Evidence-based early stage type 2 diabetes follow-up in Belgian primary care practices: Impact of multi-professional teams and care protocols

AIM

The aim of this research is to explore the current early-stage diabetes mellitus type 2 care in Belgian general practices. This, to find out if the care is provided according to the proposed evidence-based national diabetes care guideline. Additionally, this research aims to detect which person and practice characteristics can be associated with a more evidence-based care provision.

METHODS

People were included in the study if they were recently diagnosed with type 2 diabetes by the participating practice. Practice and person characteristics, and clinical parameter monitoring and lifestyle monitoring data were collected by using a questionnaire and a topic list.

RESULTS

A total of 27 general practices participated and a total of 249 people were included through their patient records. People monitored in a practice according to a self-developed protocol were 5.5 times more likely to have a better clinical parameter follow-up. Larger practices (>2000 patients), follow-up by general practitioners and practice nurses together and according to self-developed protocols were associated with a significantly better lifestyle follow-up.

CONCLUSION

Practices providing multidisciplinary diabetes care, in collaboration with practice nurses, and with diabetes care based on self-developed protocols achieved a more comprehensive follow-up.

Practice nurse support and task suitability in a general practice: a cross-sectional survey in Belgium

Single-handed general practices and group practices are the two predominant modes of primary care provision across European countries. In Belgium, single-handed practices have been the main form of primary care provision for years, but recently a trend is emerging towards introducing more group practices where a number of primary care physicians collaborate with other health professionals such as primary care nurses. The aim of this study was to measure the current support in general practices, and to gain insight in the general practitioner attitudes towards being supported by a practice nurse. A cross-sectional study was conducted among general practitioners who were currently working in a general practice in Flanders (Belgium). 271 general practitioners filled out an online questionnaire. 30% declared to be supported by a practice nurse. The majority (>80%) of general practitioners showed positive attitudes towards collaboration with practice nurses, however the job profile and ethical framework of practice nurses remain insufficiently clear. Nurses are found most suitable to take on tasks concerning patient education and technical nursing skills. Despite the lack of governmental incentives in Belgium, general practitioners have taken the initiative to employ practice nurses - possibly - based upon an experienced necessity.

An overview of systematic reviews on the collaboration between physicians and nurses and the impact on patient outcomes: what can we learn in primary care?

Background

Primary care needs to be strengthened in order to address the many societal challenges. Group practices in primary care foster collaboration with other health care providers, which encourages care co-ordination and leads to a higher quality of primary care. Nursing roles and responsibilities expanded over time and nurses have been found to often provide equal high-quality chronic patient care compared to physicians, even with higher patient satisfaction. Inter-professional collaboration between primary care physicians and nurses is a possible strategy to achieve the desired quality outcomes in a strengthened primary care system. The objective of this research is to synthesize the evidence presented in literature on the impact of collaboration between physicians and nurses on patient outcomes in primary care or in comparable care settings.

Methods

A systematic review of peer-reviewed reviews was performed in four databases: COCHRANE, MEDLINE, EMBASE and CINAHL. All studies from 1970 until May 22 2016 were included in the search strategy. Titles, abstracts and full texts were respectively reviewed. At least two of the three authors independently reviewed each of the 277 abstracts and 58 full texts retrieved in the searches to identify those which contained all the inclusion criteria. Two authors independently appraised the methodological quality of the reviews, using the AMSTAR quality appraisal tool.

Results

A total of eleven systematic reviews met all the inclusion criteria and almost fifty different patient outcomes were described. In most reviews, it was concluded that nurses do have added value. Blood pressure, patient satisfaction and hospitalization are patient outcomes where three or more systematic reviews concluded better results when physicians and nurses collaborated, compared to usual care. Colorectal screening, hospital length of stay and health-related quality of life are outcomes where collaboration appeared not to be effective.

Conclusions

Collaboration between physicians and nurses may have a positive impact on a number of patient outcomes and on a variety of pathologies. To address future challenges of primary care, there is a need for more integrated inter-professional collaboration care models with sufficiently educated nurses.

Electronic supplementary material

The online version of this article (10.1186/s12875-017-0698-x) contains supplementary material, which is available to authorized users.

Perinatal cortical infarction within middle cerebral artery trunks

AIM

To define neonatal pial middle cerebral artery infarction.

METHODS

A retrospective study was made of neonates in whom focal arterial infarction had been detected ultrasonographically. A detailed study was made of cortical middle cerebral artery infarction subtypes.

