Care pathway for fetal joint contractures, Fetal Akinesia Deformation Sequence and Arthrogryposis Multiplex Congenita.

Introduction The majority of arthrogryposis multiplex congenita (AMC) and lethal forms of AMC such as fetal akinesia deformation sequence (FADS) cases are missed prenatally. We have demonstrated the additional value of fetal motor assessment and evaluation in a multidisciplinary team for the period 2007-2016. An applied care pathway for fetuses presenting with joint contracture(s) in one anatomic region (e.g. talipes equinovares), more than one body part with non-progressive contractures and motility (AMC) and with deterioration over time (FADS). Methods The multidisciplinary team of Amsterdam University Medical Centre Expertise Centre FADS and AMC developed the care pathway. Additional tools are provided including a motor assessment by ultrasound examination and postmortem assessment form. Results An eight-step care pathway is presented with a proposed timing for prenatal sonographic examination, genetic examinations, multidisciplinary meetings, prenatal and postnatal counselling of the parents by specialist also treating after birth, follow-up of prenatal and postnatal findings with counselling for future pregnancies. Discussion/conclusion The scheduled serial structural and motor sonograpahic assessment together with follow-up examinations and genetic analysis, should be tailored per prenatal centre per available resources. The multidisciplinary care pathway may pave the way to increase detection rate and diagnosis of isolated contracture(s), talipes equinovares with underlying genetic causes and the rare phenotypes AMC/FADS and prompt treatment after birth within expertise teams.

Optimization of Step-By-Step Care for Patients in Intensive Care Units Based on Grade 6 of the Rehabilitation Routing Scale

Introduction. Evaluation of ICU patients on specialized scales, such as the modified Rankin scale (mRS) and the rehabilitation routing scale (RRS), allows you to determine the degree of dependence on outside help in connection with the development of PICS syndrome, to decide on the level of complexity of the upcoming rehabilitation, and to route the patient to the appropriate rehabilitation center or palliative care department. Aims: Analysis of the experience of application RRS in the system of routing patients in intensive care units for rehabilitation treatment. Methods. As a result of the application of the routing algorithm based on the application of both scales, 224 patients with the level of dependence of RRS 56 (mRS 5) were selected for the examination of the rehabilitation potential and the re-habilitation attempt during 2019. Results. At the end of the rehabilitation course, 60 patients showed a decrease in the level of dependence to 34 points for both mRS and RRS. In 164 patients, the rating on the Rankin scale did not change (mRS 5), while the score on the RRS score of dependence in 135 decreased to 5 points. By the time of discharge, 29 patients with CNS continued to meet the criteria of RRS 6. All of them were verticalized to the level of landing in the chair and included in the remote tele patronage. During the quarterly visits, 9 patients showed signs of realizing their positive prognosis, underwent repeated rehabilitation courses during 20202021, and reduced the level of dependence to RRS 45. In practical terms, a decrease in the grade of SRM to 5 indicated that the patient was ready to stay at home, while patients with SRM 6 remained in need of highly qualified care, requiring at least a referral to the palliative care unit. From the point of view of the mRS scale, both described patient categories corresponded to 5 points, i. e., based on the assessment of the patients condition according to mRS, it was not possible to draw conclusions about further patient management tactics. Conclusions. Thus, the experience of using the RRS scale demonstrated its effectiveness in routing patients with acute cerebral injury and showed greater sensitivity and specificity in comparison with mRS.

Integrative Nutrition CARE in the Community—Starting with Pharmacists

Dietary supplementation is increasingly sought after by consumers looking to meet the demands of a modern lifestyle. Effective supplementation requires knowledge of the purpose and proper use of nutritional supplements. Unverified or inadequate guidance on supplementation can propagate misconceptions and increase undue fears of side effects. Community pharmacists are best placed to guide consumers on nutritional supplement use. In this review, a panel comprised of community pharmacists, pharmacy academia, and dietitians (n = 6) convened to provide an experience- and evidence-based guidance on rational drug use, patient education, and integrated and personalized nutrition care in both community and hospital pharmacy settings. A novel framework to guide community pharmacist-led consultations on supplementation is proposed. The four-step CARE (Categorize, Assess, Recommend, Empower) guide was developed to facilitate and optimize outcomes of pharmacist-led nutritional supplement consultation. Telehealth advancements in the form of digital health applications and personalized nutrigenomic DNA testing support Integrative Nutrition Care, and will further promote appropriate supplementation use to improve overall well-being in the community. Practical implementation of the CARE guide is necessary to ascertain its applicability for optimizing outcomes of pharmacist-led consultation and the recommendation of nutritional supplements.

