J.C.M. Lavrijsen

DUTCH ELDERLY CARE PHYSICIAN: A NEW GENERATION OF NURSING HOME PHYSICIAN SPECIALISTS

transaminase of 256 U/L (normal range 7–40 U/L), albumin of 3.6 g/dL (normal range 3.5–5.5 g/dL), international normalized ratio of 1.0 (normal range 0.8–1.2), carbohydrate antigen 19–9 of 438,075 U/mL (normal rangeo40 U/mL), and carcinoembryonic antigen of greater than 200 ng/mL (normal rangeo5.0 ng/mL). Her renal function was normal, with serum creatinine of 0.8 mg/dL (normal range 0.6–1.2 mg/dL), blood urea nitrogen of 20 mg/dL (normal range 7–18 mg/dL), and a calculated creatinine clearance of greater than 60 mL/min per 1.73 m (normal range). An ultrasound of her abdomen and kidneys was unremarkable. A noncontrast computed tomography scan and noncontrast magnetic resonance imaging showed a soft tissue mass in the porta hepatis associated with intrahepatic biliary dilatation. Over the next 7 days, her total bilirubin continued to rise as high as 15. An endoscopic retrograde cholangiopancreatography was attempted, but the procedure had to be aborted because of a stricture of the biliary duct secondary to the soft tissue mass. A percutaneous transhepatic biliary stent was placed, and the patient underwent a cholangiogram to confirm the location of the biliary stent. Approximately 24 hours after the procedure, the patient developed dyspnea with bibasilar crackles on examination. Her serum creatinine had increased from 0.8 to 3.1 mg/dL, and continued to rise to as high as 3.4 mg/dL, with a calculated creatinine clearance of less than 20 mL/ min per 1.73 m. Her blood urea nitrogen rose from 20 to 55 mg/dL, and her urine output dropped to 20 to 30 mL/h. A thorough chart review confirmed that no intravenous contrast was used during any of the procedures and that she had not received any nephrotoxic drugs. A renal and bladder ultrasound showed normal kidney architecture and minimal postvoid residual urine of 50 mL (normal range 50–100 mL). Urine analysis showed more than 15 granular casts, urine sodium of 96 mEq/L (normal rangeo40 mEq/ L), and a fractional excretion of sodium greater than 3% (normal range 1–3%). Stains for eosinophils were negative, and cultures showed no growth after 48 hours. This confirmed the diagnosis of acute tubular necrosis after the use of contrast in the biliary tree. This case demonstrates an example of acute tubular necrosis causing acute renal failure in patients undergoing a cholangiographic study. We could find only one retrospective study, published close to 25 years ago, that reported this phenomenon. Of the 72 patients with a mean age of 63, three (aged 70, 75, and 61) had a rise in serum creatinine of greater than 2 mg/dL within 24 hours of the procedure. Two of these patients had retention of contrast medium in the kidney demonstrated on abdominal roentgenogram. The patient’s renal failure was unprovoked by any other etiology. We hypothesize that the mechanism by which a cholangiogram can cause acute renal failure involves contrast entering the vascular system during the procedure. This might be due to direct entry secondary to local trauma or systemic absorption in the biliary circulation. Geriatricians and other physicians and health professionals who care for elderly patients should be aware of the risk of renal failure after cholangiography. Although this appears to be an infrequent phenomenon, it has the potential to acute volume overload, as it did in this patient, as well as permanent renal dysfunction.

Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes

Objectives: To establish the prevalence of vegetative state in Dutch nursing homes, describe the patient characteristics, and highlight the possible influence of medical decisions at the end of life. Design: A cross-sectional survey. The vegetative state was defined according to the Multi Society Task Force on PVS. All Dutch nursing homes were approached to provide data on patients in a vegetative state. In cases of doubt, the researcher discussed the diagnosis with the patient’s physician and, if necessary, examined the patient. Information on patients in a vegetative state in care between 2000 and September 2003 and end of life decisions for them were also recorded. Results: All nursing homes and physicians participated. After assessment of 12 doubtful patients, 32 met the criteria of vegetative state lasting longer than one month, a prevalence of 2/1 000 000. Of these, 30 patients’ data were analysed: age 9–90 years; 73% female; duration of vegetative state 2 months–20 years (26 surviving >1 year, 13 >5 years). Stroke was the commonest cause. Between 2000 and September 2003, there were 76 patients in a vegetative state in care of whom 34 died of complications and nine after withdrawal of artificial nutrition and hydration. Conclusions: The prevalence of vegetative state in Dutch nursing homes has been established for the first time. The figures are lower than suggested in the literature. The study included a heterogeneous group of patients, of which a substantial number survived for many years. The results cannot be explained by a policy of systematically withdrawing artificial nutrition and hydration.

