Development of a practical guideline for person centred goal setting in geriatric rehabilitation: a participatory action research.

PURPOSE: To improve goal setting in Geriatric Rehabilitation (GR), by developing an evidence-based practical guideline for patient-centred goal setting. METHODS: Participatory action research (PAR) in a cyclical process, with GR professionals as co-researchers. Each cycle consisted of five phases: problem analysis, literature review, development, practical experience, feedback & evaluation. The evaluation was based on video recordings of goal setting conversations, and on oral and written feedback of the GR professionals who tested the guideline. RESULTS: In two PAR-cycles the guideline was developed, consisting of eight recommendations for setting and using goals, and of practical advices elaborating three of the recommendations, concerning conversational skills specific for goal setting conversations. After the second cycle the research team concluded that the guideline was feasible in daily practice and effective when used consciously. CONCLUSION: In this study, a practical guideline for setting and using goals in GR was developed. GR teams can improve their patient centred working with goals by discussing the recommendations in their team and choosing the recommendations to work on. This can be supported by the development of an interdisciplinary training. The effect on quality of care should be subject to further investigation.

Successful Clindamycin Therapy of an Infected Subcutaneous Permanent Pacing Lead in a Dog after a Failed Course with Potentiated Amoxicillin and Enrofloxacin.

Though permanent pacemaker implantation is the only effective therapy for certain bradyarrhythmias in dogs, it is not without risks. Bacterial infection of the device is one of the most common complications. Human guidelines recommend besides systemic antibiotics, surgical explantation of the pacing lead and pulse generator in case of device-infection. This report describes a 13.5-year-old dog that received a transvenous endocardial permanent pacemaker because of syncopal episodes resulting from paroxysmal third-degree atrio-ventricular block. Five days after an uneventful surgery, a painful swelling appeared around the subcutaneous part of the lead where this was inserted into the jugular vein. A 4-week course of amoxicillin and clavulanic acid combined with enrofloxacin failed to clear the infection on long-term. Ultrasound-guided puncture of the abscess was performed to gain a sample for bacterial culture and antibiogram. Oral clindamycin of 4 weeks' duration successfully resolved the infection with Staphylococcus aureus without having to explant the device. Repeated ultrasonographic examinations and fine-needle aspiration biopsies were used to evaluate for persistent local inflammation, guiding the length of the antibiotic therapy. Though the described approach has traditionally been ill-advised because of the risk of introducing bacteria and damaging the pacemaker lead, it was successful in our case.

[Hacking into a pacemaker; risks of smart healthcare devices]. / Inbreken in een pacemaker.

Technological progress in healthcare offers a plethora of opportunities, but they also raise important issues, such as safety. Every year, around 18,000 electronic implants with a therapeutic function, such as pacemakers and implantable cardioverter defibrillators (ICDs), are implanted in patients in the Netherlands. Most of these devices are able to establish a wireless internet connection to share technical and diagnostic information remotely with healthcare providers. If the access to the device is not sufficiently protected, a security risk arises with potential health risks. Currently, the therapeutic advantages of an ICD outweigh the potential security risks associated with the device. For healthcare providers it is a challenge to conduct a proper risk assessment in this situation. It is therefore important that manufacturers improve estimations of risks associated with their products, that incidents are shared more widely and that independent quality assurance testing is conducted.

Decreased Quality of Life Due to Driving Restrictions After Cardioverter Defibrillator Implantation.

BACKGROUND: Driving restrictions for patients with an implantable cardioverter defibrillator (ICD) may require significant lifestyle adjustment and affect patients' psychological well-being. This study explored the prevalence of, and factors associated with, patient-reported decrease in quality of life due to driving restrictions in the first 2 months postimplantation. METHODS: Dutch ICD patients (N = 334; median age, 64 [interquartile range, 55-70) years; 81% male) completed questionnaires at the time of implantation and 4 months postimplantation, assessing their sociodemographic, psychological, and driving-related characteristics. Clinical baseline data were retrieved from patients' medical records. RESULTS: Nearly half of the patients (49%) reported decreased quality of life due to driving restrictions. Patient-reported reasons included dependency on others/public transport, (social) isolation, and inability to work. Patients reporting decreased quality of life were more likely to be younger (P = .01), to feel that the restriction lasts too long (P = .004), to have considered ICD refusal because of the restrictions (P = .03), and to have Type D personality (P = .02), anxiety (P = .05), depression (P = .003), and ICD-related concerns (P = .02). Multivariable analysis showed that being younger than 60 years (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.09-4.88; P = .03), feeling the driving restriction lasts too long (OR, 1.77; 95% CI, 1.23-2.55; P = .002), and depression (OR, 3.21; 95% CI, 1.09-9.47; P = .035) were independently associated with decreased quality of life due to driving restrictions. CONCLUSIONS: This study indicated that a significant group of ICD patients may experience decreased quality of life because of the driving restrictions postimplantation. The restrictions seem to particularly affect patients who are younger and distressed and patients who feel that the restriction lasts too long.

Pacemaker-Mediated Programmable Hypertension Control Therapy.

BACKGROUND: Many patients requiring a pacemaker have persistent hypertension with systolic blood pressures above recommended levels. We evaluated a pacemaker-based Programmable Hypertension Control (PHC) therapy that uses a sequence of variably timed shorter and longer atrioventricular intervals. METHODS AND RESULTS: Patients indicated for dual-chamber pacing with office systolic blood pressure (oSBP) >150 mm Hg despite stable medical therapy were implanted with a Moderato™ pulse generator that delivers PHC therapy. Patients were followed for 1 month (Run-In period) with conventional pacing; those with persistent oSBP >140 mm Hg were included in the study and had PHC therapy activated. The co-primary efficacy end points were changes in 24-hour ambulatory systolic blood pressure and oSBP between baseline and 3 months. Safety was assessed by tracking adverse events. Thirty-five patients met the initial inclusion criteria and underwent Moderato implantation. At 1 month, oSBP was <140 mm Hg in 7 patients who were excluded. PHC was activated in the remaining 27 patients with baseline office blood pressure 166±11/80±10 mm Hg despite an average of 3.2 antihypertensive medications. During the Run-In period, oSBP and 24-hour ambulatory systolic blood pressure decreased by 8±13 and 5±12 mm Hg (P<0.002), respectively. Compared with pre-PHC activation measurements, oSBP decreased by another 16±15 mm Hg and 24-hour ambulatory systolic blood pressure decreased by an additional 10±13 mm Hg (both P<0.01) at 3 months. No device-related serious adverse effects were noted. CONCLUSIONS: In pacemaker patients with persistent hypertension despite medical therapy, oSBP and 24-hour ambulatory systolic blood pressure are decreased by PHC therapy. Initial indications are that this therapy is a safe and promising therapy for such patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02282033.