Shifting Responsibilities:Developing a Pan-European Service Model for an eHealth Technology Supporting Self-Management of People with Chronic Obstructive Pulmonary Disease and Comorbidities

Introduction: Active participation of patients in their care via self-management is an important pillar to manage chronic conditions. Self-management education and continuous support are needed to improve patients’ confidence to take such active role. One way to do this is through eHealth technologies. However, those technologies can only be successful when actively used in daily practice and when integrated in overall care. Therefore, this study investigated how a self-management eHealth technology could be implemented that emphasises the active role of patients in their care. Methods: The service modelling method was utilized as implementation strategy. The design process consisted of five phases with salient stakeholders and consortium members of a European project to develop the service model. Studies with salient stakeholders were carried out in three different countries (Italy, Estonia, the Netherlands). A combination between face-to-face and online methods facilitated the participatory design process. Results: Due to the pan-European context, different stakeholders in the three countries were identified. Research nurses and case managers were not yet established in practice but once implemented, expected to contribute to optimal implementation. During service modelling, a crucial step was revealed: providing self-management training before technology use to let patient familiarise with the concept of taking an active role. As HCPs felt that they were not necessarily equipped to guide patients in terms of self-management, they also should have access to such self-management training. Conclusion: By demonstrating a way for implementation while emphasising patients’ active role, we also showed the complexity of the method in two ways. First, by demonstrating the fine line between the descriptive and prescriptive model. Thus, showcasing the need to recognize that prescriptive models may be hampered by the delay in changing work practices. Second, by highlighting the importance of identifying country-specific differences in the pan-European context, revealing that service modelling is not a one-size-fits-all approach.</p

The Need to Feed: Effects of amino acid administration on protein metabolism and antioxidant defense in preterm infants

Neonates with a gestational age <37 weeks are called preterm. This thesis, however, presents studies in very preterm infants (gestational age <28 weeks), some being even extremely preterm (gestational age <26 weeks). Apart from gestational age, preterm neonates can be classified according to birth weight: low birth weight infants, weighing <2500 gram; very low birth weight infants, weighing <1500 gram; and extremely low birth weight infants, weighing <1000 gram. The cause of prematurity is multifactorial. Maternal factors (preeclampsia, life style, age, infection), pregnancy factors (placenta previa, premature rupture of membranes, polyhydramnion) , as well as fetal factors (multiple gestation, congenital anomalies) play a role

Technology-supported shared decision-making in chronic conditions:a systematic review of randomized controlled trials

Objectives: To describe the role of patients with a chronic disease, healthcare professionals (HCPs) and technology in shared decision making (SDM) and the use of clinical decision support systems (CDSSs), and to evaluate the effectiveness of SDM and CDSSs interventions. Methods: Randomized controlled studies published between 2011 and 2021 were identified and screened independently by two reviewers, followed by data extraction and analysis. SDM elements and interactive styles were identified to shape the roles of patients, HCPs and technology. Results: Forty-three articles were identified and reported on 21 SDM-studies, 15 CDSS-studies, 2 studies containing both an SDM-tool and a CDSS, and 5 studies with other decision support components. SDM elements were mostly identified in SDM-tools and interactions styles were least common in the other decision support components. Conclusions: Patients within the included RCTs mainly received information from SDM-tools and occasionally CDSSs when it concerns treatment strategies. HCPs provide and clarify information using SDM-tools and CDSSs. Technology provides interactions, which can support more active SDM. SDM-tools mostly showed evidence for positive effects on SDM outcomes, while CDSSs mostly demonstrated positive effects on clinical outcomes. Practice implications: Technology-supported SDM has potential to optimize SDM when patients, HCPs and technology collaborate well together.</p

Structured medication reviews in Parkinson’s disease:pharmacists’ views, experiences and needs – a qualitative study

Background: Executing structured medication reviews (SMRs) in primary care to optimize drug treatment is considered standard care of community pharmacists in the Netherlands. Patients with Parkinson’s disease (PD) often face complex drug regimens for their symptomatic treatment and might, therefore, benefit from an SMR. However, previously, no effect of an SMR on quality of life in PD was found. In trying to improve the case management of PD, it is interesting to understand if and to what extent SMRs in PD patients are of added value in the pharmacist’s opinion and what are assumed facilitating and hindering factors. Objectives: To analyse the process of executing SMRs in PD patients from a community pharmacist’s point of view. Design: A cross-sectional, qualitative study was performed, consisting of face-to-face semi-structured in-depth interviews. Methods: The interviews were conducted with community pharmacists who executed at least one SMR in PD, till data saturation was reached. Interviews were transcribed verbatim, coded and analysed thematically using an iterative approach. Results: Thirteen pharmacists were interviewed. SMRs in PD were considered of added value, especially regarding patient contact and bonding, individualized care and its possible effect in the future, although PD treatment is found already well monitored in secondary care. Major constraints were time, logistics and collaboration with medical specialists. Conclusion: Although community pharmacist-led SMRs are time-consuming and sometimes logistically challenging, they are of added value in primary care in general, and also in PD, of which treatment occurs mainly in secondary care. It emphasizes the pharmacist’s role in PD treatment and might tackle future drug-related issues. Improvements concern multidisciplinary collaboration for optimized SMR execution and results.</p

