Why are we seeing more COVID cases in fully vaccinated people? An expert explains

Nathan Bartlett, University of Newcastle

Many people are worried about reports of “breakthrough” COVID-19 infections overseas, from places like Israel and the United States.

A breakthrough infection is when someone tests positive for COVID after being fully vaccinated, regardless of symptoms.

The good news is most breakthrough infections usually result in mild symptoms or none at all, which shows us that vaccines are doing exactly what they’re supposed to do — protecting us from severe disease and death. Vaccines aren’t designed to protect us from getting infected at all (known as “sterilising immunity”).

People with breakthrough infections can go on to infect others. Preliminary evidence indicates immunised people can have high levels of virus in the nose, potentially as high as unvaccinated people.

However, if you’re vaccinated you’ll clear the virus more quickly, reducing the length of time you’re infectious and can pass the virus on.

Here’s why breakthrough cases are happening, and why you shouldn’t worry too much.

Waning immunity

Two studies from the United Kingdom suggest the immunity we get from COVID vaccines wanes over time, after about four to six months.

While the more-infectious Delta variant continues to circulate, waning immunity will lead to more breakthrough infections.

But the reduction isn’t large currently. Vaccine effectiveness is very high to begin with, so incremental reductions due to waning won’t have a significant effect on protection for some time.

Israeli data shows some vaccinated people are becoming ill with COVID. But we need to keep in mind Israel’s vaccine rollout began in December 2020, and the majority of the population were vaccinated in early 2021. Most are now past six months since being fully vaccinated.

Given most people in Israel are vaccinated, many COVID cases in hospital are vaccinated. However, the majority (87%) of hospitalised cases are 60 or older. This highlights what’s known about adaptive immunity and vaccine protection — it declines with age.

Therefore we’d expect vulnerable groups like the elderly to be the first at risk of disease as immunity wanes, as will people whose immune systems are compromised. Managing this as we adjust to living with COVID will be an ongoing challenge for all countries.

What would be concerning is if we started seeing a big increase in fully vaccinated people getting really sick and dying — but that’s not happening.

Globally, the vast majority of people with severe COVID are unvaccinated.


Read more: COVID cases are rising in highly vaccinated Israel. But it doesn’t mean Australia should give up and ‘live with’ the virus


We’ll probably need booster doses

Waning immunity means booster doses will likely be needed to top up protection, at least for the next couple of years while the virus continues to circulate at such high levels.

Our currently approved vaccines were modelled on the original strain of the virus isolated in Wuhan, not the Delta variant, which is currently dominant across most of the world. This imperfect match between vaccine and virus means the level of protection against Delta is just a little lower.


Read more: What’s the Mu variant? And will we keep seeing more concerning variants?


Because the level of effectiveness is so high to begin with, this small reduction is negligible in the short term. But the effects of waning over time may lead to breakthrough infections appearing sooner.

mRNA vaccines in particular, like Pfizer’s and Moderna’s, can be efficiently updated to target prevalent variants, in this case Delta. So, a third immunisation based on Delta will “tweak”, as well as boost, existing immunity to an even higher starting point for longer-lasting protection.

We could see different variants become endemic in different countries. One example might be the Mu variant, currently dominant in Colombia. We might be able to match vaccines to whichever variant is circulating in specific areas.

The dose makes the poison

Your level of exposure to the virus is likely another reason for breakthrough infections.

If you’re fully vaccinated and have merely fleeting contact with a positive case, you likely won’t breathe in much virus and therefore are unlikely to develop symptomatic infection.

But if you’re in the same room as a positive case for a long period of time, you may breathe in a huge amount of virus. This makes it harder for your immune system to fight off.

This may be one reason we’re seeing some health-care workers get breakthrough infections, because they’re being exposed to high viral loads. They could be a priority for booster doses.

Might unvaccinated kids be playing a role?

It’s unclear if children are contributing to breakthrough infections.

Vaccines aren’t approved for young children yet (aged under 12), so we’re seeing increasing cases in kids relative to older people. Early studies, before the rise of Delta, indicated children didn’t significantly contribute to transmission.

More recent studies in populations with vaccinated adults, and where Delta is the dominant virus, have suggested children might contribute to transmission. This requires further investigation, but it’s possible that if you’re living with an unvaccinated child who contracts COVID, you’re likely to be exposed for many, many hours of the day, hence you’ll breathe in a large amount of virus.

The larger the viral dose, the more likely you’ll get a breakthrough infection.

Potentially slowing the number of breakthrough infections is one reason to vaccinate 12 to 15 year olds, and younger children in the future, if ongoing trials prove they’re safe and effective in this age group. Another is to protect kids themselves, and to get closer to herd immunity (if it’s achievable).


Read more: High priority: why we must vaccinate children aged 12 and over now


A silver lining

Breakthrough infections likely confer extra protection for people who’ve been fully vaccinated — almost like a booster dose.

We don’t have solid real-world data on this yet, but it isn’t surprising as it’s how our immune system works. Infection will re-expose the immune system to the virus’ spike protein and boost antibodies against the spike.

However, it’s never advisable to get COVID, because you could get very sick or die. Extra protection is just a silver lining if you do get a breakthrough infection.

As COVID becomes an endemic disease, meaning it settles into the human population, we’ll need to keep a constant eye on the interaction between vaccines and the virus.

The virus may start to burn out, but it’s also possible it might continually evolve and evade vaccines, like the flu does.


Read more: How will Delta evolve? Here’s what the theory tells us


Nathan Bartlett, Associate Professor, School of Biomedical Sciences and Pharmacy, University of Newcastle

This article is republished from The Conversation under a Creative Commons license. Read the original article.

How rare are blood clots after the AstraZeneca vaccine? What should you look out for? And how are they treated?

Karlheinz Peter, Baker Heart and Diabetes Institute and James McFadyen, Baker Heart and Diabetes Institute

With COVID-19 community transmission on the rise once again, those aged over 50 are weighing up the benefits of being vaccinated against the virus with the very rare risk of blood clotting induced by the AstraZeneca vaccine.

Since the first reports of blood clotting after the AstraZeneca vaccine emerged in March 2021, our understanding of the clotting disorder, called vaccine-induced thrombotic thrombocytopaenia (VITT) or thrombosis with thrombocytopenia syndrome (TTS), has grown.

We now know how to diagnose and treat it, so we’re likely to see better outcomes for patients with the condition.

How common and deadly is it?

Thankfully, developing blood clots after the AstraZeneca vaccine is very rare.

So far in Australia, out of 2.1 million doses of the AstraZeneca vaccine, 24 cases of TTS have been reported. So the risk of TTS is approximately one in 88,000.

These figures are similar to those reported in the UK, Europe, the Middle East and Canada.

Although early reports from Europe indicated approximately 20% of cases of TTS were fatal, in Australia, to date, one out of 24 TTS cases has been fatal, so just over 4%.

The Conversation, CC BY-ND

What exactly is thrombosis with thrombocytopenia syndrome?

Although we don’t yet have the full explanation, it appears that the AstraZeneca vaccine can activate platelets, which are small cells in our blood important for forming blood clots that prevent bleeding.

In some people, activated platelets can release a protein called platelet factor 4 (PF4), which binds to the AstraZeneca vaccine. It is thought that this binding of PF4 can induce the immune system to activate more platelets, making them stick together and thereby diminishing their numbers. This leads to blood clotting (thrombosis) and a low platelet count (thrombocytopaenia).

Having blood clots with a reduced number of platelets is a key feature of TTS.


Read more: What is thrombocytopenia, the rare blood condition possibly linked to the AstraZeneca vaccine?


Different to other blood clots

This mechanism is quite different to the usual process by which blood clots occur.

TTS appears to result from an irregular immune response, so current evidence suggests people with a history of heart attack, stroke, deep vein thrombosis, pulmonary embolism (a clot in the lung) or on regular blood thinners aren’t at any increased risk of TTS.

However, as a precautionary measure, the Pfizer vaccine is currently recommended for people aged under 50 years, or those with a history of clots in the brain, in the abdomen or previous low platelet count after taking the blood-thinning drug heparin.

Testing and treatment has improved

A key development is diagnostic tests and guidelines to recognise and treat cases of TTS. In most cases, patients will have a low platelet count, evidence of a blood clot, and antibodies directed against PF4. Many of these tests can be done quickly.

Treatment can now begin immediately, with specific blood thinners and medications to dampen the immune system.

As of May 20 when the latest vaccine safety report was released, 21 of the 24 Australians with TTS had recovered and been discharged from hospital and two were stable and recovering in hospital.

So what side effects are normal, and what might indicate a clot?

General side effects are common after any vaccine. In the case of the AstraZeneca vaccine, these occur in the first two days after vaccination and include:

  • headache
  • fever (chills)
  • muscle and joint aches
  • nausea
  • fatigue
  • pain at the site of injection, which tends to resolve with simple measures such as paracetamol.

In many cases, the blood clots in TTS occur in unusual locations such as the veins in the abdomen (splanchnic vein thrombosis) and brain (cerebral venous sinus thrombosis). They typically occur four to 30 days days after vaccination.


Read more: I’m over 50 and can now get my COVID vaccine. Is the AstraZeneca vaccine safe? Does it work? What else do I need to know?


Therefore, symptoms that could indicate TTS after getting the AstraZeneca vaccine include:

  • persistent or severe headache
  • blurred or double vision
  • shortness of breath
  • severe abdominal, back or chest pain
  • swelling, redness, pain in a leg
  • unusual bleeding or bruising.

If you experience any of these symptoms four to 30 days after your vaccination, seek urgent medical attention.

Balancing the risk and benefits

While TTS is very rare, some people will have concerns and will want to discuss them with their doctor. This is essential to allow people to make an informed choice.


Read more: I’m over 50 and hesitant about the AstraZeneca COVID vaccine. Should I wait for Pfizer?


However, with the ongoing risk of COVID outbreaks in Australia and their potential deadly consequences, as well as the potentially severe long-term effects of COVID-19, for the vast majority of people, the benefits of vaccination against COVID-19 as soon as possible outweigh the risks.

Karlheinz Peter, Lab Head, Atherothrombosis and Vascular Biology and Deputy Director, Baker Heart and Diabetes Institute; Interventional Cardiologist, Alfred Hospital; Professor of Medicine and Immunology, Monash University, Baker Heart and Diabetes Institute and James McFadyen, Research Fellow, Baker Heart and Diabetes Institute, Haematologist, Alfred Hospital, Baker Heart and Diabetes Institute

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Coordinating Care for Adults With Complex Care Needs: Challenges and Solutions

Patient Summary

Identity: 85-year-old male.

Situation

The client is widowed, lives alone at home, and able to drive. Does not have a good social support structure, has two children, one works away and other lives interstate. Both the patient and the wife had been under community care for over three years, but since being widowed, over two years ago, the client has not been coping very well and has been experiencing a gradual decline in health.  

Medication: Aspirin 100mg, Metoprolol 50mg, Atorvastatin 10mg, Ramipril 10mg daily, Paracetamol MR 1330mg three times a day.   

Medical History: Heart Attack, recent fall, and dizziness.

Plan: Care plan review

Medical Issues

      The main issues noted include safety, depression/ loneliness, mobility, and dizziness. The safety issues are related to the dizziness and the patient not wanting to give up driving.  The patient has a history of heart attacks and is on a combination of antiplatelet and antihypertensives such as, Metoprolol, Atorvastatin and Ramipril. The dizziness could be secondary to the antihypertensives  that are currently prescribed (Olowofela & Isah, 2017). It is important to assess the times the patient has the dizzy spells and to adjust the medication accordingly, a daily sitting and standing blood pressure check is indicated. Drastic physical changes happen when people age, one of them is visual deterioration, in old age, eyes become less sensitive to light and refocusing from one object to another becomes longer and harder (Frank et al., 2021).

           Another issue is the poor mobility, the decline in mobility is expected in the elderly. Mobility issues in the elderly living in the community represent a preclinical transitional stage to a pathway to disability (Cruz-Jimenez, 2017). Studies show that individuals who lose their independence are less likely to remain in the community, have higher rates of disease, have a poor quality of life, and have greater chances of social isolation. Poor mobility often means that the patient is at increased risk of falls and frequent hospitalisation (Musich et al., 2018).  Decrease in mobility is a major contributor to the high rates of fall experienced in older adults, Studies show that even when injury does not happen, the fall can trigger a loss of confidence which leads to reduction in activity which further increases falls.

  (Musich et al., 2018). It is estimated that 1 in 3 older Australians have experienced a fall in the past 12 months with 1 in 5 requiring hospitalisation ( Australian Institute of Health and Welfare, 2020).  

         Thirdly, loneliness, depression, and social isolation. loneliness and social isolation are associated with poor health outcomes across all population groups. Studies show that the biggest contributing factors to loneliness is the death of a spouse, children moving away, loss of independence, fear of becoming a burden and a deterioration in friendship network (Reducing Social Isolation and Loneliness in Older People: 2017). Studies show that loneliness is associated with poor physical and mental health outcomes. With research suggesting they may even increase the likelihood of premature death. Loneliness has been shown to affect sleep patterns and increase levels of stress. Studies also show that loneliness increases the likelihood of accelerated cognitive decline and the onset of various forms of dementia, which in turn makes it hard to care for the patient in the community (Seyfzadeh et al., 2017).

Areas of Support

         The patient will be assessed using the I-CAN functional assessment tool. The I-CAN functional assessment measures the individual’s ability to perform self-care and physical activities. It also assesses the individual’s psychosocial, communication, and community involvement. This patient will be assessed on the ability to perform physical activities, sleep patterns, dietary habits, driving, and the ability to perform all the activities of daily living. this includes hearing, vision and digestive issues, social support structures and gross motor skills like mobility. The client will need assistance with four main critical areas these are, medication management, mobility, house modification and physical health ( Instrument for the Classification and Assessment of Support Needs – 2021).

          In dealing with safety, the patient’s living arrangement will need a review by the Occupational Therapist for recommendations on house modification and the necessary adaptation processes. Care planning must centre around the issues that arise because of a decline in mobility. Things to consider in this case is the installation of toilet rails, having a chair in the shower during personal care for falls prevention. It is important in this case to maximise the skills that the patient can already do and only help with tasks that the patient cannot do (Hyett et al., 2019). Post-fall, it is also good practice to have the patient reviewed by the physiotherapist to assess any physical limitation and to assess if the patient needs any mobility aids. Physiotherapists generally have an important role when it comes to working with the elderly, they are involved in preventing disease and disability, through symptom management. In this case, the role of the physiotherapist is the prevention of disability through nonpharmacological pain management like massages, heat/ cold treatment and dry needling and maintenance of muscle tone through stability exercises. A physiotherapist would also be able to come up with an exercise regime to help with falls prevention. Studies show that challenging balance exercises for two hours per week on an ongoing basis reduces falls risk in older adults living in the community (Falls Prevention Home_Exercises. 2021). In dealing with dizziness the physiotherapist would be able to conduct vestibular testing to work out if there something wrong with the vestibular portion of the ear and then come up with management plan. For example, Epley maneuverer is an effective nonpharmacological intervention for managing dizziness (Kowalska et al., 2019).

Role of a Coordinator.

         The role of the care coordinator is the efficient management of resources, in this patient’s case, the main role is to look at the big picture and to help the patient navigate through the health care system. The care coordinator is responsible for setting up appointments, sending referrals and implementing the changes. Another role of the care coordinator is to facilitate the easy access and share of information among professionals and all direct care workers. The care coordinator is also responsible for sourcing funding for the patient and to inform the patient of the resources available. It is the duty of the care coordinator in this patient to explicitly define the roles among team members and define the tasks and responsibility towards the patient, especially in a multidisciplinary care system (What Does a Care Coordinator Do, 2020).

         Finally, the role of care coordinator is decision support. Decision support refers to the delivery of up to date evidenced based patient centered care. It is important for the care coordinator to ensure that there no gaps in the knowledge among team members with regards to the latest best evidence practise.  Under decision support, it is the role of the care coordinator to provide continuous education to all team members, and to make sure that all their competencies are up to date. Continuous education and constant review of the policies to figure out what is working, ensures that the clinicians are using the best update practice guideline in patient care (What Does a Care Coordinator Do, 2020).

Care Plan

AssessmentGoalsDiagnosisPlanning       ImplementationEvaluation/rationale  
DizzinessThe client will stop filling dizzyDizziness likely related to cardiac issues and hypertensive medicationsDoctor’s referral for investigation on the cause of the dizzinessBlood panel, vestibular assessment.The client will not complain of dizziness.Investigation will be done for falls prevention and safety reasons
Safety IssuesThe patient will fill safe and supportedSafety issues Related to living alone and decreased in mobility and functional status  Doctor to assess the patient ability to drive.  Support services to help social mobility. Drive client to appointment. Drive client to adult day care centres.Help client with shopping.  The client has not missed appointments.The client gets to attend activities outside home regularly.  
Falls  To fill safe and not fallFall related to old age and the dizzinessPhysiotherapy referral for a fall’s management plan.Stability exercise, Strength exercises, pain management Dry needling.Massages.  Will not have falls Strength exercises help prevent falls.
Loneliness and depressionTo have daily medical, social and emotional supportLoneliness and depression related to being widowed and living alone.  To involve client in adult day care centres so that the client can socialise with other people  Silver chain to drive resident too and from the centres 3 times a week. Potable call bell in case of an emergencyThe client has been participating in community elderly activities on a regular basis and is enjoying them.To prevent rapid cognitive decline
House ModificationTo be safe while at home and alone.Related to living alone and dizziness.  Referral to the OT for house modification consultationInstallation of toilet rails. Paint house for easy navigation of surrounding. Shower chairs. Organise support staff.   Organise therapy assistants.  The client will feel secure and safe at home. For safety and falls prevention. Would allow client to remain in the community for as long as possible
Medication managementTo take medication on time.Related to decreased functional ability and history of heart attacks.Have the medication packed in web star pack and reminders set for when to take medication. Self-medication assessment to be done by GPEducation on importance of taking medication  Schedule a call every four hours to remind client to take medication. The times of medication must be charted during the times when care staff are visiting client.  The client will take medication every day. To prevent another heart attack. To prevent drastic functional decline.
Dietary managementTo have at least one hot nutritional meal a dayDietary issues related to living alone, being unable to cook and decrease in functional ability. Enrol of the services of SNAP to provide nutritional food for free.SNAP to deliver meals a once dayThe client will maintain a healthy diet. To prevent weight loss. Client does not have to think about food preparation.
Funding from the government for increased support.To source all the available fundingRelated to the patient needing more support in the way of community care.Assess the needs of the patient to set up a plan for care.  Application to my aged care for an assessment and to determine the funding structureThe client will have all funding available to them all year round.
Personal care needsTo have optimal oral and physical hygiene.Related to decrease in functional ability.Assistant nurses to help with some aspects of the client personal hygiene.Assistant nurse to visit client every morning to help client start the day. And to help with personal care.All activities of daily living will be attended to and documented in the progress notes.

Complex Care Model

            The complex care model used for this care plan is the Wagner chronic care disease model, the planning and intervention are all based on the physical, psychological, perceptual, and cognitive assessment that is done by the doctor and allied health care workers. The Wagner chronic care disease model has six main elements, these are the community, health systems, delivery systems designs, decision support, clinical information systems, and self-management support.  Self-management support aims at empowering the patient to take a lead role in managing their own health. Self-management support involves helping the patient in goal setting, providing compassionate and patient centered care, making referrals to community group and physiotherapy appointments. Self-management is a multidisciplinary approach and aims at tailoring the education specifically to the patient’s current condition.  The care plan will above is not rigid structure and will be subject to changes based on the condition of the client (Reynolds et al., 2018).

The Community

         On top of the professional care provided by the clinical staff and allied health care workers, the client would benefit from having community support groups like faith institutions and not-for-profit organisations to ensure that the patient is adequately supported. Depending on the assessment by the Doctor, and before any pharmacological interventions regarding the loneliness and depression, the patient should be encouraged to socialise and be informed of adult day care centres (Cheng et al., 2018). The purpose of these adult care centres is to encourage the elderly to socialise, engage in activities and eat a hot meal in a supervised setting. In Western Australia these centres are run by Silver chain, Silver chain can also provide support workers to drive the patient to and from these centres. These centres are also useful for families needing respite. Another community support group that the patient can benefit from is the SNAP. These are local charities that provide seniors with nutritional meals and the opportunity to socialise, these groups will in some cases provide free transport (Social Support For Seniors | Home Care Services Perth – Silver Chain, 2021).

Delivery Systems Designs

        This involves the creation of a system that enables professionals to know what care has been provided for the client. In this case, the use of regular progress notes is important so that all the professionals have access to the information, and to know what the other professionals have done and have been doing. Progress notes helps the care coordinator look at the big picture and figure out the interventions that have been effective and the those that are not.  An electronic medical information system would be ideal for this patient (Kharrazi et al., 2018).  In this system, only the professionals that have been given permission by the care coordinator to have access to the patient records can make changes and recommendations. Electronic systems allow for efficient delivery of care as any changes to patient care can be seen in real time and recommendations can be acted upon in a timely manner (Kharrazi et al., 2018). For example, some electronic systems will link all professionals together in a way that when the care coordinator makes a referral, other health care workers would be able to receive the referral instantly.  Delivery systems designs shifts the focus of delivering care from that which is reactionary to that which is proactive (Baumann et al., 2018).

 Clinical Informational Systems

              This is the use of clinical technology to provide information about the patient to all professionals directly involved in the care of the patient. Electronic information provides an easy access to information and to monitor the patient’s health status. It also makes it easier to share and coordinate information among professionals and enables the coordinator to monitor the performance of clinicians and the health care system (Morley & Cashell, 2017). It enables the care team to develop a patient-centred care plans and makes it easier to make changes to the care plan. There are about ten different electronic care systems available on the market, Matrix care would be ideal for community care patients. All professionals and support staff responsible for the care of this patient must download the program, it would then be mandatory to have at least one progress note after each visit. In this patient case having an electronic system takes the pressure away from the patient to constantly remember information or remember to health records to all appointments (Baumann et al., 2018).

Justification

         The above framework is used because it allows clinical staff to create a care plan that is tailored to the patient’s needs. It is a multilayered framework that takes into account, how information is transferred between professionals, community support workers and the family (Lall et al., 2018). The Wagner model is also ideal for individuals that are independent with most care and only need support for safety reasons and to prevent fast decline in functional status.   Community care in general allows for the client to choose and be in control of the services they want (Braillard et al., 2018). They get to eat meals they feel like and the type of support care workers they can have. This core principle of this care is self-management support, the Wagner model allows for the creation of services that feels in the gaps for the services that the client needs. For example, if the client still can drive and shower safely, then these activities should not be done for them for as long as it is possible to do so.

Conclusion     

    This paper looked at the importance of care coordination in the efficient management and delivery of care. The complex care model used to formulate the care plan is the Wagner Chronic care disease model. The aim for this patient is to improve quality of life, through symptoms management and falls prevention.

References

Baumann, L. A., Baker, J., & Elshaug, A. G. (2018). The impact of electronic health record systems on clinical documentation times: A systematic review. Health Policy, 122(8), 827–836. https://doi.org/10.1016/j.healthpol.2018.05.014

Braillard, O., Slama-Chaudhry, A., Joly, C., Perone, N., & Beran, D. (2018). The impact of chronic disease management on primary care doctors in Switzerland: A qualitative study. BMC Family Practice, 19(1), 159. https://doi.org/10.1186/s12875-018-0833-3

Cheng, Y., Xi, J., Rosenberg, M. W., & Gao, S. (2018). Intergenerational differences in social support for the community-living elderly in Beijing, China. Health Science Reports, 1(11), e96. https://doi.org/10.1002/hsr2.96

Cruz-Jimenez, M. (2017). Normal Changes in Gait and Mobility Problems in the Elderly. Physical Medicine and Rehabilitation Clinics of North America, 28(4), 713–725. https://doi.org/10.1016/j.pmr.2017.06.005

Falls_Prevention_Home_Exercises.pdf. (n.d.). Retrieved February 13, 2021, from https://www.activeandhealthy.nsw.gov.au/assets/pdf/Falls_Prevention_Home_Exercises.pdf

Frank, S. M., Bründl, S., Frank, U. I., Sasaki, Y., Greenlee, M. W., & Watanabe, T. (2021). Fundamental Differences in Visual Perceptual Learning between Children and Adults. Current Biology, 31(2), 427-432.e5. https://doi.org/10.1016/j.cub.2020.10.047

Hyett, N., Kenny, A., & Dickson-Swift, V. (2019). Re-imagining occupational therapy clients as communities: Presenting the community-centred practice framework. Scandinavian Journal of Occupational Therapy, 26(4), 246–260. https://doi.org/10.1080/11038128.2017.1423374

Kharrazi, H., Gonzalez, C. P., Lowe, K. B., Huerta, T. R., & Ford, E. W. (2018). Forecasting the Maturation of Electronic Health Record Functions Among US Hospitals: Retrospective Analysis and Predictive Model. Journal of Medical Internet Research, 20(8), e10458. https://doi.org/10.2196/10458

Kowalska, J., Mazurek, J., Kubasik, N., & Rymaszewska, J. (2019). Effectiveness of physiotherapy in elderly patients with dementia: A prospective, comparative analysis. Disability and Rehabilitation, 41(7), 815–819. https://doi.org/10.1080/09638288.2017.1410859

Lall, D., Engel, N., Devadasan, N., Horstman, K., & Criel, B. (2018). Models of care for chronic conditions in low/middle-income countries: A ‘best fit’ framework synthesis. BMJ Global Health, 3(6), e001077. https://doi.org/10.1136/bmjgh-2018-001077

More older Australians hospitalised for fall-related head injuries—Australian Institute of Health and Welfare. (n.d.). Retrieved February 13, 2021, from https://www.aihw.gov.au/news-media/media-releases/2019/september/more-older-australians-hospitalised-for-fall-relat

Morley, L., & Cashell, A. (2017). Collaboration in Health Care. Journal of Medical Imaging and Radiation Sciences, 48(2), 207–216. https://doi.org/10.1016/j.jmir.2017.02.071

Musich, S., Wang, S. S., Ruiz, J., Hawkins, K., & Wicker, E. (2018). The impact of mobility limitations on health outcomes among older adults. Geriatric Nursing, 39(2), 162–169. https://doi.org/10.1016/j.gerinurse.2017.08.002

Olowofela, A. O., & Isah, A. O. (2017). A Profile of Adverse Effects of Antihypertensive Medicines in a Tertiary Care Clinic in Nigeria. Annals of African Medicine, 16(3), 114–119. https://doi.org/10.4103/aam.aam_6_17

Reducing social isolation and loneliness in older people: A systematic review protocol | BMJ Open. (n.d.). Retrieved February 13, 2021, from https://bmjopen.bmj.com/content/7/5/e013778.abstract

Reynolds, R., Dennis, S., Hasan, I., Slewa, J., Chen, W., Tian, D., Bobba, S., & Zwar, N. (2018). A systematic review of chronic disease management interventions in primary care. BMC Family Practice, 19(1), 11. https://doi.org/10.1186/s12875-017-0692-3

Seyfzadeh, A., Hagighatian, M., & Mohajerani, A. (2017). The Relationship Between Social Isolation and Health Among the Tehranian Elderly. J Educ Community Health, 4(3), 19–25. https://doi.org/10.21859/jech.4.3.19

Social Support For Seniors | Home Care Services Perth—Silver Chain. (n.d.). Retrieved February 13, 2021, from https://www.silverchain.org.au/wa/home-care/community-and-companionship/

Web link—I-CAN: Instrument for the Classification and Assessment of Support Needs—ADCET. (n.d.). Retrieved February 13, 2021, from https://www.adcet.edu.au/resource/8910/i-can-instrument-for-the-classification-and-assessment-of-support-needs

What Does a Care Coordinator Do? (2020, March 20). Rider University. https://online.rider.edu/blog/what-does-a-care-coordinator-do/

Grab a rope: seven reasons why skipping is so good for you

Lindsay Bottoms, University of Hertfordshire

While many of us may remember skipping as something we did as children, the pastime has regained popularity during the pandemic as a way of keeping fit.

Not only is jumping rope a fun, affordable and portable form of exercise, it also has many benefits for our health and fitness. Here are just a few reason why jumping rope is such a good form of exercise:

1. It improves cardiovascular fitness

Jumping rope has long been used by boxers as a form of training to help improve their footwork and general conditioning.

Jumping rope will cause an increase in heart rate and breathing similar to if you went jogging. If you were to do ten minutes of jump rope everyday, you would create adaptations to your body that are beneficial to cardiovascular health, such as lowering blood pressure and reducing resting heart rate.

Jumping rope will also increase your cardiorespiratory fitness which essentially means your body becomes more efficient at taking up and using oxygen.

Research has shown that cardiorespiratory fitness is linked to improved health and longevity. Improved cardiorespriatory fitness has been shown to reduce blood pressure, improve insulin sensitivity, reduce inflammation in the body and lower chances of developing diabetes and many other chronic disease.

2. It’s a full body workout

Skipping is a full body workout which uses your abdominal muscles to stabilise the body, your legs for jumping, and your shoulders and arms for turning the rope. It therefore provides an all over workout rather than just isolating one portion of the body.

Full body workouts increase muscle tone, which will help with all daily activities, and increase our resting metabolism, which helps us burn calories even while resting.

3. It improves coordination and motor skills

Skipping involves coordination to time your jump with the rope. Research has shown that it improves coordination, balance and basic movement skills in children. These are important fitness components for later in life as they reduce our chances of trips and falls.

There are so many different exercises you can do with the rope and each one requires different coordination to complete the exercise. This may help exercise your brain as well.

4. It increases bone mineral density

Jumping rope involves making impact with the ground with every jump. These impacts cause our bones to remodel themselves to become stronger, thus increasing bone density. Bone density can be a benefit later on in life, when it naturally begins to decrease.

Research has shown that jumping rope increases bone mineral density. Higher bone mineral density makes you less likely to break a bone or develop osteoporosis as you get older. Hip fractures are a major cause of morbidity and mortality in older people, leading to loss of independence and a huge economic burden. Improving bone density and balance throughout your life reduces the chances of trips and falls later on.

5. It increases speed

Because jumping rope requires fast movement of the feet and arms, it’s considered a plyometric exercise. This is where the muscles exert maximum force in short intervals of time, with the goal of increasing power.

Plyometric exercise is used in the sporting world to increase an athlete’s speed. A lot of exercises, such as jogging, only improve cardiovascular health – whereas jumping rope has the added benefit of improving speed as well. Daily jump rope practice may help you run quicker than before.

6. Time efficient

Jumping rope offers many health benefits that may be achieved in a short period of time. Because it’s a full body exercise that requires speed and coordination, you could argue that it’s a form of high intensity interval training (HIIT).

HIIT exercise is where you have short bouts of high intensity efforts followed by a short rest intervals. This is repeated several times. HIIT has been shown to produce higher levels of cardiorespiratory fitness in comparison to traditional endurance training.

It’s also more time efficient, as you can perform exercise over a shorter period. This is why HIIT training has become the most popular workout worldwide.

Jumping rope is easily adaptable, and can be a high-intensity workout depending on the effort and power a person puts into their training.

7. Enjoyable

One of the most important points we need to consider to help us change our exercise habits is that what we do needs to be enjoyable to us. One of the biggest barriers for people when it comes to sticking with exercise is enjoyment. And research shows enjoying exercise is critical for helping us change our exercise habits and continue exercising.

The great thing about skipping is that there are so many different ways you can jump, and hop over the rope. You can create a varied workout which helps maintain your enjoyment.

However, it’s worth noting that skipping can put a lot of force on our lower limbs when we land. Though this improves our bone mineral density, it can lead to lower-body injury, especially if we’re not used to this force. But different jumping styles can be used to help ease force and reduce chance of injury. As with all types of exercise, it’s good to build up duration gradually. This will help minimise injury.

Overall, jumping rope could be a very beneficial form of exercise. Not only does it improve many important aspects of our health – including cardiovascular health, and improving bone density – but it’s also affordable, portable and doesn’t require much space.

Lindsay Bottoms, Reader in Exercise and Health Physiology, University of Hertfordshire

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Exploring the Impact of the Medical Planning and Decision Act on Nursing Practice

         A legislation is a law that has been enacted by the governing body, in Australia it is the parliament that makes laws. The role of the Judge is to interpret the law in a broader context and in specific circumstances (Strahl et al., 2021). The purpose of legislation is to regulate, outlaw, provide, to sanction, grant, declare or restrict behaviours (Grant, 2021). For example, under law, informed consent is a person’s decision that is given voluntarily, to agree to health care treatment. This follows the provision of accurate and relevant information about health interventions and the alternate options available (Teven et al., 2017).  Informed consent means that the individual must have adequate knowledge and understanding of the benefits and the material risks of the proposed intervention relevant to the person receiving the medical intervention. Broadly, any treatment that is given without the individual consenting is tantamount to battery, and maybe grounds for criminal investigation (Heinrichs, 2019).  Good clinical practice ensures that informed consent is validly and appropriately obtained. Informed consent also forms part of the professional code of conduct for nurses. In a broader context consent is about the patient’s autonomy, it puts the patient at the centre of all decision-making process (Zahle, 2017).

Legislation

         The aim of this paper is to explore the impact of the Medical Planning and Decision Act of 2018, and the Aged Care Act of 1997 on nursing care of the elderly people. The medical planning and decision act are part of the broader shift towards empowering people to make their own treatment decisions. The act establishes a single framework for individuals that have the capacity to decide for themselves. It tries to ensure that patient receive treatment that is consistent with their own preferences and values. Under the act, individuals can make legally binding advance health care directives about the treatment consents and interventions they do not want. They can make instructions, such as only pursue treatment that lesson pain and allows them to die with dignity. Individuals can appoint a medical decision-maker and support person (Medical Treatment Planning and Decisions Act, 2016). This is different from the regular advanced health care directive that only gives instructions on what nurses must do if the heart stops. They do not give a directive of what must happen when the individual suffers a medical emergency, and as result it takes away their right to die with dignity, as is the case with falls. The previous laws surrounding ACDs did not give guidance on what sort of treatment to have, or at what point during care should a conversation be had with client to consider comfort care (Carr & Luth, 2017).  End of life care is complicated with Individuals who do not have family but also lack the capacity to make an informed decision.  Under the law, if the individual cannot decide for themselves, a next of kin in form of a family member can make decision on their behalf. Complexity, in this case, is when the individual does not have any immediate family members to make medical decisions on there behalf. State appointed public advocates can only do so much in the way of advocating for the patients’ rights (Hack et al., 2017).

           Secondly, the Aged Care Act of 1997.  The Aged Care act of 1997 governs laws surrounding government-funded aged care and community care services (Federal Register of Legislation , 2021). It sets out rules for things such as funding, regulations, approval of providers, quality of care and the rights of the people receiving care. The commonwealth Community Support Program (CHSP) is part of the Aged Care Act, CHSP is designed to provide funding and support for older people living at home and want to maintain their independence. Service providers work with clients to maintain their independence, support can include help with daily tasks, home modification, transport, social support, and nursing care. CHSP providers receive funding from the government in form of grant agreements, they then provide subsidised services. Clients, in this case, contribute a fee towards a range of services. Clients are expected to contribute to the services they can afford. The CHSP is regulated by the Aged Care Quality and Safety Commission (Commonwealth Home Support Programme , 2021).  

      The commission is a national end to end regulator of aged care services, it has the responsibility of approving providers and receiving compulsory reports on the services provided. The commission indirectly accredits, assesses, and monitors aged care services that are subsidised by the government. The commission also conducts home care investigations and determine compliance requirements and is responsible for imposing sanctions if the standards of care are not met. The commission was created to make sure that the standards and quality of care are maintained in the health systems and to protect the rights of the consumers.  Imposing sanctions means increased scrutiny on the practices of staff and reduced funding which further increases the levels of stress in the organisation. Reduced funding inevitably impacts the levels of services the organisation can offer (Commonwealth Home Support Programme Key Changes, 2019). Assessment teams consisting of registered quality assessors undertake performance assessment through assessments, site, review, and quality audits. Assessment teams conduct performance assessment by collecting evidence of the quality of care, including observations, interviews, and document review.  They collect statistics on falls, wounds, and the general quality and improvement cycle of the organisation. The accreditation team will also look at the quality of the food provided.  Awarding accreditation to an organisation assures the community that the facility meets the safety and quality standards. The accreditation process aims to make sure that the standards of care are maintained across the health care system.  (The NSQHS Standards, 2021). 

Impact on Food and housing Security

         The Aged Care Act affects food security in two main ways; firstly, the funding structure is long and complicated, different aged care sectors have a different funding structure. Secondly, how much funding an organisation receives is dependant on the education and competence of staff within the organisation. The quality of care the client receives depends on the competency of the care coordinator and how well the coordinator can source funding. It also relies on the training of the personal care workers and how well they can document the patient’s condition and the general care needs. Because community care does not require clinical staff to be with the client all the time, day to day care is done by personal care workers, the risk here is that small changes in the client’s condition can be missed.

           Secondly, Home community care services are very expensive and hard to co-ordinate, for individuals that have financial trustees it is even harder to work out the financial payment method. 24hour home community care is even more expensive for individuals that do not have private health insurance, in this case the choice of services they are able to have at home is also limited. The basic medical care will be provided but the extra home and community care services are limited.  If the client cannot afford a small contribution to the care, in most cases the individual’s equity is sold. The money raised is used as bond prior to nursing home admission. Aged care homes are funded through the Aged care funding Instrument (ACFI) (Health, 2019).  ACFI, is a needs-based instrument, funding is based on the assessed needs of the client on a day to day basis. Community care, on the other hand, is done through the CHSP program, the CHSP program is available across Australia and funds a large variety of organisation to deliver services. Clients under this scheme must contribute up to 10% towards their care (Community Care Program |2019).  The contribution fees vary between providers and the level of services the clients receive are dependent on how wealthy they are. To get funding, assessors will normally come and review client to determine what level of support they are eligible to receive. More wealthy clients will be able to afford 24hour care at home. However, for clients from low social economic status, that need more care and community care is not suitable, aged care then becomes the only option.

 Implication on Nursing Practice

           The medical planning and decision act help nurses have a decision-making framework when caring for the elderly. It helps the clinicians figure out what sort of interventions can be pursued should a critical event happen.  This act goals beyond the narrow provision of whether to resuscitate or not to resuscitate. In this case the role of the care coordinator is to help the patient and the family make informed treatment preferences, appropriate prognosis, and the available options. Under this law the individual can specify specific instances for hospital transfer and the sort of treatment the hospital can explore.  It means that when creating a care plan, the care coordinator must work with the patient on what type of care they want and the care expectations.  For nurses the ethical value of patient autonomy and the families must be respected but must also be weighed against the use of expensive management.   It is important to explain to the patient and the families that advanced technologies do not hold a promise of full recovery and in most cases, the recovery can be so humiliating and burdensome for the patient.

Ethical Issues

          legislations that are made to protect the interest of the vulnerable are generally good, if they are implemented properly. If they are not implemented properly it can be a source of major psychological stress between carers and clinical staff. Provisional laws are generally created for maximum utility, meaning for the greater good of the wider community and do not account for specific differences within the community.  They do not account for the social, cultural, and religious differences in the community. For example, advanced care planning laws have the best of intentions and that is to safeguard the interest of the elderly. But ACDs are made at a point in time, they are meant to be reviewed yearly or when there is a change in the client’s condition.  Advanced care directives do not account for cases where the individual suffers a medical event that lives them unable to make decision for themselves, and do not have family to communicate what the client would have wanted should they deteriorated further (Hack et al., 2017).  Families playing the role of the surrogate tend to be emotionally attached to the client and hence their moral interest often lean towards active treatment. It is also hard to tell in most cases if the interest in the patient from the family is purely what is in best interest of the client.  While, an advanced care directive gives the patient the right to refuse medical interventions. For nurses however, it is often hard to workout at what point should care be considered futile. This is partly out of fear of litigation from the family, and the healthcare workers own moral leanings. Another reason is that while the client may have come to terms with the fact that they are dying, in majority of cases the families are not, and will want to do anything possible to prolong the process.  

Cultural Issues

          Finally, the law forces nurses to consider all aspects of care planning, especially when caring for culturally diverse communities, as is the case with Aboriginal people. When providing patient-centred care for Aboriginal clients, the coordinator needs to find out if the individual has a person who they would like to be involved in the discussion about their health. As they may have a decision-maker and spokesperson (Palliative Care and End-of-Life Care , 2019) . Things to consider when creating an end of life care plan includes who the client wants to call during the dying process and what music they would like to be played. In culturally religious groups like Muslims, only certain people trained in the Islamic way of performing last orifices can do that, in some cases nurses are not even allowed to touch the body. And in Many of these cultures, autopsies are also forbidden. In some African cultures, they do not burry the body for at least three days after death. In most cases, the body is taken home placed in the middle of the living room and people will morn for a week before the actual burial. Having an open dialogue with families and the client enables the care coordinator to know exactly what the patients want and ensures that their end of life pathways is respected.

Conclusion

       This paper has looked at the ethical, cultural, and professional impact of the aged care act of 1997 and the medical planning and decision act of 2016. This paper also looked at the implications of the medical planning act on nursing practice, particular focus was on the impact it has hard on the care of culturally diverse communities.

