Success factors and barriers in interprofessional collaboration between dental hygienists and dietitians in community-dwelling older people: Focus group interviews

INTRODUCTION

Poor nutritional status can impair oral health while poor oral health can influence the individual's dietary intake, which may result in malnutrition. This interaction between nutritional status and oral health in older age requires attention, coordination and collaboration between healthcare professionals. This qualitative study explores dental hygienists' and dietitians' opinions about current collaboration with the aim of identifying success factors and barriers to this interprofessional collaboration.

METHODS

Three focus group interviews were held with Dutch dental hygienists and dietitians about nutritional and oral healthcare in community-dwelling older people.

RESULTS

In total, 9 dietitians and 11 dental hygienists participated in three online focus group interviews. Dental hygienists and dietitians seldom collaborated or consulted with each other. They struggled with the professional boundaries of their field of expertise and experienced limited knowledge about the scope of practice of the other profession, resulting in conflicting information to patients about nutrition and oral health. Interprofessional education was scarce during their professional training. Organizational and network obstacles to collaborate were recognized, such as limitations in time, reimbursement and their professional network that often does not include a dietitian or dental hygienist.

CONCLUSION

Dental hygienists and dietitians do not collaborate or consult each other about (mal)nutrition or oral health in community-dwelling older people. To establish interprofessional collaboration, they need to gain knowledge and skills about nutrition and oral health to effectively recognize problems in nutritional status and oral health. Interprofessional education for healthcare professionals is needed to stimulate interprofessional collaboration to improve care for older people.

Validation of the ELAN-HF Score and self-care behaviour on the nurse-led heart failure clinic after admission for heart failure

AIM

To validate the predictive value of the European coLlaboration on Acute decompeNsated Heart Failure (ELAN-HF) score, and to assess the effect of self-care behaviour on readmission and mortality in patients after admission with acute decompensated heart failure (ADHF).

DESIGN

Quantitative, prospective, single centre, cohort study.

METHODS

N-Terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured on admission and discharge, and were used together with clinical and laboratory parameters to calculate the ELAN-HF score. Patients were stratified into four risk groups (low, intermediate, high, very high) according to their ELAN-HF score. The performance of the ELAN-HF score was evaluated and compared to the original study. Self-care behaviour was assessed by the European Heart Failure Self-care Behaviour Scale (EHFScBS-9). Survival analysis was used to estimate the association between both scores and re-admission for HF and/or all-cause mortality within 180 days.

RESULTS

88 patients were included. The median age of the study population was 75 years (IQR 69-83), 43% was female. NYHA III/IV functional class was present at discharge in 68 patients (85%) and 27 patients (34%) had a left ventricular ejection fraction < 40%. Complete data and 180 day follow up was available for 80 patients. 55% reached the endpoint of readmission and/or all-cause mortality. There was a significant association between the ELAN-HF score and re-admission and/or mortality < 180 days (HR = 1.25, 95% CI 1.08-1.45, p = 0.003). The median EHFScBS-9 score was 68.1 (IQR 58.3 - 77.8). There was no significant association between the EHFScBS-9 score and readmission and/or mortality < 180 days (HR = 1.01, 95% CI 0.99-1.03, p = 0.174).

CONCLUSION

This study confirms the validity and therefore the potential of the ELAN-HF score to triage patients with ADHF before discharge. Using this score may optimize the follow-up treatment on the nurse-led heart failure clinic in order to decrease readmission and mortality. Self-care behaviour was non-significantly associated with readmission and/or mortality in our study population.

TRIAL REGISTRATION

This study has been registered with the ethics committee MEC-U (Nieuwegein, The Netherlands), registration nr: V.160999/W18.208/HG/mk.

Early lumen diameter loss after percutaneous transluminal coronary angioplasty is related to coronary plaque burden: a role for viscous plaque properties in early lumen diameter loss

OBJECTIVES

We tested the hypothesis that lumen diameter loss within 1 h after percutaneous transluminal coronary angioplasty is related to plaque volume parameters.

