Interprofessional collaboration in the home care setting: perspectives of people receiving home care, relatives, nurses, general practitioners, and therapists-results of a qualitative analysis.

BACKGROUND: About one million people in need of home care in Germany are assisted by 15,400 home care services. Home healthcare is mostly a complex endeavour because interprofessional collaboration is often challenging. This might negatively impact patient safety. The project interprof HOME aims to develop an interprofessional person-centred care concept for people receiving home care in a multistep approach. In one of the work packages we explored how people receiving home care, relatives, nurses, general practitioners, and therapists (physiotherapists, occupational therapists, and speech therapists) perceive collaboration in this setting. METHODS: Semi-structured interviews were conducted with 20 people receiving home care and with 21 relatives. Additionally, we worked with nine monoprofessional focus groups involving nurses of home care services (n = 17), general practitioners (n = 14), and therapists (n = 21). The data were analysed by content analysis. RESULTS: Three main categories evolved: "perception of interprofessional collaboration", "means of communication", and "barriers and facilitators". People receiving home care and relatives often perceive little to no interprofessional collaboration and take over a significant part of the organisational coordination and information exchange. Interprofessional collaboration in steady care situations does exist at times and mostly occurs in coordination tasks. Contact and information exchange are rare, however, interprofessional personal encounters are sporadic, and fixed agreements and permanent contact persons are not standard. These trends increase with the complexity of the healthcare situation. Joint collaborations are often perceived as highly beneficial. Means of communications such as telephone, fax, or e-mail are used differently and are often considered tedious and time-consuming. No interprofessional formal written or electronic documentation system exists. Personal acquaintance and mutual trust are perceived as being beneficial, while a lack of mutual availability, limited time, and inadequate compensation hinder interprofessional collaboration. CONCLUSIONS: Interprofessional collaboration in home care occurs irregularly, and coordination often remains with people receiving home care or relatives. While this individual care set-up may work sufficiently well in low complex care situations, it becomes vulnerable to disruptions with increasing complexity. Close interactions, joint collaboration, and fixed means of communication might improve healthcare at home. The findings were integrated into the development of the person-centred interprofessional care concept interprof HOME. TRIAL REGISTRATION: This study is registered on the International Clinical Trails registry platform ClinicalTrials.gov as NCT05149937 on 03/11/2021.

[Preclinical early detection and diagnosis of sepsis - step by step]. / Präklinische Früherkennung und Diagnostik der Sepsis ­ Schritt für Schritt.

Because of very unspecific sepsis symptoms, early recognition of the emergency sepsis is difficult. If the disease is recognized in time it is possible to initiate diagnosis and treatment quickly. Rapid treatment of sepsis leads to lower mortality and less severe long-term consequences. Early detection is therefore of central importance in the diagnostic and therapeutic process, also in the outpatient setting.

Evaluation of a novel moving threshold gating strategy for assessment of reticulated platelets in dogs using the ADVIA 2120 analyzer.

BACKGROUND: A novel method using a moving threshold (r-PLTmt) to determine canine r-PLTs (reticulated platelets) has been introduced for ADVIA 2120 software v6.11.7. OBJECTIVES: We aimed to evaluate absolute (ar-PLTmt) and percent (%r-PLTmt) prior to and after visual inspection of scattergrams (ar-PLTmtv, %rPLTmtv) compared with flow cytometry (flow) and to determine reference intervals (RIs) in 120 dogs. METHODS: For method comparison, 42 blood samples of healthy and thrombocytopenic dogs were included. Calculation of Spearman's rho, Bland-Altman, and Passing-Bablok analysis was performed. Coefficients of variation (CVs) were determined for three concentration levels. RESULTS: Moderate correlations between %r-PLTmt and %r-PLTmtv (rs 0.75-0.76) were seen compared with flow cytometry. The CV for medium %r-PLTs counts assessed with flow cytometry was 12.9%. Comparable CVs were obtained for ar-PLTmt (14.4%) and %r-PLTmt (15.7%), and ar-PLTmtv and %r-PLTmtv (10.9% and 12.9%, respectively). At low and high concentration levels, CVs for % and absolute r-PLTmt/rPLTmtv ranged between 23%-30% and 15%-20%. In patients with microcytic hypochromic erythrocytes, CVs for ar-PLTmt and %r-PLTmt were 36%-66%. Visual inspection of scattergrams resulted in a marked decrease in CV ranging between 15% and 20%. A proportional bias of 10.8% between %r-PLTmt and flow cytometry became lower (9.7%) after visual validation of scattergrams. Passing-Bablok analysis showed proportional and constant error. RIs for r-PLTmt and r-PLTmtv were 0.2%-3.8% and 0.6-10.2 × 109 /L and 0.3%-4.5% and 1.1-10.3 × 109 /L, respectively. Median values for %r-PLTmtv were higher in young adults (≤2 years) than in older dogs (P = 0.03). CONCLUSIONS: r-PLTmt and r-PLTmtv were moderately correlated with flow cytometry. Visual inspection of scattergrams is recommended.

