Improvement of shared decision making in integrated stroke care: a before and after evaluation using a questionnaire survey.

BACKGROUND: Shared decision making (SDM) is at the core of policy measures for making healthcare person-centred. However, the context-sensitive nature of the challenges in integrated stroke care calls for research to facilitate its implementation. This before and after evaluation study identifies factors for implementation and concludes with key recommendations for adoption. METHODS: Data were collected at the start and end of an implementation programme in five stroke services (December 2017 to July 2018). The SDM implementation programme consisted of training for healthcare professionals (HCPs), tailored support, development of decision aids and a social map of local stroke care. Participating HCPs were included in the evaluation study: A questionnaire was sent to 25 HCPs at baseline, followed by 11 in-depth interviews. Data analysis was based on theoretical models for implementation and 51 statements were formulated as a result. Finally, all HCPs were asked to validate and to quantify these statements and to formulate recommendations for further adoption. RESULTS: The majority of respondents said that training of all HCPs is essential. Feedback on consultation and peer observation are considered to help improve performance. In addition, HCPs stated that SDM should also be embedded in multidisciplinary meetings, whereas implementation in the organisation could be facilitated by appointed ambassadors. Time was not seen as an inhibiting factor. According to HCPs, negotiating patients' treatment decisions improves adherence to therapy. Despite possible cognitive or communications issues, all are convinced patients with stroke can be involved in a SDM-process. Relatives play an important role too in the further adoption of SDM. HCPs provided eight recommendations for adoption of SDM in integrated stroke care. CONCLUSIONS: HCPs in our study indicated it is feasible to implement SDM in integrated stroke care and several well-known implementation activities could improve SDM in stroke care. Special attention should be given to the following activities: (1) the appointment of knowledge brokers, (2) agreements between HCPs on roles and responsibilities for specific decision points in the integrated stroke care chain and (3) the timely investigation of patient's preferences in the care process - preferably before starting treatment through discussions in a multidisciplinary meeting.

Determination of ITPase activity in erythrocyte lysates obtained for determination of TPMT activity.

The indication for the determination of both thiopurine methyltransferase (TPMT) and inosine triphosphate pyrophosphohydrolase is identical (i.e., adverse drug reactions toward mercaptopurines). Therefore, we tested whether or not our standard procedure to prepare erythrocyte lysates for measurement of TPMT activity, which includes treatment with Chelex 100 (a chelating resin), was suitable for the measurement of ITPase activity. It also was tested to see if ITPase activity differs in EDTA and Heparin anti-coagulated blood samples. We found that there was no difference between the ITPase activity in erythrocyte lysates prepared from EDTA or Heparin anti-coagulated blood. Treatment with a chelating resin or omission of magnesium from the assay procedure resulted in decreased and nearly absent ITPase activity, respectively. We conclude that untreated erythrocyte lysates obtained for determination of TPMT activity are suitable for determination of ITPase activity. However, after treatment with Chelex 100 the erythrocyte lysates become unsuitable for determination of ITPase activity.

Specific and sustained down-regulation of genes involved in fatty acid metabolism is not a hallmark of progression to cardiac failure in mice.

Preferential and specific down-regulation of genes involved in fatty acid (FA) uptake and metabolism is considered a hallmark of severe hypertrophic remodeling and progression to cardiac failure. Therefore, we investigated the time course of changes in cardiac metabolic gene expression (1) in mice subjected to regional myocardial infarction (MI) for 4 days, 1 month, or 3 months and (2) in mice overexpressing calcineurin (Cn) which initially develop concentric hypertrophy progressing after the age of 4 weeks to dilated cardiomyopathy and failure. In both models, hypertrophy was characterized by increased expression of beta-myosin heavy chain protein and atrial natriuretic factor mRNA, indicative of marked structural remodeling. Fractional shortening progressively decreased from 31% to 15.1% and 3.7% 1 and 3 months after MI, respectively. One month post-MI, the expression of several metabolic genes, i.e., acyl-CoA synthetase (-50%), muscle-type carnitine palmitoyl transferase 1 (-37%) and citrate synthase (-28%), was significantly reduced in the surviving myocardium. Despite overt signs of cardiac failure 3 months post-MI, the expression of these genes had returned to normal levels. In hearts of both 4- and 6-week-old Cn mice, genes involved in both FA and glucose metabolism and mitochondrial citrate synthase were down-regulated, reflecting an overall decline in metabolic gene expression, rather than a specific and preferential down-regulation of genes involved in FA uptake and metabolism. These findings challenge the concept that specific and sustained down-regulation of genes involved in FA uptake and metabolism represents a hallmark of the development of cardiac hypertrophy and progression to failure.