BACKGROUND

Early lumen diameter loss after coronary balloon angioplasty may predict restenosis and may paradoxically decrease late lumen diameter loss. Viscous properties of the vessel wall, as would be determined by tissue volume and composition, may be involved in early lumen diameter loss.

METHODS

Early lumen diameter loss was measured with quantitative coronary angiography as the loss in lesion lumen diameter (significant loss 0.4 mm) occurring between 5 min and a median of 40 min after successful coronary balloon angioplasty in 68 patients. Thirty-nine patients were evaluated with intravascular ultrasound at the narrowest lumen cross-section of the dilated lesion, 29 patients formed a control group without intravascular ultrasound imaging. We tested the relation between intravascular ultrasound parameters and early lumen diameter loss.

RESULTS

Early lumen diameter loss of > or = 0.4 mm was present in eight patients (12%), decreasing lumen diameter from 2.26 +/- 0.36 mm to 1.73 +/- 0.43 mm. There was no difference in the frequency of early lumen diameter loss between the groups with or without intravascular ultrasound imaging. Univariate intravascular ultrasound determinants of early lumen diameter loss were media bounded area (p = 0.01), maximal plaque thickness (p = 0.02), eccentricity index (p = 0.03) and the presence of hard lesions (p = 0.02).

CONCLUSION

Early lumen diameter loss in the first hour after successful coronary balloon angioplasty occurs in a small proportion of patients. It is related to hard lesion type, maximal plaque thickness and eccentricity index, favoring a role for viscous plaque properties in early lumen diameter loss.

Videodensitometric quantitative angiography after coronary balloon angioplasty, compared to edge-detection quantitative angiography and intracoronary ultrasound imaging

AIMS

To assess the value of videodensitometric quantification of the coronary lumen after angioplasty by comparison to two other techniques of coronary artery lumen quantification.

METHODS AND RESULTS

Videodensitometric quantitative angiography, edge detection quantitative angiography and 30 MHz intracoronary ultrasound imaging were performed after successful balloon angioplasty in 161 patients. Lumen cross-sectional areas were mean (SD) 2.82 (1.15) mm(2)for edge detection quantitative angiography, 3.67 (1.5) mm(2)for videodensitometric quantitative angiography and 5.32 (1.75) mm(2)for intracoronary ultrasound imaging (P<0.001). The correlation between intracoronary ultrasound imaging and videodensitometric quantitative angiography (r=0.44) was almost similar to that of intracoronary ultrasound imaging and edge detection quantitative angiography (r=0. 47). The correlation between the three techniques was not significantly influenced by the presence of ruptures and dissections on intracoronary ultrasound imaging. The absence of calcifications improved the correlation between videodensitometry and intracoronary ultrasound imaging.

CONCLUSIONS

The luminal dimensions as measured by videodensitometric quantitative angiography matched intracoronary ultrasound imaging derived dimensions more closely than edge detection quantitative angiography. Videodensitometric quantitative angiography represents an on-line alternative to intracoronary ultrasound imaging for quantitative analysis regardless of the degree of vessel damage.

Greater late lumen loss after successful coronary balloon angioplasty in the proximal left anterior descending coronary artery is not explained by extent of vessel wall damage or plaque burden

OBJECTIVES

We investigated whether the greater late lumen loss after coronary balloon angioplasty in the proximal left anterior descending artery (P-LAD) compared with that in other segments might be related to differences in vascular dimensions or morphology as determined by angiography and intravascular ultrasound imaging.

BACKGROUND

The greater late lumen loss after angioplasty in the P-LAD that has been observed in several studies has not been explained.

METHODS

We studied 178 patients and 194 coronary artery lesions by quantitative angiography and 30 MHz intravascular ultrasound imaging after successful balloon angioplasty. Vessel wall morphology was compared among three proximal and three nonproximal segments. Follow-up quantitative angiography for late lumen loss calculation was performed in 168 lesions. Multivariate analysis was used to determine predictors of late lumen loss.

