Living with motor neurone disease: lives, experiences of services and suggestions for change

Factors that facilitate and hinder the manageability of living with amyotrophic lateral sclerosis in both patients and next of kin

AIM AND OBJECTIVES

This study aims to illuminate factors that facilitate and hinder the manageability of living with amyotrophic lateral sclerosis in patients and next of kin. Fourteen patients and 13 next of kin were interviewed.

BACKGROUND

The whole family becomes affected when a person gets the disease. Therefore, it is important to identify strategies for managing the life situation among both patients and their next of kin.

DESIGN

A qualitative descriptive study.

METHOD

This study based on individual interviews was performed in spring 2007. The interviews were subjected to qualitative content analysis.

RESULTS

The results indicate constant fluctuation between opportunities and limitations in individual ability - of patients and family members - to manage the life situation. Both patients and next of kin devised strategies to manage their situations through acceptance, living in the present and perceiving real presence and support from family, friends and authorities. Dysfunctional relationships with family members, friends, or authorities reduced the manageability of the situation. Furthermore, patients experienced difficulties managing their situations when forced into passivity and increased dependence. Next of kin experienced decreased ability to manage because of burden, lack of own time and feelings of being controlled.

CONCLUSION

The fluctuations in manageability and the similarities and differences between the pairs, indicate the importance of support, both for the individual and the family.

RELEVANCE TO CLINICAL PRACTICE

Fluctuations in manageability and similarities and differences between approaches to managing the situation suggest a need for input from caregivers, for the whole family. Family members need support and time for their own needs and also the opportunity to increase their awareness and understanding of the needs of other family members. This study may give health personnel insight into how to help families devise strategies to manage a complex life situation.

Clinical attention and assistance profile of patients with amyotrophic lateral sclerosis

OBJECTIVE: To evaluate the functional status of amyotrophic lateral sclerosis (ALS) patients diagnosed at this institution; to analyze hospital and palliative care; to identify patients' knowledge about home care and supportive resources. METHOD: Twenty-nine patients were evaluated on the ALSFRS-R scale and two semi-structured questionnaires, at the start of the study and every four months thereafter for 1 year. RESULTS: ALSFRS-R score was 30.1±11.5 initially and 24.4±10.5 at 1 year. There was an increase in use of physiotherapeutic care and adaptive aids. The primary caregivers were spouses (55.2%), parents/children/cousins (20.7%), friends (10.3%) and private nurses (3.5%); 10.3% of patients had no caregivers. Basic ALS patient care was provided by the public health system. CONCLUSION: ALS patients' multidisciplinary care was provided by UNICAMP hospital and its outpatient clinics and, in some patients, complemented by a private health plan or personal expenditure. Few ALS patients were aware of the possibility of home nursing. It is necessary to implement national and regional public home nursing in addition to multidisciplinary specialized care of ALS patients.

Information needs of informal caregivers of older adults with chronic health conditions

OBJECTIVE

To systematically examine current evidence pertaining to information needs of informal caregivers of older adults with chronic health conditions.

METHODS

Structured search of MEDLINE, MEDLINE IN-PROCESS, CINAHL, and PsycINFO databases to identify studies of caregiver information needs, followed by data extraction and syntheses.

RESULTS

The 62 articles that met the stated inclusion criteria highlighted extensive needs among informal caregivers for practical, accessible, timely information.

CONCLUSION

The identified information needs of informal caregivers can inform organizations and agencies that seek to provide disease and illness-related information.

PRACTICE IMPLICATIONS

Existing evidence supports the implementation of a health information delivery system designed to meet the needs of informal caregivers of older adults with chronic health conditions.

Rifampin combination therapy for nonmycobacterial infections

The increasing emergence of antimicrobial-resistant organisms, especially methicillin-resistant Staphylococcus aureus (MRSA), has resulted in the increased use of rifampin combination therapy. The data supporting rifampin combination therapy in nonmycobacterial infections are limited by a lack of significantly controlled clinical studies. Therefore, its current use is based upon in vitro or in vivo data or retrospective case series, all with major limitations. A prominent observation from this review is that rifampin combination therapy appears to have improved treatment outcomes in cases in which there is a low organism burden, such as biofilm infections, but is less effective when effective surgery to obtain source control is not performed. The clinical data support rifampin combination therapy for the treatment of prosthetic joint infections due to methicillin-sensitive S. aureus (MSSA) after extensive debridement and for the treatment of prosthetic heart valve infections due to coagulase-negative staphylococci. Importantly, rifampin-vancomycin combination therapy has not shown any benefit over vancomycin monotherapy against MRSA infections either clinically or experimentally. Rifampin combination therapy with daptomycin, fusidic acid, and linezolid needs further exploration for these severe MRSA infections. Lastly, an assessment of the risk-benefits is needed before the addition of rifampin to other antimicrobials is considered to avoid drug interactions or other drug toxicities.