RESULTS

Forty infarctions, with the exception of those in a posterior cerebral artery, were detected ultrasonographically over a period of 10 years. Most were confirmed by computed tomography or magnetic resonance imaging. Factor V Leiden heterozygosity was documented in three. The onset was probably antepartum in three, and associated with fetal distress before labour in one. There were 19 cases of cortical middle cerebral artery stroke. The truncal type (n=13) was more common than complete (n = 5) middle cerebral artery infarction. Of six infarcts in the anterior trunk, four were in term infants and five affected the right hemisphere. Clinical seizures were part of the anterior truncal presentation in three. One of these infants, with involvement of the primary motor area, developed a severe motor hemisyndrome. The Bayley Mental Developmental Index was above 80 in all of three infants tested with anterior truncal infarction. Of seven patients with posterior truncal infarction, six were at or near term. Six of these lesions were left sided. Clinical seizures were observed in three. A mild motor hemisyndrome developed in at least three of these infants due to involvement of parieto-temporal non-primary cortex.

CONCLUSIONS

Inability to differentiate between truncal and complete middle cerebral artery stroke is one of the explanations for the reported different outcomes. Severe motor hemisyndrome can be predicted from neonatal ultrasonography on the basis of primary motor cortex involvement. Clinical seizures were recognised in less than half of the patients with truncal infarction; left sided presentation was present in the posterior, but not the anterior truncal type of infarction. Asphyxia is a rare cause of focal arterial infarction.

Neonatal focal temporal lobe or atrial wall haemorrhagic infarction

AIMS

To describe two variants of infarction within the temporal lobe, associated with local matrix bleeding and mild to moderate intraventricular haemorrhage.

METHODS

The files of 10 neonates, extracted from a sonographic study of 560 very low birthweight infants conducted between 1993 and 1997, were retrospectively examined.

RESULTS

Seven lesions were located in the middle to posterior area of the temporal lobe, three others faced the atrium. All except two of those with a temporal site were VLBW infants with hyaline membrane disease. Except for one fatal case, intraventricular bleeding was mild to moderate. Computed tomograms or magnetic resonance imaging were used to illustrate the haemorrhagic nature of three lesions. Survivors of this so far undescribed entity who were followed up for more than 18 months did not have a uniform type of cerebral palsy but some scored in the low normal range on the Bayley Mental Development Index. One girl developed temporal lobe epilepsy.

CONCLUSIONS

This pattern of injury seems to be one of venous infarction associated with temporal or para-atrial matrix haemorrhage. The temporal site fits the picture of venous infarction within the area drained by the inferior ventricular vein. A less constant lateral atrial vein, either draining into the basal or internal cerebral vein, is probably involved in the para-atrial lesion. Sonography may be the only practical tool currently available for detection in life.

Lyme disease in a child presenting with bilateral facial nerve palsy: MRI findings and review of the literature

We report a 7-year-old boy with neuroborreliosis presenting with headache and bilateral facial nerve palsy. MRI demonstrated tentorial and bilateral facial and trigeminal nerve enhancement.

Retarded and aberrant splicings caused by single exon mutation in a phosphoglycerate kinase variant

The molecular abnormality of a phosphoglycerate kinase variant which was associated with severe tissue enzyme deficiency and episodes of muscle contractions and myoglobinuria was examined. Analysis of the patient's DNA showed the existence of a nucleotide transversion A/T - C/G in exon 7. No other nucleotide change was detected in the coding region of the variant gene. The mutation should produce a single amino acid substitution Glu - Ala at protein position 251 counting from the NH2-terminal acetyl serine residue. The protein abnormality caused by the amino acid substitution cannot explain the enzyme deficiency. Northern blot hybridization indicated that the PGK mRNA content of the patient's lymphoblastoid cells was only about 10% of that of normal. Nucleotide sequence analysis revealed the existence of two PGK mRNA components in the patient's cells. The major component corresponds to the normal PGK mRNA except for A - C change at nucleotide position 755 counting from adenine of the chain initiation codon. The minor component contains 5' region (52 bases) of intron 7 between exon 7 and exon 8. An inframe chain termination codon exists in the minor mRNA component, and the COOH-terminal half is expected to be deleted in the translation product. These results indicate that the low PGK activity in the patient's tissues is mainly due to retarded and aberrant pre-mRNA splicings caused by the change of the consensus 5' splice sequence AGgt to a nonconsensus sequence CGgt at the junction between exon 7 and intron 7 of the variant gene.

