain errors of omission.ObjectiveTo evaluate the quality of online antidepressant drug information in English and Finnish.MethodsForty Web sites were identified using the search terms antidepressants and masennuslääkkeet in English and Finnish, respectively. Included Web sites (14 English, 8 Finnish) were evaluated for aesthetics, interactivity, content coverage, and content correctness using published criteria. All Web sites were assessed using the Date, Author, References, Type, Sponsor (DARTS) and DISCERN quality assessment tools.ResultsEnglish and Finnish Web sites had similar aesthetics, content coverage, and content correctness scores. English Web sites were more interactive than Finnish Web sites (P < .05). Overall, adverse drug reactions were covered on 21 of 22 Web sites; however, drug-alcohol interactions were addressed on only 9 of 22 Web sites, and dose was addressed on only 6 of 22 Web sites. Few (2/22 Web sites) provided incorrect information. The DISCERN score was significantly correlated with content coverage (r = 0.670, P < .01), content correctness (r = 0.663, P < .01), and the DARTS score (r = 0.459, P < .05).ConclusionsNo Web site provided information about all aspects of antidepressant treatment. Nevertheless, few Web sites provided incorrect information. Both English and Finnish Web sites were similar in terms of aesthetics, content coverage, and content correctness.     

Genetic Variant in HK1 Is Associated With a Proanemic State and A1C but Not Other Glycemic Control�CRelated Traits

OBJECTIVE

A1C is widely considered the gold standard for monitoring effective blood glucose levels. Recently, a genome-wide association study reported an association between A1C and rs7072268 within HK1 (encoding hexokinase 1), which catalyzes the first step of glycolysis. HK1 deficiency in erythrocytes (red blood cells [RBCs]) causes severe nonspherocytic hemolytic anemia in both humans and mice.

RESEARCH DESIGN AND METHODS

The contribution of rs7072268 to A1C and the RBC-related traits was assessed in 6,953 nondiabetic European participants. We additionally analyzed the association with hematologic traits in 5,229 nondiabetic European individuals (in whom A1C was not measured) and 1,924 diabetic patients. Glucose control–related markers other than A1C were analyzed in 18,694 nondiabetic European individuals. A type 2 diabetes case-control study included 7,447 French diabetic patients.

RESULTS

Our study confirms a strong association between the rs7072268–T allele and increased A1C (β = 0.029%; P = 2.22 × 10⁻⁷). Surprisingly, despite adequate study power, rs7072268 showed no association with any other markers of glucose control (fasting- and 2-h post-OGTT–related parameters, n = 18,694). In contrast, rs7072268–T allele decreases hemoglobin levels (n = 13,416; β = −0.054 g/dl; P = 3.74 × 10⁻⁶) and hematocrit (n = 11,492; β = −0.13%; P = 2.26 × 10⁻⁴), suggesting a proanemic effect. The T allele also increases risk for anemia (836 cases; odds ratio 1.13; P = 0.018).

