Supporting shared decision making for older people with multiple health and social care needs: a realist synthesis

Background: Health care systems are increasingly moving towards more integrated approaches. Shared decision making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; particularly for older people with complex needs. The aim of this review was to provide a context relevant understanding of how interventions to facilitate SDM might work for older people with multiple health and care needs, and how they might be applied in integrated care models. Methods: Iterative, stakeholder driven, realist synthesis following RAMESES publication standards. It involved: 1) scoping literature and stakeholder interviews (n-13) to develop initial programme theory/ies, 2) systematic searches for evidence to test and develop the theories, and 3) validation of programme theory/ies with stakeholders (n=11). We searched PubMed, The Cochrane Library, Scopus, Google, Google Scholar, and undertook lateral searches. All types of evidence were included. Results: We included 88 papers; 29 focused on older people or people with complex needs. We identified four context-mechanism-outcome configurations that together provide an account of what needs to be in place for SDM to work for older people with complex needs. This includes: understanding and assessing patient and carer values and capacity to access and use care, organising systems to support and prioritise SDM, supporting and preparing patients and family carers to engage in SDM and a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that allow older people to feel that they are respected and understood, and that engender confidence to engage in SDM. Conclusions: To embed SDM in practice requires a radical shift from a biomedical focus to a more person-centred ethos. Service providers will need support to change their professional behaviour and to better organise and deliver services. Face to face interactions, permission and space to discuss options, and continuity of patient-professional relationships are key in supporting older people with complex needs to engage in SDM. Future research needs to focus on inter-professional approaches to SDM and how families and carers are involved

The Effect of 40 Hours of Constant Wakefulness on Number Comparison Performance

We investigated the effects of sleep loss and circadian rhythm on number comparison performance. Magnitude comparison of single-digits is robustly characterized by a distance effect: Close numbers (e.g., 5 versus 6) produce longer reaction times than numbers further apart (e.g., 2 versus 8). This distance effect is assumed to reflect the difficulty of a comparison process based on an analogous representation of general magnitude. Twelve male participants were required to stay awake for 40 h in a quasi-constant-routine protocol. Response speed and accuracy deteriorated between 00:00 and 06:00 h but recovered afterwards during the next day, indicating a circadian rhythm of elementary cognitive function (i.e., attention and speed of mental processing). The symbolic distance effect, however, did not increase during the nighttime, indicating that neither cumulative sleep loss nor the circadian clock prolongs numerical comparison processes. The present findings provide first evidence for a relative insensitivity of symbolic magnitude processing against the temporal variation in energy state.

Isolation and molecular characterization of brain microvascular endothelial cells from human brain tumors

Brain tumor formation and growth is accompanied by the proliferation and infiltration of blood capillaries. The phenotypes of endothelial cells that make up capillaries are known to differ not only in the tissues in which endothelial cells are located but also as a result of the microenvironment to which they are exposed. For this reason, primary cultures of brain endothelial cells were isolated from human brain tumors removed by surgery and compared with cells from normal tissue. The primary confluent monolayers that grew out of isolated capillary fragments consisted of closely associated, elongated, fusiform-shaped cells. But brain tumor-derived endothelial cells in culture exhibited significantly less expression of endothelial-specific Factor VIII-related antigen compared with cells isolated from normal tissue. Cultured cells that exhibited binding of Ulex europaeus lectin were shown to take up Dil-Ac-Ldl and formed continuous monolayers that were joined together by tight junctions. The cells also exhibited characteristics of the cells of the brain microvasculature in vitro as seen by the presence of large numbers of mitochondria and few pinocytotic vesicles and by the absence of Weibel-Palade bodies within the cells. The expression of vascular cell adhesion molecule-1, E-Selectin, and the tight junction associated protein ZO-1 but not intercellular adhesion molecule-1 was demonstrated by immunohistological staining or reverse transcriptase-polymerase chain reaction methodologies. Comparative studies of these endothelial cells with endothelial cells from normal tissue will be useful for determining and understanding how the blood-brain barrier differs and functions in tumor and healthy tissues and may lead to strategies for brain tumor therapeutic approaches

Pulmonale Komplikationen beim erworbenen Immundefektsyndrom: Ergebnisse einer prospektiven Untersuchung

Höffken G, Lode H, Dissmann T, et al. Pulmonale Komplikationen beim erworbenen Immundefektsyndrom: Ergebnisse einer prospektiven Untersuchung. Deutsche medizinische Wochenschrift. 1988;113(19):755-762.Zwischen 1983 und 1987 wurde bei 37 von 100 HIV-Antikörper-positiven Patienten mit 40 bronchopulmonalen Infektionen prospektiv ein abgestuftes diagnostisches Programm durchgeführt, das im wesentlichen aus einer flexiblen Bronchoskopie, verbunden mit einer Lavage, transbronchialen Biopsie und (oder) bronchialem Bürstenabstrich, bestand. Unter Berücksichtigung sämtlicher intravitaler und autoptischer Untersuchungsverfahren hatten 25 der 37 Patienten eine Pneumocystis-carinii-Pneumonie (67,5 %), dreizehn Patienten bakterielle Pneumonien, davon sechs mykobakterielle Infektionen (atypische Mykobakterien n = 4), acht Patienten Neoplasien (pulmonales Kaposi-Sarkom n = 5, Plattenepithelkarzinom n = 2, M. Hodgkin n = 1) und vier Patienten eine Cytomegalievirus-Infektion. Die diagnostische Gesamtausbeute der flexiblen Bronchoskopie betrug 78 %, bezogen auf die Pneumocystis-Pneumonie 91 %.Between 1983 and 1987, a stepwise diagnostic programme was undertaken prospectively in 37 of 100 HIV-positive patients with 40 bronchopulmonary infections. It consisted chiefly of flexible bronchoscopy combined with lavage, transbronchial biopsy and/or removal of bronchial brush cells. Taking into account all examinations performed in life and at autopsy, 25 of the 37 patients had Pneumocystis carinii pneumonia (67.5 %), 13 had bacterial pneumonia, six of these were mycobacterial infections (atypical mycobacteria in four), eight had neoplasms (pulmonary Kaposi's sarcoma in five, squamous-cell carcinoma in two, and Hodgkin's disease in one), and four patients had cytomegalovirus infection. Total diagnostic success of bronchoscopy was 78 %; related to Pneumocystis pneumonia it was 91 %