High diagnostic performance of CT scan for analgesic nephropathy in patients with incipient to severe renal failure

Recently, well performing diagnostic criteria for analgesic nephropathy in end-stage renal failure (ESRF) patients were defined by the demonstration of a bilateral decrease in renal volume combined with either bumpy contours or papillary calcifications. In this study, the diagnostic value of computed tomography (CT) scan was compared to the previously used renal imaging techniques (sonography and conventional tomography). In a first study, a cohort of 40 analgesic abusers (defined as daily use of analgesic mixtures during at least 5 years) and 40 controls, all ESRF patients without a clear renal diagnosis, were investigated with sonography, tomography and CT scan without injection of iodinated contrast material, to search for the imaging signs of analgesic nephropathy. Using CT scan, sonography and tomography, renal size could be evaluated with comparable results while CT scan was superior in the detection of papillary calcifications (sensitivity 87%, specificity 97%). In a second controlled study of 53 analgesic abusers with a serum creatinine between 1.5 to 4 mg/dl in the absence of a clear renal diagnosis, a CT scan was performed and scored for the presence of decreased renal volume, bumpy contours and papillary calcifications. It was found that the renal image of analgesic nephropathy on CT scan in an early stage of renal failure is comparable with the observations made in ESRF patients. Particularly the demonstration of papillary calcifications showed a high sensitivity of 92% with a specificity of 100% for the early diagnosis of analgesic nephropathy.

Plasma apolipoprotein A-IV metabolism in patients with chronic renal disease

The plasma concentration and distribution of apolipoprotein A-IV were investigated in normotriglyceridaemic patients with end-stage renal disease and compared with those in a sex- and age-matched control group with normal renal function. A three-fold elevated plasma mean concentration of apolipoprotein A-IV was found in patients with end-stage renal disease treated by haemo- or peritoneal dialysis (58.5 +/- 18.9 mg dl-1 or 50.5 +/- 12.2 mg dl-1, respectively) compared with the controls (18.3 +/- 6.4 mg dl-1). The plasma distribution of apolipoprotein A-IV was studied in patients treated by haemodialysis and in controls by gel permeation chromatography. In the haemodialysis group, 40.3% of the apolipoprotein A-IV was found to be associated with the fraction of high density lipoproteins, whereas the rest (59.7%) was not associated with lipoproteins. This distribution was significantly different from that in the control group (24.8% vs. 75.2%, 0.01 less than P less than 0.05). The elevated plasma concentrations of apolipoprotein A-IV in the patients are not related to triglyceride levels and therefore are unlikely to result from an impaired catabolism of triglyceride-rich lipoproteins. The accumulation of apolipoprotein A-IV in high density lipoproteins from patients with end-stage renal disease might reflect the impaired reversed cholesterol transport mechanisms which are believed to be a major cause of the high prevalence of atherosclerotic diseases in these patients.

Effect of simvastatin treatment on the dyslipoproteinemia in CAPD patients

HMG-CoA reductase inhibitors have been proven effective in decreasing the plasma cholesterol levels in patients affected with various forms of hypercholesterolemia, familial dysbetalipoproteinemia, familial combined hyperlipidemia and in nephrotic and diabetic dyslipidemia. The purpose of this study was to monitor and evaluate the efficiency and safety of the therapy with simvastatin, an HMG-CoA reductase inhibitor, in a group of patients treated by continuous ambulatory peritoneal dialysis (CAPD) with severe hypercholesterolemia. Monitoring of the changes occurring in the various lipids and apolipoproteins in these patients included the measurements of the plasma lipids and apolipoproteins A-I, A-II, B, C-II, A-IV and Lp(a). Lipoproteins were separated by gel filtration, on a Superose 6HR column, before and after 24 weeks of treatment. The patterns were compared to those observed in a group of primary hyperlipidemic patients treated with Lovastatin, a compound of the same class. The drug was well tolerated by the CAPD patients and no adverse reaction was observed. In addition to the decrease of the total and LDL cholesterol, similar to that reported in other groups of patients, we further observed a decrease of the apo E concentration in both the CAPD and the hyperlipidemic patients. This decrease was especially pronounced in the HDLE fraction and could involve an upregulation of the apo B-E and/or apo E receptor. These results should provide information about the mechanism of action of this drug in patients with end-stage renal disease.

Itraconazole pharmacokinetics in patients with renal dysfunction

The single-dose pharmacokinetics of 200 mg of oral itraconazole were studied in seven uremic patients, seven patients treated by hemodialysis, and five patients treated by continuous ambulatory peritoneal dialysis. Plasma concentration-versus-time profiles showed wide intersubject variation. This study could not demonstrate any significant effect of renal dysfunction and hemodialysis or continuous ambulatory peritoneal dialysis treatment upon the pharmacokinetics of itraconazole, and firm conclusions concerning dosing in such patients should await confirmation of our data in a larger patient population.

