Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home

Objectives

For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home.

Methods

Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting.

Results

A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study.

Conclusion

The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT.

Innovation

Adapting family conferences to primary care for frail patients with polypharmacy.

Endomyocardial biopsies in the diagnosis of myocardial involvement in systemic lupus erythematosus

BACKGROUND

Endomyocardial biopsy (EMB) is considered the gold standard for diagnosing myocardial involvement in most inflammatory conditions, including systemic lupus erythematosus (SLE). However, EMBs are rarely performed, and most of the myocardial histopathology reports in SLE consist of postmortem data. We therefore sought to describe the histopathologic findings of contemporary EMBs in SLE performed in clinical practice.

METHODS

A retrospective review of histopathology reports from SLE patients who underwent EMB from 1994 to 2017 was performed. A total of 41 SLE patients had cardiac pathology reports. Of these, 11 histopathology reports were EMBs, and the remaining were valvular specimens.

RESULTS

A total of 11 SLE EMBs were reviewed. It was found that 45% of the patients had hypertension, 27% had coronary artery disease, 9% had hyperlipidemia, and 36% had end-stage renal disease. None had diabetes or smoked. The mean left ventricular ejection fraction was 37%. On histopathology, 10 had mild interstitial fibrosis, 9 had myocyte hypertrophy, 3 had organized blood clots, and 3 had a mild infiltration of lymphocytes and macrophages without clear evidence of myocarditis. None had vasculitis, endocarditis, ischemia, amyloid deposition, or lamellar or curvilinear inclusions.

CONCLUSION

EMBs are rarely performed in SLE. In this case series, nonspecific interstitial fibrosis and myocyte hypertrophy were the most common findings, suggesting EMBs have limited value in the diagnosis of cardiac involvement in SLE and rather rule out competing conditions. These data support the need for diagnostic methods with high sensitivity and specificity for SLE heart disease.

Prediction of Antiphospholipid syndrome using Annexin A5 competition assay in patients with SLE

A significantly high correlation between reduced activity of Annexin A5 by the flow cytometric assay (FCA) and the diagnosis of antiphospholipid syndrome (APS) has been reported. The aim of this study was to assess the clinical and laboratory significance of the Annexin A5 competition assay among patients with systemic lupus erythematosus (SLE). The FCA competition assay was performed on blood samples from 57 consecutive SLE patients. The FCA was performed according to a previously validated method. Forty-seven patients (82.5 %) had SLE without APS and ten (17.5 %) had SLE with APS. Twenty-four (42 %) of the patients had mean levels of AnxA5 fluorescence below the mean and standard deviation of the controls and were considered positive. SLE patients with a positive FCA were found to have an increased risk for a hypercoagulable or vascular state (86 % of the patients had cerebrovascular disease, 89 % had Raynaud's phenomenon, and 80 % had deep vein thrombosis). The risk for any hypercoagulable or vascular state was significantly increased (P = 0.012, RR-2.3, 95 % CI 1.4-3.8). A positive FCA assay was found in 90 % of the patients with APS (P < 0.001), with a sensitivity of 90 % and a specificity of 68 % for this diagnosis. The positive and negative predictive values were 0.4 and 0.97, respectively. Correlations were found between positive FCA and positive Anti-Cardiolipin antibody (P < 0.001), and Anti-β2 glycoprotein I levels (P = 0.013). Our findings suggest that the FCA is a practical assay for the detection of clinically relevant APS among patients with SLE.

[A survey of Local Physicians and Psychotherapists on Cooperation in Regional Networks for Early Child Interventions in Saxony-Anhalt]

BACKGROUND

Early childhood interventions positively contribute to health related child development. For these interventions, networks are a necessary prerequisite as they promote interdisciplinary and interprofessional cooperation. This holds especially true for the integration of health system protagonists.

