Application of MAPO (Movement and Assistance of Hospitalized Patients) method in hospitals and nursing homes: frequency of manual patient handling-part 2

This study examines the evolution of MAPO method for estimating the frequency of overloading tasks in healthcare workers during different shifts. The data presented were collected from 51 in-patient wards (25 hospitals and 26 nursing homes), and 917 workers: the frequency of MPH tasks is a complementary value to the MAPO exposure level, which is useful to implement a prevention plan targeted towards the reduction of overloading tasks. Based on the frequency of manual patient handling, it appears that the afternoon shift is at greatest risk, with tasks liable to cause overloading occurring within a frequency range of 70-85 per worker. The study analyzes different pieces of equipment and their relative percentages of use, concluding that, overall, they are underutilised (especially minor aids and height-adjustable beds). Practitioner summary: The organisational data collected in hospitals and nursing homes confirms the availability of patient handling aids and equipment, but also indicates that they are underutilised with respect to the frequency of overloading tasks.

The Cancer Risk Profile of Systemic Lupus Erythematosus Patients

ABSTRACT

Systemic lupus erythematosus (SLE) patients have a well-established increased risk for cancer. Research from the past 2 decades has identified the specific malignancies that afflict SLE patients at disproportionate rates. Systemic lupus erythematosus patients are at heightened risk for several hematologic malignancies as well as for certain solid tumors, including lung, thyroid, and hepatobiliary cancers. They are at decreased risk for several cancers as well, including prostate and melanoma. Improved understanding of the unique cancer risk profile of SLE patients has led some professional societies to recommend specialized cancer screening and prevention measures for these patients and has enabled clinicians to better serve the SLE patient population.

A prescription for exercise in systemic lupus erythematosus

Patients with systemic lupus erythematosus (SLE) have increased cardiovascular risk, and fatigue is a major subjective complaint. Sedentary lifestyle has been shown to have negative health impacts in cardiovascular and rheumatic disease, though exercise has not traditionally been incorporated into routine therapy recommendations. Regular exercise in SLE may improve difficult to treat Type 2 symptoms, such as fatigue, depression, stress, and quality of life. Insufficient counseling on exercise by physicians is a notable barrier for SLE patients to engage in physical activity. Aerobic exercise regimens are more commonly studied, and have been shown to improve cardiovascular health in SLE. Exercise may improve some inflammatory markers, though does not definitively affect SLE clinical disease activity. Physical activity should be recommended to improve quality of life and cardiovascular health in patients with SLE. Developing clearer guidelines for exercise regimens in a patient-centered manner is warranted, especially given diverse phenotypes of SLE patients and varying degrees of physical limitations.

Subcutaneous Immunoglobulin for Antibody Deficiency in Antineutrophil Cytoplasmic Antibody (ANCA)-associated Vasculitis

Objectives

Intravenous immunoglobulin G (IVIG) is used to treat antineutrophil cytoplasmic antibody (ANCA) patients with recurrent infections as a result of hypogammaglobulinemia (HG) induced by treatment regimens. We sought to characterize clinical features, treatment, and outcomes for patients treated with the novel subcutaneous IgG (SCIG) for the aforementioned purpose. 

Methods

We conducted a retrospective study of 136 patients in our ANCA database to identify patients with recurrent infections and HG subsequently treated with SCIG. Patient demographics, serologies, treatment, and immunological parameters were assessed. 

Results

Of 136 patients, four were treated with SCIG. All were Caucasian, proteinase-3 (PR3)-positive, and the majority (n = 3) were females. All patients had pulmonary involvement, and regimens of cyclophosphamide (CYC) and/or rituximab (RTX) were employed for induction and remission. Three patients each experienced recurrent bouts of respiratory tract infections and shingles. Ig levels (G, M, and A) were reduced in all patients, except for one patient who had normal IgA levels. CD19/20 cells were depleted and CD3/4/8/NK cells were preserved in all patients. Three patients had no discernible antibody response to the pneumococcal vaccine (specific pneumococcal serotypes measured pre- and post-vaccine). The mean duration elapsed between the first rituximab administration and commencement of SCIG was 7.2 years. The IgG level normalized and none of the patients had a recurrence of infection since the initiation of SCIG. 

Conclusion

This data, albeit preliminary, is the first series that demonstrates SCIG can be a reliable alternative to IVIG in ANCA patients with recurrent infections secondary to HG. Early identification of this subset of patients is likely to mitigate infectious risks, associated morbidity, and hospitalization.

