Neuro-NICUs: Nurturing the Tiniest of Brains

Neuro-NICUs are the latest in NICU programs, with a focus on nurturing tiny brains using the latest in research, technology, and common sense. In this column, we talk with expert Kathi randall, RN, CNS, NNP, who has helped NICUs incorporate this new program into their units.

[Treatment of elderly patients with combination of coronary artery disease and aortic valve pathology]

Increasingly, there are patients with concomitant coronary artery disease and aortic valve, especially in elderly patients, who often have severe comorbidities and high surgical risk, which is undoubtedly a certain effect on the choice of method and tactics of treatment. Today, there are several approaches to the treatment of patients in this category, and all of them have certain advantages and disadvantages.

Graves'-Basedow disease in pregnancy. New trends in the management and guidance to reduce the risk of birth defects caused by antithyroid drugs

Thyroid hormones are essential development factors and maternal thyroid dysfunction may cause pregnancy complications and diseases in the fetus/child. In the present review we discuss new data on the incidence of Graves'-Basedow disease (GBD) in and around pregnancy, and how hyperthyroidism may affect the risk of spontaneous abortion and stillbirth. A special concern in pregnant women is the potential side effects from the use of antithyroid drugs (ATDs). One type of side effects is the allergic/toxic reactions to the drugs, which seem to be similar in and outside pregnancy, and another is that ATDs tend to over treat the fetus when the mother with GBD is made euthyroid. To avoid fetal hypothyroidism, the lowest possible ATD dose should be used to keep maternal thyroid function at the upper limit of normality with low serum TSH. Birth defects after the use of methimazole (MMI) (or its prodrug carbimazole) have been considered to be very rare, and no risk has previously been associated with the use of propylthiouracil (PTU). However, a recent Danish national study found that 1/30 of children exposed to MMI in early pregnancy had birth defects associated with this, and many defects were severe. PTU exposure was associated with defects in 1/40, and these defects were less severe. Proposals are given on how to reduce the risk of ATD associated birth defects.

Surveillance of the adult cancer survivor

The term "cancer survivor" refers to anyone living with a diagnosis of cancer. As the U.S. population ages, cancer screening increases, and cancer treatments improve, millions more Americans will be classified as cancer survivors in the future. Although many survivors wish to continue care with their oncologists, patients benefit from care provided by a family physician. Many survivors are older and have comorbidities, which should be addressed to optimize function and longevity. Common late effects of cancer and its treatment include second primary cancers, sexual dysfunction, and psychosocial issues. Cancer recurrence is a significant concern. After treatment for colorectal cancer, intensive surveillance, including colonoscopy, imaging, and serology, confers an overall survival benefit. Breast cancer survivors should receive annual mammography. Prostate cancer survivors should undergo prostate-specific antigen testing every six to 12 months. Melanoma survivors should be counseled on sun protection, including daily sunscreen use, and recognizing characteristics of potentially malignant skin lesions. Female survivors of Hodgkin lymphoma who were treated with chest or axillary radiation between 10 and 30 years of age are at high risk of breast cancer, and should be screened with mammography and magnetic resonance imaging annually starting eight to 10 years after the diagnosis. All cancer survivors treated with chest radiation are at increased risk of cardiovascular disease, and should be screened for other cardiovascular risk factors and treated as indicated.

Emergency department visits for heart failure and subsequent hospitalization or observation unit admission

BACKGROUND

Treatment of acute heart failure in the emergency department (ED) or observation unit is an alternative to hospitalization. Both ED management and observation unit management have been associated with reduced costs and may be used to avoid penalties related to rehospitalizations. The purpose of this study was to examine trends in ED visits for heart failure and disposition following such visits.

METHODS

We used the National Hospital Ambulatory Medical Care Survey, a representative sample of ED visits in the United States, to estimate rates and characteristics of ED visits for heart failure between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit.