METHODS

In a cross-sectional survey local paediatrists, gynaecologists, general practitioners, and psychotherapists were asked about their knowledge, experiences, desires, and reservations regarding cooperation in early childhood intervention networks.

RESULTS

64 out of 1747 (3.7%) eligible clinicians answered the survey. On average they estimated that 10.1% of the families they are treating would benefit from early childhood interventions. Participants rated themselves as competent to offer appropriate early childhood interventions. The youth welfare service was judged as the most important institution for their own professional practice by 84.4%. Additionally to an applicable agenda, a fair group moderation of network meetings was seen as a substantial requirement in order to take part in network meetings.

CONCLUSION

Health professionals are important protagonists in early childhood interventions. Clinicians should assess relevant problems in families and offer appropriate support on a regular basis. Alongside clearly defined regional contacts, interprofessional continuing education seems mandatory.

[Perspectives on advance directives among German intensive care physicians in leading positions]

INTRODUCTION

Six years after introduction of a law for advance directives (AD) in 2009, AD are still discussed controversially. For the first time in Germany, this study investigates intensive care physicians' perspectives on implementation of AD, and corresponding experience of ethical issues.

METHODS

A standardized questionnaire was sent to German hospitals with > 300 beds and anesthesiologist-led intensive care units. The questionnaire was based on results of a previous qualitative study and was intended to be answered by one leading intensive care physician per hospital.

RESULTS

N = 222/299 (74.2 % response) physicians answered the survey. Despite a number of reported problems regarding the implementation of AD, 70.6 % (n = 154/218) rated AD generally as helpful. 86.5 % (n = 185/214) would prefer a more goal-oriented approach to an intervention-oriented approach to formulate AD. Furthermore 95.9 % (n = 207/216) plead for qualified professional counseling for intensive care topics in AD. Acceptance for interventions that equal termination of treatment can be perceived. Terminal extubation in correspondence with the patient's will is done in 79.4 % (n = 173/218) of hospitals, however 54.8 % (n = 113/206) of the physicians experience terminal extubations as burdening.

DISCUSSION

Supporting concepts and measures will be necessary in order to prepare valid AD and to effectively improve implementation in intensive care practice.

Die Kehlkopfkonfiguration beim Flüstern

BACKGROUND

The purpose of the study was to assess glottal and supraglottal configurations during whispering in comparison to habitual phonation and to visually estimate to what extent force is exerted onto the vocal fold epithelium during whispering. Is whispering a good compromise between preservation of epithelium and permission to communicate orally, e. g. postoperatively?

PATIENTS AND METHODS

We investigated on 100 patients with organic or non-organic voice disorders. Patients with vocal fold immobility and patients with organic lesions large enough to impede glottal closure were excluded. Videolaryngoscopy and stroboscopy was performed via flexible endoscopy. During fiberoscopy the patients were asked (i) to phonate and then whisper a series of vowels in various loudness levels and (ii) to count to 10 voiced and whispered in various loudness levels. The extent of vocal fold adduction and supraglottal configuration were assessed and whispering compared with voiced phonation.

RESULTS

Interindividual differences in glottal and supraglottal configuration during whispering were seen. The two different and most frequently seen glottal area patterns were determined by the position of the vocal processes - either adducted or abducted. Adduction resulted in sole cartilaginous triangle formation or 'kissing processes', abduction in ligamentous and cartilaginous triangle. Another surprising result was that with increasing loudness either a narrowing or widening of glottal and supraglottal structures was visible.

CONCLUSIONS

There are different patterns of glottal and supraglottal configuration during whispering. Although the vocal folds can show partial or total contact over the membranous parts, the lack of additional vibration of the vocal folds suggests that epithelial forces are smaller than with additional vibratory shear stress. Thus, whispering may be considered and allowed for postoperative communication purposes, when patients follow instructions for low-effort whispering.