The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies

One of the worst outcomes of acquired brain injury is the vegetative state, recently renamed ‘unresponsive wakefulness syndrome’ (VS/UWS). A patient in VS/UWS shows reflexive behaviour such as spontaneous eye opening and breathing, but no signs of awareness of the self or the environment. We performed a systematic review of VS/UWS prevalence studies and assessed their reliability. Medline, Embase, the Cochrane Library, CINAHL and PsycINFO were searched in April 2013 for cross‐sectional point or period prevalence studies explicitly stating the prevalence of VS/UWS due to acute causes within the general population. We additionally checked bibliographies and consulted experts in the field to obtain ‘grey data’ like government reports. Relevant publications underwent quality assessment and data‐extraction. We retrieved 1032 papers out of which 14 met the inclusion criteria. Prevalence figures varied from 0.2 to 6.1 VS/UWS patients per 100 000 members of the population. However, the publications’ methodological quality differed substantially, in particular with regards to inclusion criteria and diagnosis verification. The reliability of VS/UWS prevalence figures is poor. Methodological flaws in available prevalence studies, the fact that 5/14 of the studies predate the identification of the minimally conscious state (MCS) as a distinct entity in 2002, and insufficient verification of included cases may lead to both overestimation and underestimation of the actual number of patients in VS/UWS.

The reliability and validity of the PALOC-s : A Post-Acute Level of Consciousness scale for assessment of young patients with prolonged disturbed consciousness after brain injury

The objective of the study was the validation of the Post-Acute Level of Consciousness scale (PALOC-s) for use in assessing levels of consciousness of severe brain injured patients in a vegetative state or in a minimally conscious state. A cohort of 44 successively admitted patients (between 2 and 25 years of age), who were treated in an early intensive neurorehabilitation programme, were included in the study. Each patient was examined, using the Western Neuro Sensory Stimulation Profile (WNSSP) and the Disability Rating Scale (DRS), once every two weeks resulting in 327 examinations (all videotaped). To determine the reliability of the PALOC-s, six observers rated one videotape of each patient. One of the observers rated the same tapes a second time, 3–4 months later. Validity was determined by correlating 100 ratings of one observer with the scores on the WNSSP and the DRS. To determine the responsiveness of the PALOC-s, the size of change between the scores of the first and last examinations was calculated. The inter-observer correlations and agreement scores varied between .82 and .95. The intra-observer correlation and agreement scores varied between .94 and .96. Correlations with the WNSSP varied between .88 and .93, and with the DRS between .75 and .88. The responsiveness was significantly high (t = 8.2), with a standardised effect size of 1.30. It is concluded that the PALOC-s is a reliable, valid, and responsive observation instrument provided it is administered after a structured assessment by an experienced and trained clinician. The PALOC-s is feasible for use in clinical management, as well as in outcome research.

Concrete steps toward academic medicine in long term care

Over the past 5 years, many articles have been published about the role of nursing home (NH) physician specialists in the quality of medical care in long term care settings.1e12 Recently, Katz and Pfeil7 argued in the Journal that there is a necessity to increase the credibility of NH physicians. One of the initiatives of the board of directors of the American Medical Directors Association (AMDA) was to develop a core set of competencies for physicians working in NHs. Katz and Pfeil7 state that there is also a need for NH leadership and that physicians who are embedded in the organizational culture of the homes are more likely to find success in leadership and therefore can have great impact on quality of care. Finally, Katz and Pfeil7 call for more research to demonstrate the link between physician competency and quality of care. That research can improve quality of care is also argued by Rolland and de Souto Barreto.13 They state that research can improve ongoing training of NH staff, encourage new strategies of care, including medication and nonpharmacological interventions, enhance daily practice, and can help to change negative cultural and societal representations of NHs and their workers.13 However, improving research in NHs poses many challenges for academics, as there is neither a research culture nor an adequate infrastructure to perform highquality research. Although some of the articles have pointed at the Dutch situation, most of the authors insufficiently recognize the achievements and the developments of the Dutch long term care sector and that the Netherlands already has provided some answers to the challenges raised before. We point at 2 concrete initiatives: (1) the establishment of a NH physician specialty with a 3-year training program, and (2) the establishment of academic networks of NHs providing an infrastructure for teaching, research, and best practices.

Prevalence, causes, and treatment of neuropathic pain in dutch nursing home residents: a retrospective chart review.