Implementation, mechanisms of change and contextual factors of a complex intervention to improve interprofessional collaboration and the quality of medical care for nursing home residents: study protocol of the process evaluation of the interprof ACT intervention package.

BACKGROUND: To improve interprofessional collaboration between registered nurses (RNs) and general practitioners (GPs) for nursing home residents (NHRs), the interprof ACT intervention package was developed. This complex intervention includes six components (e.g., shared goal setting, standardized procedures for GPs' nursing home visits) that can be locally adapted. The cluster-randomized interprof ACT trial evaluates the effects of this intervention on the cumulative incidence of hospital admissions (primary outcome) and secondary outcomes (e.g., length of hospital stays, utilization of emergency care services, and quality of life) within 12 months. It also includes a process evaluation which is subject of this protocol. The objectives of this evaluation are to assess the implementation of the interprof ACT intervention package and downstream effects on nurse-physician collaboration as well as preconditions and prospects for successive implementation into routine care. METHODS: This study uses a mixed methods triangulation design involving all 34 participating nursing homes (clusters). The quantitative part comprises paper-based surveys among RNs, GPs, NHRs, and nursing home directors at baseline and 12 months. In the intervention group (17 clusters), data on the implementation of preplanned implementation strategies (training and supervision of nominated IPAVs, interprofessional kick-off meetings) and local implementation activities will be recorded. Major outcome domains are the dose, reach and fidelity of the implementation of the intervention package, changes in interprofessional collaboration, and contextual factors. The qualitative part will be conducted in a subsample of 8 nursing homes (4 per study group) and includes repeated non-participating observations and semistructured interviews on the interaction between involved health professionals and their work processes. Quantitative and qualitative data will be descriptively analyzed and then triangulated by means of joint displays and mixed methods informed regression models. DISCUSSION: By integrating a variety of qualitative and quantitative data sources, this process evaluation will allow comprehensive assessment of the implementation of the interprof ACT intervention package, the changes induced in interprofessional collaboration, and the influence of contextual factors. These data will reveal expected and unexpected changes in the procedures of interprofessional care delivery and thus facilitate accurate conclusions for the further design of routine care services for NHRs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03426475 . Registered on 07/02/2018.

[Intra-abdominal pressure measurement]. / Intraabdominelle Druckmessung ­ Schritt für Schritt.

An elevated intra-abdominal pressure (IAP) above 12 mmHg is a pathological finding in critically ill patients. IAP are classified into different degrees of intra-abdominal hypertension and, in the presence of associated organ failure, as abdominal compartment syndrome. Both disease entities represent an underestimated factor in intensive care patients and are associated with increased mortality and prolonged intensive care and hospital stay. The measurement of intra-abdominal pressure in critically ill patients in intensive care units is not widely established and there is often considerable uncertainty regarding measurement conditions and methods. If risk factors are present, intra-abdominal pressure should be monitored every 4 hours. Bladder pressure measurement is the gold standard for determining intra-abdominal pressure. The measurement is a non-invasive, cost-effective, easy to perform bedside and safe method for the patient.

Prospective Observational Cohort Study to Describe the Use of Panitumumab in Combination with Chemotherapy in Real-World Clinical Practice for Patients with Wild-Type RAS mCRC.

INTRODUCTION: This study aimed to better understand panitumumab use in real-life clinical practice in first- and second-line treatment of metastatic colorectal cancer in five European countries. METHODS: This is a combined analysis of two observational, non-interventional prospective cohort studies, one of which was conducted in Germany and France, the other in Bulgaria, Czech Republic, and Hungary. The studies observed patients with wild-type [Kirsten] rat sarcoma viral oncogene homolog ([K]RAS/RAS) metastatic colorectal cancer (mCRC), who had been treated with panitumumab in combination with fluorouracil, leucovorin, and oxaliplatin (FOLFOX) in the first line or with panitumumab combined with fluorouracil, leucovorin, and irinotecan (FOLFIRI) in the second line following fluoropyrimidine-based chemotherapy. The planned duration of observation was 12 months from the first dose of panitumumab. RESULTS: A total of 332 patients treated with panitumumab + FOLFOX in the first line and 94 patients treated with panitumumab + FOLFIRI in the second line were analyzed. The median number of panitumumab infusions was 10.0 in first-line FOLFOX patients and 11.5 in second-line FOLFIRI patients; the median duration of panitumumab exposure was 5.7 and 6.9 months, respectively. The unadjusted overall response rate (complete or partial response) in patients with available post-baseline response assessment (n = 290) was 51.7% in first-line FOLFOX and 44.9% in second-line FOLFIRI patients. In the first-line setting, resectability was achieved in 9.3%. Reported hospitalizations were mostly cancer-related visits such as scheduled anticancer treatment administrations, tumor assessment visits, or interventions. The majority of adverse drug reactions were skin disorders, with 75.3% in first-line FOLFOX patients and 72.3% in second-line FOLFIRI patients. CONCLUSION: Overall, the study results show that treatment patterns, clinical efficacy, and the safety profile of panitumumab in routine clinical practice were comparable to those in randomized controlled trials. The relatively low skin toxicity rate could be attributed to increasing experience in managing panitumumab-associated rash and some degree of underreporting. FUNDING: Amgen.