[The significance of videostroboscopy in laryngological practice]

The assessment of laryngeal pathology and voice dysfunction requires knowledge of anatomy and physiology as well as thorough understanding of the biomechanical (non)linear behaviour of vocal fold vibration. Videostroboscopy adds useful information to voice assessment, which always includes perceptual voice assessment and endoscopy of the larynx. Videostroboscopy can help in differentiating between benign vocal fold lesions, invasive processes, vocal fold scarring and functional disorders. Videostroboscopic evaluation can be improved by using different endoscopes and specific evaluation manoeuvres.

[Bright white vocal folds and capillary ectasias. Late sequelae after radiotherapy]

We report on visible laryngeal changes after radiotherapy. In this study, three women and two men aged 50-64 years were involved. In three cases, the primary tumor was a carcinoma of the thyroid gland and in one case a carcinoma of the esophagus. Due to dysplasia of the vocal folds, one patient underwent primary radiotherapy. Endoscopy was performed 4 to 22 years after radiotherapy. The larynx was examined by video-laryngoscopy and stroboscopy. We found a characteristic pattern of the vocal folds in all patients: bright white vocal fold surface, ectasia of capillaries and increased angiogenesis. We only found this pattern in patients after radiotherapy. In our opinion, these findings are late sequelae of radiotherapy. The picture of laryngitis due to radiotherapy can be distinguished from chronic laryngitis of other etiology using these criteria.

Einseitige auditorische Neuropathie

Auditory neuropathy presents with normal otoacoustic emissions combined with pathological findings in brainstem evoked response audiometry. Normally, the auditory neuropathy is bilateral. We report about a 9 year old child where we could diagnose a unilateral deafness in spite of regular TEOAE and DPOAE. No reproducible biosignals were seen when the right ear was stimulated with alternating click stimuli at a level of 80 dB. On the left side, the latency of the potentials was normal. A cranial MRI showed normal anatomy. In order to determine a unilateral deafness, objective tests (e.g., OAE, BERA) and subjective tests should be used.

Differential expression of ryanodine receptors in the rat cochlea

This study examined the localization and functional expression of ryanodine receptors (RyR) within the cochlea using a combination of reverse transcription-polymerase chain reaction, immunolabeling techniques, and confocal Ca2+ imaging. All three RyR isoform mRNA transcripts were detected in the adult rat cochlea. Immunoperoxidase and immunofluorescence labeling showed that the three isoforms were differentially expressed. The most pronounced RyR protein expression, involving all three isoforms, occurred in the cell bodies of the spiral ganglion neurons. RyR3 labeling extended to the synaptic terminals innervating the inner and outer hair cells. RyR2 expression also occurred in the inner hair cells and supporting cells of the organ of Corti, while cells associated with ion homeostasis in the cochlea, such as the interdental cells of the spiral limbus (RyR1), and the epithelial cells of the spiral prominence and basal cells of the stria vascularis (RyR2 and RyR3), were also immunopositive. The functionality of RyR-gated Ca2+ stores in the spiral ganglion neurons was shown by confocal calcium imaging of fluo-4 fluorescence in rat cochlear slices. Caffeine (5 mM) evoked an increase in intracellular Ca2+ concentration in the cell bodies of the spiral ganglion neurons which occurred inthe absence of external Ca2+. Ryanodine (50 nm-1 microM) evoked comparable increases in intracellular Ca2+ concentration. These findings suggest that RyR-mediated Ca2+ release may be involved in auditory neurotransmission, sound transduction, and cochlear electrochemical homeostasis.

