Place of the Advanced Practice Registered Nurse within the vascular team: a qualitative study of vascular medicine physicians and nurses caring for patients with peripheral artery disease

Introduction

Advanced Practice Registered Nurses (APRNs) treat and diagnose diseases, counsel the public about health problems, manage chronic diseases, and participate in continuing education. In the cardiovascular field, Peripheral Arterial Disease (PAD), one of the manifestations of atherosclerotic cardiovascular disease, is archetypal in combining multiple cardiovascular risk factors (hypertension, hyperlipidemia, diabetes mellitus smoking). Vascular medicine faces the challenge of improving their care and quality of life, but some goals cannot be achieved with all patients. Patients with PAD should benefit from APRN care, but to date there is little published on the place of APRN in vascular medicine worldwide, and none in France.

Objective

It appeared important to us to assess the perception of their role by physicians and nurses in vascular medicine. As the status of APRN in France has only been enacted by law in 2018, we aim to investigate physicians and nurses working with patients suffering from PAD, to gather their opinions and draw the cooperation outlines these practitioners could have with an APRN.

Methods

Multicentre exploratory qualitative study by semi-directive interview conducted until data saturation and thematic analysis carried out with healthcare practitioners taking care of patients with PAD: 10 physicians working either in private practice setting or hospital setting or both, and 8 nurses in a vascular unit for hopsitalised patients.

Results

Three main themes emerged from responders' verbatims: a specific organization of vascular medicine with its inherent challenges, particularly regarding patients with PAD (specific psychosocial profile of patients, lack of therapeutic education, time, knowledge of non-specialist physicians, tedious follow-up outside hospitals, complex care trajectory, and lack of medical-surgical collaboration). Second, a role for APRN, particularly in consultation as part of patient follow-up, with expected benefits for the patient and the care team. The APRN is wanted to fill part of this gap. The expected benefits include a smoother care pathway and increased capacity for cardiovascular education and prevention, especially during consultations. Third, there are certain pitfalls that need to be clarified to integrate these new practitioners into the vascular teams already in place. In particular, the need to inform the vascular medicine teams about this new profession, and the indispensable presence of the conditions necessary for the development of a relationship of trust.

Conclusion

APRN could be the missing link in a Vascular team by creating a continuum in the care of patients with PAD, ensuring clinical assessment, nursing supervision, adverse event screening, and renewing drug prescriptions with the necessary adjustments, while ensuring an essential part of therapeutic education personalized to each PAD patient.

Funding Acknowledgement

Type of funding sources: None.

Ergotism with acute limb ischemia, provoked by HIV protease inhibitors interaction with ergotamine, rescued by multisite transluminal balloon angioplasty

Acute limb ischemia induced by arterial vasospasm remains an exceptional situation, favoured by the use of arterial vasoconstrictors. The risk of these substances is largely underestimated in the general population, especially with the co-administration of strong cytochrome inhibitors like human immunodeficiency virus (HIV) protease inhibitors. A 33-year-old woman, who used to take dihydroergotamine for orthostatic hypotension, was prescribed a post-exposure HIV prophylaxis including lopinavir and ritonavir. One day later, she presented an acute bilateral limb ischemia with a sudden pain in both calves, initially while walking and then at rest with bilateral ischemic toes. Angiography confirmed diffuse arterial vasospasm of the lower limb arteries. A first-line therapy with isosorbide dinitrate and amlodipine was ineffective, with rapid clinical worsening. A combination of intra-arterial injections and intra-venous infusions of vasodilators, transluminal balloon angioplasty and bilateral 4-Compartment fasciotomies permitted rapid improvement and finally resulted in both lower limbs rescue. This case and literature review illustrate ergotism due to ergotamine overdose after taking HIV protease inhibitors. It also demonstrates the benefit of an interventional procedure besides medical therapy with vasodilators in severe arterial vasospasm. All along the lower limb arterial tree, transluminal balloon angioplasty restored the blood flow, without vasospasm recurrence. CONCLUSION: In case of ergotism with acute lower limbs ischemia, combining medical vasodilator therapy with interventional procedure can restore the arterial blood flow, thus allowing to save lower limbs.