LOX-catalyzed collagen stabilization is a proximal cause for intrinsic resistance to chemotherapy.

The potential of altering the tumor ECM to improve drug response remains fairly unexplored. To identify targets for modification of the ECM aiming to improve drug response and overcome resistance, we analyzed expression data sets from pre-treatment patient cohorts. Cross-evaluation identified a subset of chemoresistant tumors characterized by increased expression of collagens and collagen-stabilizing enzymes. We demonstrate that strong collagen expression and stabilization sets off a vicious circle of self-propagating hypoxia, malignant signaling, and aberrant angiogenesis that can be broken by an appropriate auxiliary intervention: Interfering with collagen stabilization by inhibition of lysyl oxidases significantly enhanced response to chemotherapy in various tumor models, even in metastatic disease. Inhibition of collagen stabilization by itself can reduce or enhance tumor growth depending on the tumor type. The mechanistical basis for this behavior is the dependence of the individual tumor on nutritional supply on one hand and on high tissue stiffness for FAK signaling on the other.

Inhibition of Lysyl Oxidases Improves Drug Diffusion and Increases Efficacy of Cytotoxic Treatment in 3D Tumor Models.

Tumors are characterized by a rigid, highly cross-linked extracellular matrix (ECM), which impedes homogeneous drug distribution and potentially protects malignant cells from exposure to therapeutics. Lysyl oxidases are major contributors to tissue stiffness and the elevated expression of these enzymes observed in most cancers might influence drug distribution and efficacy. We examined the effect of lysyl oxidases on drug distribution and efficacy in 3D in vitro assay systems. In our experiments elevated lysyl oxidase activity was responsible for reduced drug diffusion under hypoxic conditions and consequently impaired cytotoxicity of various chemotherapeutics. This effect was only observed in 3D settings but not in 2D-cell culture, confirming that lysyl oxidases affect drug efficacy by modification of the ECM and do not confer a direct desensitizing effect. Both drug diffusion and efficacy were strongly enhanced by inhibition of lysyl oxidases. The results from the in vitro experiments correlated with tumor drug distribution in vivo, and predicted response to therapeutics in murine tumor models. Our results demonstrate that lysyl oxidase activity modulates the physical barrier function of ECM for small molecule drugs influencing their therapeutic efficacy. Targeting this process has the potential to significantly enhance therapeutic efficacy in the treatment of malignant diseases.

Reproducibility of fetal ductus venosus blood flow velocity waveforms during first stage of labor.

OBJECTIVES: Fetal ductus venosus (DV) blood flow velocity waveforms are significantly altered during contractions in first stage of labor. We have evaluated the reproducibility of these waveforms during and between contractions. METHODS: 90 women between 37th and 41st week of gestation were included in the study. The measurements of the DV were obtained by three different investigators during and between contractions. The pulsatility index for veins (PIV), peak velocity index for veins (PVIV), and fetal heart rate (FHR) were calculated offline. Furthermore, differences in PVIV (PVIVdiff) and PIV (PIVdiff) and a mean of FHR (FHRmean) were calculated. Statistical analysis was used to verify differences in the PIV, PVIV and FHR during and between contractions of each subgroup as well as for the PVIVdiff, PIVdiff and FHRmean between the subgroups. RESULTS: Investigator 1 examined 49 patients (group 1); investigator 2, 17 patients (group 2) and investigator 3, 24 patients (group 3), respectively. In all subgroups, there was a significant difference for the PVIV and PIV during and between contractions, but not for FHR. There was a correlation between gestational age and PVIVdiff, PIVdiff and FHRmean as well as for maternal age and PVIVdiff and PIVdiff. PVIVdiff and PIVdiff showed significant differences in group 1 compared to groups 2 and 3 (p < 0.001), but not between groups 2 and 3. CONCLUSIONS: Significant differences in the measurements in the three subgroups have been revealed, which may be due to different timing of measurement during the contraction. For future studies further standardization of the measurement protocol should be established.