Ultrastructural alterations in the sialic acid distribution in minimal change disease and membranous glomerulonephritis

Kidney biopsy specimens from patients with minimal change disease and membranous glomerulonephritis were embedded in glycolmethacrylate and stained with phosphotungstic acid (PTA) at low pH. Biopsy specimens from patients without proteinuria served as a control. The PTA staining at low pH on glycolmethacrylate sections was used to study the changes in the sialic acid content of the lamina rara externa of the glomerular basement membrane. This method also gives a clear picture of the changes occurring at the epithelial cell coat and these alterations have implications on the distribution of the negative charges. In minimal change disease no alterations could be observed in the sialic acid content of the lamina rara externa. But the luminal epithelial cell coat showed obvious changes in conjunction with extensive foot process widening. In membranous glomerulonephritis with heavy deposits the staining of the lamina rara externa became almost completely negative and the foot process architecture was strongly affected. Obvious defects at the luminal epithelial cell coat, as observed in minimal change disease, were also found regularly. The alterations at the epithelial cell coat are tentatively related to the selective proteinuria reported in minimal change disease. In addition the non-selective proteinuria observed in non-minimal glomerulopathies, may find its origin in the absence of sialic acid molecules from the lamina rara externa.

Pseudo-Kaposi's sarcoma as a complication of Cimino-Brescia arteriovenous fistulas in hemodialysis patients

Pseudo-Kaposi's sarcoma is a skin lesion that is associated with chronic venous insufficiency and/or congenital arteriovenous fistulas. Theoretically, this lesion could also be expected in connection with hemodialysis vascular accesses. Nevertheless, this disease has been reported only once in conjunction with a Cimino-Brescia arteriovenous fistula, and no attention has been paid to the potential complications of this disease. In the present paper 3 cases are reported. In 1 patient pseudo-Kaposi's sarcoma was complicated by an infected open wound as a consequence of a trauma. In the 2 other patients, a skin biopsy was followed by local infection and retarded healing of the wound. Evaluation by fistulagraphy and/or Doppler revealed venous outflow stenosis in only 1 case. After reconstruction or ligation of the fistula, correction of the lesions was observed. It is concluded that pseudo-Kaposi's sarcoma can occur as a complication of Cimino-Brescia arteriovenous fistulas, necessitating early correction of the fistula. The performance of a skin biopsy might be associated with infection and delayed wound healing, so that this diagnostic procedure should only be performed in cases where the clinical diagnosis is not obvious.

Influence of progressive salt restriction on urinary bicarbonate wasting in uremic acidosis

In steady state, the acidosis in the majority of 17 uremic patients was characterized by a persistent bicarbonaturia (FEHCO3 ranging between 0% and 17.65%). An NH4Cl loading test in 17 patients revealed two distinct groups: group A (n = 11) with complete disappearance of the urinary bicarbonate loss and a mean UpH of 5.39 +/- 0.10 at a PHCO3 level of 13.3 +/- 0.5 mEq/L; and group B (n = 6) with urinary acidification disturbances with a persistent FEHCO3 ranging between 1.06% and 3.15% and a mean UpH of 6.53 +/- 0.06 at a PHCO3 level of 13.5 +/- 0.7 mEq/L. Between the two groups, there were no differences in CCr, plasma Na, K, Cl, Ca, PO4, PCO2, and aldosterone levels. Calculation of the THCO3/TNa reabsorption ratio over a wide range of PHCO3 levels revealed no differences between the two groups. The mean levels of circulating PTH were significantly higher in group B compared with group A (40.1 +/- 10.8 mU/dL v 19.3 +/- 4.4 mU/dL; P less than .05), and the spontaneous steady-state FENa was more pronounced in group B than in group A (12.1% +/- 1.5% v 4.9% +/- 0.7%; P less than .05). Four patients from group B with a well-documented salt-losing nephropathy (FENa ranging from 10.20% to 15.10%) were submitted to a progressive dietary salt restriction over several weeks. At this stage, the four patients no longer had bicarbonaturia, and the urinary pH decreased to levels between 5.15 and 5.65 during NH4Cl-induced acidosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of premercurial resetting of intrarenal vascular resistance on HgCl2-induced acute renal failure