References

Carr, D., & Luth, E. A. (2017). Advance Care Planning: Contemporary Issues and Future Directions. Innovation in Aging, 1(igx012). https://doi.org/10.1093/geroni/igx012

Commonwealth Home Support Programme key changes fact sheet | Aged Care Quality and Safety Commission. (n.d.). Retrieved February 21, 2021, from https://www.agedcarequality.gov.au/resources/commonwealth-home-support-programme-key-changes-fact-sheet

Community Care Program | Health. (n.d.). Retrieved February 21, 2021, from https://www.health.act.gov.au/services/community-care-program

Federal Register of Legislation—Australian Government. (n.d.). Retrieved February 21, 2021, from https://www.legislation.gov.au/Series/C2004A05206

Grant, T. R. (n.d.). Guides: Legal Research: Finding the purpose, scope and intention of specific legislation. Retrieved February 21, 2021, from https://uow.libguides.com/law/find-purpose-scope-intention-legislation

Hack, J., Buecking, B., Lopez, C., Ruchholtz, S., & Kühne, C. (2017). [Advance directives in clinical practice: Living will, healthcare power of attorney and care directive]. Zeitschrift Fur Rheumatologie, 76(5), 425—433. https://doi.org/10.1007/s00393-017-0318-0

Health, A. G. D. of. (2019, December 12). The Aged Care Funding Instrument (ACFI) [Text]. Australian Government Department of Health; Australian Government Department of Health. https://www.health.gov.au/initiatives-and-programs/residential-aged-care/funding-for-residential-aged-care/the-aged-care-funding-instrument-acfi

Heinrichs, B. (2019). Myth or Magic? Towards a Revised Theory of Informed Consent in Medical Research. The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine, 44(1), 33–49. https://doi.org/10.1093/jmp/jhy034

Medical Treatment Planning and Decisions Act 2016—Health.vic. (2021). Retrieved February 21, 2021, from https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-care/advance-care-planning/medical-treatment-planning-and-decisions-act

Palliative Care and End-of-Life Care—Health System. (n.d.). Australian Indigenous HealthInfoNet. Retrieved February 21, 2021, from https://healthinfonet.ecu.edu.au/learn/health-system/palliative-care/

Strahl, B., Breda, A. D. P. van, Mann-Feder, V., & Schröer, W. (2021). A multinational comparison of care-leaving policy and legislation. Journal of International and Comparative Social Policy, 37(1), 34–49. https://doi.org/10.1017/ics.2020.26

Teven, C. M., Park, J. E., & Song, D. H. (2017). Social Media and Consent: Are Patients Adequately Informed? Plastic and Reconstructive Surgery, 140(5), 770e. https://doi.org/10.1097/PRS.0000000000003805

The NSQHS Standards | Australian Commission on Safety and Quality in Health Care. (n.d.). Retrieved February 21, 2021, from https://www.safetyandquality.gov.au/standards/nsqhs-standards

Zahle, J. (2017). Privacy, Informed Consent, and Participant Observation. Perspectives on Science, 25(4), 465–487. https://doi.org/10.1162/POSC_a_00250

Schizophrenia: An Overview

Schizophrenia is a severe and chronic mental health disorder affecting about 20 million people in the world (Schizophrenia, 2020). It is characterised by hallucinations and delusions. Hallucinations refer to experiences of hearing, seeing and smelling things that are not there (Barrell et al., 2018). Delusions, on the other hand, are sets of beliefs that are false and cannot be explained by either their cultural or religious background (Alzheimer’s and Hallucinations, Delusions, and Paranoia, 2020). Schizophrenia is a serious mental health issue that affects all aspects of an individual’s life including their emotional, social, financial, and physical wellbeing. Their connection with others is impacted through loss of touch with reality and consequently this causes significant distress for the patient and people close to them (Ganguly et al., 2018). The exact cause of schizophrenia is largely unknown, studies however have indicate that schizophrenia can develop as a result of interactions between genetic and environmental factors (Kaskie et al., 2017). This care plan aims to maximise independence and to improve the quality of life through symptoms management, stress reduction and managing the factors related to the needs of the patient. The care plan will be developed in collaboration with the family and will change based on the current needs of the patient (Etiology of Schizophrenia, 2016).  

Case study

The patient was a 21-year-old Caucasian male, single, and lived in shared housing with friends. The patient was referred to the psychiatrist by the primary physician due to auditory hallucinations and paranoia. During the assessment the psychiatrist found the patient to be having persecutory delusions, third-person auditory hallucinations, running commentary, thought insertion and somatic hallucinations. The patient was having a psychotic disorder and the most likely diagnosis is schizophrenia.

Care Needs

        The nursing care plan goals for schizophrenia involves; recognising schizophrenia, establishing trust and rapport, maximising the level of functioning, assessing positive and negative symptoms, assessing medical history and evaluating support structures (Ganguly et al., 2018). The chief aim with this patient presenting with hallucinations and persecutorial delusions is safety. It is important to establish the contents of the auditory hallucinations, in some schizophrenia presentations, voices tell patients to either harm themselves or others. 

Auditory hallucinations are one of the most common symptoms of schizophrenia, hearing voices is varied, it can involve hearing one voice to hearing multiple voices. Most common in schizophrenia patients is that they hear multiple voices that are male, abusive, and repetitive (Hugdahl & Sommer, 2018). In this case, the patient has verbalised wanting to commit suicide by using medication but does not have the means to. Pharmacotherapy and hospitalisation are therefore warranted and must be discussed with the family as to ensure medication compliance and safety of the patient. 

            Individuals with schizophrenia lead a generally poor quality of life, this is due to poor medical attention, homelessness, unemployment, financial constraints, lack of education and poor social structures (Michalska da Rocha et al., 2018). Patients having persecutorial delusions will either attack the people they are suspicious of, or they will isolate themselves as a defence mechanism (Freeman, 2016). In this case, the patient will only go out of the room if the housemates have gone out, and this has been going on for over two months, suggesting the patient may be experiencing loneliness and possibly poor dietary intake. Loneliness is a very common experience for people with schizophrenia, theoretical models in the general population propose that loneliness is identical to the feeling of being unsafe. Loneliness is accompanied by enhanced environmental threat perceptions and can lead to poor physical, emotional and cognitive function (Eglit et al., 2018). The patient has been brought to the appointment by his mother, suggesting there is an element of trust between the mother and the patient. It may be beneficial in this case to explore the possibilities of the parents being the primary carers upon discharge.

        Secondly, although medications play a very important role in the management of schizophrenia, addressing nonpharmacological interventions such as financial management, regular exercise, living arrangements and friendship dynamics are essential in providing holistic care. It is important in this case to assess the financial situation of the parents and how they would cope with being full-time carers once the patient has been discharged (Fekadu et al., 2019). The financial and emotional burden on families is massive because they experience and endure most of the negative effects of the illness (Lippi, 2016). Taking in to account the welfare and safety of the parents by providing the correct support and resources is paramount to the recovery process. A social worker is required to work with the family on the various programmes they would benefit from, upon discharge. Furthermore, a diagnosis of schizophrenia is considered a disability, the social worker should discuss with the family their eligibility to receive government payments (Services Australia, 2020). 

Assessment

Assessment criteria
History of Presenting complaintPresented to the clinic with persecutory delusions, third-person auditory hallucination, running commentary, thought insertion and somatic hallucination
Biological History  Patient appears clinically healthy.
Social History  Regularly smokes cannabis and occasionally uses methamphetamines. Lives in shared housing with friends.
Psychiatric History  No evidence given of previous psychiatric history other than the presenting issues listed above.  The symptoms have been going on for over two months.
Appearance and behaviour  Presented well, normal work of breathing, alert and conversant. Appropriately dressed.  The patient appears underweight and older than actual age, skin appears dry.  
Mood and Affect (note congruence)Presents with a flat affect. Unsettled and appears suspicious. Patients is also anxious and keeps on looking around the room.
Thought Process and Content  The patient has prosecutorial delusions, thinks the British secret service have implanted a device in his brain and they are controlling his thoughts.
Sensorium and Cognition   While it is easy to understand the speech, and the content, the patient is unaware the voices are only in his head.  Patient appears alert to place and time.
Insight and Judgement  Patient is alert to place and time; patient is however suicidal and suspicious. Patients also appears to be having somatic hallucinations.
Self-concept and Self-care considerationsWould benefit from having an exercise regime to manage stress and outer act the effect of medication.  
Cultural considerations  N/A
Risk assessment  Has knife and is suspicious of his house mates. Stays in room and come out when his leave the house. Possible risk of self-harm or his house mates. Verbalised wanting to end his life, preferred choice is medications. The patient however does not have the means to.
MMSE score (if indicated)  NA
Clinical Formulation  Auditory hallucination, with no organic cause plus persecutorial delusions, running commentary with low affect. The patient also thought insertion and somatic hallucination. The patient’s is at risk of self-harm, has a knife and a baseball bat.  The symptoms are consistent with schizophrenia and warrants a review by the psychiatrist for pharmacotherapy and possible hospitalisation.  

Trauma and Psychosis

         The neural diathesis-stress model could explain the development of psychosis, the diathesis-stress model, posits that the development of mental health issues can be a mixture of environmental and genetic factors (Pruessner et al., 2017). Studies show that there is a link between trauma and development of psychosis (Popovic et al., 2019). This is not the case with this patient, there is no evidence of stress or past trauma, however the patient verbalised to being a heavy user of cannabis and methamphetamine. Important during the assessment process is to determine the reasons for use of illicit drugs. Some common reasons for the use of drugs include; stress, pain, abuse, and depression. This is essential for ongoing symptoms management, prevention of relapse, and eventual hospitalisation (National Institute on Drug and Abuse, 2020). For example, (Patel et al., 2020), found that individuals who are exposed or use cannabis are at increased risk of developing schizophrenia.  Evident by the fact that there is a high frequency of psychotic disorders with cannabis users. Cannabis-induced psychosis forms part of the schizophrenia spectrum that eventually convert to schizophrenia. People with the disorder have a higher tendency to use cannabis (Cuesta et al., 2017). Cannabis and schizophrenia have a close relationship primarily through the action of the Tetrahydro cannabinoid (THC) on the cannabinoid molecular system. This is especially in genetically predisposed individuals. THC also makes the psychosis worse and causes more relapses and hospitalisation (Zou & Kumar, 2018).

Care Plan

ProblemGoalPlanReview and Evaluation
Risk of self-harm related to the auditory hallucination, patient hearing voicesThe patient to stay safe and not act on the voices The patient will identify at least two stressful events that trigger hallucination.The patient will learn ways to refrain from responding to voicesExplore how the hallucinations are being experienced by the patient Consider environmental precautions. Find out if the patient has the means to self-harm. Evaluate the need for medication Evaluate the need for hospitalisation Help the client identify the times that the hallucinations are most prevalent     The patient will verbalise that they have not experienced any hallucinations.Will have no attempt at self-harm. Patient will socialise with friends.
Flat affectTo improve mood   For the patient to display appropriate emotions.   For patient to maintain social relationships  Cognitive behavioural therapy with the psychologist.   Needs medication to manage the mood.    The patient is displaying some level of satisfaction in daily tasks. The patient continues to attend cognitive behavioural therapy and complies with the medication regime. The patient will continue to perform physical activity.
Altered perception related to alteration in the brain chemistry. Either due to cannabis or methamphetamine use.The patient will express reality-based thoughts.   To take medication as prescribed   The patient to stop using cannabis.For Family to help the patient with medication compliance. Together with the family develop a plan to manage and minimise hallucinations through stress reduction Enrol in an addiction program Teach the family the positive and negative symptoms of schizophrenia and signs that the patient has stopped taking their medication. Clinical staff to assess if medication have reached therapeutic levels.Family will verbalise understanding of the positive and negative symptoms of schizophrenia. The patient will stop using illicit drugs.
Defensive coping related to paranoid and persecutorial delusionsPatient will state that they feel safe and in control with interactions with the environment, family, study and work.    Help the patient find ways to manage the anxiety and stress caused by the paranoia. Enrol patient in an addiction program to help manage drug dependence.The patient can interact with family and friends appropriately.The patient can apply various stress and anxiety reducing techniques. The patient will identify stress triggers to avoid further psychosisThe patients will demonstrate decreased suspicious behaviours with their interactions with others
Family role shift.The family will have access to support groups post discharge. The family will be helped financially  Teach the family and the client the warning signs of a relapse. Referral to the social worker.The patient and the family will understand a and verbalise the signs of relapse and when to seek help The family will verbalise the importance of taking medication. The family will have access to various government funded program for mental health. The family will have access to the financial help from the government

Collaborative Care

          Collaborative care planning values and prioritises the preferences of the person with lived experiences, there carers, families and kinship groups. Involvement of carers, families and kinship groups in the development, application and review of the care plan will often provide valuable nonclinical information to help personalise care which leads to improved outcomes (Morley & Cashell, 2017). Collaborative care is based on the current and perceived needs of the patient and must to be reviewed and amended whenever there is a change in the patient’s condition. Cost-effective studies also show that collaborative care practices lead to decreased cost to the health care system and improved overall quality of life. And while the overall cost of regular outpatient may be expensive, studies show that the cost of inpatient treatment was reduced (Camacho et al., 2016). CCP is a multidisciplinary approach to mental health and in this model of care patients have access to a psychologist, social workers and psychiatrist to help the patient manage the mental health. The goal may include, increasing exercise, finding a job, learning to manage stress and helping the patient manage substance abuse. The care plan review will be done every four to six weeks upon discharge, and whenever there is a change in the patient’s condition.  A successful care plan, in this case will be judged on how well the patient has integrated into the community.

         The framework used for this care plan is the Recovery-Oriented Practise framework. (Coffey et al., 2019) found that when recovery-focused care planning was high, the quality of care was also rated high among patients and families.  The recovery-oriented practise framework is a holistic and personalised plan that focuses on promoting the autonomy of the patient (Victoria State Government, 2020).  The main priorities of this care plan are safety, positive and negative symptom management and helping the client, together with the family, come up with strategies to manage the illness in the community. The management strategies are a mixture of pharmacological and non-pharmacological interventions. Non-pharmacological interventions proposed include stress reduction and cognitive behavioural therapies as studies show that stress hormones such as cortisol are elevated in most psychotic disorders .  Signs of high cortisol levels are; weight gain, irritability, anxiety, low libido, erectile dysfunction and headaches.  Other studies show that patient with acute schizophrenia had been exposed to stressful events in the preceding 3 months prior to the onset of symptoms (Karanikas & Garyfallos, 2015).

           Secondly, in dealing with the hallucinations, for safety reasons, it is essential to determine the content of the hallucination. The first-line treatment in the management of positive symptoms is medication; most positive symptoms can be managed with antipsychotics (Huhn et al., 2019). It is important to discuss with the family the possibility of having the patient hospitalised to make sure that the medication reaches therapeutic levels (Kaskie et al., 2017).  It is vital in this case to deal with the paranoia and hallucination for the non-pharmacological interventions to be effective. Antipsychotics are generally prescribed to manage and treat positive symptoms and not the root cause of schizophrenia. Most medications to manage schizophrenia deal with the hallucination and delusion, they work by reducing the positive symptoms by blocking dopamine receptors (Haddad & Correll, 2018).

            Finally, cognitive behavioural therapy (CBT) is a therapy technique that helps modify the undesirable mode of thinking, behaviours, and feelings.  CBT involves practical self-help strategies to reduce the positive symptoms of schizophrenia, it combines cognitive and behavioural techniques and the combination of these helps the patients gain healthy thoughts and behaviours (Carpenter et al., 2018). CBT involves establishing a collaborative relationship and developing a shared understanding of the problems. In this case, it is about helping the patient and the family come up with strategies to reduce and manage the symptoms of the illness at home non pharmacologically (Health Quality Ontario, 2018). The nurse needs to help the client come up with strategies for stress reduction themselves and some of the triggers of psychosis (Morley & Cashell, 2017).  This helps the client have some levels of control over their lives and in the long run, will promote independence.

References

https://nurseslabs.com/schizophrenia-nursing-care-plans/

Kaskie, R. E., Graziano, B., & Ferrarelli, F. (2017). Schizophrenia and sleep disorders: Links, risks, and management challenges. Nature and Science of Sleep, 9, 227–239. https://doi.org/10.2147/NSS.S121076

Abuse, N. I. on D. (2020, May 26). The Science of Drug Use: Discussion Points. National Institute on    Drug Abuse. https://www.drugabuse.gov/drug-topics/criminal-justice/science-drug-use-discussion-points

Alzheimer’s and Hallucinations, Delusions, and Paranoia. (n.d.). National Institute on Aging. Retrieved November 19, 2020, from http://www.nia.nih.gov/health/alzheimers-and-hallucinations-delusions-and-paranoia

Barrell, K., Bureau, B., Turcano, P., Phillips, G. D., Anderson, J. S., Malik, A., Shprecher, D., Zorn, M., Zamrini, E., & Savica, R. (2018). High-Order Visual Processing, Visual Symptoms, and Visual Hallucinations: A Possible Symptomatic Progression of Parkinson’s Disease. Frontiers in Neurology, 9. https://doi.org/10.3389/fneur.2018.00999

Camacho, E. M., Ntais, D., Coventry, P., Bower, P., Lovell, K., Chew-Graham, C., Baguley, C., Gask, L., Dickens, C., & Davies, L. M. (2016). Long-term cost-effectiveness of collaborative care (vs usual care) for people with depression and comorbid diabetes or cardiovascular disease: A Markov model informed by the COINCIDE randomised controlled trial. BMJ Open, 6(10), e012514. https://doi.org/10.1136/bmjopen-2016-012514

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A. J., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35(6), 502–514. https://doi.org/10.1002/da.22728

Coffey, M., Hannigan, B., Barlow, S., Cartwright, M., Cohen, R., Faulkner, A., Jones, A., & Simpson, A. (2019). Recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings: A cross national comparative mixed methods study. BMC Psychiatry, 19(1), 115. https://doi.org/10.1186/s12888-019-2094-7

Cuesta, M. J., Sánchez-Torres, A. M., Lorente-Omeñaca, R., & Moreno-Izco, L. (2017). Chapter 5—Lifetime Cannabis Use and Cognition in Psychosis Spectrum Disorders. In V. R. Preedy (Ed.), Handbook of Cannabis and Related Pathologies (pp. 44–52). Academic Press. https://doi.org/10.1016/B978-0-12-800756-3.00006-5

Eglit, G. M. L., Palmer, B. W., Martin, A. S., Tu, X., & Jeste, D. V. (2018). Loneliness in schizophrenia: Construct clarification, measurement, and clinical relevance. PLoS ONE, 13(3). https://doi.org/10.1371/journal.pone.0194021

Etiology of Schizophrenia—An overview | ScienceDirect Topics. (n.d.). Retrieved November 19, 2020, from https://www.sciencedirect.com/topics/medicine-and-dentistry/etiology-of-schizophrenia

Fekadu, W., Mihiretu, A., Craig, T. K. J., & Fekadu, A. (2019). Multidimensional impact of severe mental illness on family members: Systematic review. BMJ Open, 9(12), e032391. https://doi.org/10.1136/bmjopen-2019-032391

Freeman, D. (2016). Persecutory delusions: A cognitive perspective on understanding and treatment. The Lancet Psychiatry, 3(7), 685–692. https://doi.org/10.1016/S2215-0366(16)00066-3

Ganguly, P., Soliman, A., & Moustafa, A. A. (2018). Holistic Management of Schizophrenia Symptoms Using Pharmacological and Non-pharmacological Treatment. Frontiers in Public Health, 6. https://doi.org/10.3389/fpubh.2018.00166

Haddad, P. M., & Correll, C. U. (2018). The acute efficacy of antipsychotics in schizophrenia: A review of recent meta-analyses. Therapeutic Advances in Psychopharmacology, 8(11), 303–318. https://doi.org/10.1177/2045125318781475

Health Quality Ontario. (2018). Cognitive Behavioural Therapy for Psychosis: A Health Technology Assessment. Ontario Health Technology Assessment Series, 18(5), 1–141.

Hugdahl, K., & Sommer, I. E. (2018). Auditory Verbal Hallucinations in Schizophrenia From a Levels of Explanation Perspective. Schizophrenia Bulletin, 44(2), 234–241. https://doi.org/10.1093/schbul/sbx142

Huhn, M., Nikolakopoulou, A., Schneider-Thoma, J., Krause, M., Samara, M., Peter, N., Arndt, T., Bäckers, L., Rothe, P., Cipriani, A., Davis, J., Salanti, G., & Leucht, S. (2019). Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: A systematic review and network meta-analysis. The Lancet, 394(10202), 939–951. https://doi.org/10.1016/S0140-6736(19)31135-3

Karanikas, E., & Garyfallos, G. (2015). Role of cortisol in patients at risk for psychosis mental state and psychopathological correlates: A systematic review. Psychiatry and Clinical Neurosciences, 69(5), 268–282. https://doi.org/10.1111/pcn.12259

Kaskie, R. E., Graziano, B., & Ferrarelli, F. (2017). Schizophrenia and sleep disorders: Links, risks, and management challenges. Nature and Science of Sleep, 9, 227–239. https://doi.org/10.2147/NSS.S121076

Lippi, G. (2016). Schizophrenia in a member of the family: Burden, expressed emotion and addressing the needs of the whole family. The South African Journal of Psychiatry : SAJP : The Journal of the Society of Psychiatrists of South Africa, 22(1). https://doi.org/10.4102/sajpsychiatry.v22i1.922

Michalska da Rocha, B., Rhodes, S., Vasilopoulou, E., & Hutton, P. (2018). Loneliness in Psychosis: A Meta-analytical Review. Schizophrenia Bulletin, 44(1), 114–125. https://doi.org/10.1093/schbul/sbx036

Morley, L., & Cashell, A. (2017). Collaboration in Health Care. Journal of Medical Imaging and Radiation Sciences, 48(2), 207–216. https://doi.org/10.1016/j.jmir.2017.02.071

Patel, S., Khan, S., M, S., & Hamid, P. (n.d.). The Association Between Cannabis Use and Schizophrenia: Causative or Curative? A Systematic Review. Cureus, 12(7). https://doi.org/10.7759/cureus.9309

Payments for people living with an illness, injury or disability—Services Australia. (n.d.). Retrieved November 21, 2020, from https://www.servicesaustralia.gov.au/individuals/subjects/payments-people-living-illness-injury-or-disability

Popovic, D., Schmitt, A., Kaurani, L., Senner, F., Papiol, S., Malchow, B., Fischer, A., Schulze, T. G., Koutsouleris, N., & Falkai, P. (2019). Childhood Trauma in Schizophrenia: Current Findings and Research Perspectives. Frontiers in Neuroscience, 13. https://doi.org/10.3389/fnins.2019.00274

Pruessner, M., Cullen, A. E., Aas, M., & Walker, E. F. (2017). The neural diathesis-stress model of schizophrenia revisited: An update on recent findings considering illness stage and neurobiological and methodological complexities. Neuroscience & Biobehavioral Reviews, 73, 191–218. https://doi.org/10.1016/j.neubiorev.2016.12.013

Schizophrenia. (n.d.). Retrieved November 19, 2020, from https://www.who.int/news-room/fact-sheets/detail/schizophrenia

Services, D. of H. & H. (n.d.). Recovery-oriented practice in mental health. Department of Health & Human Services. Retrieved November 21, 2020, from https://www2.health.vic.gov.au:443/mental-health/practice-and-service-quality/service-quality/recovery-oriented-practice-in-mental-health

Zou, S., & Kumar, U. (2018). Cannabinoid Receptors and the Endocannabinoid System: Signalling and Function in the Central Nervous System. International Journal of Molecular Sciences, 19(3). https://doi.org/10.3390/ijms19030833

Writing needs to be taught and practised. Australian schools are dropping the focus too early

Claire Wyatt-Smith, Australian Catholic University and Christine Jennifer Jackson, Australian Catholic University

The recently released report of the NAPLAN review — commissioned by the New South Wales, Queensland, Victorian and Australian Capital Territory education ministers — found many young people are reaching Year 9 without being able to write properly.

The number of students below the national minimum standard is higher in regional and remote areas. The difference in performance between males and females is significant and has been evident each year since 2008.

The review says the NAPLAN data indicate writing has not improved since 2011.

When we talk about writing, we are not talking about the fine motor skills associated with forming letters or handwriting, gripping a pencil or typing. We are talking about writing to communicate meaning and the role of writing in how young people learn in the curriculum.

Being able to write is important for future success. In 2019, the United Nations Educational, Scientific and Cultural Organisation (UNESCO) characterised writing as a:

… foundational skill required for communication, future learning and full participation in economic, political and social life as well as in many aspects of daily life.

But while education systems have prioritised teaching reading, far less attention and expertise has been directed to teaching writing, beyond perhaps spelling.

We surveyed more than 4,000 primary and secondary school teachers in NSW to find out how often they explicitly teach writing, and what strategies they use.

Our data show there is an emphasis on basic writing skills in primary school. But once students enter secondary school, it appears teaching subject knowledge competes with a focus on teaching basic writing skills.


Read more: NAPLAN results show Year 3 students perform better than Year 9 in writing, and it’s a worrying trend


The dangerous assumption, it seems, is that students have developed these skills in earlier years. For many students this is simply not the case.

How often do teachers teach writing?

Our survey was commissioned by the NSW Education Standards Authority. It was completed by 4,306 NSW teachers, across all sectors, stages of schooling and curriculum areas.

We asked the teachers how much time they spent on teaching writing in the past fortnight, and how often they used specific strategies. Some of these included:

  • asking students to set goals for their writing
  • analysing good models of writing with students
  • modelling good writing
  • composing text together with students in their chosen genre
  • allocating time for students to practise specific writing strategies
  • explicitly teaching students how to plan, draft, revise and edit their work.

Results show teachers in Years K-2 emphasise explicitly teaching writing. This peaks in Years 3-6, and dips significantly in Years 7-10. Following this decline, there is a noted increase in focus on explicitly teaching writing in Years 11-12.

This could reflect the emphasis on writing in most subjects as teachers prepare students for the NSW Higher School Certificate.

For instance, 58.5% of teachers in Years 3-6 spent between one to five hours in the preceding fortnight teaching writing. But this fell to 48.3% in Year 7-10, and it went up again to 56.5% in Years 11-12.

In Years 3-6 nearly 25% of teachers taught writing for five to ten hours in the preceding fortnight, compared to only 6% of teachers in Years 7-10, and 7% in Years 11-12.

What about the way they taught writing

Our survey showed Years 7-10 teachers were less likely (never, or rarely) to use interactive, instructional practices compared to teachers in other year levels. These include asking students to set goals, and helping them analyse a model of good writing to identify what works and what may not.

In K-Year 2, nearly 50% of teachers said they spent most lessons modelling writing to children. This dropped to 25% in Years 3-6, 12% in Years 7-10 and 16% in Years 11-12.

Around 70% of teachers in K to Year 6 allocated time regularly or in most classes for students to practise writing strategies independently. But this fell to 38% in Years 7-10.


Read more: Too many adjectives, not enough ideas: how NAPLAN forces us to teach bad writing


Allocating time for students to practise writing strategies with the support of the teacher, and then independently, is critical for student success.

Like other complex skills, if you don’t practise, how can you improve?

Research also suggests explicitly teaching writing strategies such as planning, drafting and revising is a particularly effective method for improving writing skills of all students.

But while more than 50% of teachers in K to Year 6 explicitly taught students to do this regularly or in most classes, only 35% of teachers did so in Years 7-10. Exactly 50% of teachers did this in Years 11-12 regularly or in most classes.

Explicitly teaching these skills connects thinking and writing and makes such connections visible and meaningful for students.

We also found far less focus on sentence construction in secondary school.

While most K-2 and Years 3-6 teachers indicated they regularly or during most lessons engaged in teaching “sentence structure”, the focus dips in Years 7-10. Only 44% of teachers regularly engaged in the practice.


Read more: ‘I’m in another world’: writing without rules lets kids find their voice, just like professional authors


Secondary teachers need a greater focus on teaching how to structure sentences and paragraphs as part of explicit regular teaching practice.

Writing must be practised, continuously

Teaching writing skills needs to be a baseline requirement for all students. The explicit teaching of these skills must be continuously revisited, building on student knowledge throughout their years of school.

Writing is a difficult skill to master and a difficult skill to teach. At the very least, secondary schools need to allocate more time to teaching this skill and for students to practise writing.

Claire Wyatt-Smith, Professor of Educational Assessment and Literacy and Institute Director of the Learning Sciences Institute Australia, Australian Catholic University and Christine Jennifer Jackson, Senior Research Officer, Assessment, Writing and Reporting, Australian Catholic University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Burnout in Nursing

      This paper is about a nurse who was sexually and physically assaulted while in charge of a dementia-specific ward. The Nurse was assaulted by a patient who was in his early 60s, with early-onset dementia, schizophrenia and used to be a boxer.  Dementia is the loss of cognitive, remembering and behavioural function. Behavioural issues include physical/verbal aggression, anxiety, and irritability (Gale et al., 2018). For families and health care professionals, dementia care can lead to higher levels of anxiety, depression, use of psychotropics, and chronic fatigue (Narme,2018). All of which can be symptoms of burnout. A meta-analytic estimation of burnout done on mental health nurses found that they had higher levels of emotional exhaustion and are more likely to exhibit depersonalisation behaviours (López-López et al., 2019). The study also found that variables such as workload, work-related stress and aggressions tend to contribute to the burnout.

          Burnout is described as a syndrome that results from workplace stress that has not been managed. Burnout can manifest in three ways, these are; energy depletion, increased mental distance and reduced professional efficacy. Burnout can affect professional and personal life (Information et al., 2020). Especially in cases where nurses who care for dementia residents, will also care for loved ones with dementia at home. Professionals that are burnt out are very negative, cannot concentrate properly, and lack creativity (Rudman et al., 2020). Studies show that there is a link between burnout and increased likelihood of infections among patients. Other studies show that burnout was a significant predictor for type two diabetes, coronary heart disease, hospitalisation and other cardiovascular disorders among nurses (Garcia et al., 2019).

          Health care professionals deal with death, the dying process and people with complex health conditions. They not only have to care for the individual with the illness, but also provide emotional support to the family of the patient. It is very easy in these circumstances to depersonalise from work and life as a coping mechanism. Burnt-out nurses are very aggressive, unempathetic and generally impatient. At an organisational level, nurses who are burnt out tend to be physically and emotionally exhausted and frequently miss work. This can contribute to high staff turnover, which inevitably affects patient care (Garcia et al., 2019).

           The diathesis model of psychology is a framework for understanding the development of psychological disorders. According to the general model, everyone possesses some degree of inherent vulnerability for a given disorder, all the person needs is a trigger. This is usually a combination of environmental and genetic factors (Broerman, 2017). Stress is part of nursing, and there is no way of avoiding it, some areas of nursing are more stressful than others. The question then is not why some nurses suffer psychological issues due to stress. But rather what prevents 100% of the nurses working in the same field from suffering psychological issues.  The interaction between stress and diathesis could explain why some individuals develop psychological issues while others do not (Broerman, 2017). 

         The self-care model appropriate to this nurse is the ‘ART’ model.  The ‘ART model’ involves acknowledging a feeling or wound that needs healing, recognise choices and act or turn outwards towards self and others. The ART model posits that how one feels cannot be removed from the workplace, and the individual and collective feelings count in the efforts to provide care (Enhancing Professional Quality of Life, 2019). The misconception in professional life of not showing emotions in a tragedy is not only damaging to the professional’s mental health, but it also makes the nursing profession mechanical and ungenuine. This is because pain and anguish are part of life and are impossible to avoid; suppressed emotions will always manifest themselves in other ways. Either through anger or other high-risk behaviours like drugs and alcohol. Acknowledging how one feels and realising there is a problem is the first step in finding better protective strategies.  

References

Broerman, R. (2017). Diathesis-Stress Model. In V. Zeigler-Hill & T. K. Shackelford (Eds.), Encyclopedia of Personality and Individual Differences (pp. 1–3). Springer International Publishing. https://doi.org/10.1007/978-3-319-28099-8_891-1

FT, V. T.-F., PhD, RN. (2019). Compassion Fatigue and Burnout in Nursing, Second Edition: Enhancing Professional Quality of Life. Springer Publishing Company.

Gale, S. A., Acar, D., & Daffner, K. R. (2018). Dementia. The American Journal of Medicine, 131(10), 1161–1169. https://doi.org/10.1016/j.amjmed.2018.01.022

Garcia, C. de L., de Abreu, L. C., Ramos, J. L. S., de Castro, C. F. D., Smiderle, F. R. N., dos Santos, J. A., & Bezerra, I. M. P. (2019). Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina, 55(9). https://doi.org/10.3390/medicina55090553

Information, N. C. for B., Pike, U. S. N. L. of M. 8600 R., MD, B., & Usa, 20894. (2020). Depression: What is burnout? In InformedHealth.org [Internet]. Institute for Quality and Efficiency in Health Care (IQWiG). https://www.ncbi.nlm.nih.gov/books/NBK279286/

Narme, P. (2018). Burnout in nursing staff caring for patients with dementia: Role of empathy and impact of empathy-based training program. Geriatrie Et Psychologie Neuropsychiatrie Du Vieillissement, 16(2), 215–222. https://doi.org/10.1684/pnv.2018.0735

Rudman, A., Arborelius, L., Dahlgren, A., Finnes, A., & Gustavsson, P. (2020). Consequences of early career nurse burnout: A prospective long-term follow-up on cognitive functions, depressive symptoms, and insomnia. EClinicalMedicine, 27. https://doi.org/10.1016/j.eclinm.2020.100565

Dementia and Falls Prevention

      Figures from 2013, show that the average cost for hospitalisation of a dementia resident is higher than the general public (Dementia Care in Hospitals, 2013). Aged care usually has high staff turnover, meaning nursing homes are constantly faced with the choice of either relying on agency nurses or employing and training new staff. This takes time, money and resources, and even after they have been trained, there is no guarantee that they will stay on as nurses for longer than three months. Reasons for this turnover are many, they range from injuries, low pay, work stress and lack of challenging or engaging work (Parliament of Australia, 2020). But while staff turnover is dependent on the industry, a high turnover in most cases suggests a problem with the way the industry is run. Engaged employees are generally happier, perform better and stay in the industry longer. Studies show that a high turnover of staff in nursing home inevitably affects the continuity of care and the general operation of the facility (Emmanuel et al., 2020). Having a robust framework that accounts for this high staff turnover and ensures there are no gaps in the way falls are managed. Will In the short term save time and resources and long term it will improve the general quality of life for residents and allow them to be in an environment they are familiar with. 

     At the patient level, studies show that hospitalisation among the elderly comes with a lot of risks (Husaini et al., 2015). There are three main reasons why people with dementia are at higher risk of readmission. Firstly, people with dementia have difficulty following directions, taking medication and performing activities of daily living like toileting (Tible et al., 2017). This inevitably leads to poor health and increases the risk of falls. Secondly, people with dementia find it hard to express their symptoms, especially the ones that cannot communicate (Gale et al., 2018). It then becomes hard to work out if the resident is deteriorating, especially when there are no regular staff to provide the continuity of care. For example, after a fall, minus vomiting and increased drowsiness, all other symptoms associated with concussions can be attributed to behavioural and psychological issues of dementia (CDC Injury Center, 2019). Knowing if a dementia resident is deteriorating, in this case, relies on staff knowing what behaviours are normal for resident and the behaviours that need urgent attention. Studies show that the risk of readmission is dependent on the stage of dementia. Acute readmission is more common in advanced stages of dementia (Pickens et al., 2017). Often when people with dementia are admitted to the hospital, they are more confused, unsettled and are at higher risk of falls. Because the hospital is not an ideal place to manage behavioural issues, dementia patients are often medicated for their safety and the safety of other patients (Nakanishi et al., 2018). Also, people with dementia usually need a rigid routine of sleep to work time, this is essential when managing challenging behaviours which they cannot have at the hospital (Cipriani et al., 2015).  

Between 2016-2017, there were 1.6 million emergency department visits among people over the age of 65. The three most common presentations where chest pain, and musculoskeletal issues related to falls (Falls Resulting in Patient Harm in Hospitals, 2018). Dementia people living in residential aged care facilities are vulnerable, frail and often have many comorbidities that put them at risk of falls (Fernando, Fraser, Hendriksen, kim &Hunter, 2017) For many of these resident’s hospitalisation, carries it with it a lot of risks. (Bail et al., 2015) Found that urinary tract infections, pressure areas, pneumonia and delirium are preventable hospital-acquired complications that place a heavy financial burden on the health care system. Studies show that while people with dementia are at higher risk of hospital readmission, many of these hospitalisations are preventable (Ma et al., 2019). Using the change model- Plan- Do-Study- Act (PDSA), this learning plan will explore some of the way’s hospital transfers can be reduced in people with dementia through various falls prevention and management strategies. The PDSA model is a four-step interactive model for improving a process. The first step is the development of a plan in which the desired outcomes are clearly outlined (Christoff, 2018). The training program is suited for graduate nurses, new staff and assistant nurses. 

Policy Issues

     Currently, no laws are regulating the way nursing homes are staffed per shift. Some nursing homes are not required to have a registered nurse on-site and are run by enrolled nurses or care workers (Parliament House, 2019). There are a few reasons why more and more nursing homes are understaffed. One reason could be the labour cost, the labour cost for a nursing home is higher compared to other health care sectors. This is largely due to the decline in the functional status, meaning most the residents need help with all aspects of their ADLs. Staffing in nursing homes is dependent on the acuity of the resident and not the number of residents in the facility (Health, 2019). Funding from the government is also dependant on how much care is needed for one resident and not the facility. It is not unusual to find one Registered Nurse overseeing 70 residents (Parliament House, 2019). Moreover, funding from the government does not automatically mean that the facility will employ more staff. In the end, what ends up happening is that the nursing home will stretch the staff they already have. 

      Without enough nurses and nursing assistants, nursing homes will be unable to provide a level of care that is personalised to each resident. It also means that subtle changes to the residents’ conditions are missed, which can lead to care becoming reactionary. Understaffed nurses do not have the time and resources to pay attention to the conditions of the patient so when there is a big change in the resident’s functional status they are often sent to hospital (Kiekkas et al., 2019). In this case, the dementia residents that lack the ability to communicate are at higher risk of neglect. Moreover, nursing homes lack the hierarchy of competency and a framework of escalation of critical events. In hospitals, there is a clear framework for the escalation of a deteriorating patient. Nurses know, who is responsible for referrals and advanced care directives are clearly stated and handed over. One way to limit unnecessary hospital transfers is to have clinical nurse managers and registered nurses always respond to emergencies in the wards they are responsible for. Reason being most clinical nurses are in the same ward all the time, they know more about the resident’s condition and are the ones responsible for family conferences and initiating the palliative care pathway.

     Secondly, there are no clear guidelines from the government on the use of psychotropics in dementia. Recent changes to the safety and quality standards demanding that nurses only use psychotropics as last resort make care even more complicated considering how understaffed nursing homes are (Janus et al., 2017). Studies show that the use of these medications which have been known to increase the likelihood of falls are normally a case of striking a balance between other resident safety, their own safety, and the safety of the staff (Harrison et al., 2020). Overuse of psychotropics is considered as chemical restraint, moreover, evidence shows that their effectiveness in managing behavioural issues in dementia to be substandard (Spek et al., 2018). In short, aged care has too many competing interests. There is a high unrealistic expectation from the families, regulatory agencies wanting a certain level of care to warrantee funding, the government wanting to cut cost and nurses trying to advocate for the patient’s rights. All this without the funding and proper staffing levels to meet these requirements. 

Support Structures 

      For this project to be successful, it needs support from facility managers, clinical nurses and the families. As the population ages so will the number of falls increase in the future. The government, in this case, should consider investing in ways nursing homes can reduce hospitalisations related to falls. This, in the long run, will save time, money and resources, resources that can better be spent elsewhere. The tools required are an overhead projector, a meeting room, handouts on falls management, fall preventions and behavioural management. The training session will be in form of case studies and discussions. Discussions are ideal in this case as they promote team collaboration and allows for nurses to learn from each other. 

Tools and Resources

    The sessions will begin with the simple PowerPoint presentation on falls and the impact they have on the health care system and the role nurses have in preventing falls. The whole group will discuss the case study on the PowerPoint initially. This is a way of working out the levels of knowledge within the group. After the presentation which will take about 10- 15 minutes, the group will be split into two, each with a different case study to discuss. The use of case studies is ideal in that they help learners read between the lines and develop critical thinking skills. The nurses will be expected to point out the issues within the case study and the potential issues, and the best way to manage the patient to optimise the quality of life. The nurses will also learn the assessment required post-fall, symptoms of concussions and the importance of full neurological observations, especially in the first 73 hours after a fall. A quiz will be given at the end of the session of which answers can be discussed. 

Potential Outcomes 

The first potential outcome of this project is a reduction in the number of hospitalisations due to falls. Ott, 2018, found that education on falls and the risk factors that contribute to falls within the elderly population reduced the number of falls. Other studies show that most falls are not only predictable but also avertable (Ayton et al., 2017). Reduction of falls needing hospitalisation will mean residents stay in the environment they are familiar with, reduce the chances of recurrent falls, save resources and maintain or improve the quality of life. That is why educating residents and nursing staff on some of the fall’s reduction strategies is the first step in reducing the number of falls among the elderly. Recent studies demonstrate that most patients are unprepared to manage their physical limitation after discharge from the hospital. This, in turn, contributes to the labour cost experienced post-hospital discharge (Naseri et al., 2018). 

    The final potential outcome of this project is that nurses and direct care workers will know the current best practice guidelines for managing falls once they have happened. Also, the nurses will learn what to look for when a resident is deteriorating gradually and the referrals appropriate. The aim here is to manage the symptoms as much as possible at the facility and only send to the hospital if the quality of life is affected and the facility do not have resources and experience to manage the patient. The nurses will learn the symptoms of concussion and hip fractures. The nurses here will also have learnt all the assessment required after a fall has happened. By the end of the session, they will have learnt how to fill in a FRAT, frequency of neurological observation and instances it is appropriate to send the resident to the hospital. If successful, the yearly education can be done over the internet, this is specifically suited for the more experienced nurses. To mitigate the confusion and gaps in information, a flow chart for escalation and management of falls will be placed in every nurse’s station. 