RESULTS

Absolute and relative late loss were significantly greater at the P-LAD compared with the pooled group of other segments (0.42 +/- 0.60 mm vs. 0.10 +/- 0.48 mm, p = 0.0008 and 0.14 +/- 0.24 vs. 0.03 +/- 0.17, p < 0.001). Also, a greater percentage of calcific lesions (65% vs. 44%, p = 0.034), a lower incidence of rupture (51% vs. 74%, p = 0.009) and a larger reference segment plaque area (5.4 +/- 2.2 mm2 vs. 4.7 +/- 1.9 mm2, p = 0.05) were found in the P-LAD. In multivariate analysis however, these variables were not predictive of late loss.

CONCLUSIONS

Greater late lumen loss after coronary balloon angioplasty of the P-LAD is not explained by differences in atherosclerotic plaque burden or in vessel wall damage.

Coronary atherosclerosis within a myocardial bridge, not a benign condition

In patients with myocardial bridging, the area within the bridge usually remains free from atherosclerotic disease. The case of a 47 year old man is described who had the rare combination of myocardial bridging with an atherosclerotic plaque within the area of bridging, which was detected with intravascular ultrasound but not with coronary angiography. The clinical history of the patient demonstrates that this is not a benign condition. In symptomatic patients the bridged segment should be screened for the presence of plaque with intracoronary ultrasound.

An analogue laser optical disc in comparison with cinefilm for visual analysis of coronary narrowings before and after coronary angioplasty

This study evaluated an analogue laser optical disc (MVP) as an alternative for cinefilm angiography in the visual analysis of coronary angiograms. Visual analysis was performed independently by 5 observers using cinefilm and MVP before and after PTCA (194 coronary lesions in 88 patients) and the outcomes were compared with QCA. The mean percentage diameter stenosis on cinefilm and MVP yielded similar results compared to QCA. Regression analysis showed a good correlation between the mean cinefilm and MVP values per diameter stenosis (p < 0.001). Bland-Altman plots confirmed these findings. Qualitative analysis for detection of coronary dissections after PTCA showed an incidence of 31.3% (cinefilm) and 21.8% (MVP) (p < 0.05). The results of this study indicate that the visual analysis of the coronary angiograms using the analogue laser optical disc (MVP) yields similar results compared to the cinefilm concerning coronary lesion severity, although there is an underestimation of coronary dissections.

Arterial remodeling after balloon angioplasty of the coronary artery: an intravascular ultrasound study. PICTURE Investigators. PostTreatment IntraCoronary Transluminal Ultrasound Result Evaluation

OBJECTIVE

Before balloon dilation, failure of compensatory enlargement and even arterial shrinkage are frequently observed at the lesion site in response to plaque accumulation. Balloon angioplasty may be regarded as artificial remodeling to enlarge the artery. The prevalence of the different types of arterial wall remodeling after applied stretch by balloon angioplasty is unknown.

METHODS AND RESULTS

In 181 patients an intravascular ultrasound study was performed after coronary balloon angioplasty (n = 200 lesions). The vessel area was measured at a proximal and distal reference site and at the lesion site. Subsequently, the relative vessel area [(Vessel area lesion site)/Vessel area reference site) x 100] was calculated. Lesions were classified in three groups on the basis of their relative vessel areas: > or =105%, <105% but >95%, and < or =95%. A relative vessel area > or =105%, indicating enlargement compared with the reference site, was observed in 84 (44%) lesions. A relative vessel area <105% but >95% was observed in 43 (22%) lesions. A relative vessel area < or =95%, indicating "shrinkage" compared with the reference site, was observed in 66 (34%) lesions.

CONCLUSIONS

After balloon angioplasty, the vessel area was found to be smaller compared with the reference site in 34% of the lesions. This small vessel area at the lesion site compared with a reference site may be a reflection of insufficient stretch by balloon angioplasty.

Prediction of restenosis after coronary balloon angioplasty. Results of PICTURE (Post-IntraCoronary Treatment Ultrasound Result Evaluation), a prospective multicenter intracoronary ultrasound imaging study

BACKGROUND

Intracoronary ultrasound (ICUS) imaging is potentially suitable to identify lesions at high risk of restenosis after percutaneous transluminal coronary angioplasty (PTCA), but it has not been studied systematically.