Hyperhomocysteinemia and Lupus Nephritis

Background  In SLE, both disease-specific and traditional risk factors are important. Increased serum homocysteine levels are seen in approximately 15% of patients with systemic lupus erythematosus and are associated with an increased risk of atherothrombotic events in this population. The serum level of homocysteine in patients with lupus nephritis has not been well described. Methods We performed a retrospective review of patients who had both biopsy-proven lupus nephritis (class II-VI) and measured homocysteine levels during routine evaluation. Clinical and laboratory data were obtained from reviews of medical records. Results Of the 15 patients with lupus nephritis, 10 had elevated homocysteine levels. The ages ranged from 21-68 years and were predominately African-American females. There were three patients with class III, one with class III-V, two with class IV, and two with class V lupus nephritis. Two patients had more than one biopsy each, one with class III, IV-V, and one with III and IV. At the time, when the serum homocysteine level was measured, of the 10 patients with elevated homocysteine levels, five patients had positive anti-dsDNA, and four had hypocomplementemia predominately low C3 (three patients). All patients were on hydroxychloroquine. Conclusions  This study demonstrates that patients with lupus nephritis are at a higher risk (66.6%) for developing elevated homocysteine levels.

Anakinra for Recurrent Fevers in Systemic Lupus Erythematosus

Fever is a common manifestation in systemic lupus erythematosus (SLE) and may be associated with disease activity, but should be closely evaluated for infection, drug reaction, thromboembolism, malignancy, or other etiology. We present the case of a 44-year-old Peruvian female with SLE with periodic high fevers and elevated high-sensitivity C-reactive protein (hs-CRP) levels, treated with anakinra, an interleukin-1 (IL-1) inhibitor. Following the birth of her first child, she developed frequent episodic fevers followed by multiple hospitalizations, approximately two to three times per year. She was started on anakinra in September 2016 and had improvement of fevers and joint symptoms. On 26-month follow-up, she had one episode of fever with bandemia requiring hospitalization but otherwise remained afebrile with a significant drop in CRP. Anakinra is well-tolerable and safe due to a short half-life. We report that the inhibition of IL-1 may be a safe and effective treatment for recurrent fevers in SLE.

Pauci-immune Glomerulonephritis in Systemic Lupus Erythematosus (SLE)

Glomerulonephritis (GN) in lupus is generally an immune complex glomerulonephritis from the deposition of immunoglobulin and complements. Pauci-immune GN is the most common cause of rapidly progressive GN and is frequently associated with an anti-nuclear cytoplasmic antibody (ANCA). We report a patient with a history of systemic lupus erythematosus who presented with worsening proteinuria and was subsequently diagnosed with pauci-immune GN on renal biopsy, in the absence of ANCA.

Ranolazine-induced Elevation of Creatinine Kinase in the Absence of Statin Usage

Ranolazine received Food and Drug Administration (FDA) approval in 2006 for the treatment of chronic angina. Ranolazine has previously been linked to the development of statin-induced myopathy, because it also inhibits CYP3A4, which increases serum statin levels. In the absence of concomitant statin therapy, elevated creatinine kinase (CK) and myalgias on ranolazine monotherapy has never been reported.

Cerebral Venous Thrombosis Mimicking a Discrete Brain Mass: A Case Report and Literature Review

The differential diagnosis for a focal brain lesion in a patient with systemic lupus erythematosus (SLE) is broad and includes infection, malignancy, and vascular and inflammatory etiologies. One rarely considered vascular pathology is cerebral venous thrombosis (CVT), which is often associated with a delay in diagnosis because of variable presentation and rare incidence. We present the case of a young woman with a new discrete brain lesion that appeared in the context of highly active SLE and was ultimately diagnosed with a CVT. We provide a literature review for diagnosis and management of cerebral venous thrombosis, a potentially serious complication of untreated systemic lupus erythematosus.

Long-term Clinical Course of Antineutrophil Cytoplasmic Antibody-associated Vasculitis Patients off Maintenance Therapy

Objectives

The optimal duration of maintenance immunosuppressive therapy in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is still controversial. The aim of our study is to describe the characteristics and outcomes of patients with AAV who were able to stop maintenance agents completely while remaining on daily prednisone (< 5 mg) for at least 36 months.

Materials and methods

AAV patients treated at our center from 2000 to 2016 and who were not on maintenance agents while remaining on prednisone < 5 mg daily for at least 36 months were identified by the providers, and their records were retrospectively reviewed. Relapse was defined by the reinitiation of immunosuppressive therapy for biopsy-proven glomerulonephritis or any extra-renal organ involvement.