References

Australia’s health 2018, Falls resulting in patient harm in hospitals. (2018). Australian Institute of Health and Welfare. Retrieved September 26, 2020, from https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/indicators-of-australias-health/falls-resulting-in-patient-harm-in-hospitals

Ayton, D. R., Barker, A. L., Morello, R. T., Brand, C. A., Talevski, J., Landgren, F. S., Melhem, M. M., Bian, E., Brauer, S. G., Hill, K. D., Livingston, P. M., & Botti, M. (2017). Barriers and enablers to the implementation of the 6-PACK falls prevention program: A pre-implementation study in hospitals participating in a cluster randomised controlled trial. PLoS ONE, 12(2). https://doi.org/10.1371/journal.pone.0171932

Bail, K., Goss, J., Draper, B., Berry, H., Karmel, R., & Gibson, D. (2015). The cost of hospital-acquired complications for older people with and without dementia; a retrospective cohort study. BMC Health Services Research, 15. https://doi.org/10.1186/s12913-015-0743-1

Christoff, P. (2018). Running PDSA cycles. Current Problems in Pediatric and Adolescent Health Care, 48(8), 198–201. https://doi.org/10.1016/j.cppeds.2018.08.006

Cipriani, G., Lucetti, C., Carlesi, C., Danti, S., & Nuti, A. (2015). Sundown syndrome and dementia. European Geriatric Medicine, 6(4), 375–380. https://doi.org/10.1016/j.eurger.2015.03.006

corporateName=Commonwealth Parliament; address=Parliament House, C. (n.d.-a). 3. Mandating Minimum Staffing Levels (Australia) [Text]. Retrieved October 10, 2020, from https://www.aph.gov.au/Parliamentary_Business/Committees/House/Health_Aged_Care_and_Sport/StaffingRatioBill/Report/section?id=committees%2Freportrep%2F024218%2F26821

corporateName=Commonwealth Parliament; address=Parliament House, C. (n.d.-b). The crisis in the caring workforce (Australia) [Text]. Retrieved October 10, 2020, from https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook44p/CaringWorkforce

Dementia care in hospitals: Costs and strategies, Summary. (n.d.). Australian Institute of Health and Welfare. Retrieved September 27, 2020, from https://www.aihw.gov.au/reports/aged-care/dementia-care-in-hospitals-costs-and-strategies/contents/summary

Emmanuel, T., Dall’Ora, C., Ewings, S., & Griffiths, P. (2020). Are long shifts, overtime and staffing levels associated with nurses’ opportunity for educational activities, communication and continuity of care assignments? A cross-sectional study. International Journal of Nursing Studies Advances, 2, 100002. https://doi.org/10.1016/j.ijnsa.2020.100002

Fernando, E., Fraser, M., Hendriksen, J., Kim, C. H., & Muir-Hunter, S. W. (2017). Risk Factors Associated with Falls in Older Adults with Dementia: A Systematic Review. Physiotherapy Canada, 69(2), 161–170. https://doi.org/10.3138/ptc.2016-14

Gale, S. A., Acar, D., & Daffner, K. R. (2018). Dementia. The American Journal of Medicine, 131(10), 1161–1169. https://doi.org/10.1016/j.amjmed.2018.01.022

Harrison, F., Cations, M., Jessop, T., Aerts, L., Chenoweth, L., Shell, A., Sachdev, P., Hilmer, S., Draper, B., & Brodaty, H. (2020). Prolonged use of antipsychotic medications in long-term aged care in Australia: A snapshot from the HALT project. International Psychogeriatrics, 32(3), 335–345. https://doi.org/10.1017/S1041610219002011

Health, A. G. D. of. (2019, December 12). The Aged Care Funding Instrument (ACFI) [Text]. Australian Government Department of Health; Australian Government Department of Health. https://www.health.gov.au/initiatives-and-programs/residential-aged-care/funding-for-residential-aged-care/the-aged-care-funding-instrument-acfi

Husaini, B., Gudlavalleti, A. SV., Cain, V., Levine, R., & Moonis, M. (2015). Risk Factors and Hospitalization Costs of Dementia Patients: Examining Race and Gender Variations. Indian Journal of Community Medicine : Official Publication of Indian Association of Preventive & Social Medicine, 40(4), 258–263. https://doi.org/10.4103/0970-0218.164396

Janus, S. I. M., Reinders, G. H., van Manen, J. G., Zuidema, S. U., & IJzerman, M. J. (2017). Psychotropic Drug-Related Fall Incidents in Nursing Home Residents Living in the Eastern Part of The Netherlands. Drugs in R&D, 17(2), 321–328. https://doi.org/10.1007/s40268-017-0181-0

Kiekkas, P., Tsekoura, V., Aretha, D., Samios, A., Konstantinou, E., Igoumenidis, M., Stefanopoulos, N., & Fligou, F. (2019). Nurse understaffing is associated with adverse events in postanaesthesia care unit patients. Journal of Clinical Nursing, 28(11–12), 2245–2252. https://doi.org/10.1111/jocn.14819

Ma, C., Bao, S., Dull, P., Wu, B., & Yu, F. (2019). Hospital readmission in persons with dementia: A systematic review. International Journal of Geriatric Psychiatry, 34(8), 1170–1184. https://doi.org/10.1002/gps.5140

Nakanishi, M., Okumura, Y., & Ogawa, A. (2018). Physical restraint to patients with dementia in acute physical care settings: Effect of the financial incentive to acute care hospitals. International Psychogeriatrics, 30(7), 991–1000. https://doi.org/10.1017/S104161021700240X

Naseri, C., McPhail, S. M., Netto, J., Haines, T. P., Morris, M. E., Etherton-Beer, C., Flicker, L., Lee, D.-C. A., Francis-Coad, J., & Hill, A.-M. (2018). Impact of tailored falls prevention education for older adults at hospital discharge on engagement in falls prevention strategies postdischarge: Protocol for a process evaluation. BMJ Open, 8(4), e020726. https://doi.org/10.1136/bmjopen-2017-020726

Ott, L. D. (2018). The impact of implementing a fall prevention educational session for community‐dwelling physical therapy patients. Nursing Open, 5(4), 567–574. https://doi.org/10.1002/nop2.165

Pickens, S., Naik, A. D., Catic, A., & Kunik, M. E. (2017). Dementia and Hospital Readmission Rates: A Systematic Review. Dementia and Geriatric Cognitive Disorders EXTRA, 7(3), 346–353. https://doi.org/10.1159/000481502

Spek, K. van der, Koopmans, R. T., Smalbrugge, M., Nelissen-Vrancken, M. H., Wetzels, R. B., Smeets, C. H., Teerenstra, S., Zuidema, S. U., & Gerritsen, D. L. (2018). Factors associated with appropriate psychotropic drug prescription in nursing home patients with severe dementia. International Psychogeriatrics, 30(4), 547–556. https://doi.org/10.1017/S1041610217001958

Symptoms of Traumatic Brain Injury (TBI) | Concussion | Traumatic Brain Injury | CDC Injury Center. (2019, March 11). https://www.cdc.gov/traumaticbraininjury/symptoms.html

Tible, O. P., Riese, F., Savaskan, E., & von Gunten, A. (2017). Best practice in the management of behavioural and psychological symptoms of dementia. Therapeutic Advances in Neurological Disorders, 10(8), 297–309. https://doi.org/10.1177/1756285617712979

Vegetarian and vegan diet: five things for over-65s to consider when switching to a plant-based diet

Taibat Ibitoye, University of Reading

Plant-based diets continue to grow in popularity, worldwide. There are plenty of reasons people switch to a plant-based diet, including ethical and environmental reasons. However, a growing number of people are shunning meat for health reasons. Evidence shows that plant-based diets may help support the immune system, lower the risk of heart disease and stroke, and may be good for overall health.

While a well-planned plant-based diet can support healthy living in people of all ages, our nutritional needs change with different life stages, so people over the age of 65 may need to take more care when opting for a plant-based diet. They may have specific nutritional needs and may need certain nutrients, vitamins and minerals to stay healthy.

Here are some things over-65s may want to consider when switching to a plant-based diet:

1. Eat enough protein

Older adults need more protein compared to the general adult population in order to preserve lean body mass, body function and good health. While most adults only need around 0.75g of protein per kilogram of body weight a day, it’s recommended that healthy older adults should increase their daily protein intake to 1.0-1.2g per kilogram of body weight. This is even higher for older adults who are malnourished or have a severe illness, as these conditions trigger a hypermetabolic state, where the body needs more energy and protein to function.

To ensure adequate protein intake, make sure meals and snacks contain plant-based proteins, such as chickpeas, tofu, black-eyed beans, kidney beans, lentils, quinoa, wild rice, nuts and seeds, nut butters and soya alternatives to milk and yoghurt. Eggs and dairy products are also good protein sources if you’re including these in your diet.

2. Include calcium and vitamin D

Calcium and vitamin D both play an important role in maintaining good bone health, which is extremely important in older age as osteoporosis and associated fractures are a major cause of bone-related diseases and mortality in older adults.

Most adults need 700mg of calcium per day. However, women past the menopause and men over 55 should have 1200mg of calcium per day. There’s a wide range of non-dairy food products that contain calcium for those who are plant-based, including calcium fortified soya milk and almond milk, calcium fortified cereals, pitta bread, chapatti and white bread.

For those who include fish in their diet, fish such as whitebait, and sardines and pilchards (with bones) contain good amounts of calcium per serving.

Older adults are also recommended to get 10 micrograms (mcg) of vitamin D daily. Not only is vitamin D important for bone health, it’s also one of the nutrients involved in supporting the immune system and helping it to function properly. Older adults are more vulnerable to deficiency as they may have less sunlight exposure, and their skin is less able to synthesise vitamin D.

Mushrooms grown in sunlight, fortified spreads, breakfast cereals, and dairy alternatives are all good sources of vitamin D.

Having said this, it’s hard to get vitamin D from diet alone, so a supplement of 10mcg a day (especially in the winter for those who may not get outside often), is recommended. It’s worth noting that some vitamin D supplements aren’t suitable for vegans, as they may be derived from an animal source, so vitamin D2 and lichen-derived vitamin D3 may be used instead.

3. Get your vitamin B12

Vitamin B12 is essential for making red blood cells, keeping the nervous system healthy, and providing energy. Older adults need 1.5 micrograms of vitamin B12 per day, similar to younger adults. But many older people may be at risk of vitamin B12 deficiency, affecting an estimated one in twenty people aged 65 to 74 and one in ten people over 75.

Those who don’t eat meat, fish or eggs may not be getting enough vitamin B12, as it’s found abundantly in animal-based food sources. Some plant-based sources of vitamin B12 include fortified breakfast cereals, yeast extracts (like Marmite), soya yoghurts, and non-dairy milks. People may consider taking a Vitamin B12 supplement. Taking 2mg or less a day of vitamin B12 in supplements is unlikely to cause any harm. However, they should consult their doctor or registered dietitian first.

4. Eat iron-rich foods

Low iron intake can be an issue for those who don’t have a varied diet, especially for men aged 65 and over living in residential care homes and women over 85.

Iron is essential for making red blood cells, which carry oxygen around the body. It’s also essential for physical performance, wound healing, supporting the immune system, cognitive development and function and thyroid metabolism. Older adults need 8.7mg of iron a day.

Plant sources include wholegrains, green leafy vegetables like spinach, seeds, pulses and dried fruits. Since iron in plant foods is absorbed less efficiently compared to iron in animal proteins, having vitamin C-rich foods like citrus fruits, green pepper and broccoli can help iron be better absorbed.

5. Make every bite count

Some people find their appetite decreases as they get older. This can be caused by difficulties with chewing and swallowing, constipation, acute illness, impaired taste, vision and smell. But reduced appetite can contribute to unintentional weight loss and nutritional deficiencies. It’s therefore important to find ways to get adequate nutrition in every meal, especially when plant-based, such as:

  • Including protein in each meal.
  • Eat small meals and snacks in between throughout the day.
  • Include plant-based milks (such as soya, almond, or coconut milk) in your tea, coffee or smoothie.
  • Add olive, vegetable or sunflower oil to your favourite meals.
  • Mix plant creams or vegan cheese in mashed potatoes, soups and stews.
  • Add nut butters to bread, dairy-free yoghurt and smoothies.

No matter your age, switching to a plant-based diet may have many health benefits if planned properly. Consulting with a registered dietitian before making the switch may help you develop the best plant-based diet tailored to your specific needs.

Taibat Ibitoye, Registered Dietitian and Doctoral Researcher, University of Reading

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Reducing Hospital Transfers through Falls Prevention

        Between 2016-2017, there were 1.6 million emergency department visits among people over the age of 65. The three most common presentations where chest pain, and musculoskeletal issues related to falls ( Falls Resulting in Patient Harm in Hospitals, 2018). Dementia people living in residential aged care facilities are vulnerable, frail and often have many comorbidities that put them at risk of falls (Fernando et al., 2017). For many of these resident’s hospitalisation, carries it with it a lot of risks. (Bail et al., 2015)  Found that urinary tract infections, pressure areas, pneumonia and delirium are preventable hospital acquired complications that place a heavy financial burden on the health care system. Studies show that while people with dementia are at higher risk of hospital readmission, many of these hospitalisations are preventable (Ma et al., 2019).   Using the change model- Plan- Do-Study- Act (PDSA), this paper will explore some of the way’s hospital transfers can be reduced in people with dementia through various falls prevention and management strategies. The PDSA model is a four-step interactive model for improving a process. The first step is the development of a plan in which the desired outcomes are clearly outlined (Christoff, 2018). The first part of the paper is the suggested framework for hospital admission reduction. This is in the form of a concept map. The paper also has a learning program for falls prevention and management that is suited for new nurses and new employees. The aim is to have no gaps in nursing practice, regardless of the years of experience and how long the nurses have been employed.  Secondly, it will explore some of the underlying reasons why so many elderly people are sent to the hospital, despite all the falls preventions strategies that are in place.  

Learning Principles

      The first learning principle that will be utilised for this training program will be, relevance. For nurses and adults in general, learning should be a problem-centred approach rather than content-based (Yang & Yang, 2013). Studies show that people are motivated to learn when the material they are learning has immediate and long-term implications. Hospital transfers and return from hospital care are usually very time consuming and labour intensive (Albrecht & Karabenick, 2018). For example, minor fractures can cause significant functional decline, pain and distress. Sometimes even minor falls can cause fear of falling in older people, this causes them to reduce their activity and this is when there slowly lose their independence.

     Secondly, transference, this principle deals with how the material learnt can be transferred to the specific facility and residents. Transfer of training can happen when the trainees can incorporate into their practice the knowledge and the skill that they have learnt. Transference, in this case, is most likely to happen when nurses and direct care workers can associate the new information with what they already know and are practicing. Another way is if the new information learnt is similar to the material they already know, and all the educator is doing is building slightly on the existing schema. For example, during the learning process ,Vygotsky believed that there is a zone between what the learner can do without help and those they can achieve with guidance ( ScienceDirect Topics, 2010).  In other ways, if the information is too complicated people tend to not want to learn and if it is too easy, they become bored. The aim of transference, in this case, is to build on the existing policies and procedures and find ways the facility can manage time and resources efficiently (Jackson et al., 2019).

      Thirdly, retention, for nurses to benefit from the learning experience, it is important for them to retain the new knowledge and for them to use the information in their daily practice. People generally retain information when they perceive the information as meaningful.  The amount of retention is related to the degree of original learning. Other studies show that retention of information is affected by the amount and the degree of practice among adults. It is then important that when this information is transferred, the more senior and experienced staff should oversee and help the new nurses and care workers on the policies around falls management and prevention. Another way to help the nurses retain the information is through skills test and refresher courses  (Frank & Kluge, 2019).  

    Finally, reinforcement, reinforcement is about helping the nurses and direct care workers retain and apply the knowledge and the skills they have learnt. In this case, it involves actively encouraging the nurses to use the skills in there day to day practice. Positive reinforcement is about offering the nurses incentives that reward good behaviours and promote good practice (Mayer et al., 2020). For example, efficient use of resources would mean more money can be freed to hire more staff. Negative reinforcement is about taking steps to limit poor practice. For example, harm caused by bad practice and negligence can lead to lawsuits and loss of income.

Learning Objectives

         At the end of this learning program, nurses will have gained knowledge on the factors that contribute to falls.  The training sessions will cover the role UTI and psychotropics have in incidents of falls among dementia residents.  Due to the decline in physical fitness, many adults become less and less active as they get older. Studies show that the risk of major falls related to injuries, such as hip fractures and mortality is higher among people with dementia (Fernando et al., 2017). Several reasons could account for this. People with dementia are more likely to have problems with their mobility, balance and muscle weakness, can have issues with their memory and finding a way around (Wheatley et al., 2019). This often contributes to behavioural issues which in turn places the resident at a higher risk of falls and hospital readmission.

     Secondly, at the end of the training session, the nurses and direct care workers will have learnt on the best practice guidelines of post-fall management and ongoing care.  Under this objective, nurses will learn the importance of neurological observation, the frequency and the duration. Nurses will also have learnt the principles of head and hip injury management and instances when it is appropriate to escalate for a hospital transfer (Fall Response, 2020).

       Thirdly, at the end of the training session, the nurses will have demonstrated that they know how to fill the falls risk assessment tool (FRAT) post every fall. The FRAT score is a 4 item falls risk screening tool for sub-acute and residential care. It has three parts, the first part is the risk status, part two has the risk factor checklist and part three is the action plan.  The strongest predictors of falls are usually a history of falls, this is because an individual’s reason for falling the first time is likely to happen again. Filling this form accurately helps the facility have a good picture of the reasons for the falls, this, in turn, helps the facility explore strategies to minimise falls (Cattelani et al., 2015). 

       At the end of this training session the nurses will have also learnt some of the falls preventions strategies that are specifically used in dementia residents. Nurses here will learn the importance of simple tasks like having a toileting schedule for dementia residents and the effect it has on behavioural management (Meyer et al., 2019). This is especially important for residents that cannot communicate. The staff will learn the importance of good behavioural management strategies in the reduction of falls. Other strategies that can be explored include; the use of hip protectors for residents that are at higher risk of falls and the use of alarm mats or censor beams when residents go to sleep. Nurses will also learn the importance of monthly review of pain and behaviours and the regular review of the effectiveness of medications such as psychotropics (Janus et al., 2017).

         Finally, nurses will learn the ongoing management of the patient’s post-fall, especially in the first three days. Important to learn, in this case, are the symptoms of concussion and hip injuries. Suspected concussion and hip injuries should always be sent to the hospital. For example, increased confusion, headaches, increased drowsiness, repeated vomiting, excruciating pain and limb shortening can all be reasons for sending the patient to the hospital for further investigation (Peters & Gardner, 2018). These symptoms are not always apparent every time after a fall, hence the three days full neurological observation. And if the resident does not have these symptoms, education will also explore what other professionals the resident would benefit from seeing. For example, a review from the physiotherapist is always warranted to work out if the resident needs a mobility aid or having the existing aid adjusted. Other aspects to consider post falls is a medication review by the doctor. 

     These learning objectives will be achieved through feedback from nurses and families. Nurses will also be assessed by using simple quizzes on falls and falls prevention. Another way to work out if the training has been successful and the nurses are incorporating the information into their practice is through monthly review of all falls in the facility. Success will not solely be based on the reduction of falls in the facility, but also, of the falls that happened in a month, how many needed to be hospitalised.

        The education session will be presented in form of case studies and group discussions. Case studies and group discussions are ideal because they promote team collaboration and enhance group participation (Heale & Twycross, 2018). Discussions and use of case studies also helps the presenter know the levels of knowledge within the group. The nurses will be given a case study and then in small groups to discuss the different patients in the case studies. And then after 10-15 minutes, the group will then discuss the patient and the strategies for prevention and post fall management. This allows the nurses to learn from each other, and for new nurses to learn from the older nurses (Florence, 2020).  

Needs Analysis

        A training needs analysis identifies gaps within the knowledge, skills and attituded that people in the organisation have (Holloway et al., 2018). Aged care homes usually have a high turnover of staff, this means that aged care homes tend to spend more time and money educating new staff on their policies and procedures (Roche et al., 2015). The training program is suited for newly graduated nurses and newly employed staff.  Regular staff usually know the resident, they know the ones that are high falls risk and those on medication that can cause bleeding.  The key achievement upon completion of this training program is to have uniformity in practice among staff regardless of their levels of competency and how long they have been at the facility. The second achievement of the paper is to hopefully reduce hospital transfers and the functional decline that often happens post return from hospital. The training package will be given to every newly employed nurse as part of the orientation training package and a flow chart will be put in the orientation pack of agency nurses. For experienced nurses, to promote retention, the training package will form part of the yearly mandatory education competency refresher courses.

Training Tools

           The training tools required for this learning program is a meeting room, educational hand outs and overhead projector which will be supplied by the facility. The handouts will be on, falls prevention and post-fall management. All these educational handouts can be downloaded from PubMed or NCBI for free. The only cost here is for paper and ink. Most facilities have meeting room fitted with projectors; the job of the presenter then is to have a PowerPoint with visual representations. During the teaching process, the aim is to teach new information to the new staff and for old more experienced nurses the aim is to consolidate the existing knowledge so that there is uniformity in the practice. The training sessions will last for an hour and can be done at the end of the shift. For experienced nurses, the incentive for attending the education session is that this can be used as part of the hours for continuous improvement needed by nurses for registration. For new nurses this training will be mandatory upon employment. Post fall management procedure flow chart will be put in every nursing station for everyone to read.

Evaluation of Training

       Evaluation of the effectiveness of training will be done monthly by reviewing the facilities falls register and hospital transfers. Success, in this case, will be based on the reduction in the number of falls over the month and the number of falls needing hospital admissions. The aim is to have an 80% reduction in hospital admission within six months of implementation. The training program will form part of the yearly educational competency for all nurses in the facility or whenever there is a sudden increase in the critical incidents in the facility. If successful, subsequent training does not have to be face to face, a yearly refresher on falls prevention can be over the internet. A training app most facilities use is Bridge. A training program can be done on Bridge together with a quiz. Upon completion, the participants will have to get a certificate to hand in into management.

      The effects of falls on dementia patients are massive, the general assumption among families is that a hospital is always a safe place for the resident. But too often when dementia patients are sent to the hospital, they tend to be more confused upon readmission to the care home (Tible et al., 2017). This is because dementia patients usually need a rigid routine of sleep to work time and when to have meals, which is important when managing challenging behaviours (Cipriani et al., 2015). Depending on the nature of the injury, it also means that more resources are allocated to one patient for rehabilitation. Studies show that hospitalisation is often harmful to people with dementia and results in higher costs to the health care system. Figures from 2013 estimates that the average cost for hospitalising a dementia patient was higher than the general public (Dementia Care in Hospitals, 2013). That is why a comprehensive dementia care program may reduce the number of admissions to the hospital and the wider implementations of falls management strategies would allow for the resident to stay in the facilities in the environment they are familiar with.

       In addition, making sure that there are no gaps in practice among nurses regardless of how long they have been in the facility is also important during the accreditation process. To continue to receive subsidies from the government, Australian nursing homes are required to be accredited (Aged Care Quality and Safety Commission, 2020).  Accreditation involves the periodic full audit of the facility to assess compliance with the quality standards. The commission monitors the quality of care and services within the facility and they also manage noncompliance in aged care standards ( Aged Care Quality and Safety Commission, 2020). The accreditation process judges the care home based on the eight safety and quality standards, and this report is then released online. Sub-optimal care or non-compliance would mean loss of funding from the government and an eventual loss of business as more and more people opt not use the nursing home.  

      In conclusion, this paper has explored some of the reasons for the high rates in hospitalisation in dementia patients living in nursing homes. A PDSA model was used to come up with a possible framework for reducing unnecessary hospitalisation of residents from aged care homes. Thirdly, the paper looked at how this can be achieved through a training session. The training is suited for newly graduated nurses and new staff. The framework for reduction aims to account for the high turnover of staff in aged care, the aim is to have no gaps among nurses in falls prevention and management.

References

About accreditation | Aged Care Quality and Safety Commission. (2020). Retrieved September 27, 2020, from https://www.agedcarequality.gov.au/consumers/about-accreditation

Albrecht, J. R., & Karabenick, S. A. (2018). Relevance for Learning and Motivation in Education. The Journal of Experimental Education, 86(1), 1–10. https://doi.org/10.1080/00220973.2017.1380593

Australia’s health 2018, Falls resulting in patient harm in hospitals. (2018). Australian Institute of Health and Welfare. Retrieved September 26, 2020, from https://www.aihw.gov.au/reports/australias-health/australias-health-2018/contents/indicators-of-australias-health/falls-resulting-in-patient-harm-in-hospitals

Bail, K., Goss, J., Draper, B., Berry, H., Karmel, R., & Gibson, D. (2015). The cost of hospital-acquired complications for older people with and without dementia; a retrospective cohort study. BMC Health Services Research, 15. https://doi.org/10.1186/s12913-015-0743-1

Cattelani, L., Palumbo, P., Palmerini, L., Bandinelli, S., Becker, C., Chesani, F., & Chiari, L. (2015). FRAT-up, a Web-based Fall-Risk Assessment Tool for Elderly People Living in the Community. Journal of Medical Internet Research, 17(2). https://doi.org/10.2196/jmir.4064

Chapter 2. Fall Response. (n.d.). Retrieved September 26, 2020, from http://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man2.html

Christoff, P. (2018). Running PDSA cycles. Current Problems in Pediatric and Adolescent Health Care, 48(8), 198–201. https://doi.org/10.1016/j.cppeds.2018.08.006

Cipriani, G., Lucetti, C., Carlesi, C., Danti, S., & Nuti, A. (2015). Sundown syndrome and dementia. European Geriatric Medicine, 6(4), 375–380. https://doi.org/10.1016/j.eurger.2015.03.006

Dementia care in hospitals: Costs and strategies, Summary. (2013). Australian Institute of Health and Welfare. Retrieved September 27, 2020, from https://www.aihw.gov.au/reports/aged-care/dementia-care-in-hospitals-costs-and-strategies/contents/summary

Fernando, E., Fraser, M., Hendriksen, J., Kim, C. H., & Muir-Hunter, S. W. (2017). Risk Factors Associated with Falls in Older Adults with Dementia: A Systematic Review. Physiotherapy Canada, 69(2), 161–170. https://doi.org/10.3138/ptc.2016-14

Florence, W. M. (2020). A cross-sectional study: Collaborative learning approach enhances learning attitudes of undergraduate nursing students. GSTF Journal of Nursing and Health Care (JNHC), 5(1), Article 1. http://dl6.globalstf.org/index.php/jnhc/article/view/2008

Frank, B., & Kluge, A. (2019). Is there one best way to support skill retention? Putting practice, testing and symbolic rehearsal to the test. Zeitschrift Für Arbeitswissenschaft, 73(2), 214–228. https://doi.org/10.1007/s41449-018-00136-9

Heale, R., & Twycross, A. (2018). What is a case study? Evidence-Based Nursing, 21(1), 7–8. https://doi.org/10.1136/eb-2017-102845

Holloway, K., Arcus, K., & Orsborn, G. (2018). Training needs analysis – The essential first step for continuing professional development design. Nurse Education in Practice, 28, 7–12. https://doi.org/10.1016/j.nepr.2017.09.001

Jackson, D., Fleming, J., & Rowe, A. (2019). Enabling the Transfer of Skills and Knowledge across Classroom and Work Contexts. Vocations and Learning, 12(3), 459–478. https://doi.org/10.1007/s12186-019-09224-1

Janus, S. I. M., Reinders, G. H., van Manen, J. G., Zuidema, S. U., & IJzerman, M. J. (2017). Psychotropic Drug-Related Fall Incidents in Nursing Home Residents Living in the Eastern Part of The Netherlands. Drugs in R&D, 17(2), 321–328. https://doi.org/10.1007/s40268-017-0181-0

Ma, C., Bao, S., Dull, P., Wu, B., & Yu, F. (2019). Hospital readmission in persons with dementia: A systematic review. International Journal of Geriatric Psychiatry, 34(8), 1170–1184. https://doi.org/10.1002/gps.5140

Mayer, J., Stone, N. D., Leecaster, M., Hu, N., Pettey, W., Samore, M., Pacheco, S. M., Sambol, S., Donskey, C., Jencson, A., Gupta, K., Strymish, J., Johnson, D., Woods, C., Young, E., McDonald, L. C., & Gerding, D. (2020). Reinforcement of an infection control bundle targeting prevention practices for Clostridioides difficile in Veterans Health Administration nursing homes. American Journal of Infection Control, 48(6), 626–632. https://doi.org/10.1016/j.ajic.2019.09.019

Meyer, C., Hill, K. D., Hill, S., & Dow, B. (2019). Falls prevention for people with dementia: A knowledge translation intervention. Dementia, 1471301218819651. https://doi.org/10.1177/1471301218819651

Peters, M. E., & Gardner, R. C. (2018). Traumatic brain injury in older adults: Do we need a different approach? Concussion, 3(3). https://doi.org/10.2217/cnc-2018-0001

Quality Standards consumer resources | Aged Care Quality and Safety Commission. (n.d.). Retrieved September 27, 2020, from https://www.agedcarequality.gov.au/consumers/standards/resources

Roche, M. A., Duffield, C. M., Homer, C., Buchan, J., & Dimitrelis, S. (2015). The rate and cost of nurse turnover in Australia. Collegian, 22(4), 353–358. https://doi.org/10.1016/j.colegn.2014.05.002

Tible, O. P., Riese, F., Savaskan, E., & von Gunten, A. (2017). Best practice in the management of behavioural and psychological symptoms of dementia. Therapeutic Advances in Neurological Disorders, 10(8), 297–309. https://doi.org/10.1177/1756285617712979

Wheatley, A., Bamford, C., Shaw, C., Flynn, E., Smith, A., Beyer, F., Fox, C., Barber, R., Parry, S. W., Howel, D., Homer, T., Robinson, L., & Allan, L. M. (2019). Developing an Intervention for Fall-Related Injuries in Dementia (DIFRID): An integrated, mixed-methods approach. BMC Geriatrics, 19(1), 57. https://doi.org/10.1186/s12877-019-1066-6

Yang, J. H., & Yang, B. (2013). Nursing Students’ Experiences with Facilitator in Problem-Based Learning Class. Asian Nursing Research, 7(4), 198–204. https://doi.org/10.1016/j.anr.2013.10.002

Zone of Proximal Development—An overview | ScienceDirect Topics. (n.d.). Retrieved September 27, 2020, from https://www.sciencedirect.com/topics/psychology/zone-of-proximal-development

What are ‘fasting’ diets and do they help you lose weight?

Clare Collins, University of Newcastle

Trying to lose weight is hard work. You need to plan meals and snacks, and make a big effort to avoid situations that trigger more eating and drinking than you’d planned. Dieting can also be very antisocial. But what if you could speed up weight loss, spend less time “dieting”, with the “promise” of better results? This is where “fasting” diets come in.

What is a ‘fasting’ diet?

Intermittent fasting is the broad name for diets when you fast to some degree on some, but not all, days of the week; you eat normally on the other days.

On “fast” days, the kilojoule (energy) restriction is severe, at about 25% of what you would normally eat. This is only 2,000 to 3,000 kilojoules a day. An average person needs around 8,700 kilojoules a day (depending on body size and activity level) to maintain their current body weight.

To lose between one quarter and half a kilogram a week you would need to reduce your energy intake by 2,000 kilojoules a day. Over a whole week, this is equivalent to cutting back total energy intake by 14,000 kilojoules. Fasting diets compress this 14,000 kilojoule reduction into fewer days of dieting. In practical terms, this means that you reduce your intake by so much on a couple of days, you do not to be so strict on the other days.

Depending on the type of “fasting” diet, you focus all your weight loss efforts into sticking to the severe restriction for either two days a week (as in the 5:2 diet) or every second day (for three to four days days a week), as in alternate-day fasting. Another variation is the 16-hour overnight fast where eating is restricted every day to an eight-hour window, such as 11am to 7pm. Across all types of intermittent energy restrictions diets, we don’t know the longer-term benefits or harms.

Any intermittent fasting approach will work if you can tolerate the hunger pains and stick to it. Sounds easy, but it is a very hard thing to do and for many it is not realistic. When you are fasting, your body thinks there is a famine and will try to get you to eat. The idea is that by including non-fasting periods, when you eat what you want, you may feel less like you are on a “diet”, and that makes it easier to stick to.

Even though “fasting” dieters are told to eat what they feel like on non-fast days, most do not get a compensatory increase in appetite. In other words, they do not over-eat, but just eat normally on non-fast days. So they reduce their total kilojoule intake over the whole week.

How about very low energy diets?

A specific type of continuous (every day) fasting diet is called a protein sparing modified fast or a very low energy diet. These limit you to 1,800 to 2,500 kilojoules a day, every day. They use products called formulated meal replacements, in the form of milkshakes or snack bars to replace most meals and snacks. These are supplemented with vitamins and minerals to meet the body’s nutrient needs.

Such very low energy programs usually include one small meal that contains a couple of cups of vegetables (to boost fibre and nutrient intakes), a small amount of oil (to keep the gall bladder working) and sometimes a fibre supplement (to manage constipation). These are reserved for when you need to lose weight urgently for health reasons or ahead of surgery.

Continuous fasting using these very low energy diets is associated with a reduction in hunger. This is thought to be due to the production of molecules called ketones that cross the blood-brain barrier (from the brain’s bloodstream into its tissues) and reduce appetite.

Do ‘fasting’ diets work?

Intermittent fasting diets that last for at least six months help people lose weight. However, they are no more effective than other dietary approaches that restrict your kilojoule intake every day, but not so severely as a “fast”.

Consistent with this result, a study published last week randomised 100 adults to either alternate-day fasting, a continuous energy restriction diet, or to no intervention, for six months. They were followed for another six months after that. There was no difference in weight loss between the diet groups after a year.

And a review that compared behavioural interventions for weight management to those that also included very low energy diets found very low energy approaches achieved slightly greater weight loss for up to two years.

Who should not try a fasting diet?

Fasting diets are not for everyone. People with major medical problems, or taking a range of medications including insulin, should not go on them, unless under medical supervision; they are not suitable for children, in pregnancy or for people with eating disorders; and they may exacerbate some mental health conditions.

Fasting diets can also have side-effects. The more days you spend “fasting”, the more likely you are to have them. Side-effects can include constipation, headaches, bad breath, gall bladder disease, gout and liver inflammation.

So, before starting a weight loss diet, see your doctor for a check-up. When you need more support to improve your eating habits, or the diet you were following stops working, you need to try another approach. That is a good time to also get advice from an Accredited Practising Dietitian.

What is the best diet for weight loss?

The best diet to help you achieve a healthy weight is one you can stick with. It should also help you feel better and be healthier.

By making improvements to your usual eating habits, that you can live with permanently, you will drop some weight. It might not be your dream weight, but it is likely to be realistic. It might not sound sexy, but it’s true.

Clare Collins, Professor in Nutrition and Dietetics, University of Newcastle

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Ways Hospitlisation can be reduced Among the Elderly

Safety and Quality Issues in Aged care

      The top five areas to explore for safety care investigation are; restraint use, information sharing systems, behavioural management, staffing issues and reducing unnecessary hospital transfers in aged care.  The topic chosen to explore for safety and quality improvement is, finding ways in which hospitalisation among the elderly people living in the community or the nursing home can be reduced.

      Between 2016-2017, there was 1.6 million emergency department presentation among people over the age of 65 (Older Australia at a Glance, 2018). The three most common presentation to the emergency department was dependant on the age group. Pain in the throat or chest was the most common presentation, the other was related to musculoskeletal issues resulting from either a fall or general deterioration. Several reasons could account for this high rate in hospitalisation. For example, (Halter et al., 2017)  found that the high turnover of nurses in aged care affects the clinical leadership and the general clinical framework for managing chronic illnesses. (King et al., 2018) also found that a high number of transfers to the hospital where initiated by nurses, and in most of these cases clinical guidance from the doctor was sub-optimal. The present study also found that most of the end of life to hospital transfers could have been prevented if the facilities had a specialist doctor on-site or the GP seeing the resident before transfer (King et al., 2018).

          Reducing unnecessary hospitalisation among the elderly would be beneficial for both the resident and the health care system (Möllers et al., 2020). Hospital transfers from nursing homes are frequent, burdensome for resident and are often avoidable (Toh et al., 2017). Studies show that most resident if given a choice would rather remain in their home should their condition deteriorate (Health, 2019). Once they return to the care home, they are often more disoriented, agitated and confused, this is especially the case for people with dementia that need a proper routine to reduce challenging behaviours (Shenvi et al., 2020). Frequent hospitalisation and prolonged hospital stay, can lead to increased risk of falls, sleep deprivation and a higher risk of developing hospital acquired infections, like MRSA (Australian Commission on Safety and Quality in Health Care, 2020). 

At an institutional level, reducing the number of hospital admissions from aged care would reduce the physical and financial burden on the health care system (challenges of an Ageing Population, 2019).  For example, in the elderly, falls, are a major cause of functional decline, disability, increased lengthy hospitalisation and death (Florence et al., 2018). Studies show that exercise, particularly ones that target strength, gait and balance, reduce the risk of falls (Dellinger, 2017). Other studies show that withdraw of psychotropics or limiting the use of medication that cause dizziness, sedation, confusion and blurred vision also reduce the risk of falls (Johnell et al., 2017). A neck of femur fracture for example, would mean, extended rehabilitation, which often means more staff to cater for the needs of one patient.  In the absence of falls prevention programs, it is projected that the total cost of hospitalisation related falls will cost the Western Australian Government $174 million by 2021 (Consequences of Falls, 2020).

References

Consequences of falls. (2020). Retrieved September 5, 2020, from https://ww2.health.wa.gov.au/Articles/A_E/Consequences-of-falls

corporateName=Commonwealth Parliament; address=Parliament House, C. (n.d.). Challenges of an ageing population (Australia) [Text]. Retrieved September 5, 2020, from https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook43p/ageingpopulation

Dellinger, A. (2017). Older Adult Falls: Effective Approaches to Prevention. Current Trauma Reports, 3(2), 118–123. https://doi.org/10.1007/s40719-017-0087-x

Florence, C. S., Bergen, G., Atherly, A., Burns, E., Stevens, J., & Drake, C. (2018). Medical Costs of Fatal and Nonfatal Falls in Older Adults. Journal of the American Geriatrics Society, 66(4), 693–698. https://doi.org/10.1111/jgs.15304

Halter, M., Pelone, F., Boiko, O., Beighton, C., Harris, R., Gale, J., Gourlay, S., & Drennan, V. (2017). Interventions to Reduce Adult Nursing Turnover: A Systematic Review of Systematic Reviews. The Open Nursing Journal, 11, 108–123. https://doi.org/10.2174/1874434601711010108

Health, A. G. D. of. (2019, March 28). Advance care directive [Text]. Australian Government Department of Health; Australian Government Department of Health. https://www.health.gov.au/health-topics/palliative-care/planning-your-palliative-care/advance-care-directive

Hospital-acquired complications (HACs) | Australian Commission on Safety and Quality in Health Care. (n.d.). Retrieved September 5, 2020, from https://www.safetyandquality.gov.au/our-work/indicators/hospital-acquired-complications

Johnell, K., Jonasdottir Bergman, G., Fastbom, J., Danielsson, B., Borg, N., & Salmi, P. (2017). Psychotropic drugs and the risk of fall injuries, hospitalisations and mortality among older adults. International Journal of Geriatric Psychiatry, 32(4), 414–420. https://doi.org/10.1002/gps.4483

King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018). Impact of Fall Prevention on Nurses and Care of Fall Risk Patients. The Gerontologist, 58(2), 331–340. https://doi.org/10.1093/geront/gnw156

Möllers, T., Perna, L., Stocker, H., Ihle, P., Schubert, I., Schöttker, B., Frölich, L., Bauer, J., & Brenner, H. (2020). Alzheimer’s disease medication and outcomes of hospitalisation among patients with dementia. Epidemiology and Psychiatric Sciences, 29. https://doi.org/10.1017/S2045796019000702

Older Australia at a glance, Health care—Hospitals. (n.d.). Australian Institute of Health and Welfare. Retrieved September 4, 2020, from https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/service-use/health-care-hospitals

Shenvi, C., Kennedy, M., Austin, C. A., Wilson, M. P., Gerardi, M., & Schneider, S. (2020). Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Annals of Emergency Medicine, 75(2), 136–145. https://doi.org/10.1016/j.annemergmed.2019.07.023

Toh, H. J., Lim, Z. Y., Yap, P., & Tang, T. (2017). Factors associated with prolonged length of stay in older patients. Singapore Medical Journal, 58(3), 134–138. https://doi.org/10.11622/smedj.2016158

Dementia Care plan and Care Coordination

Introduction

       This study explores the short- and long-term care needs of a patient who was admitted to the hospital with pneumonia, worsening symptoms of dementia and has six other comorbidities. The short-term needs focus on how the hospital will manage the presenting condition and the comorbidities. The long-term goals deal with simple ways quality of life can be improved once discharged into a nursing home or community care services. The aim, in this case, is to formulate care plans, that are based on the current and perceived needs of the patient in relation to disease progression. This care plan will be done in collaboration with other health care professionals. It is also important that this care plan is not rigid and can change based on the clinical and functional status of the patient (Sørensen et al., 2020). The care plan aims to manage the patient’s condition holistically. Holistic care is care that considers the physical, emotional, social, economic and spiritual needs of the patient. (Ventegodt et al., 2016).  The paper also looks at the important role care coordinators have in ensuring that there are no gaps in access to care services while the patient is in hospital, home or nursing home. The role of the care coordinator, in this case, is to bring together professionals from other disciplines to work out a care plan that benefits the family and the patient (Wayne Zachary et al., 2016). Successful care coordination requires four main elements, these include; easy access to a range of health care services, effective care planning transitions and good communication. Also, a focus on the total health care needs of the patient and clear, simple information that the patient/carer can understand (Catalyst, 2018).