The role of renal hemodynamics in the first hours of HgCl2-induced acute renal failure was examined by studying the influence of resetting the total renal vascular resistance (RT) within the limits of autoregulation before and after the mercury administration. Intravenous HgCl2 alone (3 mg/kg) caused an early fall of glomerular filtration rate (GFR) from 69 +/- 3 to 38 +/- 4 ml/min/100 gm kidney weight (KW) and of renal blood flow (RBF) from 535 +/- 42 to 276 +/- 27 ml/min/100 gm KW, 3 hours after HgCl2 (P less than 0.01). In a second series, the RT was decreased by clamping the aorta before and after HgCl2 so that the mean renal perfusion pressure (MRPP) was lowered to a mean of 87 +/- 5 mm Hg). This maneuver did not prevent the fall in GFR (from 81 +/- 5 to 36 +/- 6 ml/min/100 gm KW) or in RBF (from 510 +/- 79 to 197 +/- 20 ml/min/100 gm KW) after HgCl2 (P less than 0.01). In a third group, the RT was increased by a rise of MRPP to 158 +/- 8 mm Hg by bilateral carotid clamping. Subsequently, 3 hours after HgCl2, the GFR decreased not significantly from 72 +/- 6 to 61 +/- 7 ml/min/100 gm KW, and RBF increased from 405 +/- 66 to 431 +/- 71 ml/min/100 gm KW. Three hours of continued carotid clamping alone caused a rise of GFR from 64 +/- 7 to 83 +/- 7 ml/min/100 gm KW (P less than 0.05) and of RBF from 425 +/- 16 to 581 +/- 28 ml/min/100 gm KW (P less than 0.01). Autoregulation of RBF was studied in a control period and after 3 hours of carotid clamping and found to be lost during prolonged carotid clamping. The autoregulatory capacity remained intact after HgCl2 alone. The renal vasoconstrictive response to norepinephrine was not affected 3 hours after carotid clamping. It is concluded that the fall of GFR and RBF after HgCl2 can be prevented by prolonged carotid clamping. This is related to a loss of the capacity to maintain renal vasoconstriction after carotid clamping because of a concomitant loss of autoregulation of RBF and points at least in part to a pathogenetic role of changes in renal hemodynamics in the first hours after HgCl2. The tubular effects of HgCl2 were, however, maintained, despite the protection of GFR.

Lipid alterations induced by renal ischemia: pathogenic factor in membrane damage

Lipids of the renal cortex and outer stripe of outer medulla were analyzed in rats during ischemia and 2 hr after blood reflow. After 15 min of ischemia, there were marked elevations of free fatty acids (FFA) and diacylglycerol (DG), increasing further at 60 min. Percentile increases were greater for polyunsaturated FFA. These elevations were accompanied by alterations in phospholipids (PL): Elevations of lysophosphatidylcholine (LPC) at 15 min, phosphatidic acid at 15 and 60 min, and declines of phosphatidylcholine and phosphatidylinositol at 60 min. Triacylglycerol (TG) showed only modest decline, at 60 min, and in insufficient degree to account for increments in FFA and DG. Two hours after 15 min of ischemia, LPC returned to control levels and other PL were normal except phosphatidylinositol which was decreased, and phosphatidic acid, which remained elevated. FFA and DG approached or reached control values. Two hours after 60 min of ischemia, LPC, FFA, DGs and phosphatidic acid remained elevated; phosphatidylcholine and phosphatidylinositol remained decreased. Histological injury was seen 2 and 24 hr after blood reflow only in kidneys injured by 60 min of ischemia. Thus, irreversible ischemic damage correlates with persistent abnormalities of phosphatidylcholine metabolism and persistent elevations of FFA, LPC, and DG. It is not known whether lipids break down at normal or accelerated rates during ischemia. In this context, accumulation of lipid breakdown products in ischemic cells may be due to failure of their reutilization, or disposal. Similarly, depletion of phospholipids during ischemia may be due to the inability of cells to reconstitute the lipid following degradation.(ABSTRACT TRUNCATED AT 250 WORDS)

Alterations in vascular function and morphology in acute ischemic renal failure

Left renal arteries of rats were clamped for 40 min, and the kidneys were studied 48 hr and 7 days following restoration of blood flow. At 48 hr, there was severe oliguria or anuria. Renal blood flow (RBF) was in the normal range, but there was a loss of RBF autoregulation between 95 to 120 mm of mercury in seven out of nine rats. Morphologically, arcuate and interlobular arteries and afferent arterioles showed focal, segmental necrosis of smooth muscle cells and diapedesis of red blood cells across their walls. At 7 days, renal function was still severely depressed. RBF showed a slight decrease that did not reach statistical significance, and RBF autoregulatory capacity was lost in 8 out of 11 rats. Morphologically, vascular lesions were characterized at this stage by marked thickening and fibrosis of the tunica adventitia of the interlobular arteries and afferent arterioles. Structural vascular alterations may impair smooth muscle contractile function and thus interfere with RBF autoregulatory function in this model of acute renal failure.