Multidisciplinary amyloidosis care in the era of personalized medicine

Amyloidosis refers to a group of conditions where abnormal protein-or amyloid-deposits in tissues or organs, often leading to organ malfunction. Amyloidosis affects nearly any organ system, but especially the heart, kidneys, liver, peripheral nervous system, and gastrointestinal tract. Neuromuscular deficits comprise some of its ubiquitous manifestations. Amyloidosis can be quite challenging to diagnose given its clinical heterogeneity and multi-system nature. Early diagnosis with accurate genetic and serologic subtyping is key for effective management and prevention of organ decline. In this review, we highlight the value of a multidisciplinary comprehensive amyloidosis clinic. While such a model exists at numerous clinical and research centers across the globe, the lack of more widespread adoption of such a model remains a major hindrance to the timely diagnosis of amyloidosis. Such a multidisciplinary care model allows for the timely and effective diagnosis of amyloidosis, be it acquired amyloid light amyloidosis (AL), hereditary transthyretin amyloidosis (hATTR), or wild type amyloidosis (TTR-wt), especially in the current era of personalized genomic medicine. A multidisciplinary clinic optimizes the delivery of singular or combinatorial drug therapies, depending on amyloid type, fibril deposition location, and disease progression. Such an arrangement also helps advance research in the field. We present our experience at The Ohio State University, as one example out of many, to highlight the centrality of a multi-disciplinary clinic in amyloidosis care.

Perceived utility of electrodiagnostic testing in critical illness myopathy and polyneuropathy: A survey of intensive care unit providers

INTRODUCTION/AIMS

Critical illness myopathy (CIM) and critical illness polyneuropathy (CIP) are common disorders associated with substantial morbidity. Electrodiagnostic studies (EDx) are effective in diagnosing CIM/CIP and identifying mimicking conditions. We surveyed intensive care unit (ICU) providers to better understand their approach to ICU-acquired weakness (ICU-AW) and the perceived utility of EDx.

METHODS

This was a single health system, Web-based survey of ICU providers.

RESULTS

Survey responses were received from 52 providers with a response rate of 22.1%. Most providers were somewhat familiar with CIM/CIP and median perceived prevalence was 30-49%. The majority (92.3%) of providers had no standard evaluation approach for ICU-AW. Electrodiagnostic testing was commonly considered, but many providers obtained it infrequently in presumed CIM/CIP cases. Electrodiagnostic studies were used to rule out other causes of weakness or to confirm the diagnosis of CIM/CIP. Many providers ordered EDx within 1 wk of identifying weakness. Finally, EDx were overshadowed by personal experience as the most helpful management tool for ICU-AW.

DISCUSSION

Overall, ICU providers perceive that CIM/CIP are commonly encountered, but they may not have a standard approach to evaluation. Clinical experience increased familiarity of ICU-AW and is central to management. EDx results are usually thought to be helpful, albeit not often ordered, and more study is needed to determine when implementation is of most assistance. Increasing education and developing institutional standards may lead to increased awareness and improved evaluation of CIM/CIP, but more study is needed to determine if algorithmic approaches would change patient outcomes.

EUPRON: nurses' practice in interprofessional pharmaceutical care in Europe. A cross-sectional survey in 17 countries

OBJECTIVES

Safe pharmaceutical care (PC) requires an interprofessional team approach, involving physicians, nurses and pharmacists. Nurses' roles however, are not always explicit and clear, complicating interprofessional collaboration. The aim of this study is to describe nurses' practice and interprofessional collaboration in PC, from the viewpoint of nurses, physicians and pharmacists.

DESIGN

A cross-sectional survey.

SETTING

The study was conducted in 17 European countries, each with their own health systems.

PARTICIPANTS

Pharmacists, physicians and nurses with an active role in PC were surveyed.

MAIN OUTCOME MEASURES

Nurses' involvement in PC, experiences of interprofessional collaboration and communication and views on nurses' competences.

RESULTS

A total of 4888 nurses, 974 physicians and 857 pharmacists from 17 European countries responded. Providing patient education and information (PEI), monitoring medicines adherence (MMA), monitoring adverse/therapeutic effects (ME) and prescribing medicines were considered integral to nursing practice by 78%, 73%, 69% and 15% of nurses, respectively. Most respondents were convinced that quality of PC would be improved by increasing nurses' involvement in ME (95%), MMA (95%), PEI (91%) and prescribing (53%). Mean scores for the reported quality of collaboration between nurses and physicians, collaboration between nurses and pharmacists and interprofessional communication were respectively <7/10, ≤4/10, <6/10 for all four aspects of PC.

CONCLUSIONS

ME, MMA, PEI and prescribing are part of nurses' activities, and most healthcare professionals felt their involvement should be extended. Collaboration between nurses and physicians on PC is limited and between nurses and pharmacists even more.