RESULTS

The number of ED visits for heart failure remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%, 95% CI -3.7% to +2.5%). Of these visits, 74.2% led to hospitalization, wheras 3.1% led to observation unit admission. The likelihood of hospitalization did not change during the period (adjusted prevalence ratio 1.00, 95% CI 0.99-1.01 for each additional year), whereas admission to the observation unit increased annually (adjusted prevalence ratio 1.12, 95% CI 1.01-1.25). We observed significant regional differences in likelihood of hospitalization and observation admission.

CONCLUSIONS

The number of ED visits for heart failure and the high proportion of ED visits with subsequent inpatient hospitalization have not changed in the last decade. Opportunities may exist to reduce hospitalizations by increasing short-term management of heart failure in the ED or observation unit.

Sex trafficking in Ireland from a health care perspective

Sex trafficking within Ireland is a hidden phenomenon. In 2010, 78 alleged victims were reported to An Garda Siochina and the recorded levels of human trafficking into Ireland have remained at this level for the last four years. Despite this, no Irish guidelines or referral pathways exist to assist health care professionals. This paper highlights that health care professionals are not aware of this occurrence nor have they been trained to identify victims. Due to a lack of awareness many potential opportunities to detect these victims may be missed. While there is no single set of symptoms or signs that differentiates sex-trafficked victims from other sex workers, an awareness of common physical and psychological health problems associated with sex trafficking by health care professionals may increase victim detection rates. This paper summarises indicators, approach mechanisms, screening questions and a referral guideline relevant to the Irish health care system. This step-by-step guide can be used by health care professionals who encounter such a situation.

Early management of the severely injured major trauma patient

The major trauma team relies on an efficient, communicative team to ensure patients receive the best quality care. This requires a comprehensive handover, rapid systematic review, and early management of life- and limb-threatening injuries. These multiple injured patients often present with complex conditions in a dynamic situation. The importance of team work, communication, senior decision-making, and documentation cannot be underestimated.

Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

OBJECTIVE

To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates.

METHODS

PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions.

RESULTS

We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded.

CONCLUSIONS

Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.

Making the case for the nurse as the leader of care coordination

Care coordination has emerged as an effective model of care that contributes to healthcare reform's triple aim of decreasing costs, understanding the needs of individuals, and improving outcomes. This paper provides an argument that nurses should be the leaders of care coordination. Relationships among care coordination, nursing education, and professional values are made to show a common thread that ties the foundations of each. Benefits to outcomes and improved costs by nurses are also presented as defense for this claim. Rebuttals to arguments against this claim attempt to repudiate their worth and continue to show nursing's strategic position to assume this role.

Using one-page profiles to personalise care

One-page profiles are regularly used to communicate information about service users in social care; this simple, concise tool can also be used in healthcare settings. This article describes how one-page profiles can benefit both patients and nurses in hospital.

Uterine cervix conization based on Pap smear results: the "see and treat" approach

BACKGROUND

The "see and treat" approach, proceeding without a biopsy directly to uterine cervix conization in women diagnosed with high grade squamous intraepithelial lesion (HGSIL) on Pap smear, shortens the treatment duration, lessens patient anxiety, and reduces health care costs.

OBJECTIVES

To evaluate the level of diagnostic accuracy and the over-treatment rate in the "see and treat" versus conventional management of women diagnosed with HGSIL.

METHODS

We retrospectively reviewed all women with HGSIL who had undergone the "see and treat" approach during 2001-2011 at Soroka University Medical Center. Similar cohorts, who were managed conventionally with a cervical biopsy prior to the conization, served as a comparison group.

RESULTS

The study population consisted of 403 women: 72 (18%) had undergone the "see and treat" approach and 331 (82%) conventional management. The false positive rate was 11% for the "see and treat" group, compared to 6% for the conventional management group (P = 0.162). Similarly, no statistically significant difference was observed when comparing the positive predictive value (PPV) of high grade dysplasia diagnosed on Pap smear (PPV 88.9%) versus cervical biopsy (PPV 93.8%) (P = 0.204). Moreover, both the false positive rate and PPV remained similar in subgroups of patients, according to age, menopausal status, number of births, and colposcopy findings.