[Experiences with intraoperative application of prednisolone during Isshiki type I thyroplasty]

Laryngeal edema is considered a postoperative problem in phonosurgery. In a prospective study we examined if a single intraoperative application of prednisolone can decrease the incidence of postoperative laryngeal edema after Isshiki type I thyroplasty. We examined ten patients undergoing unilateral type I thyroplasty [seven men and three women, age range: 19-60 years (average: 48 years)]. In six patients we administered 250 mg prednisolone i.v. during surgery. In four patients no steroids were given at all. On the 1st and 2nd postoperative day, the larynx was examined in a clinical setting. Five of six patients who received intraoperative steroid medication had no postoperative laryngeal edema. Only in one of those patients we examined a small edema of the arytenoid region. In all four patients without steroid medication a postoperative edema of the ipsilateral arytenoid hump was seen. Thus, intraoperative intravenous steroid administration seems to prevent, or at least reduce, postoperative laryngeal edema. Only in one of those patients we examined a small edema of the arytenoid region.

[Early diagnosis of language development disorders in children]

In a prospective study, we examined whether it is possible to diagnose language disorders in children in their second and third years. Twenty patients aged 17-35 months (average 26 months) were examined from August 2002 to June 2004. Language development was tested on the basis of a questionnaire for parents (ELFRA-1 or ELFRA-2) and on a detailed language assessment. After 3-8 months, the children's language was examined again by the same speech pathologist. In 12 children, in whom we had suspected a language disorder, the diagnosis was confirmed. Eight patients showed age-appropriate language development, which was confirmed in six patients at follow-up. In two cases, the follow-up revealed a language disorder. On the basis of a parent questionnaire and examination by a speech therapist, language disorders can be diagnosed in the second and third years of life. However, control assessments are necessary in order to reveal language development disturbances beginning at later ages.

[Vocal cord dysfunction. An important differential diagnosis to bronchial asthma]

Vocal cord dysfunction (VCD) is described as a functional disorder of the vocal folds which leads to an intermittent, inspiratory 'paradoxical' glottal closure. We report on three women with frequent repetitive shortness of breath attacks caused by VCD. This was diagnosed by transnasal videofiberendoscopy, with glottal closure being seen during inspiration. Because of the different etiologies, one of the patients was treated with breathing and speech therapy, another received Omeprazol for laryngopharyngeal reflux, and the third was treated by intralaryngeal botulinum toxin injections. All three patients showed a reduction in attacks. Clinically, VCD seems to mimic asthma. However, with a thorough patient history and diagnostics, especially with transnasal laryngoscopy during a (triggered) attack, a precise diagnosis seems possible.

[Influence of the head position in laryngoscopy]

INTRODUCTION

The aim of this study was to determine the optimal position of the head during larygoscopy.

MATERIAL AND METHODS

During fiberoptic evaluation of the larynx, the head position of eight subjects (5 male, 3 female) was changed systematically. The influence of reclining and anteversion, tilting and rotation of the head on the quality of the endoscopic images was determined.

RESULTS

The vocal tract became wider and the view onto the glottis could be improved by reclining the head and anteversion of the chin. On rotation of the head, the hypopharynx of the same side became narrower. This is well known and is used worldwide in the therapy of dysphagia.

DISCUSSION

Positioning of the patient is important in laryngoscopy. Reclining the head and forward inclination of the trunk (horizontal axis of the mouth) seems to be the best position for obtaining an optimal view onto the glottis.

Ausgepr�gte beidseitige mesocochle�re Schwerh�rigkeit von 40?45�dB bei regelrechten TEOAE, DPOAE und unauff�lliger Click-BERA

An objective screening method for assessment of inner ear function of babies and small children can be carried out by measuring TEOAE and DPOAE. In particular, TEOAE can be used as a cheap and quick method to determine, with very high sensitivity and moderate specificity, whether middle to severe peripheral hearing impairment is present. In order to assess the threshold more precisely, the click-BERA is routinely used. We present a case report of a 6 year old girl with regular TEOAE and DPOAE, and who also had bilateral normal thresholds in the click-BERA. With subjective audiometry, the girl could be diagnosed having bilateral mesocochlear hearing impairment (so called cookie-bite audiogram) ranging at 40-45 dB. The child was helped considerably by fitting of hearing aids bilaterally. In order to determine the auditory ability of children and to provide adequate care, subjective as well as objective tests should be used.

