Self-management: one size does not fit all

Self-management for people with chronic diseases is now widely recognized as an essential part of treatment. Despite the high expectations and the growing body of evidence in terms of its effectiveness, a wide application of self-management programs is inhibited due to several challenges. Worldwide, a variety of complex and multifactorial interventions have been evaluated in very heterogeneous patient populations leaving healthcare professionals in doubt about what works best and what works in whom. In this letter to the editor the authors systematically reflect on the current evidence of patient-specific determinants of success of self-management and argument the urge for increased scientific efforts to establish tailored self-management in patients with chronic disease.

How to increase activity level in the acute phase after stroke

AIMS AND OBJECTIVES

To study how patients with acute stroke spend their day and to determine whether activity levels of patients with acute stroke in a Dutch university hospital increase after the implementation of interventions to stimulate activity.

BACKGROUND

Previous studies suggest that patients with acute stroke are prone to inactivity. Early mobilisation and increasing levels of activities are part of several guidelines for patients with stroke. However, implementing interventions to increase activity levels is difficult owing to time and money constrains.

DESIGN

This study used a descriptive pre/postdesign.

METHODS

Outcomes is assessed on three levels: location, other people involved and activity, and it is determined by direct non-participant observation. An intervention was implemented to stimulate activity levels of the patients. This intervention consisted of (1) increasing the group therapy session and (2) providing a therapy guide that includes exercises patients can do by themselves or together with nurses, therapists or their family to stimulate the patients to be more active.

RESULTS

In total, 66 patients have been observed: 35 during the first and 31 during the second observation periods. Compared with the first observation period, patients in the second observation period spent less time in their room and spent less time lying in bed (49 vs. 29%). They did spend more time sitting in bed (13% vs. 20%) and sitting supported (14% vs. 24%).

CONCLUSION

Simple interventions can lead to less inactivity in patients with acute stroke. Nurses should be highly involved in implementing and stimulating these interventions. Also, family can play an important role in reducing inactivity in patients after stroke.

RELEVANCE TO CLINICAL PRACTICE

Nurses can play an important role in increasing activity levels of patients by using simple interventions.

An efficient way to detect poststroke depression by subsequent administration of a 9-item and a 2-item Patient Health Questionnaire

BACKGROUND AND PURPOSE

The early detection of poststroke depression is essential for optimizing recovery after stroke. A prospective study was conducted to investigate the diagnostic value of the 9-item and the 2-item Patient Health Questionnaire (PHQ-9, PHQ-2).

METHODS

One hundred seventy-one consecutive patients with stroke who could communicate adequately were included. In the 6th to 8th weeks after stroke, depression was measured using the PHQ-9 and PHQ-2 and diagnosed using the Composite International Diagnostic Interview.

RESULTS

Of the participating patients, 20 (12.2%) were depressed. The PHQ-9 performed best at a score ≥10, a sensitivity of 0.80 (95% CI, 0.62-0.98), and a specificity of 0.78 (95% CI, 0.72-0.85) and the PHQ-2 at a score ≥2 with a sensitivity of 0.75 (95% CI, 0.56-0.94) and a specificity of 0.76 (95% CI, 0.69-0.83). Administering the PHQ-9 only to patients who scored ≥2 on the PHQ-2 improved the identification of depression (sensitivity, 0.87; 95% CI, 0.69-1.04).

CONCLUSIONS

The diagnostic value is acceptable to good for PHQ-9 scores ≥10 and PHQ-2 scores ≥2. Conducting a PHQ-9 only in patients with a PHQ-2 score ≥2 generates the best results.

Educational needs of patients with a stroke and their caregivers: a systematic review of the literature

OBJECTIVE

To systematically review the research on stroke patients' and caregivers' educational needs.

METHODS

A search of the literature prior to and including the year January 2009 was conducted using Medline, CINAHL, EMBASE, PsychINFO and the Cochrane Library, yielding 959 articles. Of these, 21 studies were included in the review.

RESULTS

Stroke patients and caregivers reported many and diverse educational needs, which often were not met. The educational needs of stroke patients and caregivers concerned knowledge about the clinical aspects of stroke, prevention, treatment and functional recovery. The most commonly reported needs of caregivers involved patients' moving and lifting, exercises, psychological changes and nutritional issues. Patients and caregivers wanted information that was tailored to their situation.