METHODS AND RESULTS

We recruited 200 patients in whom ICUS studies were performed after successful PTCA and related their ICUS parameters to 6-month follow-up quantitative coronary angiography. This was performed in 164 patients (82%), yielding 170 lesions for analysis. The overall incidence of a > or = 50% diameter stenosis at follow-up (categorical restenosis) was 29.4%. Quantitative ICUS parameters were weakly but significantly related to follow-up minimal luminal diameter on quantitative coronary angiography (lumen area: R2 = .36, P = .0001; vessel area: R2 = .29, P = .0002; plaque area: R2 = -.18, P = .021; percent obstruction: R2 = -.15, P = .05), but categorical restenosis was not significantly related to these parameters (P = .63, .77, .38, and .08, respectively). There were no significant predictors of restenosis in ICUS parameters of plaque morphology: eccentric versus concentric (P = 1.0), plaque type (hard, soft, or calcific, P = .98), or the number of calcified quadrants (P = .41). There were no significant predictors of restenosis in two predefined types of vessel-wall disruptions: (1) rupture: presence (P = .79), depth (partial versus complete, P = .85), or extent in quadrants (P = .6), and (2) dissection: presence (P = .31), depth (P = .82), or extent (P = .38).

CONCLUSIONS

Qualitative ICUS parameters after PTCA did not predict restenosis. A larger lumen and vessel area and a smaller plaque area by ICUS were associated with a larger angiographic minimal lumen diameter at follow-up, but these parameters were not significantly related to categorical restenosis.

Reproducibility of quantitative measurements from intracoronary ultrasound images. Beat-to-beat variability and influence of the cardiac cycle

OBJECTIVES

The purpose of this study was to determine the variability of quantitative measurements from intracoronary ultrasound images, and the influence of the cardiac cycle on this variability, as a basis for in vivo applications.

METHODS

Two observers analysed 30 MHz cross-sectional images from 96 in-vivo coronary arterial sites. By computer-assisted contour tracing we determined lumen area, vessel area, lesion area (vessel area minus lumen area) and percent obstruction (100% x lesion area/vessel area). Intra- and inter-observer and beat-to-beat variability, and systolic to diastolic differences were calculated by paired analysis.

RESULTS

Consistent intra- and inter-observer differences (bias) were small (< or = 0.9%). Random variations in the two direct parameters were < or = 21.1%, but for the two derived parameters they were up to 40%. For all four parameters, random inter-observer variability was significantly greater (up to 119% for vessel area: 19.3 vs 8.8%) than intra-observer variability, but consistent variability was similar. Consistent beat-to-beat differences were small (< or = 1.4%), random variations were 8.9% to 17.5%. Random beat-to-beat variability for all four parameters was greater in diastolic than in systolic frames (up to 47.0% difference (11.9 vs 17.5%) for lesion area). Vascular dimensions were significantly greater in systole (2%). We found an error of 0.24 mm (2SD) for intra-observer variability of calculated mean arterial diameters, which is similar to the error described in angiographic studies (0.22 mm).

CONCLUSIONS

Quantitative measurements from intracoronary ultrasound images generally reproduce well. It is preferable to use directly measured parameters as opposed to derived parameters, as they are less subject to variability. Variability can be reduced by selecting systolic images.

Determinants of echodensity at the intima-media interface with intracoronary ultrasound imaging

A thin, echodense layer (EL) is sometimes observed at the intima-media interface on intravascular ultrasonographic images. We reviewed a series of 119 histologically matched, 30 MHz, in vitro ultrasound cross sections of human coronary arteries for factors determining the occurrence of an EL. ELs were observed in 19 (27%) of 71 images with optimal gain settings, in two (17%) of 12 with high gain settings, and in none of 26 with low gain settings. In 17 (94%) of 18 cross sections with eccentric catheter positions, an EL was visible only in parts of the vessel wall that were perpendicular to the ultrasound beam. ELs were seen behind fibrous, lipid-rich, and mixed lesions but not behind calcified lesions because of acoustic shadowing. The presence or morphologic elements of the internal elastic lamina did not influence the occurrence of an EL. We conclude that the occurrence of an EL at the intima-media interface depends on acoustic factors and gain settings, and it provides no anatomic information per se.