A neurological care pathway for meeting the palliative care needs of people with life-limiting neurological conditions

The expectancy and demand for palliative care provision beyond cancer continues to increase in the Western world. This challenge raises the need for useful tools to support palliative care practitioners and other specialists in caring for people with a range of non-malignant life-limiting diseases. This paper describes the development process and the resulting care pathway for meeting the palliative care needs of people living with neurological conditions. The pathway was designed as a template, suitable for local modification, to support timely referrals and coordination of care through a patient's illness journey incorporating the provision of palliative and end-of-life care. Although the pathway was developed for neurological conditions, it is suggested that presentation of the development process and the care pathway template may support practitioners to develop further pathways for a wider range of life-limiting conditions.

A UK literature review of progressive long-term neurological conditions

Progressive long-term neurological conditions are relatively rare, and policy attention has only recently been directed at community services for people with these conditions. This literature review draws together findings from 16 UK studies relating to the provision of care in the community for people with progressive long-term neurological conditions. The purpose is to identify elements of best practice which could be promoted at a national level to improve services. The findings point to the uneven coverage of services and their lack of flexibility. Multidisciplinary care delivery was considered essential and patients and carers highly valued the use of key workers. The studies also highlighted the potential for self-managed care. This evidence can be used to inform service developments for the delivery of community care for people with progressive long-term neurological conditions.

How people with motor neurone disease talk about living with their illness: a narrative study

AIM

This paper is a report of a study which explores patients' experiences and how they talk about living and coping with motor neurone disease.

BACKGROUND

Living with motor neurone disease is challenging, frightening and disabling. It leads to progressive physical decline, normally with a prognosis of 3-5 years. Patients have to deal with many problems, including loss of mobility and the inability to communicate. There is little evidence about how people manage these problems or live with this illness.

METHOD

Narrative case studies were used, the unit of analysis being a patient living in their own home or a care home. Thirteen adults were recruited through purposeful sampling. Longitudinal narrative interviews were conducted at three-monthly intervals over an 18-month period in 2005-06. Interviews were analysed focusing on the form and content of the patients' narratives.

FINDINGS

Four types of narrative, or storyline were identified. The sustaining storyline is about living life as well as possible through keeping active and engaged in life. In contrast, the enduring storyline concerns living in an insurmountable situation leaving the person feeling disempowered, unable to fight for life or against death. Survival is the essence of the preserving storyline, while the fracturing storyline concerns loss and fear of what is to come.

CONCLUSION

Storylines help make sense of complex narratives by encouraging closer attention and active listening to the stories and serve as organizing threads to help patients, families and healthcare professionals better understand living with motor neurone disease.

Tenofovir comedication does not impair the steady-state pharmacokinetics of ritonavir-boosted atazanavir in HIV-1-infected adults

OBJECTIVE

Our objective was to evaluate the steady-state pharmacokinetics of ritonavir-boosted atazanavir when coadministered with tenofovir in HIV-1-infected adult patients.

DESIGN

Forty adult HIV-1-infected patients received either atazanavir/ritonavir 300/100 mg once daily and nucleoside reverse transcriptase inhibitors with (n = 20) or without (n = 20) tenofovir-disoproxil fumarate (tenofovir-DF) 300 mg once daily. Twenty-four-hour pharmacokinetics were assessed after at least 2 weeks of therapy according to a standardised therapeutic drug monitoring protocol.

METHODS

Atazanavir/ritonavir plasma concentrations were measured by liquid chromatography tandem mass spectrometry, and the geometric means of minimum and maximum concentrations (C(min), C(max)), the area under the time-concentration curve (AUC), half-life (t(1/2)) and total clearance (CL(tot)) were subject to a matched pairs-analysis. Patients' pairs were matched for gender, ethnicity, weight and Center for Disease Control and Prevention (CDC) status.

