Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction.

BACKGROUND: Enhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction. MATERIALS EN METHODS: The effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications. RESULTS: 152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028). CONCLUSION: An enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.

qLessons learned from patients with access to an online self-management enhancing program for RA patients: Qualitative analysis of interviews alongside a randomized clinical trial.

OBJECTIVE: This study aims to explain the earlier findings of a Randomized Controlled Trial (RCT), which showed that rheumatoid arthritis (RA) patients did not benefit from an online self-management program. Moreover, less patients than expected used the program. METHODS: As part of an explorative RCT, patients were interviewed to explore their (non) usage of the program. Purposive sampling (n = 21) was used to select patients from four groups of patients (n = 49): 1) non-users; 2) low users; 3) high users basic; 4) high users plus. RESULTS: The program supported only a small group of patients because: 1) not all patients were motivated to use the program, 2) patients had no clear expectation or had differing expectations of the program, 3) there was a mismatch between individual patients' support needs and the needs included in the program, 4) reminders were only sent to fill in the diaries for pain and fatigue, not to use the program modules. CONCLUSION: This study offers insights in the (non-) usage of online programs and how usage could be increased in practice. PRACTICAL IMPLICATIONS: Health professionals should be involved in the implementation of this online programs and should inform patients what the program could bring them.

The support needs of parents having a child with a chronic kidney disease: a focus group study.

BACKGROUND: Parents of children with a chronic kidney disease (CKD) have a crucial role in the management of their child's disease. The burden on parents is high: they are often exhausted, depressed and experience high levels of stress and a low quality of life, which could have a negative impact on their child's health outcomes. Support aiming at preventing and reducing parental stress is essential. Therefore, it is necessary to have insight in the problems and support needs among these parents. OBJECTIVE: Our aim is to describe parents' support needs regarding the problems they experience in having a child with CKD. METHODS: Five focus group interviews were conducted with parents of children: (i) with hereditary kidney disease, (ii) with nephrotic syndrome, (iii) with chronic kidney failure, (iv) using dialysis and (v) after renal transplantation. The children were treated at a paediatric nephrology unit in one university hospital in the Netherlands. The data were thematically analysed. RESULTS: Twenty-one parents participated in the focus groups. Parents need more information about their child's CKD and treatment options, and managing their own hobbies and work. Furthermore, parents need emotional support from their partner, family, friends, peers and healthcare professionals to help them cope with the disease of their child. Additionally, parents need practical support to hand over their care and support in transport, financial management and regarding their child at school. CONCLUSION: Needs regarding balancing their personal life are seldom prioritized by parents as the child's needs are considered more important. Therefore, it is important that healthcare professionals should not only attend to the abilities of parents concerning their child's disease management, but also focus on the parents' abilities in balancing their responsibilities as a caregiver with their own personal life.

Nursing staff stress from challenging behaviour of residents with dementia: a concept analysis.

AIM: Provide insight into the concept of stress in the context of challenging behaviour of nursing home residents with dementia and its causes and consequences. BACKGROUND: Challenging behaviour is frequent in residents with dementia, but consequences for nursing staff are unclear. INTRODUCTION: Challenging behaviour of residents can be enervating for nurses and may lead to stress. Although stress in general is associated with negative outcomes, an overview of stress in this context would be a welcome addition to the field. METHOD: Concept analysis according to Walker and Avant. RESULTS: Identified antecedents of stress: physical and verbal aggression, conflicts, excessive demands and being unresponsive (residents), age, experience, tenure, nursing level and training (nursing staff). Defining attributes: disturbed homoeostasis and the personal appraisal of the situation. Identified consequences regard health, psychological aspects and behaviour. DISCUSSION: Intervening in the identified factors may contribute to prevention of stress in nursing staff. LIMITATIONS: Given a lack of strong empirical studies, our analysis is not based on a high level of evidence and needs to be tested. Papers from before 1990 might have been missed. CONCLUSION: The concept analysis revealed that nursing staff stress in the context of challenging behaviour may result from resident and nursing staff factors. Besides health and psychological consequences, behavioural consequences can enormously impact the well-being of residents. IMPLICATIONS: Application in daily care to support teams in influencing resident and nursing staff factors could prevent stress, for instance using behavioural management training or recruiting higher educated nursing staff. Given the increasing complexity of care, creating specialized units with specifically trained staff for different groups of people with dementia may be desirable.

Heterogeneous expression of extracellular matrix molecules in the red nucleus of the rat.