In vitro validation of intravascular ultrasound imaging after balloon angioplasty of coronary artery stenoses

Systematic studies of intravascular ultrasound imaging of in vitro balloon angioplasty on coronary arteries with a greater than 50% diameter stenosis on angiogram have not been performed. We used 23 plasma-perfused postmortem human coronary arteries with an angiographic diameter stenosis of > or = 50%. After balloon dilation the vessels were examined by 30-MHz intravascular ultrasound imaging (IVUS) and the presence of ruptures and dissections was noted. Ruptures were defined as disruptions of the vessel wall in a radial direction, and dissections were defined as disruptions in a circumferential direction. After pressure fixation they were studied by histology. On IVUS, 24 vessel wall disruptions were diagnosed in 14 arteries. On histology, 29 disruptions were diagnosed in 19 arteries. The sensitivity of IVUS for the detection of disruptions was 79%, the specificity was 75%. Total agreement was 79%. Accuracy was better for dissections (total agreement 96%) than for ruptures (total agreement 74%). Shadowing behind calcium and close contact of the catheter to the arterial wall were important sources of error in the IVUS analysis. We conclude that intravascular ultrasound imaging is accurate for the detection of disruptions after balloon angioplasty of angiographically significant coronary artery stenoses.

Contribution of age and intimal lesion morphology to coronary artery wall mechanics in coronary artery disease

1. Atherosclerotic changes of the coronary vascular wall include localized plaque formation and diffuse hardening, both of which influence tensile strength of the inner vascular wall. Insight into the relation between age, the atherosclerotic process and vessel wall elasticity may contribute to the prevention of secondary vascular wall damage. 2. To evaluate the determinants of coronary artery wall elasticity, we studied a group of 34 patients, aged 54.6 +/- 10.1 years, who underwent balloon angioplasty for coronary artery disease. With the use of 30 MHz intravascular ultrasound, a total of 127 cross-sections of coronary artery segments outside the balloon area were studied. The echographic appearance of the intima was classified as normal intimal thickening, fibrous lesions and calcified lesions. Fibrofatty lesions, which are believed to be rupture prone, were analysed separately. From the lumen area change, measured by semiautomated planimetry from digitized ultrasound images, and simultaneously measured aortic pressure change during the diastolic phase of the cardiac cycle, two elastic parameters were derived, pressure-strain modulus Ep and beta-stiffness. 3. In univariate analysis Ep and beta-stiffness were determined by age, vessel size, intimal composition, severity of lumen obstruction and gender, but not by eccentricity of the lesion or a specific coronary artery. In multivariate linear analysis, increased vessel wall stiffness was independently determined by advanced age, larger vessel size, intimal composition, and to a lesser extent by female gender. Elastic parameters of fibrofatty lesions were not different from other fibrous lesions. 4. Coronary artery wall elasticity is independently determined by age, vessel size and intimal composition.

Characterization of plaque components with intracoronary ultrasound imaging: an in vitro quantitative study with videodensitometry

We investigated whether videodensitometry provides a possibility of objective plaque characterization by intracoronary ultrasound imaging. Histologically matched 30 MHz ultrasound images of characteristic atherosclerotic lesions in saline solution and blood-perfused human coronary arteries in vitro were digitized, and regions of interest were analyzed by calibrated videodensitometry. Pixel gray-level distributions were represented as frequency histograms, and mean pixel gray level, skewness, and kurtosis were calculated. Similarly, images of flowing blood in vitro (n = 9; hematocrit 40%) were analyzed. Mean pixel gray levels differed between the three lesion types (lipid rich [n = 6], 71 to 92 [mean 80]; fibromuscular plaque [n = 14], 94 to 162 [mean 124]; and calcified plaques [n = 8]; 161 to 196 [mean 178]) (all comparisons p < 0.001). Ranges of mean pixel gray levels for flowing blood in vitro were within the range of those for fibromuscular plaque (86 to 103; mean 98). During blood perfusion in nine specimens, pixel gray levels were 85% +/- 7% of those during saline perfusion but with similar differences between plaque types. We conclude that homogeneous plaque types can be distinguished in vitro by videodensitometry on intracoronary ultrasound images.