Care Needs

       The immediate care needs prior to the patient being discharged to either the care home or the community, is to develop a care plan for medication administration. The care plan should include some of the reasons for refusal of medication and the strategies for administration. It is common to hear from caregivers about the challenges they face when administering medication to people with worsening dementia symptoms. When confronted with refusal of care on any the challenging behaviours it is important to remember that these behaviours are sometimes their way of communicating. The first step to managing this process is to provide a calm environment.  Sometimes, people with dementia refuse medication in response to feeling rushed, afraid and often confused as to what they are supposed to do. In some cases, refusal of medication can be in response to the feeling of loss of control, which can in turn trigger anger and agitation (Backhouse et al., 2020). But often, refusal to take medication can be attributed to the pills being too big to swallow, or the medication leaves and unpleasant taste in the mouth. After performing a swallowing assessment, consultation with the physician and pharmacist will be needed to prescribe medications that are crushable (Curyto et al., 2017).

        Since the patient does not have the cognitive ability to advocate for themselves, the care plan will be done in partnership with the family. The care plan will aim to manage the patient’s comorbidities holistically. Behavioural and Psychological Symptoms of Dementia (BPSD) represent a diverse group of non-cognitive symptoms that happen in people with dementia. BPSD represent a major component of the dementia syndrome irrespective of the type. These symptoms include; agitation, anxiety, apathy, irritability, depression and disruption in sleep. The severity of these symptoms is dependent on the patient and stage of dementia (Wang et al., 2020). In this case the family have reported that, patient has become unpredictable and refusing care, suggesting that the patient is in moderate to severe stages of dementia. This indicates that the patient will need constant behavioural management. BPSD symptoms are as clinically important as cognitive symptoms as they strongly relate to the degree of functional decline (Janus et al., 2017). The assessment of these symptoms requires a thorough examination to collect specific and detailed information about the clinical history, the patient’s   experiences and objective behaviours (Wang et al., 2020).

       Although the patient may be impacted by dementia in their communication and social skills. It is important to have an individual assessment with the patient first and when possible, it is desirable that the patient is encouraged to speak their concerns in an open dialogue. In this case information from a family member or caregiver is essential in order to cluster these symptoms and then come up with both pharmacological and non-pharmacological interventions. Another issue that is known to contribute to behavioural issues is lack of sleep (Gibson & Gander, 2019) . Night-time sleep can be encouraged by increasing daytime activities and discouraging daytime napping. While in hospital it is important to document all interactions nurses and allied health care have with the patient. This helps with the behavioural management plan if discharged to either nursing home or into community care. Also, this can be used as part of the education package for the family (Shenker & Singh, 2017).

         Thirdly, elderly patients with congestive heart failure may have more atypical presentations, this is especially the case for the more frail or cognitive impaired patients. This may be due to cognitive deficits, sedentary lifestyle or exercise limitations and other comorbidities. These factors may contribute to the late onset of symptoms and complicate the presentation of fatigue, dyspnoea and lethargy (Sano & Majima, 2018). Infections like pneumonia, renal disease with fluid overload, anaemia and hypertension tend to make the symptoms worse. Studies indicate that elderly people with heart failure are more likely to present with symptoms of decreased cardiac output, such as fatigue, weakness, dizziness and a change in mental status (Liguori et al., 2018). Moreover, the development of peripheral oedema in patients with heart failure can be attributed to excessive fluids. Therefore, fluid regulation remains one of the most important ways of managing congestive heart failure. Regulating the fluid intake while the patient is in hospital is easy, the trouble is once they are discharged. If discharged to the care home, it is standard protocol for nursing homes to do monthly weights. In this case weekly weights and fluid restriction are indicated, to improve the overall breathing quality. If the patient is discharged home to the husband, education would need to be arranged on the importance of monitoring the patient’s fluid intake and have strategies in place for the patient to take the medication for fluid regulation (Miller, 2016).

Role of care Coordinator

      Based on the Maslow’s Hierarchy of Needs, care coordination will aim to deal first with the physiological needs and then the safety issues upon discharge (Oved, 2017). The role of the care coordinator, in this case, is to bring together professionals from other disciplines and to facilitate an easy platform for communication while in hospital or the community. Typically, an individual with a chronic illness will be under the care of more than one doctor, it is the job then of the care coordinator to make sure that the scope of practice and the roles between professionals are clearly defined. For example, a patient cannot have more than one primary care physician prescribing or making daily clinical decision, this prevents polypharmacy and confusion on who to call in case of an emergency (Keine et al., 2019). And it is standard practice for that all referral to other physicians such as consultants are done by the primary physician. Furthermore, the role of a care coordinator is to compile a discharge care plans. The discharge care plan in this case, must have behavioural/pain management strategies, mobility and dietary care plan and a list of community support groups. For example, Silver Chain in Western Australia offers a range of community care services for people with varying levels of acuity. Also, Dementia Support Australia (DSA) offers support on how to manage dementia symptoms non pharmacologically. Prior to discharge, the role of the coordinator is to organise these services, have a care plans and all contacts needed for community or long-term care. 

Care Plan   

Immediate care Needs

Personal GoalsPlanningImplementationEvaluationOutcomes
The patient will take the medication on time.   Swallowing assessment from speech pathologist. Consultation with the doctor and pharmacists.Crash or crushable medications. And mix with jam or yoghurt. Nurses and personal care workers to administer medication as chartedThe patient Is able to take medication without fighting when disguised in yoghurt.After three days of establishing a routine medication administration, typically during mealtimes the patients was able to take medication.
To manage the congestive heart failureConsultation with dietician on diet that is low in in salt. And diet to maintain a healthy BMI.Daily record of the fluid balance chart and weight recording. Consultation with the doctor on the for-fluid restrictionThe patient’s weight will be stable.The patient does not have peripheral oedema. And does not have respiratory infections general quality of life is improved.

Long term needs

Personal GoalsPlanningImplementationsEvaluationsOutcomes
The patient will be trained in how to use the prescribed mobility aid.Mobility assessment and care plan will be done by the physiotherapistDaily remainder and education to use mobility aidThe patient will use the mobility aid at least 70% of the time prior to discharge.After weeks of reorientation explanation and assurance the patient can use the prescribed mobility aid.
Extreme behaviours will be minimisedBehavioural management chart, and documentation consultation with the family on the patient’s personality, like and dislikes. Documentation of positive and negative interactions.Have specific ways written up on how challenging behaviours such as aggression and irritability will be addressed. Have set routine, for example, meal and sleep times and increase daytime activities.Challenging behaviours have been minimised prior to discharge.Monthly report of challenging behaviours has been minimised.
The patient will maintain a healthy BMIMonthly weights will be done. And Mini nutritional assessment will be done. For example, measure the calf circumference.Yearly review of care plans or when there is a change in patient condition.After months of monitoring food, a and fluid intake, a health BMI was achieved.Incidence of fluid overload where reduced.
The patient will feel supported with her personal hygieneHave a continence assessment and toileting assessment from the continence nurseHave a commode or shower chair in the toilet. Toilet rails and call bell at home. Have a toileting schedule in place.Incontinence episodes diminishedOverall skin integrity improved. Incontinence episodes will be reduced due toileting schedule

National Strategic Framework for Chronic Conditions

      This care plan meets the current management priorities in the national strategic framework for chronic illness because it firstly moves away from managing dementia specifically but aims to treat the patient holistically. It supports a stronger emphasis on coordinated care across the health system. In this case, it utilises the expertise of the speech pathologist, physicians, physiotherapist, occupational therapists and personal care workers. The aim is to provide continuity of care whether in a long-term care home or community care. It does this by having easy access to information, education, and support for the patient and the families. For example, the use of discharge summaries, access to Dementia Support Australia for advice on the non-pharmacological intervention of behavioural issues. For health care professionals it is through the use of progress notes so that all care workers are kept up to date with the changes to the patient care and condition.  (Health, 2019).

The Wagner Chronic care Disease Model

         The Wagner chronic care disease model identifies six essential elements of a care system that encourages chronic disease management. This model puts the patient at the centre of the decision-making process, the hope is that through intra-professional and interprofessional partnership better health outcomes can be achieved.   These elements are the community, the health care system, self-management support, delivery system designs and clinical information systems  (Health, 2019).  This care plan aims to deal with the chronic illness irrespective of the health care setting, it also focuses on partnerships with a community organisation to develop interventions that fill the gaps in needed health care services. This care plan also fulfils the self-management principle, by utilising the use of effective self-management strategies for both the family and the patient. It does this by helping the patient set simple achievable goals and ways they can be achieved. To promote independence and empowerment for the patient, it is important to educate all direct and allied care workers to only help a resident with tasks they cannot do themselves. For example, if the patient can still feed themselves, then allow them to eat for themselves until they are not able to (Baptista et al., 2016).

Responsibilities

            The professionals responsible for organising referrals is dependent on the hierarchy of competency and the scope of practice. The job of a care coordinator in this case is to set appointments for when these professionals will see the patients.  At a micro-level, while the patient is in hospital it is the responsibility of the nurse in charge of care to make sure that these referrals are done and sent to the people involved in care.  Hand over and case conferences, in this case, provides a good opportunity for the care coordinator to follow up with all health care workers about the general progress of all the patients and to make sure there are no gaps in care delivery. The ideal platform for these referrals to be delivered is through email, and then follow- up phone calls to set the dates for appointments. It is the job of the care coordinator to educate the client why they need the referrals and consultations from other professionals.  Changes to the patient must be done in writing either by sending a letter to the primary care provider or via email.  The appendix has a list of all the referrals done during the care planning.

References

Backhouse, T., Dudzinski, E., Killett, A., & Mioshi, E. (2020). Strategies and interventions to reduce or manage refusals in personal care in dementia: A systematic review. International Journal of Nursing Studies, 109. https://doi.org/10.1016/j.ijnurstu.2020.103640

Baptista, D. R., Wiens, A., Pontarolo, R., Regis, L., Reis, W. C. T., & Correr, C. J. (2016). The chronic care model for type 2 diabetes: A systematic review. Diabetology & Metabolic Syndrome, 8. https://doi.org/10.1186/s13098-015-0119-z

Catalyst, N. (2018). What Is Care Coordination? NEJM Catalyst. https://catalyst.nejm.org/doi/abs/10.1056/CAT.18.0291

Curyto, K. J., McCurry, S. M., Luci, K., Karlin, B. E., Teri, L., & Karel, M. J. (2017). Managing Challenging Behaviors of Dementia in Veterans. Journal of Gerontological Nursing, 43(2), 33–43. https://doi.org/10.3928/00989134-20160930-01

Gibson, R. H., & Gander, P. H. (2019). Monitoring the sleep patterns of people with dementia and their family carers in the community. Australasian Journal on Ageing, 38(1), 47–51. https://doi.org/10.1111/ajag.12605

Health, A. G. D. of. (2019, August 22). National Strategic Framework for Chronic Conditions [Text]. Australian Government Department of Health; Australian Government Department of Health. https://www.health.gov.au/resources/publications/national-strategic-framework-for-chronic-conditions

Janus, S. I. M., Reinders, G. H., van Manen, J. G., Zuidema, S. U., & IJzerman, M. J. (2017). Psychotropic Drug-Related Fall Incidents in Nursing Home Residents Living in the Eastern Part of The Netherlands. Drugs in R&D, 17(2), 321–328. https://doi.org/10.1007/s40268-017-0181-0

Keine, D., Zelek, M., Walker, J. Q., & Sabbagh, M. N. (2019). Polypharmacy in an Elderly Population: Enhancing Medication Management Through the Use of Clinical Decision Support Software Platforms. Neurology and Therapy, 8(1), 79–94. https://doi.org/10.1007/s40120-019-0131-6

Liguori, I., Russo, G., Curcio, F., Sasso, G., Della-Morte, D., Gargiulo, G., Pirozzi, F., Cacciatore, F., Bonaduce, D., Abete, P., & Testa, G. (2018). Depression and chronic heart failure in the elderly: An intriguing relationship. Journal of Geriatric Cardiology : JGC, 15(6), 451–459. https://doi.org/10.11909/j.issn.1671-5411.2018.06.014

Miller, W. L. (2016). Fluid Volume Overload and Congestion in Heart Failure. Circulation: Heart Failure. https://doi.org/10.1161/CIRCHEARTFAILURE.115.002922

Oved, O. (2017). Rethinking the Place of Love Needs in Maslow’s Hierarchy of Needs. Society, 54(6), 537–538. https://doi.org/10.1007/s12115-017-0186-x

Sano, M., & Majima, T. (2018). Self-management of congestive heart failure among elderly men in Japan. International Journal of Nursing Practice, 24(S1), e12653. https://doi.org/10.1111/ijn.12653

Shenker, J. I., & Singh, G. (2017). Sleep and Dementia. Missouri Medicine, 114(4), 311–315.

Sørensen, M. ( 1 ), Groven, K. s. ( 2 ), Gjelsvik, B. ( 3 ), Almendingen, K. ( 4 ), & Garnweidner-Holme, L. ( 4 ). (2020). The roles of healthcare professionals in diabetes care: A qualitative study in Norwegian general practice. Scandinavian Journal of Primary Health Care. https://doi.org/10.1080/02813432.2020.1714145

Ventegodt, S., Kandel, I., Ervin, D. A., & Merrick, J. (2016). Concepts of Holistic Care. In I. L. Rubin, J. Merrick, D. E. Greydanus, & D. R. Patel (Eds.), Health Care for People with Intellectual and Developmental Disabilities across the Lifespan (pp. 1935–1941). Springer International Publishing. https://doi.org/10.1007/978-3-319-18096-0_148

Wang, G., Gong, H., Albayrak, A., van der Cammen, T. J. M., & Kortuem, G. (2020). Personalising Management of Behavioural and Psychological Symptoms of Dementia in Nursing Homes: Exploring the Synergy of Quantitative and Qualitative Data. BioMed Research International, 1–16. https://doi.org/10.1155/2020/3920284

Wayne Zachary, Russell Charles Maulitz, & Drew A. Zachary. (2016). What Causes Care Coordination Problems? A Case for Microanalysis. EGEMs, 4(3). https://doi.org/10.13063/2327-9214.1230

Health Check: how to start exercising if you’re out of shape

Andrew Lavender, Curtin University

Perhaps your GP has recommended you exercise more, or you’ve had a recent health scare. Maybe your family’s been nagging you to get off the couch or you’ve decided yourself that it’s time to lose some weight.

How do you find the motivation, time and resources to get fit, particularly if you haven’t exercised in a while? How do you choose the best type of exercise? And do you need a health check before you start?


Read more: Health Check: how much physical activity is enough in older age?


Overcoming barriers to exercise

Motivation

Understanding the effect a sedentary lifestyle has on your health often hits home only after a serious event such as hearing bad news from your doctor. For some people, that’s often enough motivation to get started.

Surviving a serious illness as a result of an inactive lifestyle, such as a heart attack or stroke, can also be frightening enough to provide a great deal of motivation.

So, if you have not exercised for several years or haven’t exercised before, a it’s a good idea to get a health check with your GP before starting.

Then you need to keep motivated enough to stick with your exercise program. You can track your training or fitness level and set some achievable goals to keep going.

Lack of time

Finding the time and effort to fit exercise into your daily routine is challenging. We know being “time poor” is a common reason for not exercising. And many people such as office workers, vehicle or machine operators have low activity levels at work and don’t feel like exercising after a long day.


Read more: Time scarcity is a slippery slope to inactivity


One way to get around these barriers might be to attend a group exercise session or join a sports club. If you find exercise boring, you can encourage a friend to join you or join an exercise group to make it enjoyable. If you played sport in your youth, that might provide an option.

Having a friend to exercise with or team mates to support you gives a sense of commitment so that you have to be there and will be challenged if you fail to show up.

Resources

You don’t need to join a gym with a lot of fancy equipment to get fit. There are many YouTube videos of safe routines that you can follow and adjust as you get fitter.

This one demonstrates a 15 minute cardio exercise routine that you can do at home. https://www.youtube.com/embed/VHyGqsPOUHs?wmode=transparent&start=0 You don’t need any special equipment to exercise at home along with this 15 minute cardio workout for beginners.

Many exercises – including squats, push ups and sit ups – don’t need special equipment. And rather than improving muscle strength with weights at the gym, you can fill milk bottles with water instead.

Yes, you’ll huff and puff. But it gets easier

You might be thinking about starting aerobic exercise like the cardio workout above, or walking, jogging, swimming or cycling. All need oxygen to provide energy over several minutes or longer.

When we perform aerobic exercise, our heart rate increases along with our breathing rate and depth. This is because this type of exercise requires oxygen to provide energy to keep going.


Read more: Health Check: what should our maximum heart rate be during exercise?


When we are not used to this type of exercise our body is inefficient at using the oxygen we breathe to generate energy for our skeletal muscles. That’s why when we start an exercise program we huff and puff more, get tired quickly and may not finish the exercise.

But if we keep exercising regularly, our bodies become more efficient at using oxygen and we become better at generating enough energy for our muscles to work.

Over weeks of regular exercise, the number and efficiency of our body’s mini-powerhouses – mitochondria – increase in each cell. This increases the energy they can supply to the muscles, exercising becomes easier and we recover faster from each session.


Read more: Explainer: what are mitochondria and how did we come to have them?


That’s why it’s important to continue and repeat exercise sessions, even after a shaky start or a few set-backs. Yes, it can be a big challenge, but aerobic exercise gets easier over time as the body gets used to providing the energy it needs.

Thinking of yoga or simple stretches? Here’s what to expect

Yoga is a great way to start an exercise program and you can perform it at various levels of intensity. Stretching and other moves improve flexibility and strength. Yoga also emphasises breathing and relaxation through meditation.

Yoga, like other forms of exercise, will be challenging to begin with. But it does get easier over the weeks as your body adapts. So, it is important to be persistent and make the exercise part of your routine with at least three sessions of up to one hour every week.


Read more: The yoga paradox: how yoga can cause pain and treat it


At the start, you may get sore muscles. While this can be uncomfortable, the soreness goes away after about a week. You can reduce this soreness by starting with low intensity and building gradually over the first month.

Once your muscles become used to the new movements, the soreness will be minimal as you progress.


Read more: Health Check: why do my muscles ache the day after exercise?


Watch your joints

We know being overweight or obese has detrimental effects on the heart, bones, joints and other organs including the pancreas, which regulates blood glucose (sugar) levels. Obesity can also affect brain health and is linked to poor cognition.

The good news is that regular exercise can help reduce these negative effects.

But if you are overweight or obese, taking up exercise can place great strain on your joints, particularly the articulating surface, the cartilage surface of bones that contact each other. So hips, knees and ankles can become inflamed and painful.

So it may be best to include exercise that reduces weight bearing, such as exercise in water or using a stationary exercise bike or rowing machine. Once you’ve lost some weight and your cardiovascular function has improved, then you can add more walking or jogging to your exercise program.

The right diet helps power you along

A healthy diet you can maintain in the long term is a very important part of any fitness routine. Not only can it help you lose weight, it can also provide the right type of fuel to power your new exercise program.


Read more: Health Check: what’s the best diet for weight loss?


Getting plenty of fibre from fruit, vegetables and whole grains will help to reduce weight and keep it off while exercising.

Sugar, especially the type found in fizzy drinks and sweets, are low in nutrients and increase the risk of diabetes, metabolic syndrome and cardiovascular disease. So cut down on refined carbohydrates like some breads and rice, sugary cereals and refined pasta since these include sugars we are trying to avoid and have had their fibre removed. Replace them with oats, carrots or potatoes.

It’s best to avoid fad diets, which tend to be restrictive and difficult to maintain. They can lead to a yo-yo effect where you lose weight only for it to return.


Read more: Food for fitness: is it better to eat before or after exercise?


In a nutshell

Once you’ve decided to start exercising, and had a medical check if needed, start slowly and build your exercise routine up over weeks and months. Make it interesting and enjoyable, perhaps by working out with a friend or group. Set some achievable goals, try to stick to them and don’t give up if you have a set back.

Weight loss and getting fit requires different approaches for different people so find what works for you and make it part of your lifestyle. Increase the intensity and frequency of your exercise gradually from a minimal three times a week for 20 minutes to longer, more intense sessions more often.

Andrew Lavender, Lecturer, School of Physiotherapy and Exercise Science, Curtin University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Barriers to Care Coordination.

Care coordination is the deliberate organisation of patient care activities between two or more health care workers and other people involved in patient care (Mateo-Abad et al., 2020). Effective care coordination is made possible when there is teamwork and an open dialogue between clinical staff, allied health workers and families.  Coordination of care in nursing homes is centered around the creation of individualised care plans, with input from health care workers and families.  The policy in most care homes is that all care plans must be reviewed yearly and whenever there is a sudden unexpected change in resident’s functional status. The role of a Nurse in the resident’s journey through the health care system is to make sure that there are no gaps in access to care. It involves assessing the immediate and long-term care needs of the resident.

       The first major barrier to coordinating care is staffing issues, brought on, partly due to high staff turnover. This affects the general quality of care, as more time and money are spent on training new carers. This in turn reduces the response time to the care needs of residents and affects the continuity of care. (Amjad et al., 2016), found that low continuity of care was associated with higher rates of hospitalisation and emergency department visits, the study further found that the quality of care among dementia patients is often reactive  (O’Neill et al., 2017).  Care homes do not have staffing ratios and the number of nurses to resident ratio is dependant on the time of day and the acuity of residents. It is not unusual to find one RN in charge of 50 residents. Having the same staff in charge of residents care means that changes to the resident’s condition can be assessed early and interventions can be put in place (Marshall et al., 2016).

        Another major barrier to care coordination is poor communication between clinical staff and families. This is especially the case when the resident lacks the ability to communicate or advocate for themselves as is seen in individuals with dementia or aphasia (Brighton & Bristowe, 2016).  Poor communication between families and health care workers will often lead to poor assessment, planning and implementation of care. Studies indicate that having an open-ended dialogue between clinical staff and families in matters of care, not only improves the quality of life for resident but also reduces hospital transfers (Brighton & Bristowe, 2016). Other studies show that educating assistant nurses on effective ways of communicating with residents, improves care outcomes without increasing care time (Sprangers et al., 2015).

       Poor communication among nursing staff is also a source of frustration among families especially when there is a sharp decline in the functional status of the resident and the family where not informed  (Abrahamson et al., 2016).  Decision to send families to the hospital for treatment are normally done by the primary family representatives. Studies however show that when families are informed of resident’s condition on a regular basis, they are less likely to request for a hospital transfer when the resident suddenly deteriorates (Abrahamson et al., 2016). Most nursing homes have a policy of informing families of any changes to the resident’s care and condition. Another way communication issues can be mitigated is through having regular care conferences to discuss care issues and concerns.  Care conferences are a great way to meet families and find out their care expectations (Jobe et al., 2018).

      Care coordination is intended to provide holistic person-centred care that focuses on addressing the individual needs of each resident, through clear purposeful and open-ended communication between families and health care workers (Jobe et al., 2018). Person centered practice puts the individual at the centre of every decision-making process. Older people with specific communication needs have an increased risk of experiencing functional decline. Identifying communication issues when the elderly individual is admitted to the care facility and responding to these issues would improve the quality of life. Individuals that come from ethnically diverse minorities, face the added pressure of accessing care that is culturally and linguistically responsive.  Improvement in communication can be made by simplifying sentences and if they are unable to use speech, work with the resident and their family and carers to use an alternative form of communication (Horton et al., 2016).

References

Abrahamson, K., Bernard, B., Magnabosco, L., Nazir, A., & Unroe, K. T. (2016). The experiences of family members in the nursing home to hospital transfer decision. BMC Geriatrics, 16(1), 184. https://doi.org/10.1186/s12877-016-0359-2

Amjad, H., Carmichael, D., Austin, A. M., Chang, C.-H., & Bynum, J. P. (2016). Continuity of Care and Healthcare Utilization in Older Adults with Dementia in Fee-for-Service Medicare. JAMA Internal Medicine, 176(9), 1371–1378. https://doi.org/10.1001/jamainternmed.2016.3553

Brighton, L. J., & Bristowe, K. (2016). Communication in palliative care: Talking about the end of life, before the end of life. Postgraduate Medical Journal, 92(1090), 466. https://doi.org/10.1136/postgradmedj-2015-133368

Cashin, A., Heartfield, M., Bryce, J., Devey, L., Buckley, T., Cox, D., Kerdo, E., Kelly, J., Thoms, D., & Fisher, M. (2017). Standards for practice for registered nurses in Australia. Collegian, 24(3), 255–266. https://doi.org/10.1016/j.colegn.2016.03.002

Horton, S., Lane, K., & Shiggins, C. (2016). Supporting communication for people with aphasia in stroke rehabilitation: Transfer of training in a multidisciplinary stroke team. Aphasiology, 30(5), 629–656. https://doi.org/10.1080/02687038.2014.1000819

Jobe, I., Lindberg, B., Nordmark, S., & Engström, Å. (2018). The care‐planning conference: Exploring aspects of person‐centred interactions. Nursing Open, 5(2), 120–130. https://doi.org/10.1002/nop2.118

Marshall, E. G., Clarke, B., Burge, F., Varatharasan, N., Archibald, G., & Andrew, M. K. (2016). Improving Continuity of Care Reduces Emergency Department Visits by Long-Term Care Residents. The Journal of the American Board of Family Medicine, 29(2), 201–208. https://doi.org/10.3122/jabfm.2016.12.150309

Mateo-Abad, M., González, N., Fullaondo, A., Merino, M., Azkargorta, L., Giné, A., Verdoy, D., Vergara, I., & de Manuel Keenoy, E. (2020). Impact of the CareWell integrated care model for older patients with multimorbidity: A quasi-experimental controlled study in the Basque Country. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-05473-2

O’Neill, B. J., Reid-Searl, K., Dwyer, T., & Parkinson, L. (2017). The deteriorating resident in residential aged care: A focus group study. Collegian, 24(6), 563–570. https://doi.org/10.1016/j.colegn.2016.10.010

Sprangers, S., Dijkstra, K., & Romijn-Luijten, A. (2015). Communication skills training in a nursing home: Effects of a brief intervention on residents and nursing aides. Clinical Interventions in Aging, 10, 311–319. https://doi.org/10.2147/CIA.S73053

When does getting help on an assignment turn into cheating?

Peter Hurley, Victoria University

Students – whether at university or school – can get help from many places. They can go to a tutor, parent, teacher, a friend or consult a textbook.

But at which point does getting help cross the line into cheating?

Sometimes it’s clear. If you use a spy camera or smartwatch in an exam, you’re clearly cheating. And you’re cheating if you get a friend to sit an exam for you or write your assignment.

At other times the line is blurry. When it’s crossed, it constitutes academic misconduct. Academic misconduct is any action or attempted action that may result in creating an unfair academic advantage for yourself or others.

What about getting someone else to read a draft of your essay? What if they do more than proofread and they alter sections of an assignment? Does that constitute academic misconduct?

Learning, teaching or cheating?

There are a wide range of activities that constitute academic misconduct. These can include:

  • fabrication, which is just making things up. I could say “90 % of people admit to fabricating their assignments”, when this is not a fact but a statement I just invented
  • falsification, which is manipulating data to inaccurately portray results. This can occur by taking research results out of context and drawing conclusions not supported by data
  • misrepresentation, which is falsely representing yourself. Did you know I have a master’s degree from the University of Oxford on this topic? (Actually, I don’t)
  • plagiarism, which is when you use other people’s ideas or words without appropriate attribution. For instance, this list came from other people’s research and it is important to reference the source.

Sometimes students and teachers have different ideas of academic misconduct. One study found around 45% of academics thought getting someone else to correct a draft could constitute academic misconduct. But only 32% of students thought the same thing.


Read more: Assessment design won’t stop cheating, but our relationships with students might


In the same survey, most academics and students agreed having someone else like a parent or friend identify errors in a draft assignment, as opposed to correcting them, was fine.

Generally when a lecturer, teacher or another marker is assessing an assignment they need to establish the authenticity of the work. Authenticity means having confidence the work actually relates to the performance of the person being assessed, and not of another person.

The Australian government’s vocational education and training sector’s quality watchdog, for instance, considers authenticity as one of four so-called rules of evidence for an “effective assessment”.

The rules are:

  • validity, which is when the assessor is confident the student has the skills and knowledge required by the module or unit
  • sufficiency, which is when the quality, quantity and relevance of the assessment evidence is enough for the assessor to make a judgement
  • authenticity, where the assessor is confident the evidence presented for assessment is the learner’s own work
  • currency, where the assessor is confident the evidence relates to what the student can do now instead of some time in the past.

Generally speaking, if the assessor is confident the work is the product of a student’s thoughts and where help has been provided there is proper acknowledgement, it should be fine.

Why is cheating a problem?

It’s difficult to get a handle on how big the cheating problem is. Nearly 30% of students who responded to a 2012 UK survey agreed they had “submitted work taken wholly from an internet source” as their own.

In Australia, 6% of students in a survey of 14,000 reported they had engaged in “outsourcing behaviours” such as submitting someone else’s assignment as their own, and 15% of students had bought, sold or traded notes.

Getting someone to help with your assignment might seem harmless but it can hinder the learning process. The teacher needs to understand where the student is at with their learning, and too much help from others can get in the way.


Read more: Children learn from stress and failure: all the more reason you shouldn’t do their homework


Some research describes formal education as a type of “signal”. This means educational attainment communicates important information about an individual to a third party such as an employer, a customer, or to an authority like a licensing body or government department. Academic misconduct interferes with that process.

How to deal with cheating

It appears fewer cheaters are getting away with it than before. Some of the world’s leading academic institutions have reported a 40% increase in academic misconduct cases over a three year period.

Technological advances mean online essay mills and “contract cheating” have become a bigger problem. This type of cheating involves outsourcing work to third parties and is concerning because it is difficult to detect.


Read more: 15% of students admit to buying essays. What can universities do about it?


But while technology has made cheating easier, it has also offered sophisticated systems for educators to verify the work is a person’s own. Software programs such as Turnitin can check if a student has plagiarised their assignment.

Institutions can also verify the evidence they are assessing relates to a student’s actual performance by using a range of assessment methods such as exams, oral presentations, and group assignments.

Academic misconduct can be a learning and cultural issue. Many students, particularly when they are new to higher education, are simply not aware what constitutes academic misconduct. Students can often be under enormous pressure that leads them to make poor decisions.

It is possible to deal with these issues in a constructive manner that help students learn and get the support they need. This can include providing training to students when they first enrol, offering support to assist students who may struggle, and when academic misconduct does occur, taking appropriate steps to ensure it does not happen again.

Peter Hurley, Policy Fellow, Mitchell Institute, Victoria University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Sex Determination and Differentiation

In humans as well as other species, there are obvious differences between males and females. Differences such as the development of a penis or vagina, muscle mass, body size, the distribution of fat and the amount of distribution of body hair are all the differences that can be observed. These differences are a result of a long chain of events that begin during the early phases of embryology. It Involves Complex interactions between the environment and gene expression. Being male or female is determined in stages beginning at fertilization when the sex chromosomes carried by the sperms meet the egg. Females have XX chromosomes and Males have XY chromosomes. Having XX females and XY males provides a genetic framework for developmental events that eventually give us male or female appearance.  The formation of reproductive structures observed in males and females depend on several factors, these include; gene action and other genetic and hormonal interactions within the embryo (SRY Gene – an Overview | ScienceDirect Topics, 2019).

 Having XX and XY does not always mean that the individual is either male or female. The outcome depends on the distribution of genes on the X and Y chromosome. All eggs that are produced by females carry the X chromosomes, in males about half of the mature sperms carry the X chromosomes. An egg that is fertilised by a sperm that has the X chromosomes will have XX Zygote and will develop into a female (Cummings, 2009). Establishment of chromosomal sex happens at fertilization. However, even though this is the case, external genitalia are neither male nor female until about the third month of development.

Before this, the embryo has two undifferentiated gonads present, along with both sets of the male and female duct systems.  The second phase begins at 8 to 9 weeks when gene expression activates the different developmental pathway. This then causes the undifferentiated gonads to develop into testicles or ovaries. It is important to point out that there are alternative routes that produce an intermediate outcome in gonadal sex and sexual phenotype. For boys, the differentiation is not straightforward, If the Y chromosome is present, expressions of SRY gene on the Y chromosome will cause the undifferentiated gonads to become testis. A sex-determining gene that is found on the short arm of the Y chromosome called SRY activates the expression of other genes that play a part in the way testis develop. The SRY gene provides instruction for making protein called the sex determining region Y protein (SRY Gene – an Overview | ScienceDirect Topics, 2019). 

This protein is involved in male sex development and is usually determined   by the chromosomes in an individual. People usually have 46 chromosomes. The X and Y are called sex chromosomes because they help determine whether a person will develop male or female characteristics. The SRY gene is found on the Y chromosome. The sex determining region Y protein produced from this gene acts as a transcription factor. A transcription factor is a protein that binds to specific DNA sequence and contributes to the modulation of gene expression. Transcription factors are important determinants of epigenetic state of the cells. Many transcription factors have been identified and a huge proportion of the human genome appears to code for these proteins.  Once the testis development is initiated by the SRY gene, the testis then produces testosterone and Anti-Mullerian hormone. The formation of the internal male duct system that carries sperm is caused by testosterone’s effects on the Wolffian duct system (National Library of Medicine, 2020).  Females have two X chromosomes, so their sexual differentiation is not signalled by the SRY gene. The absence of these cues’ signals their sex organs to develop.

 Embryos with two X chromosomes and the absence of the Y chromosomes causes the gonads to develop into ovaries. Ovaries are developed when the cells in the outer layers of the gonads divide and push into the inner layers. The Wolffian duct system then disintegrates because the ovaries do not produce testosterone (Cummings, 2009). Hormones also shape the male and female appearance, after gonadal sex has been established the next phase in sex determination is the development of sexual appearance. In males, testosterone is converted into dihydrotestosterone, DHT directs the formation of external male features and influences brain development and size. Gonadal sex and sexual appearance are produced by separate pathways in males and females.


Clinical note

Androgen insensitivity syndrome is a condition that affects sexual development before birth and during puberty. People with this condition are genetically male, with one X chromosome and one Y chromosome in each cell, because their bodies are unable to respond to certain male sex hormones called androgens. Complete androgen insensitivity happens when the body cannot respond to androgen at all.  People with this condition have external sex characteristic of females, but do not have the uterus and therefore cannot menstruate. Affected Individuals have male internal sex organs that are undescended, which means that they are abnormally located in the pelvis and abdomen. Undescended testis’s have a small chance of becoming cancerous if they are not surgically removed.   Individuals with complete androgen insensitivity tend to have minimal or absent hair in the pubic or the under arms. The partial and mild forms of androgen insensitivity syndrome result when the bodies tissues are partially sensitive to the effects of the androgens. Individuals with partial androgen insensitivity can have genitalia that look female and genitalia that have both male and female characteristics (National Library of Medicine, 2020).

Congenital adrenal hyperplasia is a condition in which females have overactive adrenal glands. Adrenal glands are located over the kidneys, they are endocrine glands that are responsible for the production of several hormones.  There are two types of CAH, classic and non-classic, most children with this condition do not produce enough 21-hydroxylase, which is an enzyme that aids in the production of cortisol and aldosterone. Classic CAH is the more severe form and is usually noticed during infancy and early childhood (Yau et al., 2000). Congenital adrenal hyperplasia (CAH) causes the over production of a hormone called cortisol. Cortisol is a hormone that is structurally and functionally like testosterone. Cortisol plays a part in several functions, these include; control of sugar levels, regulation of metabolism, control of salt and water balance and helps control blood pressure. Females will develop musicalized genitalia to varying degrees, some females will an enlarged clitoris like penis formation. Others will have partially fused labia, similar to the scrotum (Sex Determination and Differentiation | SexInfo Online, 2019).  


References

Reference, G. H. (n.d.-a). Androgen insensitivity syndrome. Genetics Home Reference. Retrieved July 18, 2020, from https://ghr.nlm.nih.gov/condition/androgen-insensitivity-syndrome

Reference, G. H. (n.d.-b). SRY gene. Genetics Home Reference. Retrieved July 18, 2020, from https://ghr.nlm.nih.gov/gene/SRY

Sex Determination and Differentiation | SexInfo Online. (n.d.). Retrieved July 18, 2020, from https://sexinfo.soc.ucsb.edu/article/sex-determination-and-differentiation

SRY Gene—An overview | ScienceDirect Topics. (n.d.). Retrieved July 18, 2020, from https://www.sciencedirect.com/topics/neuroscience/sry-gene

Yau, M., Gujral, J., & New, M. I. (2000). Congenital Adrenal Hyperplasia: Diagnosis and Emergency Treatment. In K. R. Feingold, B. Anawalt, A. Boyce, G. Chrousos, K. Dungan, A. Grossman, J. M. Hershman, G. Kaltsas, C. Koch, P. Kopp, M. Korbonits, R. McLachlan, J. E. Morley, M. New, L. Perreault, J. Purnell, R. Rebar, F. Singer, D. L. Trence, … D. P. Wilson (Eds.), Endotext. MDText.com, Inc. http://www.ncbi.nlm.nih.gov/books/NBK279085/

Assisted dying referendum: why NZ’s law lacks necessary detail to make a fully informed decision

Rhona Winnington, Auckland University of Technology

When New Zealanders go to the polls in September, they will also be asked to vote in a referendum on assisted dying.

Parliament already passed the End of Life Choice Act in 2019, but the referendum will decide whether it comes into force.

We will be asked if we accept or decline the right of people to seek an assisted death, without the need for consultation with family and with no stand-down period other than a requirement of 48 hours to prepare the medication. The act would allow people to choose when they die and by what means, whether the medication is self-administered or given by suitably qualified clinicians.

This appears an ideal scenario, affirming the right to choose, but it is a deeply profound decision for the public to make. Many may be unaware of issues beyond the goal of ending suffering for people with life-limiting conditions.

My research shows an assisted death can have repercussions for many people — those left behind or others struggling with a chronic disease. Experiences from countries where assisted dying has been legal for some time have highlighted these challenges.


Read more: One year of voluntary assisted dying in Victoria: 400 have registered, despite obstacles


Social consequences of assisted dying

In the Netherlands, assisted dying has been legal for 18 years. Over time, there have been notable slips in the criteria that have to be met. This includes the level of physical suffering, which is a subjective experience, and the requirement that people must be competent to agree to an assisted death at the point of administration. This may not be possible for people with dementia who have previously given written consent but can no longer consent at the point of death.

While the law hasn’t changed, its interpretation has, and people with mental illness can now also request an assisted death. Data from the Netherlands show one in 30 people now die by euthanasia, compared to one in 90 when the law was introduced in 2002.

In the US, some medical insurance companies pay for an assisted death but not for palliative care. This removes any notion of choice and autonomy from the person.

In Canada, where assisted dying has been legal for four years, the number of people seeking medical help to die has risen significantly, with figures more than doubling year on year. This has exposed unexpected consequences, such as fear of judgement for leaving family members unsupported after an assisted death and stigmatisation of clinicians, whether or not they support people choosing the time of their death.


Read more: In places where it’s legal, how many people are ending their lives using euthanasia?


Impact on those left behind

To consider assisted dying legislation as an issue of individual autonomy denies that we are part of a much larger group with complex connections. This is particularly important when we consider Māori and Pasifika populations, whose voices are notably absent from the current act in New Zealand.

The act proposes people may seek assisted dying without any consultation with whānau (family), but the impact of an assisted death reaches far beyond relieving suffering for the individual. The ripple effects can fracture families and communities. As the act currently stands, it has the potential to cause greater harm than good.

We can already see this oversees, for example in Canada and Switzerland, where those who use assisted dying and their immediate family guard this information closely. This is likely happening because of stigma attached to dying in this way, even when it is legal.

The New Zealand legislation carries this risk. It includes restrictions on disclosure of the use of the law and on individuals being recorded as having died an assisted death, often for insurance purposes.

The contagion effect

There is another significant issue to consider. One person’s assisted death could influence the decisions of others — and this contagion effect could play out in two ways.

Those who are not aware of the legislation but discover a friend or family member is accessing it may consider using it themselves. More concerning is people with chronic conditions may feel obliged to seek assisted dying, should they feel burdensome to their family.

There is a notable difference in the New Zealand population in how support for elders or unwell family members is provided. Māori and Pasifika people tend to care for their sick and elders while pākehā (New Zealanders of European descent) often rely on external support. Our research shows when one family member has an assisted death, others with a chronic illness can feel an expectation for them to consider it.

Such broader consequences of introducing assisted dying legislation are often hidden, but they must be addressed as New Zealand moves towards the referendum. The current binary positioning of the debate focuses on autonomy of the individual versus protecting the public, whereas the reality is that assisted dying is more than merely either of these opposing values. It has already been demonstrated that the effects of assisted dying legislation reach beyond the individual and, as such, must be considered as we enter this referendum. The act lacks the necessary detail to make a fully informed decision.

The idea that choice is being given to a popular vote is, in itself, problematic. It is suggestive of a government unwilling to take responsibility for the fallout, should the referendum produce a supportive vote.

We need to safeguard our families and communities from these social consequences of assisted dying legislation. Vulnerable populations have to remain safe from persuasion to die and there has to be a supportive framework for those left behind after an assisted death, so they can grieve without feeling stigmatised.

Rhona Winnington, Lecturer, Auckland University of Technology

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Mental Health Issues in Nursing Homes

  Mental health relates to any behaviours and conditions which impedes with social functioning capacity to negotiate daily life (WHO | Mental Health, 2019) .  Many older people will have some sort of mental health issue at some point, this may be due to illness, grief and loss, financial stress and loss of independence. Between 2017-18, 9.9 billion dollars was spent in mental health and 4.3 million people received mental health services. Mental health is as important as physical wellbeing for elderly people, this is also true for people with dementia (Mental Health Services in Australia, Prevalence, Impact and Burden, 2019).         The vulnerable group chosen for this paper is elderly people with dementia living in long term aged care homes and in the community. The national health priority in focus is mental health.