CONCLUSION

Patients and caregivers have many unmet educational needs. The findings call for improved education of patients and caregivers on various issues that are specific to the various recovery phases after stroke.

PRACTICE IMPLICATIONS

The findings of this review can be used to develop educational interventions for stroke patients and caregivers. Further research is needed to investigate the feasibility and effects of educational interventions and whether they meet the educational needs of patients and caregivers.

[Falls: incidence and risk factors after stroke. A systematic literature review]

Falls are common after stroke. This article presents a literature review of the incidence and risk factors of falls and the consequences for professionals working with stroke patients. It is important to consider the specific problems after stroke. Depression and cognitive impairments were found to be risk factors for fall incidents after stroke. In the relevant literature many different risk factors and circumstances are described. When patients move from bed to chair, walk to the bathroom and the first few days after the patient is discharged to another setting, - all these circumstances showed high percentages of falling. A fall during hospital stay is a significant risk factor for future fall incidents. A reliable index to measure the fall risk is not (yet) available. But scores on the Barthel Index and the Timed-Up-and-Go test can be used as fall risk indicators. Fear of falling is an important complication after a fall and therefore it is recommended prior to discharge to inquire about the patient's self efficacy in maintaining balance. Few intervention studies use the number of falls as an outcome measure. Exercising balance following a mass training protocol seems to diminish the risk of falling.

Task-oriented training in rehabilitation after stroke: systematic review

AIM

This paper is a report of a review conducted to provide an overview of the evidence in the literature on task-oriented training of stroke survivors and its relevance in daily nursing practice.

BACKGROUND

Stroke is the second leading cause of death and one of the leading causes of adult disability in the Western world. The use of neurodevelopmental treatment in the daily nursing care of stroke survivors does not improve clinical outcomes. Nurses are therefore exploring other forms of rehabilitation intervention, including task-oriented rehabilitation. Despite the growing number of studies showing evidence on task-oriented interventions, recommendations for daily nursing practice are lacking.

DATA SOURCES

A range of databases was searched to identify papers addressing task-oriented training in stroke rehabilitation, including Medline, CINAHL, Embase and the Cochrane Library of systematic reviews. Papers published in English between January 1996 and September 2007 were included. There were 42 papers in the final dataset, including nine systematic reviews.

REVIEW METHODS

The selected randomized controlled trials and systematic reviews were assessed for quality. Important characteristics and outcomes were extracted and summarized.

RESULTS

Studies of task-related training showed benefits for functional outcome compared with traditional therapies. Active use of task-oriented training with stroke survivors will lead to improvements in functional outcomes and overall health-related quality of life.

CONCLUSION

Generally, task-oriented rehabilitation proved to be more effective. Many interventions are feasible for nurses and can be performed in a ward or at home. Nurses can and should play an important role in creating opportunities to practise meaningful functional tasks outside of regular therapy sessions.

[A review of delirium rating scales]

Delirium is a severe psychiatric syndrome that is highly prevalent in elderly general hospital patients. However, the diagnosis of delirium is often missed. The use of rating scales can be helpful in detecting and measuring delirium symptom severity. This article reviews recent developments with regard to psychometric qualities, measurement goal, content and rating procedures of some of the available rating scales in clinical practise. Studies that used delirium rating scales were searched for using the MEDLINE and subsequent examination of reference lists. Ten rating scales were selected for further evaluation. The Confusional Assessment Method (CAM), NEECHAM Confusion Scale (NEECHAM) and Delirium Observation Scale (DOS) appear to be most suitable as a screening instrument, depending on the type of rater (physician or nurse). The (revised) Delirium Rating Scale (DRS(-R-98)) seems to be particularly useful for measuring delirium severity or monitoring change.