Assaultive behaviour: before it happens

This paper reviews risk factors associated with assaultive behaviour. The author will look at specific risk factors to evaluate when assessing patients with an aggressive potential and he will examine patient-staff relationships that might trigger assaultive behaviour. The author believes that a better knowledge of risk factors allows us to develop preventive attitudes, and these will be discussed in the latter part of this paper.

Anatomical dissociation of the substrates of medial forebrain bundle self-stimulation and exploration

The purpose of this research was to determine whether brain stimulation reward and exploration are induced by activation of the same set of neurons along the medial forebrain bundle. The behavioral version of the collision test was utilized with electrodes in the lateral hypothalamus (LH) and the ventral tegmental area (VTA). A collision effect obtained between LH and VTA in one behavior at the exclusion of the other was treated as evidence of the involvement of two different sets of fibers. In 4 rats, a collision effect was observed only in self-stimulation, whereas in 1 rat, a collision was obtained in exploration at the exclusion of self-stimulation. Three animals showed no collision in either behavior. These data suggest that coexistence of self-stimulation and exploration following medial forebrain bundle stimulation can be explained by current spread on two different sets of fibers.

Anatomical dissociation of the substrates of medial forebrain bundle self-stimulation and exploration

The purpose of this research was to determine whether brain stimulation reward and exploration are induced by activation of the same set of neurons along the medial forebrain bundle. The behavioral version of the collision test was utilized with electrodes in the lateral hypothalamus (LH) and the ventral tegmental area (VTA). A collision effect obtained between LH and VTA in one behavior at the exclusion of the other was treated as evidence of the involvement of two different sets of fibers. In 4 rats, a collision effect was observed only in self-stimulation, whereas in 1 rat, a collision was obtained in exploration at the exclusion of self-stimulation. Three animals showed no collision in either behavior. These data suggest that coexistence of self-stimulation and exploration following medial forebrain bundle stimulation can be explained by current spread on two different sets of fibers.

[The therapist in the face of aggressive behavior.]

All therapists working in psychiatry will have to deal orte day with an aggressive patient. Besides, the probability of such an encounter is more and more to be expected in view of the increase of violence in psychiatry. Witnessing this, the author set about researching the subject. He presents in this article a review of literature on this theme (aetiologic hypothesis, statistics, etc.) and illustrates his ideas with specific examples. He ends his article by wishing that a better understanding of this problem may help the therapists to improve treatment of these patients and to prevent their act of violence.

Psychophysical method for mapping behavioral substrates using a moveable electrode

With the use of moveable electrodes, 28 rat mesencephalic sites were examined for self-stimulation behavior (SS). The relative importance of each site in SS was established according to (1) a traditional method which consists of comparing sites based on the rates of responding (2) a psychophysical procedure based on the pulse frequency required at each site in order for the stimulation to elicit a criterion behavioral performance. It was shown that anatomical conclusions reached by the use of behavioral output procedures depend purely on the arbitrary choice of stimulation parameters. It was also demonstrated that the combination of moveable electrodes with psychophysical measurements results in enhanced mapping resolution and enables one to trace the boundaries of behaviorally relevant structures and pathways with significantly better confidence.

Friedreich's ataxia in the south of Italy: a clinical and biochemical survey of 23 patients

We report a clinical and biochemical survey of 23 patients with Friedreich's ataxia from southern Italy. They were studied clinically and by means of a clinical rating scale devised by us (Inherited Ataxias Clinical Rating Scale). Laboratory tests, based on the Quebec Cooperative Study, were also performed on our patients. No major clinical or biochemical differences were found between Italian and Canadian patients. Investigation of CSF monoamine metabolites showed that HVA decreased after probenecid and metoclopramide loading.

HLA and complement typing in olivo-ponto-cerebellar atrophy

HLA antigen typing was carried out in a family with an autosomal dominant form of spinocerebellar degeneration [possibly olivoponto cerebellar atrophy (O.P.C.A.)--Type 1]. Eleven ataxic patients, three possibly ataxic subjects, two unrelated spouses and 13 clinically normal at risk siblings were typed for ABO and Rh blood groups, HLA-A and HLA-B antigens, C4 component of the complement and a number of other serum proteins (Clq, beta-1A, beta-1C, C5, beta-lipoproteins). No solid evidence for linkage between the ataxia gene and the HLA or C4 loci could be demonstrated in this family. Certain serum proteins, and particularly beta-lipoproteins were found to be significantly reduced in some sub-groups of subjects.