RESULTS

The respective geometric means (90% CI) for atazanavir C(min), C(max) and AUC with tenfovir vs. without tenofovir were 405 (314-523) vs. 417 (304-572) ng/ml, 3,022 (2,493-3,664) vs. 2,817 (2,341-3,390) ng/ml and 34,822 (29,315-41,363) vs. 32,101 (26,206-39,321) ng x h/ml showing no significant differences between the groups. Atazanavir plasma concentrations measured at week 5 of therapy or later were lower than in the first 4 weeks (T-test for C(max), p = .080; AUC, p = .050 and CL(tot), p = .051).

CONCLUSIONS

The coadministration of tenofovir-DF did not impair the plasma concentrations of ritonavir-boosted atazanavir in a pharmacokinetic analysis of patient pairs matched for gender, ethnicity, weight and CDC status.

Perceptions of quality of life in people with ALS: effects of coping and health care

Few qualitative studies have explored the 'meaning' of life experiences for persons with ALS. We aimed to identify the meaning of QoL in five selected individuals, and to consider how their experience of health care affected perceived well-being, using a phenomenological approach. Four of the five participants were revisited. Themes that emerged included: importance of faith, search for control, importance of dignity, desire to maintain identity, importance of family, a sense of loss, importance of altruism and support, fighting amyotrophic lateral sclerosis, and appreciation of life. All participants felt that professional services contributed to their well-being. QoL remained individual and multi-dimensional and was defined by cognitive and behavioural strategies used to cope with ALS. Our findings highlight the need to consider how persons with ALS may adapt to progressive illness.

Validity of an instrument to measure the impact of valve heart disease on the patient's daily life

AIM

This study was to verify the psychometric properties of the Heart Valve Disease Impact on daily life, an instrument for measuring the impact of illness in the daily life of the heart valve disease patient, related to its construct validity, criterion-related validity and reliability.

METHODS

One hundred and twenty heart valve disease outpatients were enrolled. Data were submitted to descriptive analysis, factor analysis, Pearson's correlation coefficient and Cronbach's alpha coefficient.

RESULTS

The factor analysis generated four factors that explained 58% of the variance in response to the Heart Valve Disease Impact on daily life. Weak to moderate correlation was measured between the Heart Valve Disease Impact on daily life total score and two of its factors and the General Measure of Impact of illness, indicating criterion-related validity. A Cronbach's alpha of 0.74 was measured.

CONCLUSION

The results of the current study confirm both the construct and criterion validity and the internal consistency of the Heart Valve Disease Impact on daily life. Future studies are necessary to confirm its reliability and provide a better understanding of the meaning of the Heart Valve Disease Impact on daily life dimensions, as well as to evaluate its response to health interventions.

RELEVANCE TO CLINICAL PRACTICE

The Heart Valve Disease Impact on daily life could be a useful instrument to measure the impact of heart valve disease and to evaluate the response to health interventions.

Influence of tenofovir, nevirapine and efavirenz on ritonavir-boosted atazanavir pharmacokinetics in HIV-infected patients

OBJECTIVE

The influence of nevirapine, efavirenz and tenofovir co-administration on ritonavir-boosted atazanavir pharmacokinetics was investigated in HIV (human immunodeficiency virus)-infected patients.

METHODS

A population pharmacokinetic analysis was performed in the context of therapeutic drug monitoring (87 patients, 121 samples).

RESULTS

A significant increase of atazanavir clearance (Cl/F) was found when either tenofovir (group B), efavirenz (group C), or nevirapine (group D) were co administered with atazanavir/ritonavir in comparison with patients treated with atazanavir/ritonavir and nucleoside reverse transcriptase inhibitors (group A): 6.24+/-0.36 l h(-1) (group A) versus 7.42+/-0.25 l h(-1) (group B) versus 9.60+/-0.27 l h(-1) (group C) versus 17.53+/-0.57 l h(-1) (group D) (P<0.001). However, the decrease of the mean trough plasma concentration of atazanavir was significant only in group D: 1.02+/-0.86 mg/l (group A) versus 0.21+/-013 mg/l (group D) (P<0.001).

CONCLUSION

The increase in atazanavir clearance when it is used in combination with nevirapine, efavirenz and/or tenofovir suggests that therapeutic drug monitoring of atazanavir should be performed in such circumstances.