Patient-orientated Approach Research Articles

Sedation management in the post-COVID era: A personalised, patient-orientated approach

Intensive care patients are older, frailer, and more co-morbid than ever before, and remain at risk of a variety of adverse outcomes, both in ICU, and after discharge. Sedation and delirium play an intricate role in this complex system, and it can be difficult to determine if they are a contributor or consequence in any given situation. During the COVID-19 pandemic, the increased frequency of complex ventilatory management, including prone ventilation and neuromuscular blockade, necessitated deep sedation in many cases. In concert with infection control concerns and staffing pressures, the delivery of precision symptom- and patient-oriented sedation has waned in favour of strategies felt to be globally safe. Using the SPICE III study as a lens to understand both the importance of exploring heterogeneity of effect in large, complex RCTs of critically ill patients, and the importance of an individualised approach to sedation in the intensive care unit, we demonstrate the evolution of our understanding of sedation in this challenging environment. By following the principles that define the cornerstones of best contemporary sedation practice we can once more grow beyond the boundaries of clinical practice guidelines in the provision of personalised, patient-orientated sedation in the post-COVID intensive care unit.

Physician expert in diabetes is the natural team leader for managing diabetic patients with foot complications. A position statement of the Italian Diabetic Foot Study Group

Diabetic Foot Syndrome (DFS) is a complex disease to be managed by a Multi Disciplinary Team (MDT). Nevertheless, a Team Leader (TL) should be designated to collaborate with members of the MDT in a patient-orientated approach. A TL should know and manage diabetes, related complications and comorbidities. The TL should have deep knowledge of peripheral neuropathy and arterial disease and be able to diagnose and manage foot infections, including prompt surgical treatment when needed. In Italy, after the pioneering phase in which diabetologists began managing medical and surgical aspects of DFS to fill unmet needs, nowadays there is a network of Diabetic Foot (DF) clinics managed by diabetologists. Italy is one of the countries belonging to Organization for Economic Cooperation and Development (OECD) with the lowest amputation rate in diabetic patients. In addition to the special attention to the care of diabetes, the unique expertise of diabetologists involved in DF management may have been a contributing factor. They all share a “patient centered model” of care mainly related to their internal medicine background and have skills in podiatric surgery to manage the specific needs of DF patients with acute or chronic conditions in a timely manner. In Italy, specific training courses and university master programs have been developed in recent years, to prepare internists (diabetologists/endocrinologists) to become TL’s. This has allowed DF care to move from the initial pioneering phase to a more structured phase, with the creation of specific pathways and roles. KEY WORDS diabetes; diabetic foot; multidisciplinary Team; Team Leader

Simultaneous presence of hypercoagulation and increased clot lysis time due to IL-1β, IL-6 and IL-8

Circulating cytokines, and particularly the interleukin (IL)-family are known to play an important role in inflammation. These molecules circulate in the blood and therefore have a direct effect on the plasma molecules and the formed elements like the erythrocytes and platelets. Aberrant coagulation (hypercoagulation or blood clots that form too easily) and clot lyses (hypofibrinolysis, where clots do not dissolve properly, with an abnormally low rate of clot lysis time), are usually the hallmarks of many inflammatory conditions. However, the mechanism by which cross-linking augments clot stiffness remains undetermined. IL-1β; IL-6 and IL-8 has been found to be involved in most chronic and acute inflammatory diseases. In the present study, we investigate clot structure of healthy blood, with the addition of these 3 interleukins, to determine the individual effects at concentrations that mimic low-grade, chronic inflammation. Previous studies showed that clot rheological behavior is regulated by at least the following three factors, fibrinogen concentration, fibrin network architecture and FXIIIa-induced ligation. We investigated clot formation and lysis using thromboelastography (TEG), before and after exposure, and created clots by adding thrombin to whole blood. This allowed us to look at extensive fibrin fiber formation and their interactions with particularly the erythrocytes, using scanning electron microscopy (SEM). Our results showed that IL-1β; IL-6 and IL-8 causes hypercoagulation and results in a disheveled fibrin clot, with trapped RBCs. IL-8 showed eryptosis (a type of apoptosis in erythrocytes). Our lysis results showed that both clot lysis time and maximum rate of lysis are decreased, with the addition of the interleukins. This is a novel finding and the observations reported in this paper, therefore points to the importance of looking at the effects of individual circulating inflammagens, to better understand the role that each play in the expression of disease. These methods can be used for an individualized patient-orientated approach in healthcare to track blood viscosity in conditions with acute and chronic inflammation.

Precision Medicine and a Patient-Orientated Approach: Is this the Future for Tracking Cardiovascular Disorders?