Diagnostik von psychogenen H�rst�rungen im Kindesalter

In comparison with organic hearing loss, which is commonly reported, non-organic hearing loss is under-represented in the literature. The audiological results for 20 patients, aged between 6 and 17 years (mean 11.3), with psychogenic hearing disturbances were analysed prospectively. In 17 cases, the disturbance was bilateral and in three cases unilateral. In no case was the result of an objective hearing test exceptional, while a hearing threshold of between 30 and 100 dB was reported in single ear, pure-tone audiograms. In 12 cases, single ear speech audiograms were unexceptional. Suprathreshold tests, such as the dichotic discrimination test or the speech audiogram with noise disturbance, could lead to a clearer diagnosis in cases of severe psychogenic auditory impairment. In half of the patients, a conflict situation in the school or family was evident. After treatment for this conflict, hearing ability returned to normal. There was no improvement for six patients.

[Reinke edema--helpful in unilateral recurrent laryngeal nerve paralysis?]

We report on a 57-year-old teacher who consulted us for her known unilateral recurrent nerve paralysis subsequent to strumectomy. Video laryngoscopic and stroboscopic examinations revealed Reinke's edema in addition to the left-sided immobile vocal fold with maintenance of good vocal function. Because of the left-sided Reinke's edema, complete glottal closure was possible although the left vocal ligament remained slack. Surgical removal of the vocal fold edema in this case would presumably result in considerable impairment of vocal function. This example illustrates that in selected cases Reinke's edema can contribute to maintenance of phonation in unilateral vocal fold paralysis. In these cases, indication for edema surgery should be very restrictive and should always take the vocal function into consideration.

[Oropharyngeal vocal tract space during singing--comparison of tactile-kinesthetic and auditory perception with objective endoscopic findings]

BACKGROUND

In this study we compared the perceived diameter of the vocal tract's oropharyngeal part with the diameter that was determined endoscopically.

METHODS

28 singers (13 male, 15 female) were examined with transnasal fiberscopic pharyngoscopy while singing the vowels /a/, /i/ and /u/ in 4 different timbres (normal, opened, covered, dumpled) and 3 different pitches (chest/modal register, subjective comfortable pitch for singing, head/falsetto register). The tactile-kinesthetic and auditive rating of the singers, the auditive rating of a singing teacher and the visual-endoscopic analysis of three laryngologists were compared.

RESULTS

The tactile-kinesthetic and auditory self-perception of the singers was quite different from the auditive perception of a singing teacher and visual endoscopic findings of the laryngologists. The singers had the impression that the different singing timbres (normal, opened, covered, dumpled) influence oropharyngeal vocal tract space during singing. They judged the vowel itself and the pitch as having very little influence. Based on his auditory perception, the singing teacher also rated that the timbre plays an important role for the oropharyngeal vocal tract space but he found vowels to be the parameter with the greatest impact. Via visual endoscopic examination we found that, among the three parameters (vowel, timbre, pitch), the different vowels are most influential on the oropharyngeal vocal tract space. Analysis of video sequences revealed that pitch and timbre are less important.

CONCLUSION

Subjective tactile-kinesthetic and auditory perception of the singers differs from auditory perception of the singing teacher as well as from endoscopic findings. The endoscopically determined oropharyngeal vocal tract space during singing the vowels /i/ or /u/ tends to be larger compared to the oropharyngeal vocal tract space while singing the vowel /a/.

Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults

BACKGROUND

Displaced intracapsular fractures may be treated by either reduction and internal fixation which preserves the femoral head, or by replacement of the femoral head with an arthroplasty.

OBJECTIVES

To review all randomised trials that have compared internal fixation and arthroplasty.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), MEDLINE (1966 to January 2002), EMBASE (1988 to 2002, Week 2), Current Contents (1993 to 2002, Week 4), PREMEDLINE (January 2002) and selected orthopaedic journals and conference proceedings, and reference lists of relevant articles. We contacted trialists where possible.