        Finding ways to improve mental wellbeing for people living with dementia is important to improving quality of life. Neuropsychiatric symptoms (NPS) are now known to occur universally over the many stages of dementia. They also occur with increasing frequency in early onset of dementia. NPS in the form of mild behavioural impairment in the presence of cognitive impairment may constitute early onset of dementia. A wide range of symptoms have been reported, although they tend to aggregate into predictable groups namely depression, apathy, psychosis and agitation (Smalbrugge et al., 2017). Challenging behaviours are highly prevalent in nursing home residents, and for many it one of the main reasons why they are placed in long term care facility. These challenging behaviours lead to poor quality of life and stress and burden on care givers if not managed properly. This is especially for poorly managed aggression and agitation.  Managing these challenging behaviours demands a multidisciplinary approach, which focuses on finding and treating the underlying cause of the behaviour (Backhouse et al., 2016).

       Treatment and management are dependent on the stage of dementia. It can range from non-pharmacological intervention to pharmacological intervention like the use of psychotropics.  Evidence of the efficacy of psychotropics in the treatment and management of NPS symptoms has been shown to be sub-optimal (Groot Kormelinck et al., 2019). Studies now indicate that their use, may even worsen the symptoms of NPS, they may increase the likelihood of falls and increased hospital transfers. Finding ways to manage these symptoms non pharmacologically will provide dignity and improve the quality of elderly people with dementia (Groot Kormelinck et al., 2019). 

         Recent changes to the National Quality Standards demand, that care homes find different ways of managing these symptoms and only use psychotropics as a last resort ( Aged Care Quality and Safety Commission, 2020). This makes managing mental health issues in elderly people with dementia a lot more challenging. One reason could be the staffing issues. In many nursing homes it is not unusual to have one registered nurse in charge of 40 -50 residents.  In dementia specific wards, there is normally 20-40 resident in a secured location, and staffing ratios is dependent on the acuity of the resident. Hence most nursing homes use group activities to manage behaviours rather than targeted therapies. The use of psychotropics is normally a case of striking a balance between the rights of individual resident with behaviours and the rights of the other residents in the facility. This could account for high levels of inappropriate prescriptions and overuse of psychotropics.

        In conclusion, managing mental health issues in dementia has become increasingly challenging due to the shortage of trained staff. Aged care usually has a high degree of staff turnover and most people use it as a steppingstone to other careers, this means there is no continuity of care (Costello et al., 2019). The high turnover, especially carers means that facilities spend more time constantly training new care staff in the targeted behavioural management strategies of the individual residents in the facility. Low continuity of care is defined as increased fragmentation of health care workers. Low continuity of care has been shown to be associated with higher hospitalisation (Amjad et al., 2016).


References

Amjad, H., Carmichael, D., Austin, A. M., Chang, C.-H., & Bynum, J. P. W. (2016). Continuity of Care and Health Care Utilization in Older Adults With Dementia in Fee-for-Service Medicare. JAMA Internal Medicine, 176(9), 1371–1378. https://doi.org/10.1001/jamainternmed.2016.3553

Backhouse, T., Killett, A., Penhale, B., & Gray, R. (2016). The use of non-pharmacological interventions for dementia behaviours in care homes: Findings from four in-depth, ethnographic case studies. Age and Ageing, 45(6), 856–863. https://doi.org/10.1093/ageing/afw136

Costello, H., Walsh, S., Cooper, C., & Livingston, G. (2019). A systematic review and meta-analysis of the prevalence and associations of stress and burnout among staff in long-term care facilities for people with dementia. International Psychogeriatrics, 31(8), 1203–1216. https://doi.org/10.1017/S1041610218001606

Groot Kormelinck, C. M., van Teunenbroek, C. F., Kollen, B. J., Reitsma, M., Gerritsen, D. L., Smalbrugge, M., & Zuidema, S. U. (2019). Reducing inappropriate psychotropic drug use in nursing home residents with dementia: Protocol for participatory action research in a stepped-wedge cluster randomized trial. BMC Psychiatry, 19(1), 298. https://doi.org/10.1186/s12888-019-2291-4

Self-assessment tool for recording consumers receiving psychotropic medications | Aged Care Quality and Safety Commission. (2020). Retrieved May 16, 2020, from https://www.agedcarequality.gov.au/resources/self-assessment-tool-psychotropic-medications

Smalbrugge, M., Zwijsen, S. A., Koopmans, R. C. T. M., & Gerritsen, D. L. (2017). Challenging Behavior in Nursing Home Residents with Dementia. In S. Schüssler & C. Lohrmann (Eds.), Dementia in Nursing Homes (pp. 55–66). Springer International Publishing. https://doi.org/10.1007/978-3-319-49832-4_5

WHO | Mental Health. (2020). WHO; World Health Organization. Retrieved May 16, 2020, from http://www.who.int/mental_health/en/

Health Focus: What is Sundowning Syndrome?

Sundowning syndrome or nocturnal delirium is used to describe a wide range of behaviours of neuropsychiatric (NPS) symptoms that often happen in people with dementia. The behavioural and neuropsychiatric symptoms seen in people with dementia and Alzheimer’s disease include; repetitive behaviours, delusions, misidentification, wandering, suicidal and sociopathic behaviours. Both normal ageing and dementia are associated with changes to the circadian regulation of physiology and behaviour (Cipriani et al., 2015).  Sundowning syndrome is not a disease but rather a set of symptoms that happen at specific times of the day usually around 16:00 – 17:00.  It can happen at any stage of dementia, but research shows it tends to peak during the middle stages of dementia. Sundowning shares the same similarities as delirium, e.g. attention deficits and activity disturbances.  

     A major difference between sundowning and delirium is that delirium tends be acute in onset and fluctuates during the day. Diagnosis of sundowning behaviours is purely clinical, and characterised by a wide range of cognitive, affective and behavioural issues. The impact of sundowning syndrome are huge, both in terms of the financial burden that are placed on the individual care of patients with dementia, and the emotional distress to the families. According to studies, sundowning symptoms are the main reasons families decide to move individuals with dementia to long-term care homes. The actual cause of sundowning syndrome is unknown, there are however several theories that attempt to explain this phenomenon. The literature that has attempted to explain sundowning can be grouped into three major themes, physiological, psychological and environmental (Khachiyants et al., 2011).

One of the most accepted pathophysiological mechanism underlying sundowning behaviours is centered around the dysfunction of the circadian rhythm. This is supported by the detection of pathological changes in the suprachiasmatic nucleus in people with Alzheimer’s. The suprachiasmatic nucleus is a small region of the brain in the hypothalamus, situated above the optic chiasm, it is known to be responsible for regulating the circadian rhythm (Ma & Morrison, 2020). The regulation of sleep is regulated by the haemostatic physiology of the circadian rhythm. The circadian rhythm is a 24-hour clock in the brain that regulates the sleep cycle. It regulates the cycles of alertness    and sleepiness by responding to light changes in the environment. Studies show that the body and behaviours is shaped by the earth’s rotation and axis. Without this in-built clock, individuals would not be able to optimise energy expenditure of the internal physiology of the body (Reddy et al., 2020).  The pineal gland is a central structure in the circadian system responsible for the production of melatonin under the control of the central clock. Melatonin production is controlled by the circadian timing system and is also suppressed by light. Light and dark changes constitute the principle timing signal of melatonin secretion from the pineal gland. The circadian clock is synchronised to the 24-hour day environmental light, which is transmitted from the retina to the SCN primarily through the retinohypothamlamic tract (Wu & Swaab, 2005). 

      The disruption of circadian system in dementia can in theory explain sleep disorders, agitation, confusion and other symptoms of dementia and may also contribute to the development of sundowning syndrome (Cipriani et al., 2015). Ageing and dementia can lead to the reduction in the consolidation of NREM sleep, decreased sleep efficiency, increased sleep disturbances and elevated levels of daytime napping. These sleep disturbances are common in ageing and are made worse by the presence of dementia. Over 38% of the elderly report having difficulties with sleep.  Studies show that people with dementia that have sleep disturbances also suffer from severe forms of dementia (Montag et al., 2015).  (Shenker & Singh, 2017), found that sleep disorders and neurocognitive disorders are both frequent categories of diseases, but they are often underdiagnosed. The relationship between sleep and neurocognition is complicated. In some cases, it is hard to work out whether the neurocognition disorders is causing the sleep disturbance or the sleep disturbance is causing the neurocognitive disorder.

Furthermore, sensory deprivation has been reported widely in the elderly and is generally associated with poor quality of life in all domains of the activities of daily living, such as eating and personal hygiene. People with dementia are more likely to spend time in doors with deem lights and are more likely to be isolated, which affects their sleep to wake patterns. More broadly sensory deprivation has been linked to the development of psychiatric disorders such as depression, anxiety, psychosis, dementia and sensory confusion. In the elderly, sensory depravation has been linked to rapid cognitive decline (Sahoo, 2016). Environmental factors that are said to contribute to sundowning occurrence, include; exposure to inadequate amounts of light, environmental overstimulation and low staff patient ratios in nursing homes. Other studies indicate that behavioural issues in people with dementia can be attributed to unmet needs.  But meeting the individualised care needs of every resident under a nurse’s care becomes harder without adequate staffing. Other studies have suggested that low lighting and increased shadows may increase late day confusion observed in  sundowning syndrome (Khachiyants et al., 2011).

Finally, sundowning behaviours can also be a side effect of a combination of medication and in some cases the wearing off of pharmaceuticals meant to manage dementia symptoms (Smalbrugge et al., 2017). Several medications may induce restlessness, akathisia or more serious movement disorders by causing extrapyramidal symptoms. For example, common side effects of Risperdal include; sudden often jerky involuntary motions of the head and arms. Other side effects include; dizziness, tiredness, fatigue and drowsiness. It is well known in literature that any pharmacological agents and a combination of different medications may induce cognitive, affective and behavioural changes in individuals with dementia (Janus et al., 2016). And to add to the complexity, the medications that are meant to manage the condition can also sometimes worsen the behavioural symptoms. Hypnotics, benzodiazepines and low potency antipsychotics are among the most widely used medication to manage behavioural issues related to sundowning. Side effects of such medicationsp include; akathisia, tardive dyskinesia and muscle rigidity.  Widely used benzodiazepines and other hypnotics to control agitation in elderly people with other comorbidities have been shown to create drug dependence, tolerance, and central and respiratory system depression.  Benzodiazepines have also been shown to cause paradoxical agitation and confusion in elderly individuals with pre-existing agitation who have sundowning syndrome (Nørgaard et al., 2017).  

Management of sundowning behaviours in dementia requires a multidisciplinary approach, and in these cases, there is no one size fit all approach. Management of behavioural symptoms requires a combination of pharmacological and non-pharmacological interventions. Nonpharmacological intervention should always be considered as first line and only use pharmacological agents as last resort. Tips for managing sundowning syndrome non pharmacologically include; limiting daytime napping and planning for daytime activities. Also, exposure to light during the day to encourage night-time sleep, maintaining a predictable routine for bedtime, waking and mealtimes. In the evening it is important to reduce background noise and other stimulating activities, including TV viewing. Other studies indicate that the use of melatonin, a natural hormone that helps with sleep may aid in the management of sleep disturbances in dementia. when medications to manage dementia symptoms are prescribed, it is essential to review their efficacy regularly.


References

Cipriani, G., Lucetti, C., Carlesi, C., Danti, S., & Nuti, A. (2015). Sundown syndrome and dementia. European Geriatric Medicine, 6(4), 375–380. https://doi.org/10.1016/j.eurger.2015.03.006

Janus, S. I. M., Manen, J. G. van, IJzerman, M. J., & Zuidema, S. U. (2016). Psychotropic drug prescriptions in Western European nursing homes. International Psychogeriatrics, 28(11), 1775–1790. https://doi.org/10.1017/S1041610216001150

Khachiyants, N., Trinkle, D., Son, S. J., & Kim, K. Y. (2011). Sundown Syndrome in Persons with Dementia: An Update. Psychiatry Investigation, 8(4), 275–287. https://doi.org/10.4306/pi.2011.8.4.275

Ma, M. A., & Morrison, E. H. (2020). Neuroanatomy, Nucleus Suprachiasmatic. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK546664/

Montag, C., Kannen, C., Lachmann, B., Sariyska, R., Duke, É., Reuter, M., & Markowetz, A. (2015). The importance of analogue zeitgebers to reduce digital addictive tendencies in the 21st century. Addictive Behaviors Reports, 2, 23–27. https://doi.org/10.1016/j.abrep.2015.04.002

Nørgaard, A., Jensen-Dahm, C., Gasse, C., Hansen, E. S., & Waldemar, G. (2017). Psychotropic Polypharmacy in Patients with Dementia: Prevalence and Predictors. Journal of Alzheimer’s Disease, 56(2), 707–716. https://doi.org/10.3233/JAD-160828

Reddy, S., Reddy, V., & Sharma, S. (2020). Physiology, Circadian Rhythm. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519507/

Sahoo. (n.d.). Sensory deprivation leading to late onset psychosis. Retrieved June 27, 2020, from http://www.jgmh.org/article.asp?issn=2348-9995;year=2016;volume=3;issue=2;spage=168;epage=171;aulast=Sahoo

Shenker, J. I., & Singh, G. (2017). Sleep and Dementia. Missouri Medicine, 114(4), 311–315.

Smalbrugge, M., Zwijsen, S. A., Koopmans, R. C. T. M., & Gerritsen, D. L. (2017). Challenging Behavior in Nursing Home Residents with Dementia. In S. Schüssler & C. Lohrmann (Eds.), Dementia in Nursing Homes (pp. 55–66). Springer International Publishing. https://doi.org/10.1007/978-3-319-49832-4_5

Wu, Y.-H., & Swaab, D. F. (2005). The human pineal gland and melatonin in aging and Alzheimer’s disease. Journal of Pineal Research, 38(3), 145–152. https://doi.org/10.1111/j.1600-079X.2004.00196.x

The impact of Colonialism on the Mental Health of Indigenous Australians

Between 2017-18, 9.9 billion dollars was spent in mental health and 4.3 million people received mental health services (Mental Health Services in Australia, Prevalence, Impact and Burden, 2019). The proportion of older Australians is increasing and so is the life expectancy, which means an overall increase in chronic illnesses. The prevalence of dementia in Aboriginal and Torres Islander communities is 2 -5 times higher than that of non-Aboriginal Australians (The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples, 2015).  There several factors that are said to contribute to this disturbing trend. For example, Aboriginal and Torres Strait Islanders, tend to have double the rates of traumatic injury, higher rates of smoking and have a markedly higher incidence of chronic illnesses such as diabetes, cardiovascular and renal diseases. Which are all known contributing factors to the development of dementia. The terms mental disorder can be used to describe a wide range of mental and behavioral disorders. The disorders can vary in duration and severity and can interfere with the individuals cognitive, behavioral and emotional abilities (Mental Health Conditions and Disorders, 2019).


         Dementia is a term used to describe a group of similar symptoms characterized by a gradual impairment of brain function. The changes due to this condition may affect memory, speech, cognition, behaviors and thought. In 2017, dementia was the second leading cause of death and is expected to affect up to 550,000 people by 2030 (Dementia Overview, 2017).  Finding nonpharmacological ways to  manage behavioral issues is essential to improving the overall quality of life for people with dementia (Barton et al., 2016). On top of experiencing neuropsychiatric symptoms which are known to occur universally over the many stages of dementia (Lyketsos, 2015). Indigenous people face an added stress of lack of access to good evidence based culturally sensitive care (Calma et al., 2017).  A wide range of behavioral issues have been reported, these include depression, apathy, psychosis, and agitation. Challenging behaviors are common in dementia and they are the main reasons why individuals are placed in care homes (Lyketsos, 2015). This paper will look at some of the barriers that hinder the delivery of mental health services among Aboriginal and Torres Strait Islanders.

         Studies now show that Aboriginal and Torres Strait Islander mental health and psychological issues can be attributed to cultural genocide and colonisation. The health and psychological issues seen in the Australian indigenous population can also be observed in other indigenous peoples that went through colonisation (Dudgeon et al., 2017).   Colonisation and its disruption of culture, family, and community life through dispossession, often through violent means such as the stolen generation have affected the subsequent generations of Aboriginal and Torres Strait Islanders (Aboriginal and Torres Strait Islander Stolen Generations and Descendants, 2019).  Aboriginal and Torres Strait Islanders who were removed from their families as children during the stolen generation, experience significant social and health disadvantages.

According to a survey done by the Australian Bureau of Statistics, 1 in 10 indigenous people bone in 1972, reported being removed from their families. 56% where females and the majority live in non-remote areas (Aboriginal and Torres Strait Islander Stolen Generations and Descendants, 2019). The majority live in New South Wales and in Western Australia. Two thirds are aged 50 and over, while 20% are over the age of 65. There is now substantial literature on the impact, trauma, and more broadly colonialisation has had on indigenous cultures. Common manifestations include, alcohol and substance abuse, interpersonal violence, homelessness and a disruption in meaningful social relations (Children & Young People – Healing, 2020).  Suicide has also been linked to the cultural disruption as a result of colonisation. In Australia the descendants of the stolen generation are more likely to be incarcerated in the last five years and 1.8 times as likely to rely on government payments as their main source of income. They are also more likely to experience discrimination when looking for employment.  Studies indicate that racism and the broader context of social exclusion has a negative effect on the general mental health and wellbeing of indigenous peoples (Dudgeon et al., 2017).  


         The reasons for the gap in poor health outcomes between indigenous and non-indigenous people are complicated. For Example, Calma et al., 2017, found that there is a difference in the conception of health between Indigenous people and non-indigenous people. Western medicine by in large, favors the biomedical model of health as opposed to the social model of health. The biomedical model of health focuses on the biological aspects of the disease, while the social model analyses the social aspects of health. The social model of health explores some of the issues that may lead to the health outcome (Lacasse et al., 2019). Aboriginal and Torres strait islanders view the individual as part of the community or the tribe. An individual’s physical, emotional and mental wellbeing is connected and cannot be isolated (LoGiudice, 2016). According to the National Institute of Health and Welfare, social determinants of health are responsible for 31% of the health gap ( Determinants of Health, 2016). For example, the levels of depression tend to be low in individuals with a good social and community structure (Social Isolation and Loneliness, 2019). In most African cultures, in the first months post-delivery of the baby. It is part of the tradition for the youngest sister, cousin or even the grandmother, to live with the mother of the infant, ideally until the baby is big enough to eat solids. There main Job is to help with household duties like cooking and cleaning or look after the other children, the Job of the new mother is then to eat, sleep, and breastfeed. 

         Social and emotional support structures are also needed for persons with dementia (Barton et al., 2016). A person with dementia can still lead a good quality life, but without input from family members it is difficult for them to achieve purpose and pleasure (Ferreira et al., 2020). There are several ways to plan and provide appropriate activities for people with dementia. Care should compensate for lost abilities, promote self-esteem, maintain residual skills, provide an opportunity for social contact, and care must be culturally sensitive for Indigenous and ethnically diverse groups (Li, 2017). One-way care homes can mitigate for this is, they could provide clinicians that are either Aboriginals or are from ethnic diverse communities. Another way is through access to health care workers with the same gender or if possible, facilities try and not allocate the care staff younger than 30 to help the elderly with activities of daily living like showers. Studies indicate that when there is lack of culturally responsive care, health outcomes are much poorer. Improving cultural responsiveness can, not only remove the barriers to accessing health care services but may also improve the general quality of life for Aboriginal and Torres strait Islanders (Gomersall et al., 2017).


References

Aboriginal and Torres Strait Islander Stolen Generations and descendants: Numbers, demographic characteristics and selected outcomes, Table of contents. (n.d.). Australian Institute of Health and Welfare. Retrieved June 12, 2020, from https://www.aihw.gov.au/reports/indigenous-australians/stolen-generations-descendants/contents/overview

Australia’s health 2016, Chapter 4 Determinants of health. (n.d.). Australian Institute of Health and Welfare. Retrieved June 21, 2020, from https://www.aihw.gov.au/reports/australias-health/australias-health-2016/contents/chapter-4-determinants-of-health

Barton, C., Ketelle, R., Merrilees, J., & Miller, B. (2016). Non-pharmacological Management of Behavioral Symptoms in Frontotemporal and Other Dementias. Current Neurology and Neuroscience Reports, 16(2), 14. https://doi.org/10.1007/s11910-015-0618-1

Calma, T., Dudgeon, P., & Bray, A. (2017). Aboriginal and Torres Strait Islander Social and Emotional Wellbeing and Mental Health. Australian Psychologist, 52(4), 255–260. https://doi.org/10.1111/ap.12299

Cameron, E. (2015). Is It Art or Knowledge? Deconstructing Australian Aboriginal Creative Making. Arts, 4(2), 68–74. https://doi.org/10.3390/arts4020068

Children & young people—Healing. (n.d.). Australian Indigenous HealthInfoNet. Retrieved June 20, 2020, from https://healthinfonet.ecu.edu.au/learn/health-topics/healing/children-young-people/

Dementia Overview. (n.d.). Australian Institute of Health and Welfare. Retrieved June 20, 2020, from https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/dementia/overview

Dudgeon, P., Bray, A., D’Costa, B., & Walker, R. (2017). Decolonising Psychology: Validating Social and Emotional Wellbeing. Australian Psychologist, 52(4), 316–325. https://doi.org/10.1111/ap.12294

Ferreira, A. R., Simões, M. R., Moreira, E., Guedes, J., & Fernandes, L. (2020). Modifiable factors associated with neuropsychiatric symptoms in nursing homes: The impact of unmet needs and psychotropic drugs. Archives of Gerontology and Geriatrics, 86, 103919. https://doi.org/10.1016/j.archger.2019.103919

Gomersall, J. S., Gibson, O., Dwyer, J., O’Donnell, K., Stephenson, M., Carter, D., Canuto, K., Munn, Z., Aromataris, E., & Brown, A. (2017). What Indigenous Australian clients value about primary health care: A systematic review of qualitative evidence. Australian & New Zealand Journal of Public Health, 41(4), 417–423. https://doi.org/10.1111/1753-6405.12687

Health. (n.d.). Quality of Care Amendment (Minimising the Use of Restraints) Principles 2019 (au). Attorney-General’s Department. Retrieved April 26, 2020, from https://www.legislation.gov.au/Details/F2019L00511/Html/Text, http://www.legislation.gov.au/Details/F2019L00511

Lacasse, M., Douville, F., Gagnon, C., Simard, C., & Côté, L. (2019). Theories and Models in Health Sciences Education—A Literature Review. Canadian Journal for the Scholarship of Teaching and Learning, 10(3).

Li, J.-L. (2017). Cultural barriers lead to inequitable healthcare access for aboriginal Australians and Torres Strait Islanders. Chinese Nursing Research, 4(4), 207–210. https://doi.org/10.1016/j.cnre.2017.10.009

Lindeman, M., Mackell, P., Lin, X., Farthing, A., Jensen, H., Meredith, M., & Haralambous, B. (2017). Role of art centres for Aboriginal Australians living with dementia in remote communities. Australasian Journal on Ageing, 36(2), 128–133. https://doi.org/10.1111/ajag.12443

LoGiudice, D. (2016). The health of older Aboriginal and Torres Strait Islander peoples. Australasian Journal on Ageing, 35(2), 82–85. https://doi.org/10.1111/ajag.12332 Lyketsos, C. G. (2015). Neuropsychiatric Symptoms in Dementia: Overview and Measurement Challenges. The

Health Check: What is Delirium?

About 10% of Australians over the age of 70 have delirium at the time of admission to the hospital, and a further 8% will develop delirium while in hospital. The incidence of delirium is higher in certain hospital wings, with more than 30% of patients with delirium following hip or cardiac surgery (Delirium Clinical Care Standard | Australian Commission on Safety and Quality in Health Care, 2019). Delirium is defined as an cute impairment in the global cognitive function that develops over a short period of time and tends to fluctuate during the day. Delirium represents a decomposition of cerebral function in response to one or more pathological stressors. People with delirium have an increase risk of death, falls and have a greater chance of developing dementia. (Gual et al., 2018) in a study done in a subacute unit found that, dementia was one of the main risk factors for delirium and delirium itself led to poor clinical and functional outcomes. Another cause of delirium in the elderly is infection. (Kuswardhani & Sugi, 2017) found infection to be an important cause of delirium in elderly patients. In the elderly patients with infection, the a high IL-6 and sepsis have a strong relationship with the severity of delirium. Interleukin-6 (IL-6)is a protein that is produced by a number of cells, it helps regulate immune response, it can be elevated with inflammation, infection, autoimmune disorders, CV diseases, and some cancers (O’Reilly et al., 2013). Delirium can often be  traced to one or more contributing factors, such as  chronic illness, changes to metabolic imbalance, medication, infection , and drug intoxication or withdrawal (Top Four Evidence-Based Nursing Interventions for Delirium.: Library Search, 2017).


       Delirium can also be considered a disorder of consciousness as experience is altered. During the state of delirium, delusions and hallucinations may occur as the patients experience their own alternate reality (Sanders, 2011).  Delirium presents with a wide range of symptoms and a continuum of psychomotor behaviours. Hypoactive delirium is characterised by apathy, decreased responsiveness, and withdrawal. Hypoactive delirium tends to receive less clinical attention than hyperactive delirium. Like all deliriums it can happen in a variety of patients and settings, it can be more difficult to recognise and is associated with worst outcomes than hyperactive delirium. Hyperactive delirium is characterised by restlessness, agitation, and emotional liability.  Because patient with hyperactive delirium are at increased risk of self-harm, they tend to be perceived as higher risk by clinical staff (Hosker & Ward, 2017).

         Drugs have widely been associated with the development of delirium in the elderly and they represent the most common reversible cause of this condition. Knowing this is important because treatment of delirium is dependent on identifying the underlying cause. Medication known to increase the risk of delirium in the elderly include; anticholinergic, tranquilizers, pain killers, and narcotics. For example, in the elderly disopyramide which has a strong anticholinergic effect can induce delirium (Alagiakrishnan & Wiens, 2004). As people age, there is a general reduction in the renal clearance, sometimes even in normal doses medications such as digoxin can accumulate and cause delirium.  Also, medications like diuretics can cause delirium due to dehydration and electrolyte imbalance. Another risk factor in the elderly, is polypharmacy, studies indicate that the number of medications the elderly take is a risk factor for delirium (Nikooie et al., 2019). This is because residents using a lot of medications tend to have a significant number of co-morbidities. Sometimes it is due to the way drugs interact in the body. For example, heart failure patients are at increased risk of delirium. Patients with heart failure have reduced metabolism due to hepatic congestion and reduced elimination of drugs caused by renal insufficiency. Also, in stroke and dementia patient there is an impairment of the blood brain barrier integrity. This allows more and more, potentially toxic drugs to reach the brain. Because of the relative increase in fat mass as people age, medications that have a high affinity to fat, tend to have increased volume of distribution. Which then affects how long it takes for half of the drug to be eliminated (Alagiakrishnan & Wiens, 2004).

        Several global systems are thought to be involved in the development of brain dysfunction. There are several neurotransmitters believed  to be involved in the development of delirium, these include; acetylcholine, serotonin, dopamine, and gammaaminobutyric acid. Areas of the body that are most sensitive to changes in the neurotransmitters are the cerebral cortex, striatum, substantia nigra, and thalamus (Ali et al., 2011).  When there is a neurotransmitter imbalance through disease or psychoactive medication, thalamic dysfunction may lead to sensory overload and hyperarousal. For example, dopamine is responsible for regulating mood, behaviour and cognitive function. In general, a deficiency in dopamine causes extrapyramidal symptoms such as restlessness, muscle rigidity, and tremors. While an excess in dopamine is associated with a range of psychotic disorders. A deficiency or excess of dopamine in delirium may be associated with hypoactive or hyperactive subtypes of delirium (Smith et al., 2009).       

       Management of delirium requires a fast identification of the cause and good supportive care therapy. Pharmacological management of delirium is usually not needed and should never be used as the first line management (Delirium and Behaviourally Disturbed Older Patients – Management | Emergency Care Institute, 2017).   Food and fluid intake should be given carefully, because the patient may be unwilling or physically not able to maintain a balanced intake.  For individuals suspected of having alcohol toxicity or withdrawal, therapy should include multivitamins, especially thiamine. The environment should also be stable, quiet, well lit, and discourage daytime napping to aid night- time sleep. In addition, re-orientation techniques or memory cures such as calendar, large clocks, and family photos may also be helpful.  The aim of nursing management for delirium is to maintain agitation at manageable levels and prevent the patient from becoming violent. And to also prevent the patient from harming themselves and others (Victoria State Government, 2020).

       If nonpharmacological interventions and verbal de-escalations are not successful, use of medications may be necessary. Once’s prescribed these medications must be evaluated frequently, especially in people with dementia.  All available antipsychotics and benzodiazepines are listed as potentially inappropriate, even at low doses. These medications may increase adverse effects such as prolonged sedation or paradoxical agitation in older patients (Shenvi et al., 2020).   (Nikooie et al., 2019) in a systematic review on the use of antipsychotics for the management of delirium found that, there routine use for treatment of delirium in adult patient did not improve patient outcome. The study review further found that, even though there was little evidence for neurological harm, antipsychotics   had a tendency for more frequent and potentially serious cardiac effects. When medications are used for agitation in delirium patients the aim is not sedation, but rather sufficient treatment for safe symptoms management (Shenvi et al., 2020).


Delirium V Dementia

In order to make a diagnosis of dementia, delirium must be ruled out. However, individuals with dementia are at increased risk of delirium and in some cases, they may have both (Dementia and Delirium, 2020).

Conclusion

This paper has covered what delirium is, the role the dopaminergic system has in the development of delirium and the effect certain medications, infections, and chronic illnesses have in the development of delirium in the elderly. The paper looks at some ways to manage delirium, both pharmacologically and non-pharmacologically. The paper ends by looking at some of the differences between delirium and dementia. It is important to remember that if delirium is suspected, seek medical help straight away.

References  

Alagiakrishnan, K., & Wiens, C. (2004). An approach to drug induced delirium in the elderly. Postgraduate Medical Journal, 80(945), 388–393. https://doi.org/10.1136/pgmj.2003.017236

Ali, S., Patel, M., Jabeen, S., Bailey, R. K., Patel, T., Shahid, M., Riley, W. J., & Arain, A. (2011). Insight into Delirium. Innovations in Clinical Neuroscience, 8(10), 25–34.

Delirium and Behaviourally Disturbed Older Patients—Management | Emergency Care Institute. (n.d.). Retrieved June 22, 2020, from https://www.aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/aged-care/delirium-and-management-of-behaviourally-disturbed-older-patients/delirium-and-behaviourally-disturbed-older-patients—management

Delirium Clinical Care Standard | Australian Commission on Safety and Quality in Health Care. (n.d.). Retrieved June 24, 2020, from https://www.safetyandquality.gov.au/our-work/clinical-care-standards/delirium-clinical-care-standard

Dementia and Delirium. (n.d.). Retrieved June 24, 2020, from https://www.hopkinsmedicine.org/gec/series/dementia.html

Gual, N., Morandi, A., Pérez, L. M., Brítez, L., Burbano, P., Man, F., & Inzitari, M. (2018). Risk Factors and Outcomes of Delirium in Older Patients Admitted to Postacute Care with and without Dementia. Dementia & Geriatric Cognitive Disorders, 45(1/2), 121–129. https://doi.org/10.1159/000485794

Hosker, C., & Ward, D. (2017). Hypoactive delirium. BMJ, 357. https://doi.org/10.1136/bmj.j2047

Kuswardhani, R. A. T., & Sugi, Y. S. (2017). Factors Related to the Severity of Delirium in the Elderly Patients With Infection. Gerontology and Geriatric Medicine, 3. https://doi.org/10.1177/2333721417739188

Nikooie, R., Neufeld, K. J., Oh, E. S., Wilson, L. M., Zhang, A., Robinson, K. A., & Needham, D. M. (2019). Antipsychotics for Treating Delirium in Hospitalized Adults: A Systematic Review. Annals of Internal Medicine, 171(7), 485–495. https://doi.org/10.7326/M19-1860

O’Reilly, S., Cant, R., Ciechomska, M., & van Laar, J. M. (2013). Interleukin-6: A new therapeutic target in systemic sclerosis? Clinical & Translational Immunology, 2(4), e4. https://doi.org/10.1038/cti.2013.2

Sanders, R. D. (2011). Hypothesis for the pathophysiology of delirium: Role of baseline brain network connectivity and changes in inhibitory tone. Medical Hypotheses, 77(1), 140–143. https://doi.org/10.1016/j.mehy.2011.03.048

Services, D. of H. & H. (n.d.). Preventing and managing delirium in older people in hospital. Department of Health & Human Services. Retrieved June 24, 2020, from https://www2.health.vic.gov.au:443/hospitals-and-health-services/patient-care/older-people/cognition/delirium/delirium-preventing

Shenvi, C., Kennedy, M., Austin, C. A., Wilson, M. P., Gerardi, M., & Schneider, S. (2020). Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Annals of Emergency Medicine, 75(2), 136–145. https://doi.org/10.1016/j.annemergmed.2019.07.023

Smith, H. A. B., Fuchs, D. C., Pandharipande, P. P., Barr, F. E., & Ely, E. W. (2009). Delirium: An Emerging Frontier in Management of Critically Ill Children. Critical Care Clinics, 25(3), 593–x. https://doi.org/10.1016/j.ccc.2009.05.002

Top Four Evidence-Based Nursing Interventions for Delirium.: Library search. (n.d.). Retrieved June 22, 2020, from https://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?vid=2&sid=99a69e7e-9293-498a-b86f-8a2a4237ea2d%40pdc-v-sessmgr06

What is A Reconciliation Action Plan and why it is important to improving Nursing practice

       A Reconciliation Action Plan (RAP), is a document that outline a framework for how individual organisations will help with the national reconciliation effort. It has practical actions that will drive an organisation’s contribution to reconciliation both within, and in the community in which it operates. The RAP helps to advance the five areas of reconciliation by supporting organisations develop; respect, create meaningful opportunities, and relationships with Aboriginal and Torres Islander people through collaboration.  Improving health conditions for Aboriginal and Torrs Islander people is a long-standing challenge in Australia (Reconciliation Action Plan, 2018). The gap in health status between Indigenous and non-indigenous people remains wide. For example, the maternal and perinatal outcomes for indigenous mothers is poorer than those of non-indigenous women. The death rates for indigenous individuals are much higher than non-indigenous population across all age groups (Health, 2018).  The reasons for this a multidimensional and complicated, some are social cultural, and others are institutional. The aim of this paper is to analyse how the RAP currently used by Anglicare, helps promote reconciliation and the impact it has had in reducing the health inequality in Australia. The main areas of for analysis are collaboration and building respectful and meaningful relationships.  This paper will also analyse how Anglicare plans on fostering a culture of mutual love and respect in their own organisation (Anglicare rap, 2017).

Summary

      The Anglicare reconciliation plan has three main overarching areas, these include; relationships, respect, and opportunities. In dealing with relationships, Anglicare is committed to developing effective collaborative relationships with Aboriginal and Torres islander people.  Relationships that are mutually beneficial between indigenous people and non-indigenous peoples.  This means listening to Aboriginal and Torres Islander peoples, so that the programs that are developed, reflects the needs the individual indigenous communities that Anglicare operates in. Secondly, Anglicare is committed to respecting Aboriginal and Torres islander cultures, land, and history.  The hope is that through Aboriginal cultural awareness and collaboration, meaningful relationships can be built. Thirdly, the RAP, values knowledge, understanding, experience, and relationships that are held by aboriginals and Torres islander people.

      Increasing opportunities for indigenous people within the organisation would bring new ways of viewing and solving complicated issues among Aboriginal and Torres Islanders. Fixing health inequality due to lack of access to medical care in Aboriginal communities should not be viewed as a simple case of spending more money and building more hospitals to bridge the gap (Mclean et al., 2019). In many communities with access to hospitals, there is still a gap in access to health care services. Reasons for this are many, ranging from mistrust due to colonialisation and the stolen generation. Also, there is a difference in the perception of health between Indigenous people and non-indigenous people. Hence closing the gap must be done in collaboration and building meaningful relationships with local Aboriginal and Torres Islander community elders. There is often a difference in perception of needs and the actual needs of the community (Aboriginal and Torres Strait Islander Concept of Health – Cultural Ways, 2020). Having Aboriginal and Torres Islander elders on the advisory board, ensures that the services developed, are culturally sensitive and reflect the needs of the community (Mclean et al., 2019). Other areas addressed in the Anglicare RAP include; continuous education among Anglicare staff in Aboriginal and Torres islander cultural practices. And having people on their staff that represents the people being cared for. This is done through having a weekly recruitment list of positions on offer which is sent to the aboriginal liaison (Anglicare rap, 2017).

The Framework

      One way the RAP contributes to the reconciliation process, is through building respectful programs in partnership with aboriginal community leaders.  It has done this through the development of an in-house cultural capability program in partnership with Indigenous staff and local elders. The cultural competence programs are based on the specific communities in which Anglicare operates and are facilitated by aboriginal staff. The programs are developed and tailored to meet specific barriers to accessing services in Aboriginal and Torres Islander communities. Another way the RAP contributes to the conciliation process is through Anglicare’s commitment to employing Aboriginal and Torres islander people. This is done through a weekly recruitment list of positions which are sent to the Anglicare liaison and then forwarded to the communities that Anglicare operates. These include Aboriginal health services, local Aboriginal land councils, and Aboriginal workers in Centrelink offices. The list also includes Aboriginal and Torres Islander artwork to attract Aboriginal and Torres Islander applicants. Finally, the RAP contributes to the reconciliation process through its commitment to celebrating Aboriginal art and culture in all its beauty.

     A key part of the RAP is forming meaningful relationships, with Aboriginal and Torres islander community leaders. Anglicare plans on doing this through having an Aboriginal and Torres islander advisory board.  The aim of building relationships is to understand the values and cultures of the communities. Understanding the culture would help the government authorities and health care workers develop health care programs that suit specific Aboriginal and Torres Islander communities. The RAP plans on achieving this through making sure that the organisation has Aboriginal and Torres Islander peoples on the working group.  This helps the organisation develop a framework for the delivery of health care that is targeted to communities. Collaboration with Indigenous leaders in matters of health, will help health care workers become embedded in the culture and traditional practices (Anglicare rap,2017).

Area of Improvement

      While the RAP does well at emphasising the need for collaboration and education in aboriginal culture, there is however no clear plan on how this will be integrated in the general Anglicare organisation. Learning about the culture is a lot different from living in the culture. For example, when, Zambia got its independence from Britain. The first head of state mandated that people would not go to school in their own town or tribe, this forced people to integrate. So, over the years through integration, people have intermarried within tribes that most Zambians do not know with accuracy which tribe they belong to. This is another way of forced integration and is like the busing legislation after Brown v Board of Education in America. Busing was a way the supreme court sort to remedy racial injustice by forcing integration in schools. Initially people did not like it, but over the years people have gotten used to it. And while there is still a lot of work to be done, America is a lot less segregated than before busing (History – Brown v. Board of Education Re-Enactment, 2019).  People tend to hate or are fearful of what they do not know. Anglicare could put as part of the general yearly competence that all Anglicare staff work in Aboriginal communities or have a roaster that is on a rotational basis. This would enable nonindigenous health care providers to experience the culture, learn the language and hopefully develop better ways of communicating with aboriginal and Torres Islander people.

 Area of Focus

       The area of focus for analysis is Respect.  Anglicare is committed to respecting aboriginal and Torres Islander cultures, land and people. The aim is to develop relationships that are based on mutual love and respect.  Promoting indigenous culture and understanding the language barriers is essential for several reasons. Firstly, it will help health care professionals develop effective ways care of indigenous people can be continually improved.  For example, Aboriginal cultures and Torres islander tend to value building and maintaining relationships (Communicating Effectively with Aboriginal and Torres Strait Islander People, 2016). Taking the individual before business approach will help form this relationship and build trust (Cabinet, 2016). Often when a staff member builds trust with the whole family, it is a good indication of how well the individual will respond to the service offered. In health care the first few minutes of meeting a patient are essential for establishing trust and rapport. Therapeutic relationships that are characterised by trust, respect and rapport provide better care experiences for patient. A therapeutic relationship also, goes a long way in in alleviating anxiety and stress and enhances patient involvement in the decision-making process about their own health (Bell, 2016).

        Communication difficulties between health care workers and indigenous peoples are mostly pronounced in remote areas where cultural and linguistic differences are the greatest. The close interdependence of language and culture makes the gap even wider. Many rural Aboriginal and Torres islander cultures to not speak English as there first language. Some also speak a different English dialect. Some aboriginal cultures view direct eye contact as rude, disrespectful and even aggressive. In this case, to convey respect the health care provide would avert and even lower their eyes in conversation. It is important to point out in health that a clinician is not just caring for the patients with the illness but also the family. This is especially true in some Aboriginal cultures, where due to kingship structures and relationship, decision making usually includes the input of other family members (Aboriginal Culture and History – Aboriginal Cultural Capability Toolkit , 2019). A nurse must check with the patient if their decision requires consultation from other family members. This is especially important when having discussions about end of life or palliative care. There is often a lot of ritual around how Aboriginals and Torres islander people deal with death.  People that believe in the afterlife will often approach the dyeing process different from those that do not.  