Results

Of the 18 patients who fulfilled the study inclusion criteria, 12 were male and 14 were Caucasian. The mean age at AAV diagnosis was 54 years. Seventeen patients had renal involvement and seven had lung involvement. Eleven patients received cyclophosphamide and eight patients received rituximab along with glucocorticoids for remission induction. Twelve patients were weaned completely off prednisone. The median duration of prednisone use was 20 months. Nine patients received maintenance therapy with azathioprine or mycophenolate mofetil. The median duration of maintenance therapy was 24 months. The mean follow-up time after stopping the maintenance agent was 64 months. During this period, three patients had disease relapse.

Conclusions

Stopping maintenance agents for > 36 months can be achieved in some patients with AAV. Prospective, randomized controlled trials are needed to confirm this finding.

Mycophenolate Mofetil in a Lupus Patient with Pulmonary Hypertension

Pulmonary hypertension (PH) is a life-threatening complication of several, different connective tissue diseases, including systemic lupus erythematous (SLE), systemic sclerosis, and rheumatoid arthritis. PH can present early in SLE. The severity does not correlate with other organ disease activity or with disease duration. It is still debatable whether immunosuppressive therapy is useful for PH related to SLE or autoimmune connective tissue disease, as there are no large clinical trials. However, several case reports have shown improvement with cyclophosphamide and prednisone with or without vasodilator therapy. We present a case of SLE-related PH in which a dramatic improvement in mean pulmonary artery pressure and exercise capacity was noted after the institution of treatment with mycophenolate mofetil, resulting in a decrease in corticosteroid dose. Our observations support the potential value of mycophenolate mofetil therapy for PH in SLE.

Fevers in Adult Lupus Patients

Variability in systemic lupus erythematosus (SLE) disease manifestations is well recognized. Lupus disease activity can range from mild to severe. Fever is a common manifestation of SLE and occurs in 36%-86% of patients. In the Modified Systemic Lupus Erythematosus Disease Activity Index (M-SLEDAI), fever is taken into account as disease activity scoring. Assessment of lupus patients with fever is an important diagnostic challenge, since the initial clinical presentation of a patient with lupus is very similar to the acute febrile phase of an infection. The attribution of fever to SLE holds only after other causes are excluded.

Immunotherapy of systemic sclerosis

Scleroderma is a multisystem autoimmune disease characterized by an abnormal immune activation associated with the development of underlying vascular and fibrotic disease manifestations. This article highlights the current use of drugs targeting the immune system in scleroderma. Nonselective immunosuppression, and in particular cyclophosphamide, remains the main treatment for progressing skin involvement and active interstitial lung disease. Mycophenolate mofetil is a promising alternative to cyclophosphamide. The use of cyclosporine has been limited by modest efficacy and serious renal toxicity. Newer T-cell (sirolimus and alefacept) and B-cell (rituximab)-targeted therapies have provided some encouraging results in small pilot studies. Hematopoietic stem cell transplantation can be effective for severe fibrotic skin disease, but toxicity remains a concern. Clinical efficacy and safety of antifibrotic treatments (e.g., imatinib) await confirmation. Newer biological agents targeting key molecular or cellular effectors in scleroderma pathogenesis are now available for clinical testing.

Vitamin D treatment for the prevention of falls in older adults: systematic review and meta-analysis

OBJECTIVES

To systematically review and quantitatively synthesize the effect of vitamin D therapy on fall prevention in older adults.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, CINAHL, Web of Science, EMBASE, Cochrane Library, LILACS, bibliographies of selected articles, and previous systematic reviews through February 2009 were searched for eligible studies.

PARTICIPANTS

Older adults (aged > or = 60) who participated in randomized controlled trials that both investigated the effectiveness of vitamin D therapy in the prevention of falls and used an explicit fall definition.

MEASUREMENTS

Two authors independently extracted data, including study characteristics, quality assessment, and outcomes. The I(2) statistic was used to assess heterogeneity in a random-effects model.