Functional and metabolic adaptation of the heart to prolonged thyroid hormone treatment.

In heart failure, thyroid hormone (TH) treatment improves cardiac performance. The long-term effects of TH on cardiac function and metabolism, however, are incompletely known. To investigate the effects of up to 28 days of TH treatment, male Wistar rats received 3,3',5-triiodo-l-thyronine (200 microg/kg sc per day) leading to a 2.5-fold rise in plasma fatty acid (FA) level and progressive cardiac hypertrophy (+47% after 28 days) (P < 0.001). Ejection fraction (echocardiography) was increased (+12%; P < 0.05) between 7 and 14 days and declined thereafter. Neither cardiac FA oxidation, glycolytic capacity (homogenates) per unit muscle mass, nor mRNA levels of proteins involved in FA and glucose uptake and metabolism (Northern blots and microarray) were altered. After 28 days of treatment, mRNA levels of uncoupling proteins (UCP) 2 and 3 and atrial natriuretic factor were increased (P < 0.05). This indicates that TH-induced hypertrophy is associated with an initial increase in cardiac performance, followed by a decline in cardiac function and increased expression of UCPs and atrial natriuretic factor, suggesting that detrimental effects eventually prevail.

New protocol for DNA extraction of stool.

Present methods for DNA isolation of stool have various limitations such as the amount of stool used, the requirement of lavage fluids or the use of fresh stool. In this paper, a new method is described for the isolation of human nucleic acids from stool, which is independent from the moment of collection. Fecal samples as dry as possible were collected from 75 patients; two grams of stool were mixed with a lysis buffer containing phenol. DNA yields of crude stool were variable and ranged from 9-1686 micrograms/g of feces. With dot blots in 9 of the 75 cases, the human DNA was identified and ranged from 0.06%-46%. In the remaining 66 cases, human genomic DNA was detected by nested PCR, using human K-ras gene amplification as an example. Amplification products were confirmed for human K-ras with the exonuclease-amplification coupled capture technique (EXACCT). In conclusion, the developed DNA isolation method can be used for the study of large numbers of stool samples, is independent of the age or method of stool collection and is suitable for large-scale screening studies.

The role of gamma-carboxyglutamyl residues in the positive cooperative binding of Ca2+ to blood coagulation factor X.

1. The calcium binding properties of factor X and its analogous decarboxyprotein have been compared with the aid of flow rate dialysis and ultraviolet difference spectroscopy. 2. Factor X binds approx. 20 mol of calcium per mol of protein. The first four sites exhibit positive cooperativity. 3. Changes in the ultraviolet difference spectrum when Ca2+ is bound suggest a conformational change. 4. In decarboxyfactor X low affinity of Ca2+ and no ligand-induced conformational change was observed. It is concluded that the presence of gamma-carboxyglutamate residues is a prerequisite for positive cooperative Ca2+ binding.

The effect of gamma-carboxyglutamate residues on the enzymatic properties of the activated blood clotting factor X. I. Activity towards synthetic substrates.

The esterolytic and amidolytic properties of activated blood coagulation factor X (factor Xa) and the analogous decarboxy species were compared in order to find out if the gamma-carboxyglutamic acid residues influence the function of the active centre. It was found that the two proteins (1) showed similar kinetic parameters when titrated with p-nitrophenyl-p'-guanidinobenzoate hydrochloride (2) had a similar Km and kcat for various synthetic chromogenic tri- and tetrapeptides and (3) were inhibited in the same way by benzamidine. Further it was observed that (4) Ca2+ inactivates factor Xa, but has no influence on the amidase activity of decarbyxyfactor Xa (5) factor V prevents Ca2+-induced inactivation of factor Xa but does not influence the amidase activity of both factor Xa and decarboxyfactor Xa. We conclude that the interaction of the gamma-carboxyglutamic acid residues with Ca2+ in factor X has no measurable influence on the properties of the active site per se.