Previous studies in our laboratory showed that the organization and heterogeneous molecular composition of extracellular matrix is associated with the variable cytoarchitecture, connections and specific functions of the vestibular nuclei and two related areas of the vestibular neural circuits, the inferior olive and prepositus hypoglossi nucleus. The aim of the present study is to reveal the organization and distribution of various molecular components of extracellular matrix in the red nucleus, a midbrain premotor center. Morphologically and functionally the red nucleus is comprised of the magno- and parvocellular parts, with overlapping neuronal population. By using histochemical and immunohistochemical methods, the extracellular matrix appeared as perineuronal net, axonal coat, perisynaptic matrix or diffuse network in the neuropil. In both parts of the red nucleus we have observed positive hyaluronan, tenascin-R, link protein, and lectican (aggrecan, brevican, versican, neurocan) reactions. Perineuronal nets were detected with each of the reactions and the aggrecan showed the most intense staining in the pericellular area. The two parts were clearly distinguished on the basis of neurocan and HAPLN1 expression as they have lower intensity in the perineuronal nets of large cells and in the neuropil of the magnocellular part. Additionally, in contrast to this pattern, the aggrecan was heavily labeled in the magnocellular region sharply delineating from the faintly stained parvocellular area. The most characteristic finding was that the appearance of perineuronal nets was related with the neuronal size independently from its position within the two subdivisions of red nucleus. In line with these statements none of the extracellular matrix molecules were restricted exclusively to the magno- or parvocellular division. The chemical heterogeneity of the perineuronal nets may support the recently accepted view that the red nucleus comprises more different populations of neurons than previously reported.

What do we know about rheumatoid arthritis patients' support needs for self-management? A scoping review.

BACKGROUND: Self-management support is essential to perform self-management behavior. To provide this support in an effective way, insight in the needs for self-management support is necessary. OBJECTIVE: To give an overview of self-management support needs from the perspective of rheumatoid arthritis patients to help nurses to improve self-management. DESIGN: We conducted a scoping review for the period of January 2002 to May 2013 using the following inclusion criteria: (1) studies on adult patients aged 18 years and older, (2) studies from the perspective of rheumatoid arthritis patients, (3) studies reporting results on support needs, and (4) empirical studies using any design. DATA SOURCES: We searched in PubMed, CINAHL, and PsycINFO. REVIEW METHODS: Following the steps of a scoping review, we (1) identified the research question, (2) identified relevant studies, (3) selected studies, (4) charted the data, and (5) collated, summarized, and reported results. We incorporated the optional sixth step of consultation of a multidisciplinary panel of professionals and patients to validate our findings. RESULTS: Seventeen articles were included. Our review shows that rheumatoid arthritis patients have informational, emotional, social and practical support needs. We found an information need for various topics, e.g. exercises and medication. Patients express a need for emotional support in daily life, given through other RA patients, colleagues and supervisors and nurses. For information needs, emotional and social support it is important that it is tailored to the individual needs of the patient. CONCLUSION: The most important support needs for self-management mentioned by rheumatoid arthritis patients are more informational, social and practical support and emotional support. Considering patients' perspective as a starting point for delivering support for self-management can lead to the development of nursing interventions tailored to the needs of rheumatoid arthritis patients.

Extracellular matrix molecules exhibit unique expression pattern in the climbing fiber-generating precerebellar nucleus, the inferior olive.

Extracellular matrix (ECM) accumulates around different neuronal compartments of the central nervous system (CNS) or appears in diffuse reticular form throughout the neuropil. In the adult CNS, the perineuronal net (PNN) surrounds the perikarya and dendrites of various neuron types, whereas the axonal coats are aggregations of ECM around the individual synapses, and the nodal ECM is localized at the nodes of Ranvier. Previous studies in our laboratory demonstrated on rats that the heterogeneous distribution and molecular composition of ECM is associated with the variable cytoarchitecture and hodological organization of the vestibular nuclei and may also be related to their specific functions in gaze and posture control as well as in the compensatory mechanisms following vestibular lesion. Here, we investigated the ECM expression pattern in the climbing fiber-generating inferior olive (IO), which is functionally related to the vestibular nuclei. By using histochemical and immunohistochemical methods, the most characteristic finding was the lack of PNNs, presumably due to the absence of synapses on the perikarya and proximal dendrites of IO neurons. On the other hand, the darkly stained dots or ring-like structures in the neuropil might represent the periaxonal coats around the axon terminals of olivary synaptic glomeruli. We have observed positive ECM reaction for the hyaluronan, tenascin-R, hyaluronan and proteoglycan link protein 1 (HAPLN1) and various chondroitin sulfate proteoglycans. The staining intensity and distribution of ECM molecules revealed a number of differences between the functionally different subnuclei of IO. We hypothesized that the different molecular composition and intensity differences of ECM reaction is associated with different control mechanisms of gaze and posture control executed by the visuomotor-vestibular, somatosensory and integrative subnuclei of the IO.