RESULTS

Of 1,679 potentially relevant articles, 10 met inclusion criteria. In pooled analysis, vitamin D therapy (200-1,000 IU) resulted in 14% (relative risk (RR)=0.86, 95% confidence interval (CI)=0.79-0.93; I(2)=7%) fewer falls than calcium or placebo (number needed to treat =15). The following subgroups had significantly fewer falls: community-dwelling (aged <80), adjunctive calcium supplementation, no history of fractures or falls, duration longer than 6 months, cholecalciferol, and dose of 800 IU or greater. Meta-regression demonstrated no linear association between vitamin D dose or duration and treatment effect. Post hoc analysis including seven additional studies (17 total) without explicit fall definitions yielded smaller benefit (RR=0.92, 95% CI=0.87-0.98) and more heterogeneity (I(2)=36%) but found significant intergroup differences favoring adjunctive calcium over none (P=.001).

CONCLUSION

Vitamin D treatment effectively reduces the risk of falls in older adults. Future studies should investigate whether particular populations or treatment regimens may have greater benefit.

Effects of individualized whole-body vibration on muscle flexibility and mechanical power

AIM

The first purpose of the present study was to assess acute, residual and chronic effects of whole-body vibration on hamstring and lower back flexibility through the application of an individual frequency of vibration. The second purpose was to determine whether the applied vibration intervention over time influences flexibility and reactive strength differently.

METHODS

Thirty-four young physically active subjects (19 female and 15 male) were randomly assigned to either a Control or a Vibration Group. Lower back and hamstring flexibility was measured using the Stand and Reach Test. The reactive strength was estimated calculating the power in Drop Jump.

RESULTS

During whole-body vibration the relative change in acute flexibility for the Vibration Group (5.30+/-1.67 cm, 284%) reached a level of significance (P=0.038) compared to that of the Control Group (3.14+/-2.11 cm, 84%). Statistically significant differences in residual flexibility between the two groups were found at 6-min after the conclusion of vibration (P=0.034), at which point the Vibration Group showed the maximal relative change to pre-test (6.31+/-3.36 cm, 138%) versus the Control Group (3.06+/-1.87 cm, 20%). Chronic exposure of whole-body vibration did not produce significant changes in flexibility over time (P>0.05), whereas power in the Drop Jump performance of the Vibration Group increased significantly resulting in a benefit of 16% (P=0.019).

CONCLUSION

The current study shows that individualized whole-body vibration without superimposing other exercises is an effective method of acutely increasing lower back and hamstring flexibility. Furthermore, the applied individualized whole-body vibration over time influences the reactive strength rather than flexibility.

Emergencies in Diabetic Patients in the Primary Care Setting

The diabetic patient poses special problems in the primary care setting. Symptoms that are relatively unimpressive on initial presentation, such as polyuria or dizziness, may actually be the beginning of serious medical complications. With careful evaluation and follow-up, some patients, such as those who have mild hypo- and hyperglycemia and certain infections, can be managed as an outpatients; however, many cardiovascular conditions, such as cardiac ischemia or limb-threatening peripheral vascular disease, require immediate transfer to an acute care facility. In all situations, close monitoring of glucose levels during all phases of care--in the office, in the hospital and at home--is essential to achieving target glycemic control and rapid detection of clinical conditions that often first manifest as alterations in glycemic control.

A dynamometer for evaluation of dynamic muscle work

The validation of a new dynamometer for evaluation of dynamic muscle work is presented. The device was based on a precise measurement of load displacements of any machine using gravitational loads as external resistance. It allowed, through a sensor consisting of an infrared photo interrupter, the calculation of velocity, force and power during concentric, eccentric and stretch-shortening cycle activity. To validate the dynamometer 33 male and female track and field athletes (12 throwers and 21 jumpers) participated in the study. The throwers (4 women and 8 men) were asked to perform half-squat exercises on a slide machine with a load of 100% of the subject's body mass. The day-to-day reproducibility of half-squat exercises gave a correlation coefficient of r = 0.88, 0.97 and 0.95 for average push-off force (AF), average push-off velocity (AV), and average push-off power (AP) respectively. Comparison of half-squat measurements was performed against jumping and running test evaluation by the jumpers (7 women and 14 men). The interrelationships among the different variables studied demonstrated a strong correlation between AF, AV and AP and sprinting and jumping parameters (r = 0.53-0.97; P < 0.05-0.001). Using values of AF, AV and AP developed in half-squat exercises executed with different loads, ranging from 35% to 210% of the subject's body mass, it was also possible to establish the force-velocity and power-velocity relationships for both male and female jumpers. In any individual case, the maximal error due to the measurement system was calculated to be less than 0.3%, 0.9% and 1.2% for AF, AV, and AP respectively.(ABSTRACT TRUNCATED AT 250 WORDS)