Histopathologic validation of intracoronary ultrasound imaging

The purpose of this study was to validate intracoronary ultrasound imaging by correlation with histologic examination. In this in-vitro study of pressure-perfused human coronary arteries, 104 matching intracoronary ultrasound imaging images and histologic cross-sections from 12 hearts were compared to determine the diagnostic accuracy of 30 MHz commercially available intracoronary ultrasound imaging. For lipid deposits, sensitivity was 46% and specificity 97%. The smallest lipid deposit that was visualized measured 0.25 mm in axial diameter on histologic study. For calcific deposits, sensitivity was 77% and specificity 100%. The smallest calcific deposit that was visualized measured 0.25 mm in axial diameter on histologic examination. Atherosclerotic intimal thickening could not be distinguished qualitatively or quantitatively from nonatherosclerotic intimal thickening unless there were localized deposits of lipids or calcium. Intracoronary ultrasound imaging is accurate in detecting lipid and calcium deposits. Intimal thickening in intracoronary ultrasound imaging images does not prove the presence of atherosclerosis.

Vasodilation by shear-induced platelet aggregation in extracorporeal circuits

Extracorporeal circulation may have adverse effects on vascular reactivity. To reduce such effects, we recently coated a tube connecting the carotid and the distal femoral artery of rats with albumin. When we partially occluded this perfusion line, the reduction of flow was followed by a marked increase, which seemed not to be caused by autoregulation but by release of a vasodilator at the site of occlusion. In the present study, we investigated whether this vasodilator could originate from platelets aggregating under the influence of increased shear stress at the site of occlusion. Blood distal to the site of occlusion indeed contained numerous platelet aggregates that were not present before occlusion. Continuous recording with a photometric device showed that aggregation in the tube started before flow increased and ended before flow decreased again. Blockade of serotonin S1- and S2-receptors with methiothepin prevented the flow response. Estimated shear stress (231 +/- 17 dyn/cm2) and shear rate (6,370 +/- 478 s-1) at the site of occlusion were of the magnitude known to elicit platelet aggregation. Others have recently demonstrated that shear-induced platelet aggregation is mediated by binding of von Willebrand factor to platelet glycoprotein Ib, which is inhibited by aurintricarboxylic acid. This drug (35 mg/kg iv) completely abolished both platelet aggregation and flow increase in our experiments. These results suggest that the vasodilation during partial tube occlusion is mediated by serotonin released from platelets that aggregate as a result of high shear stress.

Extracorporeal circuits and autoregulation: effect of albumin coating

Autoregulation of muscle blood flow often is difficult to demonstrate when extracorporeal perfusion is used. This could be caused by contact of blood and foreign material. Accordingly, we tested whether autoregulation is preserved when the system is coated with albumin. Polyurethane tubing between the carotid and distal femoral artery of rats was partially occluded for 1-2 min. With the system uncoated (n = 6 rats) autoregulation was absent. With coated systems (n = 6 rats) the closed-loop gain (Gc) of the apparent autoregulation (0 < Gc < 1) for the pressure range from control (137 +/- 14) to 80 mmHg was 0.40 +/- 0.24 (mean +/- SD). In most cases autoregulation was preceded by a period of "superregulation": after a variable delay flow rose above control. When the distance between occluder and tip of femoral cannula was varied in another group of rats (n = 6), the delay (20-75 s) was linearly related to transit time (10-35 s) of blood. Flow increase thus seemed to be caused by a blood-borne vasodilator originating at the occlusion site and not by a myogenic or metabolic response to decreased pressure and flow. The vasodilator did not originate from the albumin coating. Partial occlusion of an extracorporeal shunt thus can increase flow to the perfused tissue when the system is coated with albumin. The reaction readily disappears when the system is not coated.