The role of precipitation in hydrological model uncertainty

<p>Rainfall-runoff models produce outputs which differ from observations due to uncertainties in process description, process parametrization, uncertainties in observations and changing spatio-temporal variability of input and state variables. Traditionally, attention has been focused mostly on process parameters to quantify runoff uncertainty using e.g. GLUE.</p><p>Here we have focused on the role of precipitation uncertainty relating to discharge. For this purpose, we used an inverse model approach. We generated time series of daily precipitation with high spatial resolution  using a modified version of Random Mixing and the Shannon-Whittaker interpolation to improve simulated runoff using the SHETRAN (physically-based) and HBV (conceptual) models, both spatially distributed for various sub-catchments of the Neckar River in Germany.  HBV was initially calibrated using interpolated precipitation, while SHETRAN uses pre-defined parameters. The modelling goal was to find a spatio-temporal series of precipitation which improved the predicted runoff,  under the constraints that the precipitation values be the same at the measurement locations and share their spatial variability with the observations at a given step. Care was taken to select subsequent days for improvement such that the previously improved step considered the effect of the previous steps.</p><p>We asked the questions: i) does improving precipitation inputs for one sub-catchment bring runoff improvement for the others? ii) Can the improved precipitation using SHETRAN be used for HBV and still get runoff improvements as compared to the interpolated precipitation and vice versa?</p><p>Results showed that overall runoff errors were reduced by 40 to 50% for all sub-catchments. For the peaks, a reduction of 70 to 90% was observed. As compared with the interpolated fields, new fields showed similar overall distribution but different details at finer spatial scales. Swapping improved precipitations between SHETRAN and HBV showed improvement as compared with the discharge from interpolated precipitation.</p>

Management of Somatic Symptoms

Somatic symptoms that cannot be attributed to organic disease account for 15 to 20% of primary care consultations and up to 50% in specialized settings. About 6% of the general population has chronic somatic symptoms that affect functioning and quality of life. This chapter focuses on the recognition and effective management of patients with excessive and disabling somatic symptoms. The clinical presentation of somatic symptoms is categorized into three groups of patients: those with multiple somatic symptoms, those with health anxiety, and those with conversion disorder. The chapter provides information to assist with making a diagnosis and differential diagnosis. Management includes ways to improve the physician–patient interaction that will benefit the patient, a step-care model based on illness severity and complexity, and psychological and pharmacologic treatment. The chapter is enhanced by figures and tables that summarize health anxiety, symptoms, differential diagnoses, and management strategies, as well as by case studies and examples. This review contains 5 highly rendered figures, 10 tables, and 235 references.

Step Care Management of Heart Failure

not availableUniversity Heart Journal Vol. 13, No. 1, January 2017; 01

Management of Somatic Symptoms

Somatic symptoms that cannot be attributed to organic disease account for 15 to 20% of primary care consultations and up to 50% in specialized settings. About 6% of the general population has chronic somatic symptoms that affect functioning and quality of life. This chapter focuses on the recognition and effective management of patients with excessive and disabling somatic symptoms. The clinical presentation of somatic symptoms is categorized into three groups of patients: those with multiple somatic symptoms, those with health anxiety, and those with conversion disorder. The chapter provides information to assist with making a diagnosis and differential diagnosis. Management includes ways to improve the physician–patient interaction that will benefit the patient, a step-care model based on illness severity and complexity, and psychological and pharmacologic treatment. The chapter is enhanced by figures and tables that summarize health anxiety, symptoms, differential diagnoses, and management strategies, as well as by case studies and examples. This review contains 5 highly rendered figures, 10 tables, and 235 references.

‘I’ll do it step by step’: care, cover and quiet campaigning

This article explores a frontline account of care work and trade union organizing from the perspective of Maria Lozada, a care support worker and Filipino trade union organizer. Her testimony offers insight into life as a worker and organizer in the UK and highlights how migrants from outside the EU reflect upon immigration restriction and what it means for the quality of their employment relations and abilities to organize. The political and economic policy context within which the narrative is set is a move away from a demand-led UK immigration regime to further restriction for low-skilled work and immigration. Maria speaks about her role from a position of shelter, cover and anonymity, but is candid in her assessment of employers, policy changes and policymakers.