Leadership Qualities

      The first leadership quality that is embedded in the RAP is respect. One of the main important areas of nursing is treating every patient with a sense of dignity and respect  (Nursing and Midwifery Board of Australia – Fact Sheet, 2019). In health care making patients feel respected or valued is complex and multifaceted. This involves more than just recognising the autonomy of the individual. While the definition of respect is different for every patient. Most patients believe that  respecting people involves the following elements; empathy, autonomy, provision of information, recognition of individuality , worth and attention to the needs of the individual (Clark, 2019). (Mansel & Einion, 2019) found, empathy to be an inherent expectation that patients expect from health care workers. Empathy is a connection and it is all about letting people know that they matter. Having a collaborative relationship with the aboriginal and Torres islander community will hopefully create a culture of love and respect.

     Culturally safe and respectful practice forms part of the code of conduct for nurses in Australia. Under the code of conduct, a nurse while caring for patients must acknowledge that social, economic, cultural, historic and behavioural factors will have an impact on health. Both at an individual, community and population level. A nurse must also understand that only the person / the family being treated can determine whether or not the care being provided is culturally safe (Nursing and Midwifery Board of Australia – Fact Sheet, 2019). It is important to be mindful of not viewing Aboriginal and Torres Islanders as a monolith. While there is over 200 different Aboriginal and Torres islander cultures, each with distinctive traditional practices. It is essential for a health care worker to also realise that at the heart of the community or family is the individual. But the individual must be cared for as part of the community. The Aboriginal conception of the individual is in relation to the community, tribe, the land and the spiritual beings of the lore. An individual’s physical, emotional, social, spiritual and cultural needs and wellbeing is intrinsically connected and cannot be separated. Hence for any care strategy to be effective, it must not just treat the individual, but the family as well. For example, when developing a care plan to manage diabetes and for it to be effective. The care plan and implementation must focus on educating the whole family about what it means to have healthy eating habits ( Aboriginal Culture and History – Aboriginal Cultural Capability Toolkit, 2019). 

       The third leadership quality that is implicit in the RAP is communication. For any change to be effective, engagement and collaboration through clear purposeful communication is important. Good communication between nurses and patients is essential for successful health outcomes (Tuohy, 2019). To achieve this, the nurse must understand and help their patients, demonstrating curtsey, kindness and sincerity. Communication is an intrinsic human need; it can be verbal or non- verbal. Conflict and bad health outcomes can come from a breakdown in communication. Good communication between health care professionals and the patients they serve helps build meaningful relationships. In a multicultural society good personal relationship means the nurses communicate with kindness and provide information in a way that is non-judgemental. Communication that demonstrates interest and feeling of acceptance, trust and harmonias relationships. A therapeutic relationship is an essential prerequisite to effective communication between nurses and patients in order not only to give information, but also to effectively deal psychological processes which are triggered by it. The communication between health care workers and patients include the ability to voice concern for the care of the patient and the individual becomes a part of the care strategy (Mansel & Einion, 2019).

Effective communication Strategies

       Nurses must recognise that aboriginal and Torres islander people have different ways they communicate. It is important to realise when communicating with indigenous people that the nurse must choose strategies that makes the patient comfortable. For example, direct eye contact during communication is considered as rude.  The nurse needs to be aware of the patient’s body language and their own body language. It is also important not use a lot of complicated terms and the instruction that is simple and clear.  For example (Amery, 2017) found that many Yolnu and speakers of other indigenous languages do not comprehend the concept of percentages. A shading of the kidney was done showing 2% functioning and the other scalarised. The patient responded with shock and had a better dialysis participation. In addition, storytelling is an essential part of the aboriginal culture, from a very young age, stories play a role in educating children about life. Story telling is a way of sharing and interpreting experiences and can be effective way of communicating with indigenous people.

Conclusion

       Understanding Aboriginal and Torres Islander cultures will improve the nurse’s interaction and communication with patients. For example, knowing that aboriginal and Torres islander cultures prefer indirect approach to questioning, helps in the assessment of health issues. Direct questioning may lead to misunderstanding, discourage participation and make obtaining of information hard. This also means that it is important for health care professionals serving in Aboriginal and Torres Islander communities know the aboriginal basic language. Aboriginal and Torres islander leaders also play an important role in advising effective communication strategies when developing health promotions.

References

Aboriginal and Torres Strait Islander concept of health—Cultural Ways. (2020). Australian Indigenous HealthInfoNet. Retrieved June 7, 2020, from https://healthinfonet.ecu.edu.au/learn/cultural-ways/aboriginal-and-torres-strait-islander-concept-of-health/

Aboriginal Culture and History—Aboriginal Cultural Capability Toolkit. (2019). VPSC. Retrieved June 6, 2020, from https://vpsc.vic.gov.au/html-resources/aboriginal-cultural-capability-toolkit/aboriginal-culture-history/

Aboriginal Culture and History—Aboriginal Cultural Capability Toolkit—VPSC. (n.d.). Retrieved June 6, 2020, from https://vpsc.vic.gov.au/html-resources/aboriginal-cultural-capability-toolkit/aboriginal-culture-history/

Amery, R. (2017). Recognising the communication gap in Indigenous health care. The Medical Journal of Australia, 207(1), 13–15. https://doi.org/10.5694/mja17.00042

Anglicarerap_may2017.pdf. (n.d.). Retrieved June 6, 2020, from https://www.anglicare.org.au/media/3258/anglicarerap_may2017.pdf

Bell, J. M. (2016). The Central Importance of Therapeutic Conversations in Family Nursing: Can Talking Be Healing? Journal of Family Nursing, 22(4), 439–449. https://doi.org/10.1177/1074840716680837

Cabinet, P. M. and. (2016, May 25). Communicating with Aboriginal and Torres Strait Islander Audiences [Text]. https://www.pmc.gov.au/resource-centre/indigenous-affairs/communicating-aboriginal-and-torres-strait-islander-audiences

Clark, C. M. (2019). Fostering a Culture of Civility and Respect in Nursing. Journal of Nursing Regulation, 10(1), 44–52. https://doi.org/10.1016/S2155-8256(19)30082-1

Communicating effectively with Aboriginal and Torres Strait Islander people. (2020). 2.

Health, A. G. D. of. (2018, June 5). Pregnancy care for Aboriginal and Torres Strait Islander women [Text]. Australian Government Department of Health; Australian Government Department of Health. https://www.health.gov.au/resources/pregnancy-care-guidelines/part-a-optimising-pregnancy-care/pregnancy-care-for-aboriginal-and-torres-strait-islander-women

History—Brown v. Board of Education Re-enactment. (2020). United States Courts. Retrieved June 6, 2020, from https://www.uscourts.gov/educational-resources/educational-activities/history-brown-v-board-education-re-enactment

Mansel, B., & Einion, A. (2019). “It’s the relationship you develop with them”: Emotional intelligence in nurse leadership. A qualitative study. British Journal of Nursing, 28(21), 1400–1408. https://doi.org/10.12968/bjon.2019.28.21.1400

Mclean, H., Naylor, N., Griffin, D., Simpson, R., Smith, C., Bonson, L., & Sharp, J. (2019). A Collaborative Approach To Engaging Aboriginal People In Their Health. Heart, Lung and Circulation, 28, S46. https://doi.org/10.1016/j.hlc.2019.05.119

Nursing and Midwifery Board of Australia – Fact sheet: Code of conduct for nurses and Code of conduct for midwives. (2019). Retrieved June 6, 2020, from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/Fact-sheet-Code-of-conduct-for-nurses-and-Code-of-conduct-for-midwives.aspx

Reconciliation Action Plan. (n.d.). Retrieved June 6, 2020, from https://www.wa.gov.au/government/publications/reconciliation-action-plan

Tuohy, D. (2019). Effective intercultural communication in nursing. Nursing Standard, 34(2). https://doi.org/10.7748/ns.2019.e11244

Health check: What is Anemia?

Anemia can be described as a reduction in the oxygen-carrying capacity of the blood. This is usually caused by a decrease in the levels of red blood cells. This causes a reduction in the ratio of the volume of RBC and a general decrease in hemoglobin.  Hemoglobin is a protein that is responsible for transporting oxygen in the blood. It is a molecule that is comprised of four subunits, each containing an iron atom bound to a haem group. The most common cause of anemia is due to iron deficiency. The body needs iron to make hemoglobin, if there is not enough iron, hemoglobin cannot be made. Anemia has three main causes, these include; blood loss, lack of red blood cell production and high rates of red blood cell destruction. Blood loss can lead to a condition called erythroid hyperplasia, which is a condition of excessive immature red blood cells. Erythroid hyperplasia is usually a compensatory condition which can be due to hemolytic anemia, iron deficiency anemia, thalassemia, thrombotic thrombocytopenic purpura (TTP) and erythromyeloid.  Loss of blood can be acute or chronic, in acute blood loss, if the person survives, the marrow replaces the RBC. Chronic is long-term anemia that happens when the Iron levels are depleted. This can happen as a result of GI bleeds (Anemia, 2019).


    Individuals can also develop anemias from the reduced production of RBC (erythropoiesis). These types of anemias arise as a result of a deficiency in substrates necessary for RBC production. For example, Megaloblastic anemias, arise from folate and vitamin B12 deficiency. They are characterized by the presence of megaloblasts in the bone marrow and macrocytes in the blood.  Megaloblastic anemia can also result from rare inborn errors of metabolism of folate and vitamin B12.  Symptoms include; muscle weakness, abnormal pale skin, swollen tongue, loss of appetite and a fast heart rate. Another example is pernicious anemia. Pernicious anemia results from lack of intrinsic factors that are normally produced by the parietal cells in the stomach. Intrinsic factors are important for the body’s synthesis of B12. Lack of Intrinsic factors is probably due to the autoimmune response to parietal cells.  Vitamin B12 is a water-soluble substance that is present naturally in some food and available as dietary supplements and prescription medication. Vitamin B12 exists in several forms and contains the mineral cobalt. B12 is required for proper RBC formation, neurological function and DNA synthesis. Vitamin B12 that is bound to protein is released by the action of hydrochloric acid and gastric protease in the stomach. When Vitamin B12 is added to fortified foods and dietary supplements, it is already in free form and does not require this separation step.  The main causes of vitamin B12 deficiency include; vitamin B12 malabsorption from food, postsurgical malabsorption and pernicious anemia (Office of Dietary Supplements – Vitamin B12, 2020).  


Types of Anemia

Hemolytic Anemia

    This type of anemia is caused by the destruction of the RBC prematurely. There are several types of hemolytic anemias, diagnosis is based on the underlying cause. Conditions that can lead to fast destruction of RBC include; sickle cell anemias, thalassemia and bone marrow failure. Also, it can be as a side effect of blood transfusion and medications such as cephalosporins, levodopa, levofloxacin and non-steroidal anti-inflammatory can cause hemolytic anemia.  Hemolytic anemia can develop suddenly or slowly, it can range from mild to severe. Signs and symptoms include; fatigue, dizziness, heart palpitation, pale skin, headaches, confusion, jaundice and enlargement of the spleen or liver (Drug-Induced Immune Hemolytic Anemia, 2019).  


Hereditary Spherocytosis

This is an autosomal dominant disorder, resulting in membrane defects or reduction in protein that codes for spectrin. Spectrin is a cytoskeletal protein that lines the intracellular side in eukaryotic cells. RBCs become spherical, less deformable and are more prone to destruction in the spleen. The cells lose their membranes spontaneously which results in them becoming spherical. They appear as small cells with small central areas missing when the cells are stained. There are four forms of hereditary spherocytosis, which are distinguished by the severity of symptoms. They are known as mild form, moderate form, moderate/severe form and the severe form (Hereditary Spherocytosis, 2019).


Sickle Cell Anemia

   This is a hereditary disease due to point mutation; the RBCs appear sickle shaped. This results in the chronic hemolytic state. The cell membrane is rigid and non-deformable. Results in the sickle cells being destroyed in the spleen. The average survival days of the sickle cells is 20 days, normal RBC lifespan is 115 days.   Microvascular occlusions also happen because the membrane is not elastic. This increases the chances of the RBC’s adherence to the endothelium of the capillaries which then cause blockage of the small vessels.

    The severity of symptoms will vary from person to person. Sickle cell anemia can lead to various serious acute and chronic conditions. For example, hemolytic crisis happens when there is an accelerated drop in the levels of hemoglobin, this is particularly common in people with coexisting G6PD deficiency. G6PD is an enzyme designed to produce reduced glutathione in the RBC monophosphate hexose pathway. Glutathione aids in the prevention of oxidative damage to the hemoglobin and other intracellular structures. Sickle cell anemia is most common in black people (Pernicious Anemia | National Heart, Lung, and Blood Institute (NHLBI), 2019).


Aplastic Anemia 

Happens because of damage to the stem cells inside the bone marrow, aplastic anemia can happen suddenly or slowly and can be mild or severe. Risk factors include; genetics, some medications and certain environmental toxins. The low levels of blood cells increase the likelihood of developing complications such as arrhythmias and heart failure. Other symptoms include; fatigue, easy bruising and infections that last for along time.  Treatment depends on the underlying cause, it may include; immunosuppressants, blood transfusion and bone marrow transplants (Aplastic Anemia | National Heart, Lung, and Blood Institute (NHLBI), 2019).  


References

Hanna, J., Wernig, M., Markoulaki, S., Sun, C.-W., Meissner, A., Cassady, J. P., . . . Jaenisch, R. (2007). Treatment of Sickle Cell Anemia Mouse Model with iPS Cells Generated from Autologous Skin. Science, 318(5858), 1920-1923. doi:10.1126/science.1152092

Fitzsimons, E. J., & Brock, J. H. (2001). The anaemia of chronic disease: Remains hard to distinguish from iron deficiency anaemia in some cases. BMJ: British Medical Journal322(7290), 811.

Beutler, E., & West, C. (2005). Hematologic differences between African-Americans and whites: the roles of iron deficiency and α-thalassemia on haemoglobin levels and mean corpuscular volume. Blood106(2), 740–745. http://doi.org/10.1182/blood-2005-02-0713

Anemia. (2019). [Text]. National Library of Medicine. Retrieved June 11, 2020, from https://medlineplus.gov/anemia.html

Aplastic Anemia | National Heart, Lung, and Blood Institute (NHLBI). (n.d.). Retrieved June 11, 2020, from https://www.nhlbi.nih.gov/health-topics/aplastic-anemia

Drug-induced immune hemolytic anemia: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved June 11, 2020, from https://medlineplus.gov/ency/article/000578.htm

Office of Dietary Supplements—Vitamin B12. (n.d.). Retrieved June 11, 2020, from https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/

Pernicious Anemia | National Heart, Lung, and Blood Institute (NHLBI). (n.d.). Retrieved June 11, 2020, from https://www.nhlbi.nih.gov/health-topics/pernicious-anemia

Reference, G. H. (2019.). Hereditary spherocytosis. Genetics Home Reference. Retrieved June 11, 2020, from https://ghr.nlm.nih.gov/condition/hereditary-spherocytosis


Part one

WHAT MAKES COCAINE SO ADDICTIVE AND DANGEROUS?

Cocaine is a psychoactive alkaloid of the coca plant; it was originally used for local surgeries as an anaesthetic but has now become a recreational drug. Unlike amphetamines, which resemble the structural formula of dopamine and noradrenaline, cocaine has a similar structure to other synthetic sedatives. Cocaine is well absorbed when administered via the mucous membranes, the GI tract and IV route. Peak concentration happens within five minutes after intravenous injection, while the peak levels from smoking are usually reached within 60 minutes. Some cocaine is excreted in urine unchanged, the majority is metabolized into benzoylecgonine, ecgonine methyl ester, norcocaine and other metabolites. Although cocaine has a short half-life, the elimination half-life of the metabolites lasts longer. Studies also show that the half-life of cocaine may increase the longer it is used.

Cocaine acts by enhancing the action of dopamine, it does this by blocking its reuptake into the nerve terminal via the transporter and thus increasing the amount of dopamine available. Dopamine is a neurotransmitter that helps control the brain’s reward and pleasure centres. Dopamine also helps regulate movement and emotional responses. It is a neurotransmitter that projects in many areas of the brain. Physiologically dopamine is involved in many essential functions, these include; cognition, movement and reward. Disruption in the dopaminergic system has been shown to lead to a wide range of symptoms. For example, Parkinson’s disease like symptoms can appear, such as tremors. These symptoms are marked by a change in cognitive function and mood. Studies show that people with low dopamine may be more prone to addiction. The presence of specific dopamine receptors is also associated with sensation seeking people (Verma, 2015).

Cocaine, like other drugs has a euphoric and sustained mood elevation effect on the individuals taking them. This is because cocaine produces its psychoactive and addictive effects on the limbic system.  The limbic system is a series of interconnected system in the brain that regulates pleasure and motivation. An initial short-term effect of taking the drug is euphoria caused by the build-up of dopamine, this causes the desire to take the drug again.  The more dopamine molecules meet the receptors the more the electrical properties of the receiving cells are altered. To keep the cells in each region of the brain functioning at appropriate intensities, neither too high or low, the dopaminergic cells continually increase and decrease the number of molecules they produce.  They further regulate the amount of dopamine by pulling some previously released dopamine into themselves.

 Cocaine interferes with this control mechanism, by tying the transporter molecule that dopaminergic cells use to retrieve dopamine from the surrounding cells. As a result of this, the dopamine that would otherwise be picked up remains in action  (Nestler, 2005). (About Glutamate Toxicity, 2011) found that changes involving genes occur in the limbic system, which is the main site for cocaine effects. The effects are enormous and long lasting and contribute significantly to the transition from drug abuse to addiction. Studies indicate that cocaine affects the expressions of several genes in the brain, including some that influence the important neurotransmitter glutamate and the body’s natural opioid like compounds (Nestler, 2005). Glutamate is a powerful neurotransmitter that is responsible for sending signals between nerve cells. Under normal condition it plays an essential role in learning and memory.

 Cocaine increases energy, self-confidence, promotes talkativeness, alleviates fatigue and enhances mental alertness. At high doses and during chronic use, feelings of euphoria may be replaced with restlessness, excitability, sleeplessness, loss of libido, nervousness, aggression, suspicion and paranoia, hallucinations, delusional thoughts, and large dilated pupils. Chronic cocaine use may lead to a range of cardiac complications. For example, acute myocardial infarction and myocardial ischemia are common. Cocaine blocks the sodium/potassium channels, which induces abnormal depressed cardiovascular profiles.  Use of cocaine together with alcohol increases cocaine levels in the blood. Cocaine stimulates the adrenergic system by binding to norepinephrine transporters. This results in an increased effects of norepinephrine effects on post synaptic receptor sites. Blocking norepinephrine reuptake induces tachycardia and hypertension.  Other studies indicate that the perpetual use of cocaine is associated with an increase of CV complications such as hypertension and coronary spasms.  Heart attack in constant cocaine use is thought to be caused by increased oxygen demand, vasoconstriction of the coronary artery, increased platelet aggregation and thrombus formation. Also, potential arrhythmias and dysrhythmias may occur (Kim & Park, 2019).

Other long-term complications include accelerated atherosclerosis, cardiomyocyte apoptosis, sympathoadrenal-induced myocyte damage, chronic arrhythmias, cardiac hypertrophy and dilated cardiomyopathy. Regular cocaine use has also been associated with many abnormalities in the vascular system of the brain, the most common are, haemorrhagic and thromboembolic strokes. Some people are more vulnerable to cocaine-induced excited delirium, symptoms include hyperthermia, extreme behavioral agitation and in some cases, violent behaviours. This may result in collapse or sudden cardiac death (Roberts, 2007).


 Illicit use of drugs In Australia
• In 2016, around 3.1 million Australians reported using an illegal drug.
• In 2016, the most common illegal drug was cannabis, followed by misuse of pharmaceuticals, cocaine, and then ecstasy.
• While overall use of methamphetamine has decreased, use of crystal methamphetamine (ice) continues to be a problem.
• People who are using crystal methamphetamine (ice), are using it more frequently which increases the risks and harms.


Source

Elsevier. (2018, May 31). Cocaine use alters gene expression in brain reward circuits: Study investigates transcriptome-wide alterations in response to cocaine self-administration in mice. ScienceDaily. Retrieved June 20, 2018 from http://www.sciencedaily.com/releases/2018/05/180531102706.htm

Winhusen, T. M., Lewis, D. F., Somoza, E. C., & Horn, P. (2014). Pharmacodynamics Must Inform Statistics: An Example from a Cocaine Dependence Pharmacotherapy Trial. ISRN Addiction2014.

About Glutamate Toxicity. (2011, June 26). HOPES Huntington’s Disease Information. https://hopes.stanford.edu/about-glutamate-toxicity/

Kim, S. T., & Park, T. (2019). Acute and Chronic Effects of Cocaine on Cardiovascular Health. International Journal of Molecular Sciences, 20(3). https://doi.org/10.3390/ijms20030584

Nestler, E. J. (2005). The Neurobiology of Cocaine Addiction. Science & Practice Perspectives, 3(1), 4–10.

Roberts, J. R. (2007). Acute Agitated Delirium from Cocaine: A Medical Emergency. Emergency Medicine News, 29(10), 18–20. https://doi.org/10.1097/01.EEM.0000296568.05338.c5

Verma, V. (2015). Classic Studies on the Interaction of Cocaine and the Dopamine Transporter. Clinical Psychopharmacology and Neuroscience, 13(3), 227–238. https://doi.org/10.9758/cpn.2015.13.3.227

An overview of the Clotting process

Hemostasis is a complex process that involves multiple interlinked steps. The aim of the cascade is to form a plug that closes the damaged site of the blood vessels, thereby controlling bleeding. It begins with injury in the lining of the blood vessels. The process can be split into four phases, this includes; constriction of the blood vessels, formation of the temporary platelet plug, activation of the coagulation cascade and formation of the fibrin plug or the final clot. There are numerous cells that are involved in the clotting cascade, most notably are the processes associated with the endothelium, platelets and hepatocytes (LaPelusa & Dave, 2020).


Vascular Phase.

Intact blood vessels are central to moderating the blood clotting tendencies. The endothelial cells of the intact vessels prevent the clotting process by expressing a fibrinolytic heparin molecule and thrombomodulin. This prevents platelet aggregation and stopes the coagulation cascade with nitric oxide and prostacyclin. When the blood vessels are cut, the smooth muscles of the blood vessels contract, in the area of the damage. The aim of vascular spasms is to reduce the flow of blood to the area by decreasing the diameter. The cells that line the inside of the blood vessels also contract, to expose the base lamina and the underlying collagen to blood cells. The endothelial wall becomes sticky so that the opposing walls can stick together and stop blood flow. The endothelium also releases hormones and growth factors which causes vascular spasms and induce cell division in the endothelial cells.


Platelet Phase

Thrombocytes stick to the collagen and the basal lamina, as the number of sticky platelets increase, they start to stick to each other forming a platelet plug that can close off the hole of the vessel. Platelet aggregation happens very fast, usually 15 seconds after the damage. The platelets are activated as they arrive at the site and release several factors, such as thromboxane A2 and serotonin (vascular spasm). They release clotting factors PDGF for blood vessel repair and ADP for stimulation and aggregation.  They also release ions for aggregation and clotting, all this happen as a positive feedback mechanism to produce a plug and ultimately a clot.

If the clotting process is unchecked it will continue to happen, but thankfully, we have prostaglandins that will stop the aggregation process. Here we also have inhibitors from the white blood cells as well as plasma enzymes that break down the ADP.

About 30 seconds after injury, the coagulation phase begins. Although a complex process the aim of the coagulation phase is to convert the circulating fibrinogen into fibrin strands, that forms a mesh over the plug. This traps the passing RBC and platelets to form a clot (LaPelusa & Dave, 2020).


Coagulation Phase

If the platelet plug is not enough to stop the bleeding, the third phase of Hemostasis begins. Platelets contain secretory granules. When they stick to the protein in the blood vessel walls, they degranulate. This causes the release of adenosine diphosphate ADP, serotonin, and thromboxane A2 (which activates other platelets). Each of the clotting factors has specific functions. For example, prothrombin is a protein that is produced by the liver. When there is damage to the blood vessels, the nearby platelets are stimulated to release prothrombin activator. The release of prothrombin activator helps activate the prothrombin into an enzyme called thrombin.  Thrombin helps facilitate the conversion of fibrinogen into fibrin (LaPelusa & Dave, 2020).

Intrinsic and Extrinsic clotting pathway. 

Extrinsic is initiated in the blood vessel wall by tissue factor, while intrinsic is in the bloodstream when factors XII contacts collagen fibres.  The two converge in the common pathway when enzymes from either pathway activate X. This forms prothrombinase which is converted into prothrombin and then to thrombin, converting fibrinogen to fibrin.

Clot Resolution

Activated platelets contract their internal actin and myosin fibrils in their cytoskeleton. This leads to shrinkage of the clot volume. Plasminogen then activate plasmin, which promotes breakdown of the fibrin clot. This restores the flow of blood in the damaged vessel.


Clinical note;

Thrombocytopenia 

This is a condition that is characterised by abnormally low levels of platelets. If the numbers of platelets fall below 50,000, this is a medical emergency, the normal range is between 150,000 to 450,000 platelets per microliter of blood. Thrombocytopenia often occurs as a result of a separate disorder such as leukaemia or immune system-related conditions. Or it can be as a result of taking certain types of medication that have been known to reduce the number of platelets. Some clinical presentations include; easy or excessive bruising (purpura), superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs and prolonged bleeding from cuts (Thrombocytopenia | National Heart, Lung, and Blood Institute (NHLBI), 2020).

Giant Pletelet Syndrome

This condition happens when the platelets lack the ability to stick adequately to the injured blood vessel walls, this results in abnormal bleeding. The condition usually presents in newborn, infancy or early childhood with bruises, nose bleeds and gum bleeding. later problems may occur with anything that induces bleeding such as menstruation, trauma, surgery or stomach ulcers. This disease is inherited, both parents must carry a gene for the syndrome and then transmit the gene to the child. There is no specific treatment for giant platelet syndrome, bleeding episodes may require transfusion. The abnormal platelets in the syndrome are usually larger than normal platelets. However, this is not the only condition with larger platelets, specific platelet function test, as well as glycoproteins, are required to determine the diagnosis (Giant Platelet Disorder – an Overview | ScienceDirect Topics, 2019).

Gray Platelet Syndrome

This is a rare disorder, about 60 cases have been reported worldwide, individuals with the disorder tend to bruise easily and have increased risk of nosebleeds, or extended bleeding after surgery. They may also experience abnormally heavy bleeding after dental work, or minor trauma.  Women with the condition experience irregular, heavy periods. These bleeding problems are usually mild to moderate, but sometimes they can be life-threatening. A characteristic feature of the condition is myelofibrosis which is the build-up of scar tissue in the bone marrow, the scarring associated with myelofibrosis damages the marrow preventing it from making adequate blood cells. This causes other organs, more specifically the spleen, to start producing more blood cells to compensate, this process may lead to an enlarged spleen (National Library of Medicine, 2020).


Reference

Smith, S. A., Travers, R. J., & Morrissey, J. H. (2015). How it all starts: Initiation of the clotting cascade. Critical reviews in biochemistry and molecular biology50(4), 326-336.

Laurino, M., Menara, T., Stella, A., Betta, M., & Landi, A. (2015, August). Procoagulant control strategies for the human blood clotting process. In Engineering in Medicine and Biology Society (EMBC), 2015 37th Annual International Conference of the IEEE (pp. 4439-4442). IEEE.

Giant Platelet Disorder—An overview | ScienceDirect Topics. (n.d.). Retrieved June 1, 2020, from https://www.sciencedirect.com/topics/medicine-and-dentistry/giant-platelet-disorder

LaPelusa, A., & Dave, H. D. (2020). Physiology, Hemostasis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK545263/

Reference, G. H. (n.d.). Gray platelet syndrome. Genetics Home Reference. Retrieved June 1, 2020, from https://ghr.nlm.nih.gov/condition/gray-platelet-syndrome

Thrombocytopenia | National Heart, Lung, and Blood Institute (NHLBI). (n.d.). Retrieved June 1, 2020, from https://www.nhlbi.nih.gov/health-topics/thrombocytopenia

An overview of the types and causes of Edema

This is a condition that arises when there is too much fluid in the tissue spaces or cavities. In inflammation, fluid accumulation is normal, this is part of the process where the fluid that is rich in protein floods the area. This is different from non- inflammatory oedema, where the fluid accumulation is not rich in protein. This is due to the osmotic and hydrostatic pressures between the blood vessels, and tissue not functioning properly.  Intravascular hydrostatic forces and interstitial osmotic forces will move fluid in and out of the blood vessels. Opposite to this is the osmotic pressure which pushes or pulls fluid in and out of vessels. The two types of oedema include, generalised, which is when swelling is throughout the body, and localised oedema, when parts of the body are affected (Scallan et al., 2010a).

Over accumulation of fluid in the interstitial space is generally bad and it affects the proper function of the tissue. This is because the formation of oedema increases the diffusion distance of oxygen and other nutrients. And for the same reason it reduces the diffusional removal of potentially toxic substances of cellular metabolism. This is especially important in the lungs where pulmonary oedema can greatly affect exchange of gasses. Also, certain anatomical structures limit tissue expansion in response to oedema. For example, the kidneys, brain, and the skeletal muscles (Scallan et al., 2010a). This means that small incremental changes in transcapillary fluid filtration will induce a large increase in interstitial fluid pressure.

Oedema will happen when 

  • There is an increase in intravascular pressure, pushing the fluid out of the vessels into the interstitial area. This can be caused by poor venous flow especially in the lower limbs due to either a deep vein thrombosis. Also, increased venous pressure caused by congestive heart failure (right ventricle), this also causes a reduction in blood flow to the kidney. This then leads to retention of sodium and water, which then leads to the increase in blood volume.
  • There is a decrease in osmotic plasma pressure set by albumin which is produced by the liver. This is mainly caused by Kidney disease where albumin is excreted, meaning there is a reduction of flow through the kidney. Another disease that affects Osmotic pressure is Liver disease.  
  • There is blockage of the lymph flow retention of salt and water. Oedema is usually localized and because of an inflammatory response, either a neoplasm or obstruction (Scallan et al., 2010b).

Clinical note;

Acute Pulmonary Oedema 

This is a medical emergency resulting from ventricular failure. The blood returning to the heart from the lungs is slowed leading to a backup of blood back in the lungs, which results in congestion. This causes pressure in the capillaries to increase, due to increased blood volume. This then causes bleeding into the alveolar spaces. In pulmonary oedema the outlook is dependent on whether the treatment was immediate and the underlying cause. There are several conditions that contribute to heart-related pulmonary oedema. These include, pulmonary artery disease, unmanaged hypertension, congestive heart failure, some medications, kidney failure, and major injuries (Murray, 2011).

Left ventricular failure happens when there is dysfunction in the left ventricle causing insufficient delivery of oxygen to vital organs. The most common cause of left heart failure are coronary diseases and hypertension. Hypertension can cause left heart failure through left ventricular hypertrophy. Uncontrolled high blood pressure causes increased afterload which therefore increases cardiac workload. The hypertrophy seen in uncontrolled hypertension initially serves as a compensatory mechanism and can maintain cardiac output. But long term it can inhibit heart muscle relaxation leading to impaired cardiac filling. Which then reduces the cardiac output.  Hypertension also serves as a risk factors for coronary artery diseases. Other risk factors include; sedentary lifestyle, obesity, males are more at risk, and chronic anabolic steroid users. These risk factors are largely preventable hence risk factor control remains the most powerful way of preventing heart failure (Chahine & Alvey, 2020).

Cirrhosis of the liver is where healthy cells are replaced by scar tissue. The liver is then unable to perform vital functions of metabolism, production of proteins like albumin, blood clotting factors and filtering of toxins. Cirrhosis affects the normal flow of blood through the liver. This causes an increased pressure in the vein that brings blood to the liver from the intestines and the spleen. The increased pressure in the portal vein causes an accumulation of fluid in the legs and the abdomen. Portal hypertension can also cause blood to be redirected to the smaller veins. When these small veins are strained by pressure, they can burst leading to bleeding.   An increase in portal hypertension leads to the elevation of hydrostatic pressure. This causes the fluid to leak out into the interstitial spaces, this then leads to a decrease in plasma volume. The result is reduced kidney perfusion (Cirrhosis – Symptoms and Causes, 2019).

Management of Oedema

Treatment and management of fluid retention is dependent on the underlying cause. Management of oedema includes, a low salt diet, and adopting lifestyle changes in response to the underlying condition. For example, reducing alcohol intake and managing hypertension. Doctors can also use pharmacological therapies like diuretics and non-pharmacological interventions like compression stockings. Individuals can help themselves by exercising and eating healthy. This generally means making sure majority of your diet is fruits/vegetables and staying away from highly processed simple carbohydrates. Signs and symptoms of oedema include; a sudden unexplained weight gain, swollen stretched and shiny skin, puffiness of the ankles, face and eyes, tachycardia and blood pressure (Wu et al., 2017).


References

MacIver, D. H., & Clark, A. L. (2015). The vital role of the right ventricle in the pathogenesis of acute pulmonary oedema. The American journal of cardiology115(7), 992-1000.

Wilkins, M. R., Ghofrani, H. A., Weissmann, N., Aldashev, A., & Zhao, L. (2015). Pathophysiology and treatment of high-altitude pulmonary vascular disease. Circulation131(6), 582-590.

Welbourn, C. R. B., Goldman, G., Paterson, I. S., Valeri, C. R., Shepro, D., & Hechtman, H. B. (1991). Pathophysiology of ischaemia reperfusion injury: central role of the neutrophil. British Journal of Surgery78(6), 651-655.

Cadnapaphornchai, M. A., Tkachenko, O., Shchekochikhin, D., & Schrier, R. W. (2014). The nephrotic syndrome: pathogenesis and treatment of edema formation and secondary complications. Pediatric nephrology29(7), 1159-1167.

Choi, Y., Ju, S., & Chang, H. (2015). Food allergy knowledge, perception of food allergy labeling, and level of dietary practice: A comparison between children with and without food allergy experience. Nutrition research and practice9(1), 92-98.

Chahine, J., & Alvey, H. (2020). Left Ventricular Failure. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK537098/

Cirrhosis—Symptoms and causes. (n.d.). Mayo Clinic. Retrieved May 29, 2020, from https://www.mayoclinic.org/diseases-conditions/cirrhosis/symptoms-causes/syc-20351487

Murray, J. F. (2011). Pulmonary edema: Pathophysiology and diagnosis. The International Journal of Tuberculosis and Lung Disease: The Official Journal of the International Union Against Tuberculosis and Lung Disease, 15(2), 155–160, i.

Scallan, J., Huxley, V. H., & Korthuis, R. J. (2010a). Pathophysiology of Edema Formation. In Capillary Fluid Exchange: Regulation, Functions, and Pathology. Morgan & Claypool Life Sciences. https://www.ncbi.nlm.nih.gov/books/NBK53445/

Scallan, J., Huxley, V. H., & Korthuis, R. J. (2010b). Pathophysiology of Edema Formation. In Capillary Fluid Exchange: Regulation, Functions, and Pathology. Morgan & Claypool Life Sciences. https://www.ncbi.nlm.nih.gov/books/NBK53445/

Wu, S. C., Crews, R. T., Skratsky, M., Overstreet, J., Yalla, S. V., Winder, M., Ortiz, J., & Andersen, C. A. (2017). Control of Lower Extremity Edema in Patients with Diabetes: Double Blind Randomized Controlled Trial Assessing the Efficacy of Mild Compression Diabetic Socks. Diabetes Research and Clinical Practice, 127, 35–43. https://doi.org/10.1016/j.diabres.2017.02.025

An overview of the inflammatory response

     Inflammation is a pathological response that engages hundreds of mediators and different cells and tissue types. It can be initiated by any stimulus causing cell injury. Often the inflammation is a response to some sort of infection. In some cases, chemical or physical injury can also induce an inflammatory reaction. The goal of the inflammatory response is to remove the causative agent with minimal destruction to the body, and to repair the damage caused by the toxin. The duration of the inflammatory response is dependent on whether the causative agent has been eliminated. Acute inflammation is a relatively short process, lasting from minutes to a few days (Pahwa et al., 2020).

     If the acute inflammatory response is unable to remove the causative agent and restore the damaged tissue, this can lead to chronic inflammation. In which tissue destruction and repair happen while the inflammatory process continues. Chronic inflammation can also result from stimuli that initiate a low-grade asymptomatic response. Any injury that causes the cells to die will elicit an inflammatory response. The aim is to remove the debris of the dead cells and the source of the injury. Whatever type, phagocytic cells and blood proteins move to the area of infection. The response is dependent on both vasoactive and chemotactic messengers from the site of injury. The presence of chemotactic and vasoactive messengers causes the arrival of inflammatory cells to the injury site.

Acute inflammation works to remove any external invader and any necrotic cellular debris. To do this, phagocytes are attracted to the area by parts of the clotting components, through vasodilation and release of chemotactic messengers from the cells and blood plasma. The outcome of acute inflammation is dependent on the type and persistence of the injury. Also, the extent of the damage and how fast the specialised cells on the injury site increase in number. Tissue damage due to trauma, inversion of the microbes and other harmful compounds can induce an acute inflammatory response. An acute inflammatory response starts fast and symptoms may last anywhere from few days to three weeks.

  In chronic inflammation, the causative agent will stay in the body for a long time and continue to cause injury. This can last for months to several years and some chronic inflammatory illnesses are lifelong. The extent and effect of the chronic inflammatory response is dependent on the cause of the injury and the ability of the body to repair and overcome the damage. Chronic inflammation can result from; failure of eliminating the agent causing the acute inflammation such as infectious organisms like, mycobacterium tuberculosis, protozoa, fungi, and other parasites. An autoimmune disorder is also considered a chronic inflammatory response. Happens when the immune system recognises the normal components of the body as foreign and attacks the healthy tissue. As is the case with rheumatoid arthritis and systemic lupus erythematosus (Pahwa et al., 2020).


Inflammation 

Mast cells release histamine which causes vasodilation, increased plasma permeability of the vessels to phagocytic cells and fluid. This causes the injury site to be flooded with phagocytic cells, fluid and plasma proteins, this is called inflammatory exudate.

Signs of inflammation

  • Redness – dilation of the local blood vessels
  • Heat – from increased blood flow
  • Swelling – from the build-up of fluids and plasma proteins and loss of function due to tissue swelling.

The fluid and plasma proteins work by diluting any substances that may cause injury before they are drained into the hepatic system. Immunoglobulins and part of the complement cascade help to neutralise the microorganism. Other proteins like fibrinogens are converted into insoluble form, which forms a mesh at the injury site. The mesh plugs the wound and physically protecting it from infections. The first cells to arrive at the site are the neutrophils that phagocytose necrotic cellular debris, by releasing phagocytic enzymes from the lysosomes. When they have been used, the lysosomes enzymes die and become part of the debris.

The mast cells arrive at the area, monocytes are turned into macrophages when they are activated. Macrophages can regenerate their phagocytic enzymes, to aid in the digestion of the narcotic cellular debris. The lymphocytes may be part of the specific or non-specific immune mechanism or may have been freed from the tissue that was broken down by injury (Chen et al., 2017).


Repair

Repair is done through regeneration; this is where old tissue is replaced by the same type cells. And replacement by connective tissue. Regeneration of tissue can only happen when there are reserve cells at the site of injury that are able to go through mitosis. Usually there are three groups of cells:

  1. Labile cells – These are cells that generally proliferate throughout the lifespan replacing dead or dying cells that die through normal physiological means. For example, the epithelial at the surface of the skin.
  2. Stable cells – In some cases these cells regenerate, but usually don’t, because of their long survival time. For example, the cells of the glands, liver cells and the cells found in kidney collecting tubules.
  3. Permanent cells – These are neutrons and cardiac muscles cells, if a neuron dies, it is lost forever. But the axons can regenerate after an injury. Cardiac muscle cells die because of deprived oxygen, as seen in heart attacks. Repair depends on the existing framework being presented and if there is adequate blood supply.

 Angiogenesis is the formation of new blood vessels, that bud and sprout from pre-existing blood vessels. They form several branches which eventually grow and form capillary beds. They will subsequently form capillary beds and venules. Growth factors are usually involved during angiogenesis.


Mechanism of Healing 

Normal growth in cells is controlled by both growth factors and inhibitors. The most important are the factors that recruit quiescent cells to mitosis. These growth factors are called.

  1. Epidermal GF, EGF, EGR- 
  2. These play an important role in wound healing through stimulation of epidermal and dermal regeneration. EGF is important for mediating the differentiation of keratinocytes to an epithelial line and re-establishes an epithelial barrier.

PDGE –

  • These growth factors come from platelets but also from activated macrophages, endothelium, smooth muscles cells and tumour cells. It causes the migration and proliferation of fibroblasts, smooth muscle cells and the monocytes.

FGF –

  • These growth factors come from the fibroblasts, causes fibroblasts proliferation and new vascular growth. There are two types, we have the beta FGF that are found in most of the organs and secreted by the activated macrophages. The second is Alpha FGF which is in the neural tissue  (Bodnar, 2013).

 References

Darby, I. A., Laverdet, B., Bonté, F., & Desmoulière, A. (2014). Fibroblasts and myofibroblasts in wound healing. Clinical, cosmetic and investigational dermatology7, 301.

Shabbir, A., Cox, A., Rodriguez-Menocal, L., Salgado, M., & Badiavas, E. V. (2015). Mesenchymal stem cell exosomes induce proliferation and migration of normal and chronic wound fibroblasts, and enhance angiogenesis in vitro. Stem cells and development24(14), 1635-1647.

Portou, M. J., Baker, D., Abraham, D., & Tsui, J. (2015). The innate immune system, toll-like receptors and dermal wound healing: a review. Vascular pharmacology71, 31-36.

