Multicentre study of validity and interrater reliability of the modified Nursing Care Recording System (NCR11) for assessment of workload in the ICU

BACKGROUND: Reliable assessment of nursing workload is necessary for the quantitative approach to staffing of intensive care units. The Nursing Care Recording System (NCR11) scores both the nursing contribution to patient care and those related to medical procedures. The purpose of the present work was to compare NCR11 scoring with the Therapeutic Intervention Scoring System (TISS) and Nine Equivalents of Nurse Manpower use Score (NEMS) and to examine the interrater reliability of NCR11 scoring. METHODS: Bias and precision of workload scores (NCR11 vs. TISS or NEMS) were assessed for 6126 consecutive admissions (23910 ICU-days) at three intensive care units. Inter-rater reliability was analyzed by having nurses at nine ICUs score workload using NCR11 for three dummy intensive care patient cases presented over a 3-year period. Variability in scoring was analyzed using the coefficient of variation. RESULTS: Agreement between NCR11 and TISS or NEMS was poor and limits of agreement were wide. Linear relationships between NCR11 and TISS or NEMS scores differed between units. Variability in NCR11 scoring decreased significantly from 10.4% to 5.9% between dummy cases 1 and 2 and remained low for patient case 3. CONCLUSION: The NCR11 does not measure the same elements of workload in the ICU as do TISS and NEMS. Inter-rater reliability with NCR11 is good, showing little variation in scoring between nurses.     

Impaired incretin response after a mixed meal is associated with insulin resistance in nondiabetic men

OBJECTIVE: To investigate whether features of the insulin resistance syndrome are associated with altered incretin responses to food intake. RESEARCH DESIGN AND METHODS: From a population-based study, 35 men were recruited, representing a wide spectrum of insulin sensitivity and body weight. Each subject underwent a hyperinsulinemic-euglycemic clamp to determine insulin sensitivity. A mixed meal was given, and plasma levels of gastric inhibitory polypeptide (GIP) and glucagon-like peptide 1 (GLP-1), as well as insulin, glucagon, and glucose were measured. RESULTS: Insulin resistance was associated with impaired GIP and GLP-1 responses to a mixed meal. The total area under the curve (AUC) of the GIP response after the mixed meal was associated with insulin sensitivity (r = 0.54, P < 0.01). There was a significant difference between the highest and the lowest tertile of insulin sensitivity (P < 0.05). GLP-1 levels 15 min after food intake were significantly lower in the most insulin-resistant tertile compared with the most insulin-sensitive tertile. During the first hour, the AUC of GLP-1 correlated significantly with insulin sensitivity (r = 0.47, P < 0.01). Multiple linear regression analysis showed that insulin resistance, but not obesity, was an independent predictor of these decreased incretin responses. CONCLUSIONS: In insulin resistance, the GIP and GLP-1 responses to a mixed meal are impaired and are related to the degree of insulin resistance. Decreased incretin responsiveness may be of importance for the development of impaired glucose tolerance.     

Gender differences in secondary prevention of coronary heart disease: reasons to worry or not?

OBJECTIVE: To analyse potential gender differences in cardiovascular risk factors and treatment patterns, reflecting clinical practice in secondary prevention. DESIGN: Observational national study during 3 years of patients eligible for secondary prevention of coronary heart disease (CHD). SETTING: Fifty-two healthcare districts in Sweden, involving primary health care and hospitals in collaboration, participating in a national quality assurance programme for the prevention of CHD. SUBJECTS: A national sample of male and female patients surviving acute myocardial infarction, or following CABG/PTCA interventions for CHD, controlled at 3-6 months (n = 9135) and 12 months (n = 4802) of follow-up. The proportion of female patients (25%) did not differ between visits. MAIN OUTCOME MEASURES: Self-reported data on lifestyle, drug treatment and cardiovascular risk factor levels after consultation in general practice or at hospital policlinics. RESULTS: No major gender differences were recorded in risk factor levels or in cardiovascular drug treatment patterns at 12 months of follow-up. Female patients participated in educational programmes to improve lifestyle to a higher degree than males (52.0 vs 45.1%), but after 1 year were more often (p < 0.001) self-reported smokers (11.7 vs 8.4%). Female patients showed higher levels of blood pressure, total cholesterol and HDL cholesterol, but not LDL cholesterol compared to male patients. CONCLUSIONS: In general, a gender-equal level of lipid control and access to medical drug treatment has been established for patients in secondary prevention from a national sample in Sweden, followed for 1 year after CHD manifestations and related interventions.     

Multiple factors affect the loss of measurable C-peptide over 6 years in newly diagnosed 15- to 35-year-old diabetic subjects

OBJECTIVE: The aim of this study is to identify risk factors for the loss of measurable plasma C-peptide in newly diagnosed 15- to 35-year-old diabetic subjects. METHODS: This Swedish study included 778 subjects. C-peptide levels were obtained each year for 6 years after diagnosis. Loss of measurable C-peptide was defined as a level at or below the lower detection limit of the local assay (0.13 nmol/l). In addition to C-peptide, other baseline covariates included gender, age, body mass index, HLA genotype, and autoantibody levels. RESULTS: Compared with autoantibody-negative subjects, autoantibody-positive subjects had lower median baseline C-peptide (0.27 vs. 0.50, P<.001), their levels declined over the study period, and the risk of losing measurable C-peptide was significantly higher when more than one autoantibody was present [odds ratio (OR), 4.0; 95% confidence interval (CI), 2.13-7.54]. Among autoantibody-positive individuals, the presence of GAD65Ab (OR, 1.8; 95% CI, 1.24-2.51) and islet cell antibodies (OR, 1.6; 95% CI, 1.19-2.18) conferred a higher risk for loss of measurable C-peptide as did female gender (OR, 1.6; 95% CI, 1.17-2.11) and time after diagnosis (OR, 1.5 for each additional year postdiagnosis; 95% CI, 1.41-1.57). Higher baseline C-peptide levels were protective (OR, 0.5 for each additional log(e) nanomoles per liter; 95% CI, 0.36-0.58). CONCLUSIONS: This study identified autoantibody status, gender, and baseline C-peptide levels as factors that will be useful for predicting the disease course of 15- to 35-year-old diabetic individuals.     