Activation of decarboxyfactor X by a protein from Russell's viper venom. Purification and partial characterization of activated decarboxyfactor X.

1. Incubation of decarboxyfactor X with the factor X-activating enzyme from Russell's Viper venom revealed the generation of amidase activity towards Bz-Ile-Glu-Gly-Arg-pNA, but not of activity in blood coagulation. 2. The rate of activation of both factor X and decarboxyfactor X depends on the ability of the zymogens to bind Ca2+. The relationship between Ca2+ concentration and velocity of the activation reaction is sigmoid in the case of factor X, but hyperbolic with decarboxyfactor X. 3. Activated decarboxyfactor X was purified by powder column electrophoresis. 4. Identical changes of primary structure accompanied the activation of factor X and decarboxyfactor X. Identical molecular weight and common antigenic determinants were found in factor Xa and decarboxyfactor Xa. The amino acid composition was identical except for 12 glutamic acid residues in decarboxyfactor Xa and gamma-carboxyglutamic acid residues in factor Xa. 5. Unlike factor X, activated factor X has a very low electrophoretic mobility in the presence of Ca2+ at pH 8.6. This is probably due to self association of factor Xa under the influence of Ca2+. The electrophoretic mobility of activated decarboxyfactor X is only slightly decreased compared to decarboxyfactor X in the presence of Ca2+.

Purification and properties of the phenprocoumon-induced decarboxyfactor X from bovine plasma. A comparison to normal factor X.

1. By a procedure involving adsorption to barium sulfate, chromatography on DEAE-Sephadex and QAE-Sephadex and preparative polyacrylamide gel electrophoresis, decarboxyfactor X was purified from plasma of phenprocoumon-treated cows. No contaminants could be detected in the final preparation by polyacrylamide gel electrophoresis and zone-electrophoresis. 2. The molecular weight of decarboxyfactor X, as determined by sodium dodecyl sulfate polyacrylamide gel electrophoresis is approximately 55 000, which is equal to that of factor X. The protein consists of two polypeptide chains with molecular weights of 44 000 and 17 000. 3. Decarboxyfactor X has antigenic determinants in common with normal factor X. 4. The amino acid composition and aminoterminal amino acids of normal factor X and decarboxyfactor X are identical. 5. Less than one residue of gamma-carboxyglutamate could be detected per mole of decarboxyfactor X. 6. In the absence of Ca2+, normal factor X has a slightly higher electrophoretic mobility than decarboxyfactor X. In the presence of Ca2+ the mobility of factor X decreases considerably while the mobility of decarboxyfactor X remains unaltered.

The role of blood clotting factor V in the conversion of prothrombin and a decarboxy prothrombin into thrombin.

Purified PIVKA-II exhibits some factor II (prothrombin) activity in the one-stage coagulation assay and this factor II activity does not come from residual amounts of factor II but originates from PIVKA-II itself. It is shown that PIVKA-II is converted by a normal prothrombinase complex (factor Va and factor Xa adsorbed onto a phospholipid interface) more readily than by phospholipids and factor Xa alone. This suggests that binding between PIVKA-II and factor Va is an essential feature in the formation of the enzyme . substrate complex and from this we infer that a direct interaction between factor Va and prothrombin plays a rôle in the prothrombinase . prothrombin complex.

Demonstration of three anomalous plasma proteins induced by a vitamin K antagonist.

With the aid of precipitating antibodies against the bovine coagulation factors II, IX, and X three immunologically non-identical proteins can be demonstrated that are induced by the administration of a vitamin K antagonist (phenprocoumon). Each of these proteins is immunologically identical to one of three coagulation factors mentioned. The proteins differ from normal coagulation factors (a) by a lack of biological activity; (b) by a faster anodic migration rate in the presence of Ca2+. The proteins appear in the plasma concomitantly with the decrease of the normal factor.