CONCLUSIONS

The accuracy level of HGSIL diagnosis on Pap smear is similar to that of high grade dysplasia on a cervical biopsy. We therefore recommend referring patients with HGSIL directly to conization. Skipping the biopsy step was not associated with significant over-treatment or other adverse effects.

Mental health reform at a systems level: widening the lens on recovery-oriented care

This paper is an initial attempt to collate the literature on psychiatric inpatient recovery-based care and, more broadly, to situate the inpatient care sector within a mental health reform dialogue that, to date, has focused almost exclusively on outpatient and community practices. We make the argument that until an evidence base is developed for recovery-oriented practices on hospital wards, the effort to advance recovery-oriented systems will stagnate. Our scoping review was conducted in line with the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (commonly referred to as PRISMA) guidelines. Among the 27 papers selected for review, most were descriptive or uncontrolled outcome studies. Studies addressing strategies for improving care quality provide some modest evidence for reflective dialogue with former inpatient clients, role play and mentorship, and pairing general training in recovery oriented care with training in specific interventions, such as Illness Management and Recovery. Relative to some other fields of medicine, evidence surrounding the question of recovery-oriented care on psychiatric wards and how it may be implemented is underdeveloped. Attention to mental health reform in hospitals is critical to the emergence of recovery-oriented systems of care and the realization of the mandate set forward in the Mental Health Strategy for Canada.

Role of imaging in the diagnosis and management of patients with cardiac amyloidosis: state of the art review and focus on emerging nuclear techniques

Amyloidosis is an infiltrative disease characterized by deposition of amyloid fibrils within the extracellular tissue of one or multiple organs. Involvement of the heart, cardiac amyloidosis, is recognized as a common cause of restrictive cardiomyopathy and heart failure. The two major types of cardiac amyloidosis are cardiac amyloid light-chain (AL) and transthyretin-related cardiac amyloidosis (ATTR, mutant and wild types) (Nat Rev Cardiol 2010;7:398-408). While early recognition of cardiac amyloidosis is of major clinical importance, so is the ability to differentiate between subtypes. Indeed, both prognosis and therapeutic options vary drastically depending on the subtype. While endomyocardial biopsy with immunostaining is considered the gold standard, advances in imaging provide an attractive non-invasive alternative. Currently, electrocardiography, echocardiography, and cardiac magnetic resonance imaging are all used in the evaluation of cardiac amyloidosis with varying diagnostic and prognostic accuracy. Yet, none of these modalities can effectively differentiate the cardiac amyloid subtypes. Recent data with (99m)Tc-phosphate derivatives, previously used as bone seeking radioactive tracers, have shown promising results; these radiotracers selectively bind ATTR, but not AL subtype, and can differentiate subtypes with high diagnostic accuracy. This review will initially present the non-radionuclide imaging techniques and then focus on the radionuclide imaging techniques, particularly (99m)Tc-DPD and (99m)Tc-PYP, mechanism of action, performance and interpretation of the study, diagnostic accuracy, prognostic value, future clinical perspective, and outlook.

Implementing a continuum of evidence-based psychosocial interventions for people with severe mental illness: part 2-review of critical implementation issues

OBJECTIVE

In North America and internationally, efforts have been made to reduce the gaps between knowledge of psychosocial evidence-based practices (EBPs) and the delivery of such services in routine mental health practice. Part 2 of this review identifies key issues for stakeholders to consider when implementing comprehensive psychosocial EBPs for people with severe mental illness (SMI).

METHOD

A rapid review of the literature was conducted. Searches were carried out in MEDLINE and PsycINFO for reports published between 1990 and 2012 using key words related to SMI, and psychosocial practices and implementation. The Consolidated Framework for Implementation Research (CFIR) was used to structure findings according to key domains and constructs known to influence the implementation process.