Distribution of extracellular matrix macromolecules in the vestibular nuclei and cerebellum of the frog, Rana esculenta.

The axons of transected and re-apposed vestibulocochlear nerve of the frog, in contrast to mammalian species, regenerate and establish functional contacts within their original termination areas of the vestibular nuclear complex and the cerebellum. The lack of regenerative capability of the mammalian central nervous system (CNS) is partially attributed to various extracellular matrix (ECM) molecules, such as chondroitin sulfate proteoglycans (CSPG) and tenascin-R (TN-R), which exert inhibition on axon regeneration. In contrast to these molecules, hyaluronan (HA) was reported to be permissive for CNS regeneration. Using histochemical and immunohistochemical methods, we investigated the distribution pattern of these molecules in the medial (MVN), lateral (LVN), superior and descending vestibular nuclei and the cerebellum of the frog and detected regional differences in the organization of the ECM. In the vestibular nuclear complex, pericellular condensation of the ECM, the perineuronal nets (PNNs) were recognizable in the LVN and MVN and were positive only for HA. The neuropil of the vestibular nuclei showed either a diffuse appearance with varying intensity of reactions, or dots and ring-like structures, which may represent the perinodal ECM of the vestibular fibers. In the cerebellum, indistinct PNNs that were only labeled for HA were present in the granular layer. Our findings suggest that the HA-rich, but CSPG and TN-R-free PNNs may be associated with the high degree of plasticity and regenerative potential of the amphibian vestibular system.

A novel artificial intelligence method for weekly dietary menu planning.

OBJECTIVES: Menu planning is an important part of personalized lifestyle counseling. The paper describes the results of an automated menu generator (MenuGene) of the web-based lifestyle counseling system Cordelia that provides personalized advice to prevent cardiovascular diseases. METHODS: The menu generator uses genetic algorithms to prepare weekly menus for web users. The objectives are derived from personal medical data collected via forms in Cordelia, combined with general nutritional guidelines. The weekly menu is modeled as a multilevel structure. RESULTS: Results show that the genetic algorithm-based method succeeds in planning dietary menus that satisfy strict numerical constraints on every nutritional level (meal, daily basis, weekly basis). The rule-based assessment proved capable of manipulating the mean occurrence of the nutritional components thus providing a method for adjusting the variety and harmony of the menu plans. CONCLUSIONS: By splitting the problem into well determined sub-problems, weekly menu plans that satisfy nutritional constraints and have well assorted components can be generated with the same method that is for daily and meal plan generation.

Long-term intraindividual variability of serum lipids in patients with type I and type II diabetes.

The objective of this study was to estimate the long-term intraindividual variability of lipid levels in adult type I and type II diabetic patients. Total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and hemoglobin A1c were measured every 3-6 months in 135 patients attending the Austin Hospital diabetes clinic. Analysis was performed on 60 diabetic patients (33 type I and 27 type II) who had not been treated with lipid lowering drugs and who met the inclusion criteria of at least five measurements [mean +/- standard error of the mean (SEM), 9.5 +/- 0.4; range, 5-17] collected over a minimum of 4 years (5.1 +/- 0.1; 4-6.5 years). Total variability, expressed as coefficient of variation, was 8.8 +/- 0.4% for total cholesterol, 23.9 +/- 1.5% for triglycerides, 10.2 +/- 0.5% for HDL cholesterol, and 12.0 +/- 0.5% for LDL cholesterol. Biological variability, derived from total and analytical variability, was higher than previous estimates in nondiabetic subjects for total cholesterol and HDL cholesterol but similar for triglycerides and LDL cholesterol. No relationship was observed between total lipid variability and diabetes type, age, baseline or mean lipid levels, duration of follow-up, or the number of samples per patient. Men demonstrated greater variability than women for total cholesterol (men 9.5 +/- 0.5%, n = 34, women 7.9 +/- 0.5%, n = 26, p < 0.01) and triglycerides (men 26.5 +/- 2.2%, women 20.4 +/- 1.4%, p = 0.03). Total lipid variability was also unrelated to baseline or mean hemoglobin A1c or to the change in hemoglobin A1c during the study as a whole. However, the change in hemoglobin A1c was associated with the change in total cholesterol (r = 0.30, p < 0.03) and the change in LDL cholesterol (r = 0.27, p < 0.05). In conclusion, long-term intraindividual lipid variability in adult diabetic subjects is higher for total and HDL cholesterol than previously published values in nondiabetic subjects. Variability of triglycerides is at least double that of total cholesterol, HDL cholesterol and LDL cholesterol. Biological variability, not measurement error, accounts for the greatest proportion of total variability for all lipid parameters. Confidence levels calculated from these data have implications for the initiation of lipid lowering therapy and in monitoring the effects of intervention.