The latest statistics from the 2016 heart disease and stroke statistics update shows that cardiovascular disease is the leading global cause of death, currently accounting for more than 17.3 million deaths per year. Type II diabetes is also on the rise with out-of-control numbers. To address these pandemics, we need to treat patients using an individualized patient care approach, but simultaneously gather data to support the precision medicine initiative. Last year the NIH announced the precision medicine initiative to generate novel knowledge regarding diseases, with a near-term focus on cancers, followed by a longer-term aim, applicable to a whole range of health applications and diseases. The focus of this paper is to suggest a combined effort between the latest precision medicine initiative, researchers and clinicians; whereby novel techniques could immediately make a difference in patient care, but long-term add to knowledge for use in precision medicine. We discuss the intricate relationship between individualized patient care and precision medicine and the current thoughts regarding which data is actually suitable for the precision medicine data gathering. The uses of viscoelastic techniques in precision medicine are discussed and how these techniques might give novel perspectives on the success of treatment regimes of cardiovascular patients are explored. Thrombo-embolic stroke, rheumathoid arthritis and type II diabetes are used as examples of diseases where precision medicine and a patient-orientated approach can possibly be implemented. In conclusion it is suggested that if all role players work together by embracing a new way of thought in treating and managing cardiovascular disease and diabetes will we be able to adequately address these out-ofcontrol conditions.

MODERN POSSIBILITIES OF THERAPY OF TYPE 2 DIABETES MELLITUS PATIENTS. EFFECTIVENESS AND CARDIOSAFETY OF ALOGLIPTIN FROM THE POINT OF VIEW OF EVIDENCE-BASED MEDICINE

According to the IDF (2016) 1 of 11 adult patients suffers from diabetes mellitus (DM). The total number of diabetic patients is 415 million. By 2040, according to analysts of the International Diabetes Federation, the number of the sick increases and the disease will affect 1 in 10 people. It is extremely important to maintain all indicators of carbohydrate metabolism (fasting glucose and postprandial, HbA1c) within the target values. Currently existing recommendations are not obligatory and do not give the strict guidance on the priority use of a group of hypoglycemic drugs and other drugs. The choice of patient-orientated approach, based on the effectiveness and safety of drugs. On the basis of numerous clinical studies have proven the effectiveness and safety of Alogliptin in the treatment of patients with type 2 diabetes.

Novel Diagnostic and Monitoring Tools in Stroke: an Individualized Patient-Centered Precision Medicine Approach.

Central to the pathogenesis of ischaemic stroke are the normally protective processes of platelet adhesion and activation. Experimental evidence has shown that the ligand-receptor interactions in ischaemic stroke represent a thrombo-inflammatory cascade, which presents research opportunities into new treatment. However, as anti-platelet drugs have the potential to cause severe side effects in ischaemic stroke patients (as well as other vascular disease patients), it is important to carefully monitor the risk of bleeding and risk of thrombus in patients receiving treatment. Because thrombo-embolic ischaemic stroke is a major health issue, we suggest that the answer to adequate treatment is based on an individualized patient-centered approach, inline with the latest NIH precision medicine approach. A combination of viscoelastic methodologies may be used in a personalized patient-centered regime, including thromboelastography (TEG®) and the lesser used scanning electron microscopy approach (SEM). Thromboelastography provides a dynamic measure of clot formation, strength, and lysis, whereas SEM is a visual structural tool to study patient fibrin structure in great detail. Therefore, we consider the evidence for TEG® and SEM as unique means to confirm stroke diagnosis, screen at-risk patients, and monitor treatment efficacy. Here we argue that the current approach to stroke treatment needs to be restructured and new innovative thought patterns need to be applied, as even approved therapies require close patient monitoring to determine efficacy, match treatment regimens to each patient's individual needs, and assess the risk of dangerous adverse effects. TEG® and SEM have the potential to be a useful tool and could potentially alter the clinical approach to managing ischaemic stroke. As envisaged in the NIH precision medicine approach, this will involve a number of role players and innovative new research ideas, with benefits that will ultimately only be realized in a few years. Therefore, with this ultimate goal in mind, we suggest that an individualized patient-orientated approach is now available and therefore already within our ability to use.