RESULTS

The CFIR allowed us to identify 17 issues reflecting more than 30 constructs of the framework that were viewed as influential to the process of implementing evidence-based psychosocial interventions for people with SMI. Issues arising at different levels of influence (intervention, individual, organizational, and system) and at all phases of the implementation process (planning, engagement, execution, and evaluation) were found to play important roles in implementation.

CONCLUSION

The issues identified in this review should be taken into consideration by stakeholders when engaging in efforts to promote uptake of new psychosocial EBPs and to widen the range of effective psychosocial services available in routine mental health care.

[Optimization of organizational approaches to management of patients with atherosclerosis]

Despite undoubted achievements of modern cardiology in prevention and treatment of atherosclerosis, cardiologists, neurologists, and vascular surgeons are still facing severe stenotic atherosclerotic lesions in different vascular regions, both symptomatic and asymptomatic. As a rule hemodynamically significant stenoses of different locations are found after development of acute vascular events. In this regard, active detection of arterial stenoses localized in different areas just at primary contact of patients presenting with symptoms of ischemia of various locations with care providers appears to be crucial. Further monitoring of these stenoses is also important. The article is dedicated to innovative organizational approaches to provision of healthcare to patients suffering from circulatory system diseases that have contributed to improvement of demographic situation in Kuzbass.

Discharge intervention pilot improves satisfaction for patients and professionals

BACKGROUND

The risk of adverse events and information loss following hospital discharge is particularly high for vulnerable multimorbid patients. Poor coordination of care at discharge increases the burden upon patients, caregivers and professionals, and can lead to increased morbidity and costs. Targeted programs can improve efficiency and health outcomes, but the ideal organization of hospital discharge remains to be specified.

METHODS

This single-blind, randomized, controlled interprofessional pilot on two internal medicine wards in a teaching hospital in Baden, Switzerland tested a discharge management intervention using nurse care managers. Patients (n=60) were at high risk for adverse events, fulfilling criteria such as polypharmacy, therapy with anticoagulants or insulin, plus secondary criteria indicating vulnerability. Primary composite endpoint was fulfilled by any of the following: death, rehospitalization, urgent physician visit within five days of discharge or adverse medicine reaction. Secondary endpoints evaluated patient quality-of-life, caregiver burden, adequacy of information provided to primary care physicians and home care nurses, and satisfaction with discharge for all groups. Endpoint evaluation was via telephone interviews on days 5 and 30 post-discharge. Design was critically evaluated in anticipation of a larger trial.

RESULTS

Intervention acceptance was high. In the intervention group, satisfaction was higher among patients (p=0.027) and caregivers (p=0.008), and primary care physicians rated discharge information higher (p=0.031). Primary endpoint showed no significant difference between groups. Necessary design modifications were identified.

CONCLUSION

Discharge coordination and follow-up care by nurse care managers significantly improved subjective endpoints. A modified design is planned to test effectiveness in a well-powered study.

Dignity in care: time to take action

Providing care for patients and caring about patients should go hand in hand. Caring implicates our fundamental attitude towards patients, and our ability to convey kindness, compassion and respect. Yet all too often, patients and families experience health care as impersonal, mechanical; and quickly discover that patienthood trumps personhood. The consequences of a medical system organized around care rather than caring are considerable. Despite technical competence, patients and families are less satisfied with medical encounters when caring is lacking. Lack of empathy and emotional disengagement from patients typifies health care provider burnout. Caring is the gateway to disclosure; without it, patients are less likely to say what is bothering them, leading to missed diagnoses, medical errors and compromised patient safety. There are also liability issues, with most complaints levied against health care professionals stemming from failures in care tenor. Formal education for health care providers lacks a continued focus on achieving a culture of caring. If caring really matters, health care systems can insist on certain behaviors and impose certain obligations on health care providers to improve care tenor, empathy, and effective communication. Caregivers need to be engaged in looking at their own attitudes towards patients, their own vulnerability, their own fears and whatever else it is that shapes their tone of care. Health care professionals must set aside some time, supported by their institutions, to advance a culture of caring-now is the time to take action.