CONCLUSIONS

HK1 variation, although strongly associated with A1C, does not seem to be involved in blood glucose control. Since HK1 rs7072268 is associated with reduced hemoglobin levels and favors anemia, we propose that HK1 may influence A1C levels through its anemic effect or its effect on glucose metabolism in RBCs. These findings may have implications for type 2 diabetes diagnosis and clinical management because anemia is a frequent complication of the diabetes state.Type 2 diabetes is a major source of early excess morbidity and mortality, which result from lack of adequate blood glucose control in most diabetic patients (1). In the absence of widely available continuous glucose monitoring, the A1C assay has become the most popular index to evaluate the efficiency of type 2 diabetes treatments on long-term blood glucose control (2,3). A1C, which is formed through the nonenzymatic attachment of glucose to the NH₂-terminal of the β-chain of hemoglobin, is indeed commonly considered a surrogate marker of mean blood glucose concentration over the previous 8–12 weeks (i.e., a 120-day life span of erythrocytes) (4). Furthermore, the A1C assay is often used for confirming type 2 diabetes diagnosis when fasting plasma glucose (FPG) is in the pre-diabetes range (6.1 ≤ FPG <7.0 mmol/l, defining normal glycemia and overt diabetes, respectively [2]), as postprandial or post–glucose load measurements of blood glucose are difficult to widely apply in clinical practice. However, the A1C measurement displays well-known caveats, such as genetically inherited hemoglobin defects or erythrocyte (red blood cell [RBC]) life span heterogeneity in hematologically normal people, that would oblige the use of more complex measurement of glycated serum proteins or fructosamine as a surrogate of blood glucose levels (5,6).Thus far, several genome-wide association (GWA) studies have identified 22 genes or loci, increasing the risk for type 2 diabetes or modulating FPG levels (7–19). Recently, Pare et al. (20) reported a single nucleotide polymorphism (SNP), rs7072268, at the hexokinase 1 (HK1) locus (chr10q22) that strongly associates with increased A1C in a nondiabetic population. The four isozymes of the hexokinase family (HK1, HK2, HK3, and glucokinase) contribute to commit glucose to the glycolytic pathway. The predominant HK1 isozyme is expressed in the vast majority of cells and tissues, including cells that are strictly dependent on glucose uptake for their metabolic needs (21). Importantly, while most tissues express more than one HK isozyme, RBC glucose metabolism only depends on HK1 activity (22). In humans, mutations including nonsynonymous substitutions in the active site of HK1 and intragenic deletions have been shown to cause HK1 enzymatic deficiency associated with autosomal recessive severe nonspherocytic hemolytic anemia (21,23–25). A similar phenotype has been described in the Downeast Anemia (dea) mice displaying HK1 deficiency (22).Based on these observations, we postulated that HK1 genetic variation may modulate the maintenance of the RBC pool and thus indirectly alter A1C measurements independently of the ambient blood glucose concentration. We evaluated this hypothesis by assessing the impact of HK1 rs7072268 on A1C, other glucose control-related traits, type 2 diabetes risk, and RBC-related parameters in several prospective and case-control European cohorts. Our data suggest that HK1 variation through its anemic effect impairs A1C assays, which may have important clinical implications for both type 2 diabetes diagnosis and management because anemia is commonly associated with diabetes.     

Family caregivers of people with dementia

Family caregivers of people with dementia, often called the invisible second patients, are critical to the quality of life of the care recipients. The effects of being a family caregiver, though sometimes positive, are generally negative, with high rates of burden and psychological morbidity as well as social isolation, physical ill-health, and financial hardship. Caregivers vulnerable to adverse effects can be identified, as can factors which ameliorate or exacerbate burden and strain. Psychosocial interventions have been demonstrated to reduce caregiver burden and depression and delay nursing home admission. Comprehensive management of the patient with dementia includes building a partnership between health professionals and family caregivers, referral to Alzheimer''s Associations, and psychosocial interventions where indicated.     

Dimensional models of personality disorder: Diagnostic and Statistical Manual of Mental Disorders Fifth Edition and beyond

PURPOSE OF REVIEW: We describe several dimensional models of personality disorders and highlight future directions for the integration of dimensional approaches in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). This review is timely and relevant, given the upcoming revision of DSM (DSM-V). RECENT FINDINGS: Research has identified four common higher order factors that could be used to characterize personality pathology. Evidence supports the inclusion of this dimensional representation of personality disorders in DSM-V, possibly as an adjunct to the traditional categorical classification scheme. A dimensional approach would ameliorate many of the problems associated with the categorical approach. Issues that still need to be addressed are on how to integrate these dimensions into the current classification system in a way that they will be accepted by clinicians and psychopathologists. The clinical utility of the dimensional models must be demonstrated, and the development of a method that combines trait elevations and impairment associated with personality pathology is needed in order to define personality disorder from a dimensional perspective. SUMMARY: Although there may be some initial resistance to the incorporation of the dimensional models in the future diagnostic manuals, researchers and clinicians are expected to benefit from the more reliable and valid portrayal of personality pathology.     