An evaluation of paediatric hand and upper limb assessment tools within the framework of the World Health Organisation International Classification of Disability, Functioning and Health

Introduction Evaluation of hand function has traditionally focused on objective measurements involving strength and range of movement measurements. The World Health Organisation International Classification of Disability, Functioning and Health (ICF) framework has introduced a more patient-orientated approach to assessment, incorporating four distinct areas of body structures, body functions, environment and activity limitation. These can be evaluated with both questionnaires and functional tests. Whereas there seems to be agreement over adult hand assessment, children’s hand assessment leaves involved therapists and clinician often wondering, which test to perform. The objective of this review was to evaluate the currently available childrens' hand and upper limb assessment tools within the framework of the ICF. Method A review of 19 of the most commonly used paediatric hand and upper limb assessment tools in the context of the components of the ICF. The International Classification of Disability, Functioning and Health linking rules composed by Cieza et al. were used in order to map each of the meaningful concepts in these assessment tools to the domains of the ICF. Results The activities domain of the ICF was found to be well represented in all assessment tools. Four out of 19 assessment tools had items that mapped to the environment domain. The highest number of different concepts mapped was found in musculoskeletal questionnaires. The lowest number of concepts was found in the pegboard tests. Conclusion Tests are often combined to attempt to cover as many aspects of the ICF yet our findings show that this may not always be achieved. Clinicians and therapists must be aware that in order to get a more complete overview of a child’s hand and upper limb functioning sometimes time- and resource-consuming tests have to be combined.

Orthostatic Hypotension: Mechanisms, Causes, Management.

Orthostatic hypotension (OH) occurs when mechanisms for the regulation of orthostatic BP control fails. Such regulation depends on the baroreflexes, normal blood volume, and defenses against excessive venous pooling. OH is common in the elderly and is associated with an increase in mortality rate. There are many causes of OH. Aging coupled with diseases such as diabetes and Parkinson's disease results in a prevalence of 10-30% in the elderly. These conditions cause baroreflex failure with resulting combination of OH, supine hypertension, and loss of diurnal variation of BP. The treatment of OH is imperfect since it is impossible to normalize standing BP without generating excessive supine hypertension. The practical goal is to improve standing BP so as to minimize symptoms and to improve standing time in order to be able to undertake orthostatic activities of daily living, without excessive supine hypertension. It is possible to achieve these goals with a combination of fludrocortisone, a pressor agent (midodrine or droxidopa), supplemented with procedures to improve orthostatic defenses during periods of increased orthostatic stress. Such procedures include water bolus treatment and physical countermaneuvers. We provide a pragmatic guide on patient education and the patient-orientated approach to the moment to moment management of OH.

Psychological approach in cosmetic dermatology for optimum patient satisfaction

Knowledge and skills are required to deal with certain skin disorders and their corresponding cosmetic complaints. The field of cosmetic dermatology is growing as an overlap between the medical treatment of skin diseases and traditional cosmetology. This poses problems for dermatologists and other professionals, including regulation agencies. Dermatology should enable patients to benefit from all that is necessary for their care, whether that is surgery, drugs or cosmetics. There is no need to modify current regulations. A patient-orientated approach is advocated. The author tries to address fellow Dermatologists and those dealing with cosmetology on how to optimally maximize the outcome of their results by simple advices on how to deal with their patients.

Two approaches to nursing: a study of Iranian nurses

Studying nurses' experience from a sociocultural perspective can contribute to improving knowledge and understanding in this field. To describe and compare three different groups of Iranian nurses' experiences of their profession. The study was conducted in Iran and Sweden. The data were collected from semi-structured telephone interviews and analysed with latent content analysis. The participants were three groups of registered nurses (RNs) (21 persons). All RNs were born and grew up in Iran. The first group (A) were educated and had worked in Iran but were now working and living in Sweden. The second group (B) were educated and worked in Sweden. The third group (C) were educated and worked in Iran. The nurses in Sweden worked with a patient-orientated approach while nurses in Iran worked with a task-orientated approach. Nurses in all three groups explained that they suffered from stress, had a heavy workload, were underpaid and understaffed. The findings showed that RNs working with a patient-orientated approach, experienced work satisfaction to a greater extent than RNs working with a task-orientated approach, although other aspects also influenced the nurses' situation considerably.

The field of cosmetic dermatology: the need for a patient‐centred approach

Similar of knowledge and skills are required to deal with certain skin disorders and their corresponding cosmetic complaints. The field of cosmetic dermatology is growing as an overlap between the medical treatment of skin diseases and traditional cosmetology. This poses problems for dermatologists and other professionals, including regulation agencies. Dermatology should be able patients to benefit from all that is necessary for their care, whether that be surgery, drugs or cosmetics. There is no need to modify current regulations. A patient-orientated approach is advocated.

Primary nursing andstudent supervision: exemplars in practice

Primary nursing is purported to be a care management system that promotes effective student-centred learning through a partnership approach to care and supervision. Exemplars from a qualitative longitudinal study, highlighted in this paper, suggest that the student's learning is holistic and meaningful when a patient-orientated approach to care intervention is utilized. However, many of the nursing contexts in this study used a task-centred means of patient care, resulting in some fragmentation of learning.