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing internal fixation with arthroplasty for intracapsular hip fractures in adults.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed by use of a 10 item scale. Data from the majority of trials were independently extracted by three reviewers with the remaining extracted by two. Additional information was sought from trialists. After grouping into three broad categories, comparable groups of trials were subgrouped and where appropriate, data were pooled using the fixed effects model.

MAIN RESULTS

Thirteen trials involving 2091 patients were included. Internal fixation had a reduced length of surgery, operative blood loss, need for blood transfusion and risk of deep wound infection. Arthroplasty had a lower re-operation rate in comparison with fixation. No definite differences for hospital stay, mortality, degree of residual pain, regain of mobility or regain of same residential state were found.

REVIEWER'S CONCLUSIONS

Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip. Definite conclusions cannot be made for differences in pain and residual disability between the two groups. Future studies should concentrate on better reporting of final outcome measures and there is still a need for studies to define which patient groups are better served by the different treatment methods.

[Prediction of mortality, mobility and admission to long-term care after hip fractures]

INTRODUCTION

Surgical treatment, discharge planning and rehabilitation procedures are rarely based upon defined assessment procedures. It might therefore be useful to develop simple and reliable screening tools to identify patients for early discharge, intensified rehabilitation and limited treatment.

PATIENTS AND METHODS

234 patients were initially contacted. From these 217 gave informed consent. The reported study included the 134 home dwelling elderly. All patients could be contacted or died after six month. Thus,data from more than 90% could be used for the analysis. The six month mortality was 10%. A population based cohort of elderly patients referred to five local hospitals was tested. Mortality, institutionalisation and mobility were defined as major outcome criteria. Only information that was available during the first week of treatment was used in the model. Predictors expressed as odd ratios (OR) were calculated using logistic regression with variable selection.

RESULTS

The most important predictors for institutionalisation were age, inability to eat without assistance, postoperative night time confusion, stroke history, cognitive deficit and fear of falling. Outdoor mobility was strongly associated to the preoperative ADL performance measured as the Barthel-Index, history of malignancy and fear of falling. Six month mortality was associated with male sex, the Barthel-Index and fear of falling.

DISCUSSION

It seems feasible to improve postoperative resource allocation by predictor led stratification. This need to be tested in intervention trials under the specific condition of the German health care system.

Electron tomography of frozen-hydrated isolated triad junctions

Cryoelectron microscopy and tomography have been applied for the first time to isolated, frozen-hydrated skeletal muscle triad junctions (triads) and terminal cisternae (TC) vesicles derived from sarcoplasmic reticulum. Isolated triads were selected on the basis of their appearance as two spherical TC vesicles attached to opposite sides of a flattened vesicle derived from a transverse tubule (TT). Foot structures (ryanodine receptors) were resolved within the gap between the TC vesicles and TT vesicles, and some residual ordering of the receptors into arrays was apparent. Organized dense layers, apparently containing the calcium-binding protein calsequestrin, were found in the lumen of TC vesicles underlying the foot structures. The lamellar regions did not directly contact the sarcoplasmic reticulum membrane, thereby creating an approximately 5-nm-thick zone that potentially constitutes a subcompartment for achieving locally elevated [Ca(2+) ] in the immediate vicinity of the Ca(2+)-conducting ryanodine receptors. The lumen of the TT vesicles contained globular mass densities of unknown origin, some of which form cross-bridges that may be responsible for the flattened appearance of the transverse tubules when viewed in cross-section. The spatial relationships among the TT membrane, ryanodine receptors, and calsequestrin-containing assemblage are revealed under conditions that do not use dehydration, heavy-metal staining, or chemical fixation, thus exemplifying the potential of cryoelectron microscopy and tomography to reveal structural detail of complex subcellular structures.