Bodnar, R. J. (2013). Epidermal Growth Factor and Epidermal Growth Factor Receptor: The Yin and Yang in the Treatment of Cutaneous Wounds and Cancer. Advances in Wound Care, 2(1), 24–29. https://doi.org/10.1089/wound.2011.0326

Chen, L., Deng, H., Cui, H., Fang, J., Zuo, Z., Deng, J., Li, Y., Wang, X., & Zhao, L. (2017). Inflammatory responses and inflammation-associated diseases in organs. Oncotarget, 9(6), 7204–7218. https://doi.org/10.18632/oncotarget.23208

Pahwa, R., Goyal, A., Bansal, P., & Jialal, I. (2020). Chronic Inflammation. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK493173/

Structure of the Male Reproductive System

The male reproductive system includes the gonads, duct system, accessory glands, and the penis. The gonads are the testes, this is the site for sperm formation (spermatogenesis). The testis is located outside the body in the scrotum. Embryologically, the testes develop within the abdomen and usually descend about seven months during foetal development. If testes do not descend, a condition called cryptorchidism develops. Cryptorchidism is the absence of at least one testicle from the scrotum. It is the most common birth defect in male genitalia. About 3% of full-term babies and 30% of premature male infants are borne with one or both testicles undescended (OpenStax, 2013).

After descending, the testes are located outside the body, giving a temperature of 2-3 degrees Celsius cooler than the body temperature. This is the best temperature for the formation of sperms. If The testicles do not descend, particularly before puberty, the spermatogonia are destroyed by the high body temperature. This then leads to sterility. Testicles that have not descended can be corrected either surgically or through hormonal therapy. The testis is variable in size, but the average size is about 5cm long and 2.5 cm in diameter. The testis is surrounded by a thick layer of connective tissue called the Tunica albuginea, which is thicker on the posterior surface of the testis, forming the mediastinum testis.


Clinical note

Testicular Torsion.

Happens when the testicle rotates, twisting the spermatic cord that brings blood supply to the scrotum. The reduction in blood supply causes sudden and often severe pain and swelling. Testicular torsion is a medical emergency that requires emergency surgery. If treated fast the testicle can usually be saved. But when blood flow has been cut off for too long, a testicle may be badly damaged that it must be removed (Testicular Torsion – Symptoms and Causes, 2020).

Varicocele

This is when varicose veins develop in the blood supply to the testis, it is seen in 8% of normal males. 98% of the cases are on the left side due to mechanical damage to the left vein. 

Orchitis:

This is when the testis become inflamed, with one or both being affected. Orchitis is usually caused by the mumps virus. Symptoms include swelling, tenderness accompanied by fever and can lead to sterility if mumps infection is involved. Orchitis is the most common complication of mumps in males after puberty, affecting 20-30%.  Of the affected 30-50% show a degree of testicular atrophy (Masarani et al., 2006).


From the mediastinum testis, connective tissue septa penetrate the glands dividing them into 250 compartments called testicular lobules. Each lobule contains between 1 and four seminiferous tubules, which are supported by loose connective tissue that is rich in blood vessels and nerves. It is the seminiferous tubules where spermatogenesis happens.

The highly convoluted tubules are lined by a complex germinal epithelial layer, with tubules being 150-70 micro-meter in diameters and 30-70cm long. Where the tubules terminate, they become cuboidal cells having a flagellum.  These terminal regions are called tubuculi recti.

The straight tubules connect the seminiferous tubules to a labyrinth-like series of channels called the rete testis, which is found in the mediastinum. The rete testis is then connected to the epididymis by 10-20 ducts called the efferent ducts.

The seminiferous tubules around the outside of each lobule is a layer of fibrous connective tissue that is lined by a basement membrane. This layer is called the tunica propria and within this layer next to the basement membrane are flattened myoid cells.

The myoid cells act like smooth muscle and squeeze the tubules, pushing the non- motile spermatozoa towards the epididymis. The epithelium of the tubules is complex and consists of Sertoli cells and spermatogenic cells.

Sertoli cells are elongated pyramidal cells that form a sheath surrounding the lumen of the tubule and act to mediate nutrient and metabolic supply to the developing sperms.  In this way they also protect the developing sperm, from immunological attacks. This is because the immune system has developed long before sperm production begins and would recognise the sperms as foreign.

The Sertoli cells functions are essential to the integrity of the seminiferous epithelium.  These functions include; regulation of sperm formation, metabolic and structural support of the gem cells. Also, they help concentrate testosterone into the seminiferous tubules which helps spermatogenesis (Sertoli Cell – an Overview | ScienceDirect Topics, 2005).

The other cells that are found in the seminiferous tubules are the spermatogonia (46 chromosomes) which undergo mitosis to form primary spermatocytes. Spermatocytes undergo meiosis I to form secondary spermatocytes (23 chromosomes). Spermatocytes then go through meiosis II to form spermatids (23 chromosomes). Spermatids then mature to form spermatozoa. Around the seminiferous tubules is interstitial connective tissue which contains nerves and blood vessels, as well as one important cell type, called the Leydig cells which produce testosterone in the presence of luteinising hormone (OpenStax, 2013).

There are many different types of cells in the epididymis each having different functions involved in the maturation of sperms. The epithelium is involved in regulating the reabsorption and secretion of fluid, ions, organic molecules, and proteins in and out of the lumen as the sperms mature.


Clinical note:

  • Epididymitis (inflammation of the epididymis) is caused by prostatitis, UTI’s, mumps, and STI’s. Usually, only one side is affected, with the epididymis swelling and becoming hard and excruciatingly painful. Epididymitis can lead to sterility if not treated fast and efficiently; this is because the epididymis is the site for sperm maturation. Treatment is generally with antibiotics.  

The Human Sperm

  • The volume of ejaculate is between 3 and 5mls with the PH between 7.3 and 7.5
    Normal sperm count is about 75 million per ejaculate with lower numbers being 15 million. of the normal sperms, less than 20% should be abnormal. Of the possible approximately 400 million in an average ejaculate, only around 200 reach the oocyte(egg).

The Prostate

The prostate is a collection of 30-50 branched tubule-alveolar glands, the gland is surrounded by fibroelastic connective tissue. The epithelium is usually columnar but can be cuboidal or squamous in places.

The prostate contributes from 20-30% of the semen volume. Components are fibrinolysin and fibrinogenase and buffers (phosphate and bicarbonate buffers)

Clinical note: Prostatitis or inflammation of the prostate is seen in men above the age 50. Prostatitis is of unknown origin; theories suggest it may be as result of infection (UTI or STI)

From Erection and Ejaculation 

To enter the vagina the penis must be erect. Erection can be brought about by psychic or tactile means. The most important stimuli for an erection to happen is touch. The glans penis is the most sensitive part of the penis because it has rich sensory and nerve supply. Erection is caused by the parasympathetic nerve impulses from the sacral region of the spinal cord passing the penis, dilating the arteries of the penis. This causes blood, under high pressure to enter the blood sinuses of the corpus cavernosum and spongiosum of the penis.  This large quantity of blood compresses the veins leaving the penis so that most of the blood that enters stays.

As a result of this, the penis becomes engorged with blood and increases in both diameter and length. While the penis is becoming erect, the parasympathetic impulses cause the bulbourethral glands to secrete mucus that flows through the urethra to aid lubrication for intercourse.

Most of the lubrication comes from the female. Once erection has happened, the next step is getting the sperm into the female reproductive tract. Once the sexual stimulus has become highly intense, reflex centres in the spinal cord carry sympathetic impulses that leave the spinal cord at the first and second lumbar vertebrae and pass to the genitals to begin emission.

Sexual stimulation causes nitric oxide to be released into the penis. This causes increased production of guanosine monophosphate, which relaxes the smooth muscle of the blood vessels of corpora cavernosa (muscle found in the penis), allowing them to be engorged with blood. Usually, following ejaculation, the enzyme phosphodiesterase 5(PDE5) removes GMP.

Viagra was discovered initially meant for treatment of cardiac issues. However, patient on Viagra started reporting unusual side effects. Viagra works by inhibiting PDE5, thereby maintaining the erection (Penis Erection – an Overview | ScienceDirect Topics, 2020).


Key Points

  • The Male reproductive system is composed of gonads, duct system, accessory glands and the penis. The gonads are the testes this is the site for sperm formation (spermatogenesis)
  • Embryologically the testis develops within the abdomen and usually descend about seven months during the foetal development
  • Around the seminiferous tubules is interstitial connective tissue which contains nerves and blood vessels, as well as one important cell type, the Leydig cells that produce testosterone. 

Source

Rizzo, D. C. (2015). Fundamentals of anatomy and physiology. Cengage Learning.

Sweeney, M. F., Hasan, N., Soto, A. M., & Sonnenschein, C. (2015). Environmental endocrine disruptors: effects on the human male reproductive system. Reviews in Endocrine and Metabolic Disorders16(4), 341-357.

http://aclandanatomy.com/multimediaplayer.aspx?multimediaid=10528663

Masarani, M., Wazait, H., & Dinneen, M. (2006). Mumps orchitis. Journal of the Royal Society of Medicine, 99(11), 573–575.

OpenStax. (2013). 27.1 Anatomy and Physiology of the Male Reproductive System. In Anatomy and Physiology. OpenStax. https://opentextbc.ca/anatomyandphysiology/chapter/27-1-anatomy-and-physiology-of-the-male-reproductive-system/

Penis Erection—An overview | ScienceDirect Topics. (n.d.). Retrieved May 23, 2020, from https://www.sciencedirect.com/topics/medicine-and-dentistry/penis-erection

Sertoli Cell—An overview | ScienceDirect Topics. (n.d.). Retrieved May 23, 2020, from https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/sertoli-cell

Testicular torsion—Symptoms and causes. (n.d.). Mayo Clinic. Retrieved May 23, 2020, from https://www.mayoclinic.org/diseases-conditions/testicular-torsion/symptoms-causes/syc-20378270

THE IMPORTANCE OF END-OF-LIFE PLANNING

Palliative care can be defined as an approach to health that involves improving the quality of life of patients and their families that are facing issues related to chronic, incurable and life-threatening illnesses  (Wallerstedt et al., 2019). It is vital to note that, palliative care is not just limited to the elderly, but can be anyone with an incurable illness and the goal is to improve quality of life. The stages of palliative care include; stable, unstable, deteriorating, terminal and bereavement (McClelland et al., 2020). Symptoms heavily influence quality of life for individuals on palliative care, hence managing these symptoms is crucial to providing comprehensive holistic care that meets the needs of the patients and family. Evidence is growing about the beneficial role palliative care plays in improving the quality of life for individuals with incurable illnesses (Smith & Newbury, 2019).

Figures from 2017-18 show that 77,369 hospitalisations were palliative care related and 55.6% of the people admitted to hospital received palliative care before death (Australian institute of health and welfare, 2019). It is important to note that palliative care conversations must go beyond the narrow discussion of resuscitation. Instead the dialogue should discuss a wide range of concerns that are shared by palliative care patients, such as pain management and disease progression. Good communication in this case can facilitate the development of a comprehensive management plan that is evidence based (Herrmann et al., 2019)  . 

Studies indicate that most patients want to have palliative care discussions’, but practitioners are reluctant to initiate the conversation (Bergenholtz et al., 2019) . This is reflected in the percentage of people with a valid advanced health care directive. Almost 50% of people will not be able to make their own end of life decisions. Less than 15% of Australians have documented what they want in their Advanced Care Directive, It is also estimated that less than 30% of people aged 65 and above have an ACD. Research indicates that having an ACD in place can reduce anxiety, depression, and stress that is experienced by families during end of life care, and that they are more likely to be satisfied with the care of their loved ones (Australian Digital Health Agency, 2019). Palliative care presents a lot of challenges for health care workers, the patient and their families. Care of the dying patients must be considered within the context of social, spiritual and cultural factors of the patient and the families (Danielsen et al., 2018).

(Bloomer et al., 2019) In a study of elderly resident that died in subacute care, found that lack of pre-hospital Advanced Care Planning and delayed vague communication on the aim of palliative care resulted in unsatisfactory end of life care. The study found that, delay in recognising and acknowledging that the resident/patients may be declining towards death resulted in delays to re-evaluation of care and the loss of opportunity to begin appropriate end of life care management. The researchers further found that poor communication took away the opportunity to adequately prepare the family for the impending death.

 (Kouyoumdjian et al., 2019) This was a qualitative semi-structured interview whose aim was to find out the perception of physicians about the transfer of dying nursing home residents to the emergency department. The researchers interviewed twelve directors of nursing. Issues identified include; difficulties in identifying end of life situation, difficulties managing refractory symptoms of palliative care, and in not knowing the residents dying wishes. The difficulties of recognising end of life situations, managing family expectations, the uncertainty of the diagnosis with or without hospital transfer is one of the main reason’s residents were transferred to hospital.       

When it comes to managing family expectations, the study found that at the end of life the families become the main decision maker. Decisions to transfer to hospital related to family wishes where frequent. But a lack of communication between clinicians and families was responsible for most hospital transfers.  When there is no open dialogue between the clinicians and families and there is a drastic change in the resident’s functional status, families in most cases feel like they are giving up on the resident if no medical intervention is pursued.  There is also a lack of confidence in nurses that work in nursing homes compared to hospital nurses. Families feel that they will get better care in hospitals rather than nursing homes.

In France only 2.5% of the deceased had advanced care planning documentations. In just 36% of the cases, nursing home residents suffering from Alzheimer’s disease had an advocate, and just five percent had written advanced care directives. However as pointed in previous studies ACDs only give guidance on whether to resuscitate or if to transfer to hospital. They are very vague when it comes to managing refractory symptoms. These are physical and emotional symptoms for which all possible treatments have failed, or it is determined that no methods are available for palliation within the time frame that the resident or patient can tolerate. These symptoms are often hard to manage without risking the resident’s consciousness. For example, in bone cancer patients, it is not the question of whether they are in pain, in most cases it is how much pain they can tolerate (Hack et al., 2017).

(Gonella et al., 2019) This was an aggregate review of 11 articles on the current methods of communication in palliative care.  Of the reviewed, seven where quantitative, three qualitative and one mixed method study.  Articles were taken from PubMed, EBSCO and CINAHL between April and May 2018. The main goal of the meta- analysis was to review the best form of communication in the National Health Service which may contribute to better quality of care during the palliative process. Three themes where identified, firstly, communication must centre around promoting the families’ understanding of health condition and the disease progression. Secondly, planning and implementation of care must be in partnership with the patient and family, lastly use and improve resident’s preferences regarding end of life care.

 In conclusion, education in palliative care communication helps health care workers in providing person centred care[GU1]  especially during end of life care. Families and the general public must be informed on the importance of having a valid advanced health care directive, as this prevents confusion when it comes to medical intervention when the resident deteriorates. Clarifying transfer preferences for injury management within the ACD, may lead to better end of life experiences for residents and improve effective resource utilisations. Having an open-ended dialogue during the palliative care process, builds trust/ confidence between families and clinicians, which may reduce the levels of anxiety experienced by nurses when carrying out clinical decisions related to end of life care.

Refences

Australian Digital Health Agenecy, 2019, A. D. H. A., 2019. (2019, March 29). My Health Record best place for Advance Care Directives [Text]. My Health Record; My Health Record. https://www.myhealthrecord.gov.au/news-and-media/media-releases/my-health-record-best-place-for-advance-care-directives

Bergenholtz, H., Timm, H. U., & Missel, M. (2019). Talking about end of life in general palliative care – what’s going on? A qualitative study on end-of-life conversations in an acute care hospital in Denmark. BMC Palliative Care, 18(1), 62. https://doi.org/10.1186/s12904-019-0448-z

Danielsen, B. V., Sand, A. M., Rosland, J. H., & Førland, O. (2018). Experiences and challenges of home care nurses and general practitioners in home-based palliative care – a qualitative study. BMC Palliative Care, 17(1), 95. https://doi.org/10.1186/s12904-018-0350-0

Gonella, S., Campagna, S., Basso, I., De Marinis, M. G., & Di Giulio, P. (2019). Mechanisms by which end-of-life communication influences palliative-oriented care in nursing homes: A scoping review. Patient Education and Counseling, 102(12), 2134–2144. https://doi.org/10.1016/j.pec.2019.06.018

Herrmann, A., Carey, M. L., Zucca, A. C., Boyd, L. A. P., & Roberts, B. J. (2019). Australian GPs’ perceptions of barriers and enablers to best practice palliative care: A qualitative study. BMC Palliative Care, 18(1). https://doi.org/10.1186/s12904-019-0478-6

Kouyoumdjian, V., Perceau‐Chambard, E., Sisoix, C., Filbet, M., & Tricou, C. (2019). Physician’s perception leading to the transfer of a dying nursing home resident to an emergency department: A French qualitative study. Geriatrics & Gerontology International, 19(3), 249–253. https://doi.org/10.1111/ggi.13600

McClelland, S., Agrawal, N., Elbanna, M. F., Shiue, K., Bartlett, G. K., Lautenschlaeger, T., Zellars, R. C., Watson, G. A., & Ellsworth, S. G. (2020). Baseline Karnofsky performance status is independently predictive of death within 30 days of palliative intracranial radiation therapy completion for metastatic disease. Reports of Practical Oncology & Radiotherapy. https://doi.org/10.1016/j.rpor.2020.02.014

Smith, C., & Newbury, G. (2019). Palliative care for community patients diagnosed with dementia: A systematic review. British Journal of Community Nursing, 24(12), 570–575. https://doi.org/10.12968/bjcn.2019.24.12.570

Wallerstedt, B., Benzein, E., Schildmeijer, K., & Sandgren, A. (2019). What is palliative care? Perceptions of healthcare professionals. Scandinavian Journal of Caring Sciences, 33(1), 77–84. https://doi.org/10.1111/scs.12603


 [GU1]

Why does child marriage happen?

According to World Vision, the most alarming statistic about child marriage is that almost 700 million women in the world today were married as girls. A third of them before there 15th birthday. “Child marriage is a legal marriage or informal union where one or both parties are under the age of 18”. While child marriages are far more likely to happen to girls, it is not uncommon for boys to marry before the age of eighteen. Although early marriages are illegal in almost every country, enforcing them is very difficult. This is true in most developing countries and in countries where there is a mixture of British common law and traditional customary laws.

For example, in Zambia, under the marriage act of 1964, the minimum age for marriage is 21 years. However, under article 17 and 33, an individual aged 16-21 may marry provided they have parental consent. An individual under the age of 16 can be married with judicial consent assuming the circumstances of the case are not contrary to public interest. These provisions are rarely applied to customary law. Under statutory laws, child marriage is illegal and is considered child abuse. However, under traditional law, there is no age limit for consent and marriage can take place as soon as the girl hits puberty. It is common for girls in Zambia to be married or have sexual relationships under the age of sixteen (world vision, 2015).

 Before independence from Britain, Zambia had two sets of distinct legal systems. One that applied specifically to Zambians, and another to both Zambians and British individuals. Currently the judicial system has a mixture of both customary and statutory laws. In general, customary or native laws do not give many rights to women and girls compared to statutory laws. For example, while some Zambians who live in urban cities are married in civil rights that are governed by the marriage act, which is non-discriminatory.  In rural Zambia, people are still governed by customary laws.  Problems arise when these two systems collide (UNESCO, 2013).

The marriage act states, the legal age for marriage is 21, and anyone under the age of twenty-one who is not a widow or widower needs written consent from the father (or mother or guardian if the father is dead or of unsound mind). If the father refuses to consent, the child can apply to the high court judge to provide consent. Also, sex or sexual relations and contact with anyone under the age of sixteen is prosecutable with life in prison.

However, under customary law, the age for marriage is based on maturity, but the term maturity is not explicitly defined, and there is no minimum age. In this case, maturity is subjective and is dependent on what the elders deem as mature” (Ndulo, 2011). In some tribes, a girl or a boy can be married as soon as they go through the right of passage which is when they start puberty. It could be thirteen, twelve or fourteen and sometimes as soon as the child begins her menstrual cycle. In rural areas, it is not unheard of for girls to have sexual relations before the age of sixteen or be married. To add-on to this point, prosecutions are even harder because some traditional practices do not see anything wrong with child marriage. In some rural areas of Africa, there are no courts, the chiefs or the elders of the land preside over disputes (Radcliffe-Brown & Forde, 2015).

Secondly, attitude towards girls, in many traditional cultures, parents favour boys, boys are supposed to go out work, hunt and bring home the meat and basically be breadwinners. While girls are supposed to stay at home in the kitchen and give birth. One study found that many parents have a view that educating girls is a waste of money, because, they will eventually be married off and their education will only benefit the husband and the husband’s family. There is also a societal expectation that girls will have husbands that will provide for them, so investing in girls is seen as a waste of money (UNESCO, 2013).

    In the same study, one parent was quoted saying “It is better to educate a boy because after all, most girls are very foolish, they get themselves pregnant and drop out of school. Why should I waste my money?” In other studies, they also found that many communities in Africa favoured marrying off girls at a fairly young age. And in most cases, the girl ends up dropping out of school once they are married to start families. This is common especially in Muslim communities where there is a practice of betrothing girls at a very young age, sometimes at birth and then marrying them off in late adolescence (UNESCO, 2013).

Thirdly, poverty, there are cases where the parents see the girl as a way out of poverty, the perception is that through bride price/dowry, the parents have a steady flow of income. A recent study by UNICEF found that in every country where child marriage is prevalent, it is the poor and uneducated women that were most affected (UNICEF, 2014). Also, in countries where 50% of women are married as children, the marriages are prevalent in rural areas. In some cases, girls are married off as a way of paying a debt.

A recent study in Africa found that dowry or bride price is one of the reasons why domestic violence is high. Dowry is meant to act as a symbol of appreciation, a man pays to a woman’s family (Nour, 2009). The original traditional value for dowry has been lost and, in some cases, it is used as a way out of poverty. There are cases where even if a woman is being abused and run’s back to her parents, the parents will just take her back to the abusive husband. If they do not send her back, they risk losing his financial support (Lloyd & Mensch, 2008). In addition, there is the idea of honour.  In many communities in Africa, it brings great pride to the family if the girl is married off while she is still a virgin. In some cases, girls are married off as young as 12, because they are beautiful, and the family is worried that they will start having sex early. (Radcliffe-Brown & Forde, 2015).

In conclusion, while statistics on child marriages are alarming, there are several ways they can be reduced. One main way is through the education and empowerment of women. As studies have shown countries that have extended rights to women are also the most prosperous.

References

World Vision Zambia. (2015). A Situation Report on Child Marriages in Zambia Retrieved from http://www.wvi.org/zambia/article/

Hari, P. (2013). Parents and community attitudes towards girls, participation in and access to education and science mathematics and technology Retrieved from http://www.unesco.org/education/educprog/

Lloyd, C. B., & Mensch, B. S. (2008). Marriage and childbirth as factors in dropping out from school: an analysis of DHS data from sub-Saharan Africa. Population Studies, 62(1), 1-13.

Ndulo, M. (2011). African customary law, customs, and women’s rights. Indiana Journal of Global Legal Studies, 18(1), 87-120.

Nour, N. M. (2009). Child marriage: a silent health and human rights issue. Reviews in obstetrics and gynecology, 2(1), 51.

Radcliffe-Brown, A. R., & Forde, D. (2015). African systems of kinship and marriage: Routledge.

Vitamin A and Vision

Vitamins are a diverse group of organic substances that are essential in the proper functioning of the metabolic processes in the body. Many vitamins, especially those found in the B group, work as coenzymes. Vitamin A is a name given to a group of fat-soluble retinoids, including retinol, retinal, and retinyl esters. Vitamin A is involved in immune function, vision, reproduction and cellular communication.

After numerous chemical modification some retinoids are very potent drugs, used mainly in the treatment of psoriasis and acne. It is important to note that retinoids are drugs related to vitamin A and should not be thought of as vitamins and vice versa.  The scientific name for vitamin A is retinol, a name that gives a clue as to one of its functions. Vitamin A is an alcohol needed for the normal functioning of the retina. Vitamin A also supports cellular growth and differentiation, plays a very important role in the normal formation and maintenance of the heart, lungs, kidneys and other organs (Office of Dietary Supplements – Vitamin A, 2015).

Vitamin A is needed for the formation of visual purple, this is a light-sensitive pigment of the retina.  In the retina, retinol is converted into an aldehyde form. Retinal then combines with proteins called opsins, which results in the formation of four coloured compounds called the visual pigment. The retina is dark due to the presence of these pigments. These pigments change their chemical nature when they are excited by sunlight in a series of complicated chemical reactions.

One of the pigments found in the rods of the retina is purple or rhodopsin. The pigment is sensitive to low-intensity sunlight as is found in semi-darkness. Photochemical changes happen in graded potential when low-intensity light acts on rhodopsin. These changes stimulate the release of neurotransmitters and the message is recorded via the optic nerve in the visual centres of the brain as a picture.  If the pigment rhodopsin is lacking, this series of events do not happen, this leads to a condition called night blindness (NYCTALOPIA) (Rhodopsin – an Overview | ScienceDirect Topics, 2009).

Vitamin A is also needed for the differentiation and growth of the epithelial tissue. Other studies indicate that it is probably needed for the differentiation of all tissue. Vitamin A is mainly involved in the proper functioning of the mucus-secreting cells. In the absence of vitamin A, these cells become keratinised. Since the mucus-secreting cells of the respiratory tract and the genitourinary tract are part of the defence mechanism. Deficiency in vitamin A will lead to an individual being prone to infection (Vitamin A Deficiency – Nutritional Disorders, 2020).

The cornea can also become keratinised which may lead to dry eyes (xerophthalmia), this, in turn, can lead to permanent blindness.  The mechanism of action of retinal and retinoids is at the nuclear level, as such it may affect gene expression. Other signs and symptoms of vitamin A deficiency include dry skin, delayed growth in children, poor wound healing, acne breakouts and (Polcz & Barbul, 2019).

The main source of vitamin A in the diet is in the Liver, dairy products, egg yolk and fatty fish. Retinol is not found in most plant products, but fortunately for vegetarians and vegans, most plants contain a substance called carotenoid. Carotenoids act as provitamins that can be converted into retinol in the intestinal wall and the liver. The main carotenoid in the plant kingdom is beta-carotene, which gets its name from carrots. Any vegetable or fruit that is orange in colour will have this provitamin, Beta-carotene is also found in green vegetables with it colour being hidden or masked by chlorophyll. For example, next to carrots spinach has the highest concentration of Beta-carotene in all the consumed fruit and vegetables.

Vitamin A deficiency is usually caused by prolonged dietary deprivation, it is endemic in Southern and Eastern Asia, where rice, that does not have beta-carotene is in staple food.  Xerophthalmia as a result of a primary deficiency in vitamin A is the main cause of blindness among young children in developing countries.  Secondary deficiency in vitamin A may be due to reduced bioavailability of provitamin A carotenoids and interference in the absorption, storage or transport of vitamin A.

People at risk of vitamin A deficiency include; pregnant mums, people with cystic fibrosis, and premature babies. In developed countries the amount of vitamin A in breast milk is enough to meet the baby’s needs for six months. But in women with vitamin A deficiency, breast milk volume and vitamin content are minimal and not enough to meet the needs of an infant who is solely relying on breast milk (Polcz & Barbul, 2019) .

Sources 

Amengual, J., Zhou, F., Barrett, T. J., von Lintig, J., & Fisher, E. A. (2017). Role of beta-carotene conversion to vitamin a in atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology37(suppl_1), A168-A168.

Cabezas-Wallscheid, N., Buettner, F., Sommerkamp, P., Klimmeck, D., Ladel, L., Thalheimer, F. B., … & Przybylla, A. (2017). Vitamin A-retinoic acid signaling regulates hematopoietic stem cell dormancy. Cell169(5), 807-823.

Gundra, U. M., Girgis, N. M., Gonzalez, M. A., San Tang, M., Van Der Zande, H. J., Lin, J. D., … & Fisher, E. A. (2017). Vitamin A mediates conversion of monocyte-derived macrophages into tissue-resident macrophages during alternative activation. Nature immunology18(6), 642.

Office of Dietary Supplements—Vitamin A. (n.d.). Retrieved May 18, 2020, from https://ods.od.nih.gov/factsheets/VitaminA-HealthProfessional

Polcz, M. E., & Barbul, A. (2019). The Role of Vitamin A in Wound Healing. Nutrition in Clinical Practice, 34(5), 695–700. https://doi.org/10.1002/ncp.10376

Rhodopsin—An overview | ScienceDirect Topics. (n.d.). Retrieved May 18, 2020, from https://www.sciencedirect.com/topics/neuroscience/rhodopsin

Vitamin A Deficiency—Nutritional Disorders. (n.d.). MSD Manual Professional Edition. Retrieved May 18, 2020, from https://www.msdmanuals.com/en-au/professional/nutritional-disorders/vitamin-deficiency,-dependency,-and-toxicity/vitamin-a-deficiency

The Menstrual Cycle

The female reproductive system is made up of the gonads, duct system and accessory glands. It produces gametes and transports them for fertilisation. The process of birth and nurturing also happens in the female reproductive system. When the oocyte is matured, it is expelled from the ovaries and then travels down the fallopian tube, it passes through the fallopian tube to the uterus where it is fertilised. It then burrows into the walls of the uterus and perhaps turn into an embryo once fertilised.

The distal part of the uterus is the cervix, it represents boundaries between the uterus and the Virginal area. There are several ligaments that anchor the uterus, the main important ones are the ligaments that anchor the ovaries. Suspensory ligaments anchor the ovaries medially, mesovarium connects the ovaries to the posterior surface of the broad ligaments. Broad ligaments anchor the uterus to the wall of the pelvic cavity and keeps the uterus tilted towards the bladder. Uterosacral, anchor the cervix of the uterus to the sacrum.

Ovaries are almond shaped organs; they have an inner medulla that has a rich vascular bed in a rich connective tissue. And the outer cortex which has the ovarian follicles that contain the oocyte. There is no sharp distinction between the cortex and the medulla. The surface of the ovaries is covered with a continues germinal epithelium, under this epithelium is a layer of a poorly defined layer of dense connective tissue called the tunica albuginea.

There are 3 types of follicles namely; Primordial, Growing, and Tertiary. Until puberty, the only follicles that are seen are the primordial follicles. The oocyte is in resting phase of prophase 1. As the primary oocyte enlarges after puberty the follicular cells become cuboidal cells and at this stage, the structure is called a primary oocyte. Which is surrounded by an intracellular material called the Zona Pellucida.

As it continues to grow the single follicular layers of the oocyte undergoes mitosis and becomes multilayered or stratified, this is called the granulosa layer. The connective tissue layer that surrounds the cells also differentiates into a poorly defined layer. The Theca Interna surrounds the granulosa and the externa that surrounds the interna, this is important following ovulation.

As the follicles keep on growing, mainly as a result of the number of granulosa cells, small fluid-filled cavities start to form among the granulosa cells to the fluid-filled antrum. Secondary follicles are marked by the presence of a fluid-filled antrum.

Granulosa cells form a hill, at one region of the follicular wall, called the cumulus opharus, which contains the oocyte and from the time the oocyte stops growing. Growth continues until the follicle is about 1cm in diameter due to an increase in the fluid. This is called Mature or the Graafian follicle. The layer of the follicular cells that are closest to the oocyte become elongated forming the corona radiator. At ovulation, the follicles raptures and the oocyte is expelled into the peritoneal cavity.

Only one follicle develops into the Graafian follicle and the rest will go through follicular atresia (which is the disintegration of the oocyte). Also, disintegration of the granulosa cells and vascularization of the granulosa cells happens. And eventually, the Atretic Follicle is replaced by connective tissue, about 99% of the follicles degenerate.

Ovulation

Is not just an increase in follicular fluid pressure, at approximately 24-30 hours there is an increase in luteinizing hormone as well FSH. Also, stigma or macula pellucida forms on the surface of the follicles and fluid begin to ooze from it. Theca externa begins to release proteolytic enzymes, for example, Collagenases that begins to weaken the walls of the theca externa.

At that time prostaglandins are released, and new blood vessels begin to form into the follicle. At the same time, the prostaglandins cause these blood vessels to dilate so that more blood enters the follicles. This swelling combined with the disintegration of the follicular wall causes the wall to rapture.

Following the rapture, the remnants of the follicles begin to form a structure called corpus luteum, the granulosa layer fold and a central blood clot is formed. This is followed by granulosa cells increasing in size and differentiation to form the granulosa lutein cells, which produce progesterone.

Theca cells increase in size to become theca lutein cells which produce oestrogens.

Capillaries grow into the area and the corpus lutein is formed; the corpus lutein is known as the vascular endocrine gland. If fertilisation happens it sustains the growing featus until the placenta is formed. If not, it disintegrates and forms the Corpus albicans.

From day 1-4 there is the shedding of the functionalis of the endometrial lining and some primordial follicles become primary follicles.

5-14, the follicles keep on developing into the eggs, which releases oestrogens that cause the proliferation of the cells in the endometrium and replaces the functionalis layer. This is called the oestrogenic phase.

Day 14 is when ovulation happens causing the remnants of the follicles to luteinize causing the corpus luteum. 14-25 the corpus luteum secretes progesterone and estrogens. Progesterone causes the glands of the endometrium to become secretory glands.

They become a vascularised layer of the superficial endometrium. Causes the thickening of the endometrium and helps with storage of glycogen. These changes are minimal in the week after ovulation, this stage is the luteal phase.

25-28, corpus luteum regresses to become the corpus albicans which is a scar of CT and the progesterone levels fall. If pregnancy occurs the corpus luteum will be marinated until implantation.

https://doctor4patient.files.wordpress.com/2012/04/menstrual.jpg

Reference

Hodges, J. K. (1998). Endocrinology of the ovarian cycle and pregnancy in the Asian (Elephas maximus) and African (Loxodonta africana) elephant. Animal reproduction science53(1-4), 3-18.

Reed BG, Carr BR. The Normal Menstrual Cycle and the Control of Ovulation. [Updated 2018 Aug 5]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279054/

The sonic hedgehog gene

The sonic hedgehog gene is the human form of the hedgehog superfamily of inductive molecules that play a role in the development of the embryo. Sonic hedgehog is important for the development of the front part of the brain, including digits on limbs. This signaling protein helps to establish the line that separates the right and left side of the forebrain. Sonic hedgehog also plays an important role in the formation of the eyes. During early development, the cells that develop into the eye form a single structure called the eye field.  The structure is found in the centre of the developing face. Sonic hedgehog signaling causes the eye field to separate into two distinct eyes (National Library of Medicine, 2020).

The action of the hedgehog gene was first observed in the Drosophila, recent studies have found members of the gene in metazoan, sea urchin, leech, and beetle (Sudhir bar 1995). This is according to an experiment that was done in 1995 which used hybridisation and polymerase chain reaction. This experiment showed a striking similarity in Hh proteins across several species. Evident by the fact that zebrafish Shh was able to activate the signal transduction pathway of the Drosophila.  The hedgehog gene consists of two domains these are; the amino acid domain (Hh-C) where the signalling activity takes place, and the carboxyl Terminal (Hh-C) which is where cleavage takes place and is also known as the sterol recognition regions (SRR)

Hh-C terminal may also be involved in the regulation of the range of amino acids. Autocleavage of the Hh gene turns it into two intermolecular reactions; this cleavage will also allow cholesterol to be added to the amino acid terminal of the Hh gene. The hog domain of the gene can also be split into two regions; the first region is called the Hint, can be seen in both prokaryotes and eukaryotes and is like the self-splicing inteins. When synthesised the Hh proteins are precursor molecules that are 400-460 amino acid long with several different domains. In the Drosophila the carboxyl domain of the gene is globular with inteins. Cestain residue is found on the Beta strands of the Hh proteins, these are very important for auto-processing.

In the Drosophila the Hh gene produces molecules that provide positional information in the embryo and the Imaginal disc. It contains 471 codon open reading frames that can encode a polypeptide of 52,147 long. It is very hydrophobic near the N terminal between 63 and 85 residues. Vertebrae like humans, Zebrafish and chicks have three forms of the hedgehog genes these are; Sonic, Indian and desert. Sonic hedgehog in human is located on the long arm of chromosomal 7q36 it has 155,802,863 to 155,812,272 base pairs (Gilbert SF 2000). The sonic hedgehog gene encodes for the sonic hedgehog proteins that play a role in the formation of the brain, spinal cord, maintenance of the stem cell and eyes (Echelard, Epstein et al. 1993).

It is also an inducer molecule that plays a role in the activation of other transcription factors like Pax and Hox. Which are responsible for the formation of various systems during embryogenesis.  Hedgehog proteins are processed in the endoplasmic reticulum. For example, Shh has processed through its cleavage of the signal peptide and the Autocleavage of Hh processors. The processors are 19Da N- terminal (Shh-N) and 25DaC terminal, signaling activity of the gene is in the N terminal.  The carboxyl-terminal of Shh has intermolecular transferase that is responsible for the attachment of cholesterol; this attachment is what restricts the zone of activity.

Recent studies in mammals have shown that Shh is processed when it binds to a transmembrane receptor called patched. Normally patched inhibits downstream signalling when it’s bound to smoothen. When SHH binds to Patched it releases the seven transmembrane receptors Smoothened from repression. Signalling is through the transcriptional factors GLI and HRK4 which Kruppel related human gene. The malfunction in the signalling pathway has been shown to contribute to the formation of cancers, this is because of the mutation in the gene that codes for Patched causes Gorlin syndrome.

Gorlin syndrome or Nevoid basal carcinoma, is a condition that affects several areas of the body and increases the possibility of an individual developing various cancerous and non-cancerous tumors. Individuals with this illness typically start developing cell carcinomas during adolescent and early adulthood. These cancers most often occur in the face, neck, and back. Individual’s with Gorlin syndrome have a higher risk than the general population of developing other tumors. A small proportion of the affected develop brain tumors called medulloblastoma during childhood (National Library of Medicine, 2020).

References

Echelard, Y., et al. (1993). “Sonic hedgehog, a member of a family of putative signaling molecules, is implicated in the regulation of CNS polarity.” Cell 75(7): 1417-1430.

Gilbert SF (2000). Developmental Biology. 6th edition.

Sudhir bar, K. r. t. A. B., Zhi-Chun Lai, (1995). “Evolution of the hedgehog Gene Family.” Genetics Society of America.

Reference, G. H. (n.d.-a). Gorlin syndrome. Genetics Home Reference. Retrieved May 14, 2020, from https://ghr.nlm.nih.gov/condition/gorlin-syndrome

Reference, G. H. (n.d.-b). SHH gene. Genetics Home Reference. Retrieved May 14, 2020, from https://ghr.nlm.nih.gov/gene/SHH

Pharmacology basics| Drug Metabolism and Absorption.

The rate and degree of drug metabolism and absorption into the blood is dependent on several factors e.g. route of administration, dosage, genetics and comorbidities. Effective absorption from the oral route depends on both the chemical properties of the drug and the functional efficacy of the GI tract. Parenteral absorption is dependent on the extent of blood supply. The bioavailability of a drug is the most critical part of pharmacokinetics.

Bioavailability is the amount of the drug that is available to the body to produce the therapeutic effect. Bioavailability can be described as the percentage of the drug administered that is available therapeutically. This varies from 0% to 100%, and the route of administration affects the therapeutic dose. For many drugs, metabolism happens in two phases. Phase one reactions involve the formation of a modified functional group or cleavage, and these reactions are non-synthetic. Phase two involves conjugation with an endogenous substance. Substances that are formed in this stage are more polar and thus more readily excreted by the kidneys (Drug Metabolism – Clinical Pharmacology, 2019).

The primary site of metabolism in the body is the liver. So, any condition that affects the hepatic function will alter the rate and degree of metabolism. Drug metabolism is determined by the microsomal oxidative enzymes such as cytochrome P450 enzymes, and the liver’s capacity for conjugation.

After the drug has been absorbed in the GI, it is taken up in the bloodstream through the hepatic portal system. This is true of most substances that are absorbed from the Gi tract, the exception is lipids which enter the lymphatic system and are eventually deposited in the bloodstream via the thoracic duct system into the superior vena cover. The Hepatic portal system is designed to take digested food staff to the liver, where they can be processed. In some cases, they can be stored, before they are distributed to the rest of the body. As the liver is the main site for metabolism, some drugs may be extensively metabolised before reaching the rest of the body.

That means that there are some cases where an individual takes analgesia, might in theory never reach the site where the pain is. Some drugs that have a high hepatic first pass, sometimes never get passed the liver. This is true for most Narcotics that are taken orally. Hence the dose needed for drugs administered via the IV route is usually lower than drugs given orally, e.g. pethidine. Some drugs are completely metabolised in the liver that they cannot be given orally, otherwise, they will not have any therapeutic effect. Another example is, GTN, a medication used for angina if given sublingually, will evade the hepatic first pass and will reach the site needed fast.

Diseases of the liver can lead to either the accumulation of pharmacologically active agents to toxic levels or prolonged effect of the drugs or both. The impact is most significant for medications that need to metabolise before they are excreted, e.g. specific forms of narcotics and non-specific beta blockers.

Effects of Diseases on Drug Action

Gastrointestinal Issues

GI diseases can affect the rate and degree of oral absorption of drugs, e.g. Conditions affecting GI peristalsis, such as severe vomiting, diarrhoea or constipation. The rate of gastric emptying can alter the rate at which the drug is absorbed. An inflammatory condition that makes changes to the structure and function of the gut may also impede drug transit into the blood. But is this dependant on the region and the track affected and the usual site of drug absorption. Nutritional imbalances brought about by GI diseases can also affect drug metabolism.

 Diseases like circulatory shock, congestive cardiac failure and peripheral vascular disorders often reduce tissue perfusion of blood. As a result of the blood levels may be lower than expected while the injection at the site blood levels remain high. In effect, the injection site becomes a drug reservoir. If under these conditions, perfusion was to suddenly increase, the levels of circulating blood may rise as well, leading to increased drug activity and possible toxicity.

Diet

The presence of food in the gut around the time of drug administration can affect drug absorption and metabolism. Nutritional elements compete with the drug for the sites of absorption.