Meeting the challenges for gerontological nursing in Europe: The European Nursing Academy for Care of Older persons (ENACO)

In order to support the urgent need for proactive and targeted investments in care for older persons a group of geriatric nurse specialists from different European countries convened in Leuven (Belgium) in November 2002 to launch the European Nursing Academy for Care of Older persons (ENACO). The mission of ENACO is to enhance outcomes of older persons and their caregivers through strengthening gerontological clinical nursing care, education, research and health policy within an interdisciplinary context. Specific objectives of ENACO are: 1) providing up-to-date education and training by "teaching the teachers". More specifically, the target groups are master's prepared nurses specialized in gerontology who can contribute and guide the development of gerontological/geriatric nursing care in their own country; 2) developing a core curriculum for basic gerontological nursing education in Europe and; 3) developing an European network of gerontological nursing expertise. More specifically, a web page providing opportunities for interactive communication as well as a mentoring program will be developed for nurses interested in the deepening and fine-tuning of their professional experience in care for older persons. The fact that care for older persons is high on the European agenda, the collaboration with the European Academy for Medicine of Ageing (EAMA), and other professional organizations in Europe and other parts of the world, are promising elements in the development of ENACO.

Crystal structure of an ACh-binding protein reveals the ligand-binding domain of nicotinic receptors

Pentameric ligand gated ion-channels, or Cys-loop receptors, mediate rapid chemical transmission of signals. This superfamily of allosteric transmembrane proteins includes the nicotinic acetylcholine (nAChR), serotonin 5-HT3, gamma-aminobutyric-acid (GABAA and GABAC) and glycine receptors. Biochemical and electrophysiological information on the prototypic nAChRs is abundant but structural data at atomic resolution have been missing. Here we present the crystal structure of molluscan acetylcholine-binding protein (AChBP), a structural and functional homologue of the amino-terminal ligand-binding domain of an nAChR alpha-subunit. In the AChBP homopentamer, the protomers have an immunoglobulin-like topology. Ligand-binding sites are located at each of five subunit interfaces and contain residues contributed by biochemically determined 'loops' A to F. The subunit interfaces are highly variable within the ion-channel family, whereas the conserved residues stabilize the protomer fold. This AChBP structure is relevant for the development of drugs against, for example, Alzheimer's disease and nicotine addiction.

Correlation between age at neutering and age at onset of hyperadrenocorticism in ferrets

OBJECTIVE

To determine prevalence of hyperadrenocorticism in ferrets in The Netherlands and evaluate age, sex, and age at neutering in affected ferrets.

DESIGN

Prevalence survey and retrospective study.

ANIMALS

50 ferrets with hyperadrenocorticism and 1,267 ferrets without hyperadrenocorticism.

PROCEDURE

A questionnaire was sent to 1,400 members of a ferret-owners organization in The Netherlands; 492 (35%) owners returned the questionnaire, providing usable data on 1,274 ferrets. Seven of these ferrets developed hyperadrenocorticism during the survey period; medical records for these ferrets and 43 ferrets with confirmed hyperadrenocorticism were reviewed. Hyperadrenocorticism was confirmed by histologic examination of an excised adrenal gland (92% of ferrets) or clinical improvement after excision.

RESULTS

Prevalence of hyperadrenocorticism in the survey population was 0.55%. Sex was not associated with prevalence of disease. Median time interval between neutering and diagnosis of hyperadrenocorticism was 3.5 years. A significant linear correlation between age at neutering and age at time of diagnosis was detected.

CONCLUSIONS AND CLINICAL RELEVANCE

Age at neutering may be associated with age at development of hyperadrenocorticism in ferrets.

19F-MRI of perfluorononane as a novel contrast modality for gastrointestinal imaging

19F-Magnetic resonance imaging in conjunction with perfluorononane provides a new modality for gastrointestinal (GI) imaging as is demonstrated here with an animal model. Perfluorononane was found to be an ideal oral contrast agent since it is biologically inert, immiscible with water, and since it has a low viscosity and surface tension. Furthermore, its high fluorine content, together with the high sensitivity of 19F-MRI, allowed highly selective MR images of the GI tract of mice to be acquired. Due to the lack of 19F background signals, the contrast of the GI tract was only limited by the signal-to-noise ratio of the 19F-MR images. 19F-RARE images of 1-mm slices with an in-plane resolution of 0.23 x 0.23 mm2 were obtained from the GI tract after oral perfluorononane administration. The passage of perfluorononane through the entire GI tract was monitored by repetitive MR measurements with a maximal time resolution of 38 s. The three-dimensional surfaces of the GI tract were reconstructed and superimposed on corresponding 1H-MR images, which provided complementary anatomical information.