Predictors of successful long-term blood pressure control in type 2 diabetic patients: data from the Swedish National Diabetes Register (NDR)

BACKGROUND: Hypertension in patients with diabetes is a well recognized cardiovascular risk factor for which the benefits of treatment are strongly evidence based. Less is known about predictors for successful long-term blood pressure control in these patients, including the potential role of body mass index (BMI), glycaemic control, microalbuminuria and smoking. MATERIAL AND METHODS: We used longitudinal data on risk factor levels from repeated clinical surveys of 1759 type 2 diabetic patients in the Swedish National Diabetes Register (NDR), a nationwide annual registration of quality indicators in diabetes care. Subjects with successful blood pressure (BP) control (systolic BP < 135 mmHg and diastolic BP < 85 mmHg) at baseline in 1997, in 2001, and at follow-up in 2003, were compared to subjects with BP control >or= 135/85 mmHg. RESULTS: Logistic regression analysis disclosed that successful BP control during the study period was predicted by lower BMI (P < 0.001), a lower frequency of microalbuminuria (P = 0.002), and lower age (P < 0.001) at baseline in 1997, and was still associated with lower BMI (P < 0.001), a lower frequency of microalbuminuria (P = 0.01) and lower age (P < 0.001) at follow-up. Successful BP control was also associated at follow-up with a lower frequency of the metabolic syndrome (30 versus 75%) and lower predicted 10-year risks [United Kingdom Prospective Diabetes Study (UKPDS) Risk Engine] of coronary heart disease (14 versus 29%) and stroke (10 versus 22%) (all P < 0.001). CONCLUSION: A lower BMI and absence of microalbuminuria were strong independent predictors of long-term successful BP control in type 2 diabetic patients, also characterized by a lower frequency of the metabolic syndrome and lower 10-year risk of cardiovascular disease. This implies the long-term benefits on BP control of lifestyle measures as well as control of microalbuminuria.     

Islet antibodies and remaining beta-cell function 8 years after diagnosis of diabetes in young adults: a prospective follow-up of the nationwide Diabetes Incidence Study in Sweden

Objectives. To establish the prevalence of remaining β‐cell function 8 years after diagnosis of diabetes in young adults and relate the findings to islet antibodies at diagnosis and 8 years later. Design. Population‐based cohort study. Setting. Nationwide from all Departments of Medicine and Endocrinology in Sweden. Subjects. A total of 312 young (15–34 years old) adults diagnosed with diabetes during 1987–88. Main outcome measure. Plasma connecting peptide (C‐peptide) 8 years after diagnosis. Preserved β‐cell function was defined as measurable C‐peptide levels. Three islet antibodies – cytoplasmic islet cell antibodies (ICA), glutamic acid decarboxylase antibodies and tyrosine phosphatase antibodies – were measured. Results. Amongst 269 islet antibody positives (ab⁺) at diagnosis, preserved β‐cell function was found in 16% (42/269) 8 years later and these patients had a higher body mass index (median 22.7 and 20.5 kg m^?2, respectively; P = 0.0003), an increased frequency of one islet antibody (50 and 24%, respectively; P = 0.001), and a lower prevalence of ICA (55 and 6%, respectively; P = 0.007) at diagnosis compared with ab⁺ without remaining β‐cell function. Amongst the 241 patients without detectable β‐cell function at follow‐up, 14 lacked islet antibodies, both at diagnosis and at follow‐up. Conclusions. Sixteen per cent of patients with autoimmune type 1 diabetes had remaining β‐cell function 8 years after diagnosis whereas 5.8% with β‐cell failure lacked islet autoimmunity, both at diagnosis and at follow‐up.     

Toxic "ictal" confusion in middle age: treatment with benzodiazepines.

In adult and elderly non-epileptic subjects psychoactive drugs may cause an altered state of consciousness and repetitive irritative EEG discharges. The neurotoxic pathogenesis of this drug-induced confusion and the differentiation from absence status are discussed. Dramatic relief by intravenous benzodiazepines is detailed. Recovery is complete and prognosis is excellent on withdrawal of the offending drug.     

Neuroleptic neurotoxicity; electro-clinical aspects

ABSTRACT— The clinical signs of psychotropic drug-induced neurotoxicity can be based on different neurochemical actions. Patients presenting with neurotoxic signs such as epileptic phenomena and altered states of consciousness are represented. Predisposing factors, EEG and clinical data and electro-clinical correlations are discussed and related to age and the drugs involved. It appears that in young patients, electro-clinical syndromes exist differentiating early from late-onset cerebral reactions. In the elderly, signs of neurotoxicity usually show an early onset and particular electro-clinical features. Finally pathogenetic considerations are reviewed.     

Periodic EEG discharges in psychiatry

Periodic EEG discharges are signs of severe CNS dysfunction. In psychiatry they usually indicate presenile dementia of the Jacob-Creutzfeldt type. Psychiatric patients are presented in whom the occurrence and EEG features of diffuse and lateralized periodic discharges are discussed. It appears that toxic conditions other than acute barbiturate intoxication, such as drug withdrawal states and psychotropic drug overdosage, represent important etiological factors for inducing periodic EEG discharges. Their relation to clinical signs such as epileptic symptoms, metabolic dysfunction, and disturbance of consciousness is particularly stressed and related to current literature data.