SCAMP:standardised, concentrated, additional macronutrients, parenteral nutrition in very preterm infants: a phase IV randomised, controlled exploratory study of macronutrient intake, growth and other aspects of neonatal care

<p>Abstract</p> <p>Background</p> <p>Infants born <29 weeks gestation are at high risk of neurocognitive disability. Early postnatal growth failure, particularly head growth, is an important and potentially reversible risk factor for impaired neurodevelopmental outcome. Inadequate nutrition is a major factor in this postnatal growth failure, optimal protein and calorie (macronutrient) intakes are rarely achieved, especially in the first week. Infants <29 weeks are dependent on parenteral nutrition for the bulk of their nutrient needs for the first 2-3 weeks of life to allow gut adaptation to milk digestion. The prescription, formulation and administration of neonatal parenteral nutrition is critical to achieving optimal protein and calorie intake but has received little scientific evaluation. Current neonatal parenteral nutrition regimens often rely on individualised prescription to manage the labile, unpredictable biochemical and metabolic control characteristic of the early neonatal period. Individualised prescription frequently fails to translate into optimal macronutrient delivery. We have previously shown that a standardised, concentrated neonatal parenteral nutrition regimen can optimise macronutrient intake.</p> <p>Methods</p> <p>We propose a single centre, randomised controlled exploratory trial of two standardised, concentrated neonatal parenteral nutrition regimens comparing a standard macronutrient content (maximum protein 2.8 g/kg/day; lipid 2.8 g/kg/day, dextrose 10%) with a higher macronutrient content (maximum protein 3.8 g/kg/day; lipid 3.8 g/kg/day, dextrose 12%) over the first 28 days of life. 150 infants 24-28 completed weeks gestation and birthweight <1200 g will be recruited. The primary outcome will be head growth velocity in the first 28 days of life. Secondary outcomes will include a) auxological data between birth and 36 weeks corrected gestational age b) actual macronutrient intake in first 28 days c) biomarkers of biochemical and metabolic tolerance d) infection biomarkers and other intravascular line complications e) incidence of major complications of prematurity including mortality f) neurodevelopmental outcome at 2 years corrected gestational age</p> <p>Trial registration</p> <p>Current controlled trials: <a href="http://www.controlled-trials.com/ISRCTN76597892">ISRCTN76597892</a>; EudraCT Number: 2008-008899-14</p

Four-Week Nutritional Audit of Preterm Infants Born <33 Weeks Gestation

Aim: Preterm nutritional audits have previously been conducted using assumed milk composition. We audited protein and energy intakes in the first 28 days of preterm life using both assumed milk composition and milk analysis to assess their effect on weight gain and to determine if the recommended reasonable range of intakes were met. Methods: Parenteral and enteral intakes and weight gain were recorded daily for infants (n = 63) born <33 weeks gestation, using assumed milk composition. Macronutrient composition was determined by milk analysis for a subset of infants (n = 36). Linear mixed models analysis was used to assess the influence of energy and protein intakes on weight gain. Results: (Data median (range)): Infants (n = 63) gestation and birth weight were 30 (24–32) weeks and 1400 (540–2580) g, respectively. Macronutrient milk composition was variable: protein 16.6 (13.4–27.6) g/L, fat 46.1 (35.0–62.4) g/L, lactose 68.0 (50.9–74.8) g/L, energy 3074 (2631–3761) kJ/L. Intakes based on measured composition differed from assumed. Protein intake was significantly associated with weight gain. Compared to infants with longer gestations, those born <28 weeks gestation were fed lower volumes, were more reliant on parenteral nutrition, took an additional seven days to transition to fortified feeds and median weight gain velocity took a fortnight longer to reach targets.Conclusion: Preterm milk composition is variable and routine fortification using assumed composition may result in inappropriate nutrition. Fortification regimens stratified by birth gestation may be necessary to achieve preterm nutrition and growth targets. Milk analysis is required for accurate nutritional audit