Persistence of Helicobacter pylori infection in patients with peptic ulcer perforation

OBJECTIVE: In patients with perforated peptic ulcer (PPU) the convergence between the high eradication rate of Helicobacter pylori infection and low rates of ulcer relapse after treatment has been associated with reinfection by non-virulent strains. The objective of this study was to evaluate the persistence of infection by virulent H. pylori strains and ulcer recurrence in 33 patients with PPU one year after surgery and antimicrobial treatment. MATERIAL AND METHODS: The histological evaluation and molecular detection of H. pylori cagA and ureA genes, vacA allelic types and the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analyses of the glmM gene products from antral mucosa specimens were performed initially, 2-5 months and 1 year after therapy. RESULTS: The density of H. pylori colonization was temporarily decreased (p<0.05) 2-5 months after therapy. After one year, complete eradication was achieved in only 7 patients (23%) at histological examination and recurrent ulcers were found in 3/33 (9%) patients. The vacA s1a allelic type of cagA-positive strains persisted in 19/33 (58%) PPU patients with identical PCR-RFLP fingerprints in 8/9 (89%) of the patients. CONCLUSIONS: In PPU patients with a low eradication rate of H. pylori infection after surgical and antimicrobial treatment, the frequent recrudescence of the infection is mostly caused by the persisting virulent strains of the cagA and vacA s1a subtypes. In the 1-year follow-up period the recurrent ulceration can be postponed just by the lowered colonization density of H. pylori after eradicative therapy.     

Rhinovirus-associated hospitalizations in young children

BACKGROUND: Rhinoviruses frequently cause the common cold but have not been considered important causes of acute respiratory hospitalizations in children. METHODS: A population-based surveillance study was performed among children <5 years of age who were hospitalized with respiratory symptoms or fever and who resided within counties encompassing Nashville, Tennessee, or Rochester, New York, from October 2000 through September 2001. Data collected included questionnaires, nasal and throat swabs for viral culture and polymerase chain reaction testing, and chart review. Rates of rhinovirus-associated hospitalizations were calculated. RESULTS: Of 592 children enrolled, 156 (26%) were rhinovirus positive, representing 4.8 (95% confidence interval [CI], 4.3-5.2) rhinovirus-associated hospitalizations/1000 children. Age-specific rates per 1000 children were 17.6 (95% CI, 14.9-20.6) for 0-5-month-olds, 6.0 (95% CI, 5.0-7.0) for 6-23-month-olds, and 2.0 (95% CI, 1.6, 2.4) for 24-59-month-olds (P<.01). Children with a history of wheezing/asthma had significantly more rhinovirus-associated hospitalizations than those without a history (25.3/1000 children [95% CI, 21.6-29.5/1000 children] vs. 3.1/1000 children [95% CI, 2.7-3.5/1000 children]). CONCLUSIONS: Rhinoviruses were associated with nearly 5 hospitalizations/1000 children <5 years of age and were highest in children with a history of wheezing/asthma.     

Age related changes of human aortic distensibility: evaluation with ECG-gated CT

Aortic distensibility is a parameter to grade vascular diseases and age-related effects because it is related to the elastic properties of the vessel wall. In this study vascular cross-sectional area changes have been determined using ECG-gated CT to analyse the age dependency of aortic distensibility. Distensibility measurements of the aorta were performed in 31 subjects (28 to 85 years). Time-resolved images were acquired either with a 4- or 16-detector row CT system using a modified CT angiography protocol. Cross-sectional area changes of the aorta were calculated by semiautomatic segmentation, and distensibility values were obtained using additional systemic blood pressure measurements. The aorta could be segmented successfully in all subjects. A decrease of aortic distensibility with age was found (r=0.50). Below (above) the renal arteries, the annual decrease was Δ D _infrarenal =(−2.1±0.7)·10⁻⁷ Pa⁻¹a⁻¹, (D _suprarenal Δ=(−3.5±1.1)·10⁻⁷ Pa⁻¹a⁻¹). Differences between the ages, the youngest third and oldest third studied, were found to be significant (P _suprarenal =0.003; P _infrarenal =0.025). An age-dependent decrease of aortic wall elasticity can be determined in a modified routine CT angiography study.