Physician Assistants and Nurse Practitioners in Primary Care Plus: A Systematic Review.

INTRODUCTION: Shifting specialist care from the hospital to primary care/community care (also called primary care plus) is proposed as one option to reduce the increasing healthcare costs, improve quality of care and accessibility. The aim of this systematic review was to get insight in primary care plus provided by physician assistants or nurse practitioners. METHODS: Scientific databases and reference list were searched. Hits were screened on title/abstract and full text. Studies published between 1990-2018 with any study design were included. Risk of bias assessment was performed using QualSyst tool. RESULTS: Search resulted in 5.848 hits, 15 studies were included. Studies investigated nurse practitioners only. Primary care plus was at least equally effective as hospital care (patient-related outcomes). The number of admission/referral rates was significantly reduced in favor of primary care plus. Barriers to implement primary care plus included obtaining equipment, structural funding, direct access to patient-data. Facilitators included multidisciplinary collaboration, medical specialist support, protocols. CONCLUSIONS AND DISCUSSION: Quality of care within primary care plus delivered by nurse practitioners appears to be guaranteed, at patient-level and professional-level, with better access to healthcare and fewer referrals to hospital. Most studies were of restricted methodological quality. Findings should be interpreted with caution.

The effect of postoperative closed incision negative pressure therapy on the incidence of donor site wound dehiscence in breast reconstruction patients: DEhiscence PREvention Study (DEPRES), pilot randomized controlled trial.

AIM: Wound dehiscence is a serious postoperative complication associated both with high morbidity and mortality. It has a significant rate of occurrence in breast reconstruction surgeries with a deep internal epigastric perforator (DIEP) and with a profunda artery perforator (PAP) flap. Risk factors for wound dehiscence include smoking, diabetes mellitus, chronic obstructive pulmonary disease, and obesity. The aim of this pilot study was to assess whether postoperative treatment with closed incision negative pressure therapy (ciNPT) decreases the incidence of donor site wound dehiscence in breast reconstruction patients. METHOD: Women undergoing a breast reconstruction with a DIEP or PAP flap were enrolled in a pilot randomized controlled trial and assigned treatment with either ciNPT or adhesive strips. The primary outcome was wound dehiscence upon follow-up after four weeks. Secondary outcomes that were evaluated included wound infection, pain, and allergy. There was no loss to follow-up. RESULTS: This pilot study included 51 women (n = 25 ciNPT, n = 26 adhesive strips). The two groups did not differ significantly in patients demographics or comorbidities. Wound dehiscence occurred in 11 patients (n = 2 ciNPT, n = 9 adhesive strips). This difference was statistically significant: p = 0.038. There were no statistically significant differences in secondary outcomes between the two groups. CONCLUSION: In this pilot study, postoperative treatment with ciNPT decreased the incidence of donor site wound dehiscence in breast reconstruction patients. Further research is ongoing by the same hospital. This trial was registered in the Netherlands Trial Register (NTR) under ID no. NTR5808.

Standard and individually determined thermal pain stimuli induce similar brain activations.

BACKGROUND: Several functional magnetic resonance imaging (fMRI) studies use thermal pain stimuli to determine brain activation patterns during pain. Studies use either a standard temperature condition for all participants or an individualized temperature condition based on the individually determined pain threshold of the participant. The aim of the present study was to compare both conditions in the same participants. METHODS: Eighteen healthy participants (21-29 years) underwent four fMRI runs, in each of which they received three types of thermal stimuli: neutral (32 °C), warm (37 °C) and painfully hot. In two runs, the painfully hot stimulus was set at a standard temperature of 46 °C; in the other two runs, the temperature was set at the subject's individual pain threshold (46-48 °C). fMRI (blood oxygen level dependent) was performed on a 1.5 T MR scanner (GE Signa). Pre-processing and statistical analyses were performed using Statistical Parametric Mapping (SPM8) software. RESULTS: While the stimulation temperatures were lower in the standard temperature condition, both conditions activated the same brain regions. When comparing the conditions directly to each other, we did not find significantly different grey matter activation patterns. CONCLUSIONS: The similar activation patterns between the two conditions suggest that it is not necessary to use individualized stimuli per se. The temperature of 46 °C appeared to be an adequate temperature for standardized stimulation to observe significant brain activations related to thermal pain.

Rectal acetaminophen does not reduce morphine consumption after major surgery in young infants.

BACKGROUND: The safety and value of acetaminophen (paracetamol) in addition to continuous morphine infusion has never been studied in newborns and young infants. We investigated the addition of acetaminophen to evaluate whether it decreased morphine consumption in this age group after major thoracic (non-cardiac) or abdominal surgery. METHODS: A randomized controlled trial was performed in 71 patients given either acetaminophen 90-100 mg kg(-1) day(-1)or placebo rectally, in addition to a morphine loading dose of 100 microg kg(-1) and 5-10 microg kg(-1) h(-1) continuous infusion. Analgesic efficacy was assessed using Visual Analogue Scale (VAS) and COMFORT scores. Extra morphine was administered if VAS was > or = 4. RESULTS: We analysed data of 54 patients, of whom 29 received acetaminophen and 25 received placebo. Median (25-75th percentile) age was 0 (0-2) months. Additional morphine bolus requirements and increases in continuous morphine infusion were similar in both groups (P = 0.366 and P = 0.06, respectively). There was no significant difference in total morphine consumption, respectively, 7.91 (6.59-14.02) and 7.19 (5.45-12.06) mug kg(-1) h(-1) for the acetaminophen and placebo group (P = 0.60). COMFORT [median (25-75th percentile) acetaminophen 10 (9-12) and placebo 11 (9-13)] and VAS [median (25-75th percentile) acetaminophen 0.0 (0.0-0.2) and placebo 0.0 (0.0-0.3)] scores did not differ between acetaminophen and placebo group (P = 0.06 and P = 0.73, respectively). CONCLUSIONS: Acetaminophen, as an adjuvant to continuous morphine infusion, does not have an additional analgesic effect and should not be considered as standard of care in young infants, 0-2 months of age, after major thoracic (non-cardiac) or abdominal surgery.

Pain assessment in profound cognitive impaired children using the Checklist Pain Behavior; is item reduction valid?

There are both commonalities and idiosyncratic features in the reaction of pain children with profound cognitive impairment (CI), and that there is no evidence to suggest that idiosyncratic behavior is more characteristic of this population than of any other population. The main objective of this study was to identify whether the 23-item version of the Checklist Pain Behavior could be reduced to 10 items. Previous research demonstrated that only these 10 items discriminated between absence and presence of pain. Second, we wanted to explore the underlying structure of these 10 selected items including its performance. Data of 477 observations in 73 children were used. All these children were video-taped while they were admitted to the Sophia Children's Hospital for surgery, twice before and five times after surgery. These video-tapes were scored by an independent observer. A visual analogue scale (VAS) by a researcher was used to assess the presence of pain. We tested whether the underlying structure was unidimensional, and whether it had differential qualities between pain and no pain, and to which degree. Using a modern psychometric method, i.e., Mokken scaling model, we unraveled the interdependency of the pain response in CI-children, in that the structure turned out to be unidimensional. In addition, these behaviors could be hierarchically ordered in terms of frequency of occurrences. Finally, these behaviors had to a high degree the potentialities to estimate the likelihood of occurrence of pain.