To identify the prevalence and causes of neuropathic pain in Dutch nursing home residents; to establish the prevalence of painful and nonpainful diabetic polyneuropathy in a subsample of individuals with diabetes mellitus and central poststroke pain (CPSP) in a subsample of individuals who had a stroke; and to study the prescription of antineuropathic drugs.

Events and decision-making in the long-term care of Dutch nursing home patients in a vegetative state

Objective: To clarify characteristics of long-term care and treatment of patients in a vegetative state. Design: Qualitative, descriptive study in a Dutch nursing home. Methods: Review of clinical records of patients in a vegetative state after acute brain damage between 1978–2002. Results: Five patients received intensive care of a multi-disciplinary team and showed considerable co-morbidity. There was no standard scenario for end-of-life decisions. Physicians play a more proactive role by evaluating the total medical treatment instead of withholding therapy in case of incidental complications. The families’ attitude is a crucial factor in their ultimate decision. Conclusions: There is no standard solution to alleviate the fate of patients in a vegetative state and their families. Withdrawing all medical treatment, including artificial nutrition and hydration, can be an acceptable scenario for letting the patient die. More research is needed to identify the factors that contribute to acceptance of the physicians decision by the family.

Prevalence differences of patients in vegetative state in the Netherlands and vienna, austria: a comparison of values and ethics

Objective:Little is known about prevalence of persistent vegetative state/unresponsive wakefulness syndrome and comparisons between countries. The aim of this column was to explore reasons for the comparable count of patients in vegetative state found in prevalence studies in nursing homes in 1 European country (Netherlands) compared with a single European city (Vienna, Austria). Design:The column is based on a literature review of vegetative state in the Netherlands and Vienna in the period 2007-2008, in the context of professional interactions with families and physicians of patients in vegetative state. In addition, in both countries, families and physicians were interviewed to illustrate views. Results:Comparable between the 2 settings are the population characteristics and the definition of, and criteria, for vegetative state. A difference can be found in the development of authoritative policy guidelines in the Netherlands, after public debates and jurisdiction, which did not exist in Vienna at the time. There also seem to be different societal values concerning rehabilitation and end-of-life decisions for patients in vegetative state. Discussion:The most important explanation for the vegetative state prevalence differences between the Netherlands and Vienna can be found in the different societal values about patients in vegetative state and their treatment and rehabilitation. In the Netherlands, life prolonging medical treatment, including artificial nutrition and hydration, is considered futile and can be withdrawn if there is no prospect of recovery. In Vienna, however, patients in vegetative state are regarded as severely disabled and in need of long-term rehabilitation and social reintegration. There is no end-of-life discussion in this context.

Bone fractures in the long-term care of a patient in a vegetative state: A risk to conflicts

Purpose: This case report shows how recurrent bone fractures can increase the tension in the relationship between family and caregivers in the long-term care of a patient in a vegetative state (VS). The aim of this report is to prevent conflict situations elsewhere by informing the family in time about the risk of fractures in a situation of severe osteoporosis. Results: A second opinion and a density test of the bone contributed to the acceptance of the family of that risk in the daily nursing care, after all adjustments to prevent fractures and to adapt the environment were undertaken. Conclusions: The registration of immobility and the risk of fractures in the problem list is recommended, particularly in the emotional context of the long-term care of a vegetative state. This should be part of the multidisciplinary care plan, in which regular evaluations and communication with family are essential.

Ten-to-twelve years after specialized neurorehabilitation of young patients with severe disorders of consciousness: A follow-up study

Abstract Objective: To explore the long-term outcome of young patients with disorders of consciousness who had received intensive neurorehabilitation. Methods: A cross-sectional cohort study, in which the survival, level of consciousness, functional independence, mobility, communication and living situation were determined by means of a structured questionnaire. The cohort consisted of 44 children and young adults, originally either in a prolonged Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS, n = 33) or a Minimally Conscious State (MCS, n = 11) who had received a specialized neurorehabilitation programme 10–12 years earlier. Results: Response rate was 72% (34/44). Eleven patients were deceased, 10 of whom were in VS/UWS or MCS at discharge from the programme. Of the remaining 23 patients, 19 were conscious. Twelve lived independently, of whom six required some household support. One conscious patient lived permanently in a long-term care facility. All other patients lived either independently or with their parents. None of the VS/UWS or MCS patients showed any functional recovery. Conclusion: Two main long-term outcome scenarios can be recognized. Two-thirds of the participating patients who were conscious at programme discharge were able to live independently, whereas almost two-thirds of the participating patients who were in VS/UWS or MCS at discharge subsequently died.