Internal consistency and construct validity of the Quality of Life in Alzheimer's Disease (QoL-AD) proxy – a secondary data analysis

Background: The maintenance and promotion of Quality of Life (QoL) of people with dementia is a major outcome in intervention studies and health care. The Quality of Life Alzheimer's Disease (QoL-AD) is an internationally recommended QoL measurement also available in German language. Until now, only a few results on the psychometric properties of the German QoL-AD were available. Objective: Evaluation of internal consistency and construct validity of the QoL-AD proxy. Method: A principal component analysis (secondary data analysis) of the 13 QoL-AD items was carried out based on the total sample of 234 people with dementia from nine nursing homes in Germany. Subsequently, the internal consistency of the identified factors was examined using Cronbach's alpha. Results: Two factors physical and mental health and social network were determined. Both factors explain 53 % of the total variance. The stability of both factors was validated in two sensitivity analyses. The internal consistency is good for both factors with a Cronbach's alpha of 0.88 (physical and mental health) and 0.75 (social network). Conclusion: The QoL-AD proxy allows the assessment of two relevant health-related QoL domains of people with dementia. However, in future studies especially the inter-rater reliability of the QoL-AD proxy has to be examined.

Metabolic dysfunction in diabetic cardiomyopathy

Diabetic cardiomyopathy (DCM) is defined as cardiac disease independent of vascular complications during diabetes. The number of new cases of DCM is rising at epidemic rates in proportion to newly diagnosed cases of diabetes mellitus (DM) throughout the world. DCM is a heart failure syndrome found in diabetic patients that is characterized by left ventricular hypertrophy and reduced diastolic function, with or without concurrent systolic dysfunction, occurring in the absence of hypertension and coronary artery disease. DCM and other diabetic complications are caused in part by elevations in blood glucose and lipids, characteristic of DM. Although there are pathological consequences to hyperglycemia and hyperlipidemia, the combination of the two metabolic abnormalities potentiates the severity of diabetic complications. A natural competition exists between glucose and fatty acid metabolism in the heart that is regulated by allosteric and feedback control and transcriptional modulation of key limiting enzymes. Inhibition of these glycolytic enzymes not only controls flux of substrate through the glycolytic pathway, but also leads to the diversion of glycolytic intermediate substrate through pathological pathways, which mediate the onset of diabetic complications. The present review describes the limiting steps involved in the development of these pathological pathways and the factors involved in the regulation of these limiting steps. Additionally, therapeutic options with demonstrated or postulated effects on DCM are described.

[Influence of personnel staffing on patient care and nursing in German intensive care units. Descriptive study on aspects of patient safety and stress indicators of nursing]

In this article selected results of a descriptive study on personnel staffing and patient care in German intensive care units are presented and discussed. The main focus is on comparing features of personnel staffing with indicators of the job situation and patient care. The study is based on a standardized survey of nursing managers from 535 intensive care units carried out in 2011. The results show that a low nurse-patient ratio in intensive care units has a tendency to cause higher risks in patient care and also in other stress indicator situations, such as absenteeism.

Decisional responsibility for mechanical ventilation and weaning: an international survey

Introduction

Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.

Methods

A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.

Results

Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.

Conclusions

Collaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.

[Patient classification systems. Nursing workload from the perspective of applied research (part I)]

This article describes in two parts the basic principles of categorising nursing data into Patient Classification Systems (PCS) and related findings of nursing research. PCS are used to group patients into classes by using some specified criteria or indicators, e.g. needs of a patient, functional status or different nursing activities. They are often applied to constitute staff requirements. Since the large number of available classification systems differs in terms of development procedures and use of resulting data, it was rarely possible to compare different PCS with each other until now. Therefore a typology of PCS was developed, which is presented in the first part of this article. While assigning current PCS to adequate classes of the typology, the development and complexity of different PCS can be evaluated and discussed. Thus using the typology allows to identify advantages and limitations of individual classification systems. Conclusions can be drawn about requirements for further PCS development.

[Comment about the policy statement of the MDS. A position statement of the assessment group of the University Witten/Herdecke with regard to nursing documentation]

In 2005 the Medical Advisory Service of Social Health Insurance (MDS) in Germany published a policy statement with regard to the nursing process and documentation. According to the intention of the association, this statement should be considered as recommendations which are able to improve nursing practice and to contribute to streamlining of bureaucracy in nursing care. Recognising the broad impact of this publication on nursing institutions, a working group on nursing assessment of the University Witten/Herdecke conducted a critical review of the statement. Significant criteria for evaluation were the primary role of nursing documentation, quality requirements for the documentation as well as recent scientific results concerning the implementation of nursing process and assessment-based nursing diagnoses. The review revealed that the statement lacks of a clear rationale and its content appears to be merely research-based. Therefore it has to be questioned if the publication will accomplish the claimed effects. In fact, future quality criteria for health care are to be developed independently on the basis of scientific results and in consideration of the experiences of all concerned social groups.

[Position statement of the National Nursing Assessment Group of Germany: regarding the basic "nutrition and fluid requirements" policy of the elderly by the MDS (Medical Service of the Central Associations of the Health Insurance Companies), July 2003]

Assessing the nutritional state of old and dependent people demands a distinctive consideration of all aspects which might influence the individual's nutritional habits. An isolated consideration of the body mass index (BMI) does not serve the needs of elderly, because the BMI seems not to be a valid indicator for their nutrtional state. In order to prove the risk of malnutrition, also the individual life conditions as well as social, religious, cultural and economic circumstances besides the amount of energy and nu triments are to be taken into account.