 However, drug solubility has a significant influence on the degree of absorption, lipid-soluble drugs are less affected by competition than water-soluble drugs. Some medications such as tetracycline antibiotics are chelated by calcium salts predominantly found in milk products but also present in some antacid preparations.  Drug bioavailability is then lowered because the conjugated antibiotic is excreted in faeces.

Pregnancy 

The function of the drug can also be altered by hormonal changes that happen during pregnancy. Peristalsis and gastric emptying may slow down to the extent that it affects the amount of blood being absorbed by the gut. During pregnancy gastric emptying is also erratic, which can affect the degree of absorption for acidic drugs. So, when treating anyone in between the childbearing age, always inquire if the patient is pregnant.

Genetics

     Genetic variation has been identified in many drug metabolising enzymes including the cytochrome p450. This gives rise to distinct phenotypes of persons who have different metabolism capabilities ranging from extremely poor to extremely fast.  Slow metabolisers have markedly reduced or no enzyme activity. Intermediate metabolisers have reduced enzyme activity. The bulk of the population are extensive metabolisers. Utra-rapid metabolisers have high enzyme activity. It is estimated that genetic factors account for 20-95% of an individual variability in response to the prescribed drug and in some cases, dosing is dependent on this genetic polymorphism.  

 For example, CYP2D6 plays an important role in the metabolism of codeine. Codeine needs to be activated by conversion to morphine by this enzyme super family to achieve pain relief. Individuals who have variations in this enzyme (CYP2D6) will not benefit from codeine as a pain medication. Dose adjustment here is not appropriate and another analgesia must be considered. Another important problem may arise for ultra-metabolisers; because of this increased rate of conversion from codeine to morphine, severe morphine toxicity may occur (van Schaik, 2008).

References 

Shargel, L., Andrew, B. C., & Wu-Pong, S. (2015). Applied biopharmaceutics & pharmacokinetics (pp. 119-120). McGraw-Hill Medical Publishing Division.

Kanodia, J., Baldwin, M., Lo, A., Wang, D., Zhou, K., Lee, J., … & Bourdet, D. (2017). Safety, Pharmacokinetics and Pharmacodynamics of TD-0714, a Novel Non-Renally Cleared Neprilysin Inhibitor, in Healthy Humanvolunteers: Potential for Once-Daily Dosing and Predictable Exposure in Patients Regardless of Baseline Renal Function. Journal of Cardiac Failure23(8), S68.

Drug Metabolism—Clinical Pharmacology. (2019). MSD Manual Professional Edition. Retrieved May 12, 2020, from https://www.msdmanuals.com/professional/clinical-pharmacology/pharmacokinetics/drug-metabolism

van Schaik, R. H. N. (2008). 6. Dose Adjustments Based on Pharmacogenetics of CYP450 Enzymes. EJIFCC, 19(1), 42–47.

Harmful traditional practices- Female Genital Mutilation

      Female Genital Mutilation (FGM), is a non-therapeutic surgical modification of the Vagina. It is an ancient tradition that was and is still being practised in many parts of Africa (Yirga, Kassa, Gebremichael, & Aro, 2012). For a very long time, the Maasai people in Kenya, Tanzania, and parts of Nigeria have been circumcising women just to prevent them from enjoying sex. Other reasons given for supporting FGM include, it is a good tradition, a religious requirement or a necessary rite of passage for woman into womanhood. The belief is that it ensures cleanliness and raises the chances of a woman getting married. It prevents promiscuity, preserves virginity and facilitates childbirth by widening the birth canal.

     Female Genital Mutilation is often done by elders of the land, with sharp unsterilised knives and without anaesthesia. (Ahanonu & Victor, 2014) Found that Nigerian women had mixed feelings about FGM. They found that over half of the participants in the study, felt that FGM did not have any beneficial outcome for women. However, 42% of the women studied also believed that uncircumcised women will become sexually promiscuous. 

      This is supported by another Nigerian study which concluded that mothers had the opinion that FGM prevents sexual promiscuity. One of the reasons given for this is that most women that were interviewed were not aware of the negative health effects of FGM and the gynaecological problems that follow the procedure.  The study further found that there is a relationship between the mother’s educational background and their perception of FGM.

Today there is an alarming trend in some countries where the procedure is being carried out by health care providers. UNICEF estimates that one in four FGM procedures where performed by a health care personnel. Medicalising this procedure risks normalising it and just because a doctor does it does not make it any less barbaric.

The Numbers

The world health organization estimates that 200 million girls and women alive today have gone through FGM in the countries where it is still being practiced. Most girls are cut before the age of 15. It is further estimated that 3 million girls are at risk of undergoing Female genital mutilation every year (World Health Organisation, 2013. Recent studies have also indicated that countries that have high FGM also have a high maternal mortality rate (United Nations Population Fund, 2017).

Procedures used

  • Type 1 – This is the partial or complete removal of the clitoris or prepuce (clitoridectomy)
  • Type II- The clitoris and labia minora are partially or completely taken out with or without the removal of the labia majora.
  • Type III- This is the most severe form of FGM, the procedure requires the narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning of the labia minora and/or labia majora with or without the removal of the clitoris. The wound appositioning consists of stitching or holding the cut areas together for a certain period. For example, a girl’s legs are bound together to create a covering seal. Essentially the only thing left is a small opening for the female to urinate.
  • Type IV – pricking, piercing, or incising of the clitoris or both, stretching of the labia, or both; cauterization by burning the clitoris and surrounding tissue (WHO, 2013).

Other forms of FGM include; scraping of the tissue found around the vagina or cutting of the vagina, the introduction of corrosive substances or herbs into the vagina to cause bleeding or for the purpose of tightening or narrowing it.

Health risks

Immediate

  • severe pain
  • excessive bleeding (haemorrhage)
  • genital tissue swelling
  • fever
  • infections e.g., tetanus
  • urinary problems
  • Problems with wound healing
  • injury to surrounding genital tissue
  • shock
  • death.

Long-term effects can include:

  • problems with Urination; this includes, painful urination, urinary tract infections);
  • vaginal problems (discharge, itching, bacterial vaginosis and other infections);
  • problems with menstruation, for example, painful menstruations and difficulty in passing menstrual to name a few.
  • scar tissue and keloid formation
  • pain during sexual intercourse which leads to reduced satisfaction during sex.
  • increased risk of childbirth complications (difficult delivery, excessive bleeding, cesarean section, need to resuscitate the baby, etc.) and newborn deaths; need for later surgeries: for example, the FGM procedure that seals or narrows a vaginal opening (type 3) needs to be cut open later to allow for sexual intercourse and childbirth (de-infibulation).
  • Sometimes genital tissue is stitched again several times, including after childbirth, hence the woman goes through repeated opening and closing procedures, further increasing both immediate and long-term risks” (WHO, 2013)
  • psychological problems (depression, anxiety, post-traumatic stress disorder, low self-esteem, etc.);
  • health complications of female genital mutilation.
  • Other studies have indicated that it FGM, increases the chances of the women contracting HIV/AIDS
  • Women have gone through type III are more likely to have long droned out labour and more likely to have a cesarian section and excessive bleeding. There is also an increased risk of having to resuscitate the baby and a high infant mortality rate.

Finally, FGM has no health benefits, yet it is still being practised in large parts of Africa. The practice can be stopped through education and empowering women. As the paper has indicated, most of the women that subject their children to this barbaric practice do so without knowing the full ramifications.

Readings

Ahanonu, E. L., & Victor, O. (2014). Mothers’ perceptions of female genital mutilation. Health Education Research, 29(4), 683-689. doi:10.1093/her/cyt118

Yirga, W. S., Kassa, N. A., Gebremichael, M. W., & Aro, A. R. (2012). Female genital mutilation: prevalence, perceptions and effect on women’s health in Kersa district of Ethiopia. International Journal of Women’s Health, 4, 45-54. doi:10.2147/IJWH.S28805

World Health Organization. (2013). Female genital mutilation Retrieved from http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/

United Nations Population Fund. (2017). Female genital mutilation frequently asked questions Retrieved from http://www.unfpa.org/resources/female-genital-mutilation-fgm-frequently-asked-questions

Khattab, H. (1996). Women’s perceptions of sexuality in rural Giza.

Below is A list of some Common Respiratory Illnesses.

Respiratory illnesses can be divided into those of the upper and lower respiratory tract. They can further be divided into those that are caused by infectious particles like viruses, bacteria, and environmental.

The upper respiratory system consists of the nasal and laryngopharynx including the larynx while the lower respiratory tract consists of the trachea, bronchi and the alveoli. The bronchi are lined by the respiratory epithelium. Cilia trapping bacteria consists of the pseudostratified ciliated columnar epithelium (Respiratory Disorders, 2019) .

Terms

Dyspnoea

  • Difficulty breathing
  • Can further be broken down into orthopnoea where the difficulty in breathing is related to the position of the body, laying down breathing is difficult but more manageable when upright

Apnoea

  • Means not breathing.
  • Can be a medical emergency if prolonged.
  • If there is a partial blockage in the airway causing dyspnoea, you may also hear wheezing. This can be inspiratory or expiratory. Inspiratory is usually associated with the obstruction of the small airways and expiratory with COPD and asthma. If Dyspnoea is severe, it can lead to hypoxaemia which will often result in cyanosis, a blush tinge that can be seen in the lips and nail beds.

Coughing

  • Results from irritation of the airways from fluid or mucus collecting in the lungs. This can result in a productive cough. Coughing up blood is a serious sign and is called hemoptysis
  • Clubbing relates to low circulation and poor circulation at the ends of the fingers. Causes connective tissue hypertrophy and curvature of the fingernails.
  • A barrel chest is a sign of the use of the accessory chest muscle to improve breathing over an extended period as seen in emphysema.
  • Tachypnoea is when the breathing rate is faster than normal.
  • Bradypnea is when the breathing rate is slower than normal.
  • Hyperventilation is increased tidal volume.
  • Hypoventilation is decreased tidal volume.

Upper Respiratory Infections

  • Most of them are viral
  • The common cold is most commonly caused by rhinovirus (50%) and coronaviruses 15-20% currently causing Covid- 19.  For which antibiotics are ineffective but may be needed if a secondary infection occurs.
  • Treatments include rest, staying hydrated. While cough suppressants and antihistamines may help the symptoms, they do not speed recovery.
  • There are over 100 strains of the rhinovirus alone and their surface antigens keep on changing as the new strains develop
  • Spread via droplets and contact with the infected person.

Pharyngitis

  • Inflammation of the throat can be viral or bacterial. 5- 10% of bacterial pharyngitis is caused by S, pyogenes. They produce streptolysins that kill cells and leukocytes therefore antibiotics are necessary.

Epiglottitis

  • Inflammation of the epiglottis caused by the Haemophilus influenza type B. Can reach the point where it blocks the trachea in children thereby becoming life-threatening.

Laryngitis

  • The inflammation of the larynx. Maybe caused by bacterial or viral infection, environmental irritant or following other URI’s

Sinusitis

  • Inflammation of the mucous membranes of the sinuses
  • Can be a consequence of the common cold or other infections
  • Problems associated with nasal cavities
  • If the sinus drainage has a blockage, there is pressure build-up resulting in breathing problems, headaches and dizziness

LRI’s

Pneumonia

  • Can be bacterial or viral
  • General term for solidification, consolidation, of the cells and the lungs

Bacterial Pneumonia

  • Generally, is talking about the consolidation of the whole lobe of the lung while bronchopneumonia is talking about scattered consolidation in either the same lung or more than one lobe
  • Most are caused by bacteria that occurs in the Oro and laryngopharynx, while a lot of condition predisposes to the infection
  • Bacteria involved is most often S, Pneumoniae usually following a viral infection
  • And K, pneumonia and less commonly Staphylococcal and Legionella sp.
  • Pathology of pneumococcal infection in early stages sees a protein-rich fluid containing the organisms entering and filling the alveoli
  • There is a connection between the capillaries and an influx of the leukocytes. This causes an intra- alveoli haemorrhage followed by haemoptysis
  • The stage is followed by the lysis of the leukocytes and macrophages infiltration to clean up the exudate.

Viral pneumonia

  • Initially affects the alveoli epithelium, causing phagocytic infiltrations of the interstitial tissue followed by the necrosis of certainty of the epithelial cells
  • Causes; cytomegalovirus particularly in the immune compromised as seen in infants, measles virus, varicella virus (chicken pox and herpes zoster)

Influenza

  • Viral condition with a rapid onset of chills, fever, muscle pain and headaches
  • The spikes in the viral make H and N can change meaning that the immune system would not be able to recognise the new variation and an epidemic can occur
  • The virus spreads through the large population, and secondary bacterial infection is common

Acute Bronchitis

  • Short-term problems involving the inflammation of the bronchi generally after a URI or other environmental factors and can be followed by a secondary infection.
  • COPD is included here because it is a non-specific term for chronic bronchitis and or emphysema showing a reduced FEV

Chronic Bronchitis

  • Is having a productive cough with readily determined cause for more than 2 years and is most often seen in cigarette smokers.
  • Hyperplasia and hypertrophy is seen in mucus-secreting cells and an increase in mucus cells.
  • Other changes are variable but include bronchial wall thickening (mucus gland hypertrophy) thereby reducing bronchial lumen which causes mucus in the central and peripheral airways, increase goblet cells and smooth muscles. The disease is often accompanied by emphysema

Emphysema

  • Caused by the enlarging of the airspaces that are distal to the terminal bronchioles, destroying the wall but not resulting in fibrosis
  • Cigarette smoking is the main cause of emphysema.
  • Increased neutrophils are seen, which contains elastase that destroy elastin in the walls of the air spaces, it is morphologically defined according to three types, CENTRILOBULAR, PANANINAR, AND LOCALISED
  • Most sufferers are over 60 years with a long history of exertional dyspnoea and non-productive cough
  • Radiologically over inflation of the lung is most prominent and a barrel chest seen
  • The outlook is a steady decline in respiratory function evident by progressive and no treatment is adequate

Asthma

  • Variable obstruction of the air flow with airways themselves hyporesponsive to different stimuli
  • Clinical signs are wheezing, dyspnoea, and coughing
  • Can reach the severe stage that treatment would not work and is called status asthmatics
  • The most studied form of asthma involves inducing an attack by inhaling an allergen. The allergen reacts with IgE on the surface of the mast cells which de-granulate releasing histamine that cause smooth muscle contraction and increased mucus secretions
  • This happens along an increase in permeability of the blood vessel causing oedema which can cause obstruction of the airways even further
  • A whole compliment of leukocytes release factors which aggravate the bronchial, causing constriction, impair ciliary function and damage the epithelial cells.
  • It is thought that damaging of the epithelial cells stimulates the nerve ending in the mucosa to discharge more mucus causing further airway narrowing and mucus secretion.
  • The factors that the leukocytes release bring more leukocytes to the area so that whole response is amplified almost like a positive feedback mechanism.
  • A chronic result is mucus gland hyperplasia and hypertrophy of the smooth muscle which will exacerbate the asthma.

Lung abscess

  • Pus accumulation in the small areas of the lungs where there are damage and obstruction of the alveoli, airways and blood vessels
  • The most common cause is the aspiration of the bacteria from the oropharynx a complication of bacterial pneumonia and infected pulmonary emboli.
  • Alcoholism is the most common condition that will predispose an individual to lung abscess (followed by overdose, epileptic seizures) and about 20% will develop bleeding.
  • Symptoms are a cough and fever.
  • Complications can occur this includes the abscess draining into the bronchus spreading the infection to other parts of the lungs.
  • Although antibiotics have good effect, death still occurs

Pulmonary TB

  • Not really a problem in Australia
  • Caused by Mycobacterium tuberculosis
  • Adult respiratory distress syndrome is a reaction of the parenchyma cells in the normal lungs to acute trauma where there is interstitial inflammation and formation of alveolar exudate. Trauma includes respiratory viral infection, shock and gastric aspiration.
  • The alveolar are damaged by inflammatory response meaning oxygen cannot diffuse well into the blood.
  • Respiratory failure and an overall mortality rate of over 50%is the result, and in persons over the age of 50 the mortality rate can reach to 90%,

Pleura

  • Pneumothorax, this is where the air is present in the pleura space, can be a result of the perforation of the pleura
  • Traumatic pneumothorax is iatrogenic following fluid aspiration from the pleura, lungs or pleura biopsies and ventilation using positive pressure
  • Spontaneous pneumothorax is often seen in young adults
  • Pleura effusion is the accumulation of fluid in the pleural cavity
  • Pleurisy is the inflammation of the visceral and partial pleura is caused by bacterial infection of the pleura or secondary infection
  • Sharp chest pain when inspiring or coughing is the primary symptom that may mimic cardiac pain.

Pulmonary Oedema

  • This is caused by increased fluid in the alveoli and interstitium of the lungs causing decreased cardiac exchange resulting in hypoxia and hypercapnia.
  • Caused by the hemodynamic changes in the heart that increase the hydrostatic pressure in the capillaries of the lungs and blocks lymph drainage. fluid moves from the capillaries to the interstitium to the alveoli.
  • Symptoms are dyspnoea, orthopnoea and blood, frothy sputum as a result of fluid leaking from the capillaries.

References

Morton, P. G., Fontaine, D., Hudak, C. M., & Gallo, B. M. (2017). Critical care nursing: a holistic approach (p. 1056). Lippincott Williams & Wilkins.

Crescimanno, G., Greco, F., & Marrone, O. (2016). Autonomic arousals, sleep respiratory disorders and autonomic nervous system activity in neuromuscular diseases.

Respiratory Disorders: Types – Symptoms – Information. (n.d.). Disabled World. Retrieved May 8, 2020, from https://www.disabled-world.com/health/respiratory/

Needless treatments: Psychotropics are rarely effective in ‘calming’ dementia patients

         Elderly individuals with dementia often experience several neuropsychiatric symptoms such as delusion, hallucinations, anxiety, irritability and agitation. Currently, the management of these symptoms is a combination of non- pharmacological and pharmacological interventions such as use of psychotropic drugs (PDs) (Janus et al., 2016). In people with dementia, the use of these medications is less appropriate because of the side effects such as parkinsonism, rapid cognitive decline, cerebral vascular accidents and increased risks of falls caused by drowsiness (Janus et al., 2017). Studies indicate that more than half of people in residential care homes and 80% of people with dementia are receiving psychotropic medication, this number depends on the facilities  (Cousins et al., 2017). There is evidence to suggest that in some cases these medications have been prescribed inappropriately (Nørgaard et al., 2017). Inappropriate use of PDs can be classified as chemical restraint.

       Spek et al., 2018, when assessing the barriers to reducing the use of restraints, be it chemical or physical among health care professionals included; fear of resident’s injury, staff and resource limitation, lack of education and policy/management issues. Other factors pointed out includes belief and expectations of staff, family and residents and inadequate review of practices and communication barriers. Amura Francesca Fog et al., 2017, found that medical reviews in nursing homes resulted in overall less drug use, most pronounced for psychotropic drugs and opioids. Lam et al., 2017, was an observational analysis of over 2000 older people in Hongkong, the study found that the use of chemical and physical restraint was highly prevalent over the eleven-year study. This was especially evident in the most physically and cognitively impaired residents.  The study emphasised the need for dementia trained health care staff. And provision of care that is characterised by individual needs, dignity, empathy and respect. 

     Thirdly, (Ferreira et al., 2020) in a study of the factors that contribute to an increase in the likelihood of resident experiencing neuropsychiatric symptoms highlighted the need to respond to residents needs in a timely manner. The study found that unmet needs are often underrecognized and untreated and could contribute to the increase in neuropsychiatric symptoms in the elderly.  For example, not being assisted with toileting, lack of sensory stimulation during the day, which in turn affected the sleep pattern and not having ways to manage sundowning behaviours (Cohen-Mansfield et al., 2015).  However, while this could be a contributing factor, the study fails to point out the fact that people with dementia normally suffer from memory loss and will forget that there needs where met. It then becomes unrealistic to expect staff to constantly attend to one resident’s needs at the expense of the others. 

        Other studies show that the decision to use psychotropics is normally considered in the aspects of striking a balance between the rights of the individual residents and the other residents in the ward. Health care staff are usually not bothered with the individual behaviours of the residents, but nurses feel they are obliged to take further steps to limit the behaviours for the safety of other residents. This is especially so in residents that are violent, physically aggressive and verbally disruptive.  Staff also must deal with numerous competing rights, the rights of the resident with extreme behaviours, the rights of other residents to live in peace and the nurses own professional responsibility. In cases of residents resisting care and being violent, the question then becomes, for  how long do staff respect the resident’s autonomy before they are accused of neglect (Evans et al., 2018).

       Finally, psychotropic drugs are commonly prescribed in residential care homes. This is despite extensive evidence of their limited efficacy in the management of behavioural and psychological symptoms of dementia (BPSD). Studies indicate that almost 40% of residents on psychotropic drugs to manage behaviours do not need to be on them (Brimelow et al., 2019). In 2019, amendments to the quality of care principles placed explicit obligations on nursing homes to minimise the use of chemical and physical restraints. The amendment principles require that nursing staff exhaust all other alternatives and strategies to ensure that restraints are used as last resort (Health, 2019). Over prescription of medication in nursing homes has always been an issue, one reason could be that, there is currently no clear and consistent framework to guide nursing staff on the use and management of psychotropics.   

Sources

Amura Francesca Fog, Gunnar Kvalvaag, Knut Engedal, & Jørund Straand. (2017). Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo, Norway. Scandinavian Journal of Primary Health Care, 35(4), 329–335. https://doi.org/10.1080/02813432.2017.1397246

Brimelow, R. E., Wollin, J. A., Byrne, G. J., & Dissanayaka, N. N. (2019). Prescribing of psychotropic drugs and indicators for use in residential aged care and residents with dementia. International Psychogeriatrics, 31(6), 837–847. https://doi.org/10.1017/S1041610218001229

Cohen-Mansfield, J., Dakheel-Ali, M., Marx, M. S., Thein, K., & Regier, N. G. (2015). Which unmet needs contribute to behavior problems in persons with advanced dementia? Psychiatry Research, 228(1), 59–64. https://doi.org/10.1016/j.psychres.2015.03.043

Cousins, J. M., Bereznicki, L. R., Cooling, N. B., & Peterson, G. M. (2017). Prescribing of psychotropic medication for nursing home residents with dementia: A general practitioner survey. Clinical Interventions in Aging, 12, 1573–1578. https://doi.org/10.2147/CIA.S146613

Juola, A.-L., Bjorkman, M. P., Pylkkanen, S., Finne-Soveri, H., Soini, H., Kautiainen, H., Simon Bell, J., & Pitkala, K. H. (2015). Nurse Education to Reduce Harmful Medication Use in Assisted Living Facilities: Effects of a Randomized Controlled Trial on Falls and Cognition. Drugs & Aging, 32(11), 947–955. https://doi.org/10.1007/s40266-015-0311-8

Lam, K., Kwan, J. S. K., Wai Kwan, C., Chong, A. M. L., Lai, C. K. Y., Lou, V. W. Q., Leung, A. Y. M., Liu, J. Y. W., Bai, X., & Chi, I. (2017). Factors Associated With the Trend of Physical and Chemical Restraint Use Among Long-Term Care Facility Residents in Hong Kong: Data From an 11-Year Observational Study. Journal of the American Medical Directors Association, 18(12), 1043–1048. https://doi.org/10.1016/j.jamda.2017.06.018 Langford, A. V., Chen, T. F., Roberts, C., & Schneider, C. R. (2019). Measuring the impact of system level strategies on psychotropic medicine use in aged care facilities: A scoping review.

Haemodynamic Disorders, Thrombosis and Shock

Haemodynamic Disorders, Thrombosis and Shock

  • Haemodynamic in biology is how blood flows through the cardiovascular system
  • Haemodynamic is also related to cardiac output (perfusion pressure differences at various parts of the system and peripheral vascular resistance (the different perimeters combining to affect the blood flow in each organ)

Haemodynamic Disorders

  • Maintenance of a normal fluid balance is very important for survival. A large part of each cell is made of water, the surrounding component has water as does the plasma. So, an interruption to the blood supply or the fluid balance has a major impact on the functioning and the survival of the cells, tissue and the body as a whole.
  • Haemodynamic disorders mean that the perfusion is not normal and may cause injury, in the leading organ
  • Hypercapnia is divided into active and passive. Active results from an increase in the arterial blood supply and passive, happens as a decrease in the venous exit. The result is an increase in blood volume in the affected tissue.
  • Active hypercapnia is the dilation of the arterioles can be physiologically normal

Hypercapnia and Congestion

  • Congestion is closely related to oedema, poor venous drainage, distension of the veins, venules and capillaries. It may be localised or systemic
  • If the left ventricle fails, the lungs become congested leading to pulmonary oedema
  • If the right ventricle fails, systemic organs are affected, principally the liver followed by organs that drain into the liver in the flow on effect

Oedema

  • Is one condition where there is an abnormal accumulation of fluid in the tissue spaces or the cavities of the body as a result of congestion
  • In an inflammatory response fluid accumulation is a normal part of the process where a protein-rich fluid leaks in the area of injury
  • This is different from the fluid of non-inflammatory oedema, which is a fluid that is low in protein because of improper functioning of the hydrostatic and osmotic forces between the blood vessels and the tissue
  • Intravascular hydrostatic and interstitial will move fluid out of the blood vessels. This is the opposite to interstitial fluid pressure and intravascular osmotic pressure which push/pull fluid in the blood vessels. The interstitial forces are small in both cases

Oedema happens when

  1. There is an increase in the intravascular pressure
  2. There is a decrease in the osmotic plasma pressure
  3. Blockage of lymph flow and retention of salt and water

Increased Intravascular Pressure

  • Poor venous outflow – often in lower limbs, as result of (DVT)
  • Increase venous pressure in congestive heart failure (right ventricle affected)

This causes

  • Reduced renal flow (because of reduced cardiac output which results in retention of sodium therefore there is a retention in of water which causes increased blood volume, but the heart can’t cope, therefore a further increase in venous pressure happens

Decreased pressure

  • Mainly caused by kidney disease (excrete albumin), this lowers the plasma osmotic pressure which reduces flow to the kidney; therefore, retain sodium and water
  • Liver disease e.g. cirrhosis of the liver increases portal hypertension, therefore an increase in hydrostatic pressure
  • This results in the loss of plasma into the interstitium, a decrease in plasma volume and therefore a decrease in kidney perfusion

Lymphatic Drainage

  • Oedema is usually localised and is a result of an inflammatory response, neoplasm or an obstruction. E.g. filariasis a worm infection that is transmitted by mosquitos. Causes fibrosis of the lymph nodes and channels of the inguinal area < 5% develop elephantiasis- which is another form of fluid build-up

Pulmonary oedema is an example of

  • Following the failure of the left ventricle blood returning to the heart from the lungs is slowed leading to a lack of blood in the lungs with the result being congestion
  • The pressure in the capillaries increase due to increased blood volume of congestion causing
  • Haemorrhages in the alveolar spaces
  • Increased hydrostatic pressure forcing fluid in the alveolar spaces (pulmonary oedema)
  • Increased fibrosis of interstitial in the lungs
  • Pulmonary hypertension as a result of increased venous pressure backing up into the arterial system this can further cause ventricular failure and systemic venous congestion

Thrombosis

Forming of the thrombus in an otherwise an interrupted CV system, composed of RBC platelets, fibrin and other cells that may circulate within the blood. It will adhere to the endothelium. It may

  • Reduce or obstruct blood flow
  • Dislodge or fragment causing emboli
  • Form a thromboembolic

Normal haemostasis

Three key factors are involved in the making of a blood clot after the blood vessels have been cut

  1. Vascular wall injury, particularly the endothelium and the underlying CT
  2. Platelets
  3. Clotting factors
  4. If the vascular wall is intact the endothelium isolates the blood from subendothelial CT that is thrombogenic. Endothelial cells can be anticoagulants, antiplatelet or pro-coagulants

Normal Haemostasis

  1. When the endothelial is injured platelets are activated to form a clot
  2. Platelets then attach to the subendothelial collagen.
  3. Platelets release factors that cause more platelets to aggregate and cause vasoconstriction
  4. This causes the platelets to contract and form a platelet mass called a primary haemostatic plug
  5. Fibrin will be formed, and a definitive clot develops
  6. There are controls in the normal haemostasis that control coagulation these are pro and anticoagulant factors

Thrombosis

Happens in the injured via three influences

  1. Endothelial cell injury which can by its self-cause thrombosis
  2. Abnormal flow and hypercoagulability of the blood

Atherosclerosis with Thrombosis

  • Abnormal flow. During normal blood flow the red cells are separated from the endothelium by the plasma. If there is turbulence such as at vascular bifurcation. It allows the platelets to contact the endothelium thereby activating the platelets to begin the clotting process

Thrombosis

  • Slow blood flow does not allow dilution of the activated clotting factors
  • The slow blood flow slows down the inflow of clotting factor inhibitors
  • It also allows the build-up of aggregates of platelets in the area of the slow flow
  • This then causes endothelial cells injury, which in turn causes a predisposition to platelet a fibrin deposition on the vascular wall
  • Hypercoagulability is the alteration to the blood clotting mechanism which predisposes a person to thrombus formation. It is seen in some blood disorders and cancers

Thrombosis

  • Morphology- a thrombus can form anywhere in the CV but the only place they to block the flow is the chambers of the heart and of the aorta because of the fast blood flow
  • In the remainder of the CV, they are usually occlusive. They are firmly anchored at the site they originate but can develop head or tails that can fragment to form a emboli
  • Artery frequent site of development is the left ventricle over an area of the heart attack damage, the auricles, the aorta, atherosclerosis in the large arteries and in aneurysms
  • Frequent sites for the development in the venous system are the dilated superficial varicose veins. The heart valves are particularly at risk when they are affected by bacteria or fungi. Also, the deep veins of the thighs, calves, and muscular veins resulting in a DVT

Thrombosis

The thrombosis has several outcomes

  • Propagation to obstruct a blood vessel or brunch
  • Embolization part or whole
  • Removed by fibrinolytic action
  • The organisation and recanalization IE if the thrombus persist is organised by invading fibroblast and capillaries
  • Sometimes they recanalized be by capillary channels

Emboli

  • Defined as an intravascular liquid or mass that is carried to a distant site from where it was formed, most of the emboli arise from thrombi other sites of development are debris from atheroma and fat emboli. Emboli from the veins pass through the lungs and may or may not cause infarction
  • Emboli from the arterial develop in the legs, brain and the viscera and often cause infarction
  • Pulmonary emboli; over 95% of the pulmonary emboli begin the deep veins of the legs breaking off from the DVT
  • Large emboli- 5% may lodge in the pulmonary artery or straddle the bifurcations of the pulmonary artery, they can cause instant death or cardiovascular collapse
  • Medium sized emboli will occlude medium-sized peripheral pulmonary branches usually causing infarction
  • Small emboli may be clinically silent or cause fleeting chest pain is the person is suffering from cardiac failure they may get small infarctions

Treatment of Pulmonary Emboli

  • Even without treatment there, we improved perfusion through the blocked area after the first day due to fibrinolysis and contraction of the thrombus and may even resolve itself in months. Treatment is usually with blood thinning agents

Arterial Emboli

  • Systemic embolism comes from thrombi in the heart after a heart attack
  • 5-10% come from auricles (associated with rheumatic heart disease)
  • Less common sources are debris from atheroma’s or thrombi from aortic aneurysms, infective endocarditis and prosthetic valves
  • They lodge in the lower limbs, brain and viscera and the upper limbs

Fat Embolism

  •  Thrombi- emboli consists of intravascular globules of fat
  • It is most often in people with fractures of large bones with fatty marrow. It is also seen in extensive trauma in fatty tissue. In rare cases, it is seen in diseases states such as diabetes mellitus or pancreatitis
  • The outcome is dependent on the number and size of the fat globules

Air and Gas Emboli

  • This is rare but does occur in underwater workers at high pressure of O2, N2 or He. The embolism happens when there is too rapid decompression and the excess gas release intravascular bubbles. These obstruct small vessels in the muscles and around joints causing bends
  • In the bone marrow it can cause ischaemic necrosis, particularly in the heads of the long bones which then need to be replaced

Infarction

  • An infarction is a localised ischaemic necrosis in an organ or tissue from the sudden blockage of its arterial supply, it is rarely seen in venous drainage but does happen in an organ that has no potential bypass channels such as the ovary of the testis
  • The obstruction causing infarction are usually from thrombi or emboli

Shock

  • Due to the hyper perfusion of the cells a tissue because of an inadequate circulation blood volume. Can be due to Hypovolaemia (bleeding) or fluid loss (vomiting diarrhoea, large burns, not enough fluids
  • Reduced cardiac output (myocardial infarction, pulmonary embolus). Cardiogenic shock.

Shock

  • Less common are the anaphylactic shock, septic shock as a result of neurogenic and septic shock
  • Anaphylactic shock and neurogenic shock reduce circulating blood volume, causing blood to go into the periphery, so there is the small hypovolemic shock in the result
  • The consequences are metabolic, causing systemic cellular hypoxia leading to an increase in anaerobic metabolism and lactic acidosis all of which can lead to death

Clinical correlation of shock

  1. Compensated – mild hypotension tachycardia and pale cold clammy skin
  2. Decompensated – if low circulation persists the compensatory mechanism is overwhelmed- get lowered blood pressure, rapid pulse, breathing difficulties, acidosis and lowering of the renal output
  3. Irreversible – if the circulation and metabolism cannot be reversed the end result is coma and death. If the underlying cause of the shock is controlled with the fluid and electrolyte levels restored shock is reversible.

Sources 

Mitchell, R. N. (2005). Hemodynamic disorders, thromboembolic disease, and shock. Robbins and Cotran Pathologic Basis of Disease. 7th ed. Philadelphia: Elsevier, 119-144.

Teboul, J. L., Saugel, B., Cecconi, M., De Backer, D., Hofer, C. K., Monnet, X., … & Squara, P. (2016). Less invasive hemodynamic monitoring in critically ill patients. Intensive care medicine42(9), 1350-1359.

What Makes Heroin So Addictive and Dangerous?

   Firstly, it is to do with the way heroin is metabolised. There are two main ways that heroin is metabolised; one of the ways is through the Hepatic First Pass. This is done via the removal of an acetyl group when taken orally. The other way is through injections. Heroin that is administered via this route will evade the Hepatic First Pass and will quickly cross the blood-brain barrier. This is because of the presence of an acetyl group that makes it more soluble to fat. Once, in the brain, the acetyl group is removed, and heroin is reduced to 3-monoacetylmorphine and 6-monoacetylmorphine.

These compounds are reduced to morphine that then bind to opioid receptors that are found in the brain. Opioid receptors are important for autonomic processes of the body such as breathing, blood pressure, pain and arousal. When heroin binds to these receptors, it reduces pain, users of the drug also report a feeling of euphoria, dry mouth and a flush of the skin accompanied with a feeling of heavy extremities (Chetna J. Mistry, 2014). An individual can also develop tolerance to the drug, meaning more quantity of the drug may be needed to achieve the desired effect.

Research indicates that the presence of 6- MAM molecules in the blood after heroin has been reduced, could account for its high metabolism. There is also a noticeable difference in alleles among different ethnic groups. The study that was done on SNPs showed the variant Single nucleotide polymorphism A118G did not show altered binding affinities to most opioid receptors and alkaloids. However, the variant receptor A118G binds beta-endorphin and endogenous opioids that activate the Mu opioid receptors more tightly than the most common receptor (Bond, Gong & Kreek, 1998)

Also, beta-endorphins are more potent at the A118G variant than at the most common allelic forms; this is in the agonist-induced activation of the G proteins that have Potassium on their channels (Ying Zhang, 2005). The study concluded that the SNPs in the Mu receptor could alter the binding and signal transduction of the Mu receptors (Chetna J. Mistry, 2014). This may affect the normal physiology of the body, can impact on the treatment protocol, and can play a part in how individuals deal with diseases.

Studies have also found that there is a common reward pathway for drug addiction and that these addictions usually occur in individuals that are vulnerable both neurologically and genetically. This pathway is in the primitive limbic system. Opioids can affect this pathway by; increasing the postsynaptic sensitivity to dopamine or by increasing the release of dopamine by the neurons (Cherie et al., 1998).

    Heroin is a very addictive drug in that, when injected or taken orally can mimic the body’s endorphin pathway of the CNS.  The endorphins normally activate the bodies opioid receptors. These receptors are found at the surface of the cell membrane, in the Limbic system (controls pain, smell and hunger) where there are numerous. The receptors that heroin binds to influences whether the ion channels will open and, in some cases, influence the excitability of the neuron.

    In addition to this, Heroin, also affect the GABA inhibitory receptors of the ventral tegmental area. When Heroin binds to these receptors, the amounts of GABA is reduced. In normal physiology, GABA reduces the amount of dopamine that is produced in the brain. Prolonged use of the drug will cause the reduction in cAMP. Cyclic AMP is one of the molecules that determine the ability of the neuron to produce electrical impulses; it has been found that the increase in these molecules is what causes cravings in heroin users (Guitart, Thompson, Mirante, Greenberg, & Nestler, 1992).

Effects on Adolescents

    Studies have shown that prolonged use of the drug may cause structural changes to the brain by shrinking or enlarging some parts of the brain. For example, structural MRI has shown that prolonged use of the drug can cause changes to the prefrontal cortex of the brain. The images revealed that the prefrontal cortex had a lower proportion of the white matter, this is also seen in the brains of individuals with psychiatric abnormalities (Fowler, Volkow, Kassed, & Chang, 2007). These findings were correlated with the fact that individuals with these changes in the brain structure had a lower score in Wisconsin’s test. This is the area of the brain that controls logical thinking, goal setting and planning. This could explain why heroin users, which are mainly teenagers, are more likely to engage in high risk behaviours, are withdrawn from society and are aggressive.

Other signs of teenage drug addictions are; cognitive difficulties, short-term memory loss, a reduction in attention span, poor information processing and poor problem-solving skills compared to non-heroin or drug users. Some of the warning signs that a teenager is using drugs are; withdraw, low self-esteem, a sudden drop in the grades at school and when they suddenly start having older friends (Lambie, 2007).

Heroin and Pregnancy

     Heroin is a lipophilic drug, hence the use of the drug in pregnancy can cause a wide range of effects, one of them is Neonatal Abstinence Syndrome (NAS). NAS is a syndrome where the foetus together with the mother become dependent on Heroin. The symptoms are; low birth weight, excessive crying, seizures, and irritability. Children that addicted to the drug also show reduced motor and behavioural developmental issues. They are also at risk of contracting hepatitis if the mother was sharing needles during pregnancy. Current treatment of heroin addiction during pregnancy is the use of methadone (Fajemirokun-Odudeyi et al., 2006). According to the Australian government of health and warfare, NAS is most likely to be found in young Australian women, unmarried and indigenous people (AIHW, 2006).

   There a lot of factors that predisposes an individual to addiction.  Recent studies have found that children from single-parent homes and teens that come from poor families are more likely to use drugs. Also, teens with poor relationships and with a family history of drug addictions are themselves more likely to suffer from drug addiction.  Addiction can also be found in families that have no interest in education and in some cases if there is a history of any abuse, depression and anxiety (CDC, 2020). https://video.wordpress.com/embed/WbZJrztZ?hd=0&autoPlay=0&permalink=0&loop=0

References 

AIHW. (2006). Statistics on drug use in Australia 2006. from http://www.aihw.gov.au/publication-detail/?id=6442467962

CHERIE BOND, K. S. L., MINGTING TIAN, DOROTHY MELIA, SHENGWEN ZHANG, LISA BORG,, JIANHUA GONG, J. S., JUDITH A. STRONG, SUZANNE M. LEAL, JAY A. TISCHFIELD,, & MARY JEANNE KREEK, A. L. Y. (1998). Single-nucleotide polymorphism in the human mu opioid receptor

gene alters b-endorphin binding and activity: Possible

implications for opiate addiction. from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC21386/pdf/pq009608.pdf

Chetna J. Mistry, M. B., Dipika Desai, David C. Marsh, Zainab Samaan,. (2014). Genetics of Opioid Dependence: A Review of the Genetic Contribution to

Opioid Dependence. Current Psychiatry Reviews.

Fajemirokun-Odudeyi, O., Sinha, C., Tutty, S., Pairaudeau, P., Armstrong, D., Phillips, T., & Lindow, S. W. (2006). Pregnancy outcome in women who use opiates. European Journal of Obstetrics & Gynecology and Reproductive Biology, 126(2), 170-175. doi: http://dx.doi.org/10.1016/j.ejogrb.2005.08.010

Fowler, J. S., Volkow, N. D., Kassed, C. A., & Chang, L. (2007). Imaging the addicted human brain. Sci Pract Perspect, 3(2), 4-16.

Guitart, X., Thompson, M. A., Mirante, C. K., Greenberg, M. E., & Nestler, E. J. (1992). Regulation of Cyclic AMP Response Element-Binding Protein (CREB) Phosphorylation by Acute and Chronic Morphine in the Rat Locus Coeruleus. Journal of Neurochemistry, 58(3), 1168-1171. doi: 10.1111/j.1471-4159.1992.tb09377.x

Lambie, G. W., & Davis, K. M.,. (2007). Adolescent Heroin Abuse: Implications for the Consulting Professional School Counselor. Journal of Professional Counseling, Practice, Theory, & Research.

Megan Wood. (2004). Illicit drug use in australia from http://www.studnets.adelaisehs.sa.edu.au/subjects/issues/illictdrugs.pdf

Ying Zhang, D. W., Andrew D. Johnson, Audrey C. Papp and Wolfgang Sadée. (2005). Allelic Expression Imbalance of Human mu Opioid Receptor (OPRM1) Caused by Variant A118G*. Journal of biological chemistry.

CDC. (2020, April 30). Data and Statistics About Opioid Use During Pregnancy | CDC. Centers for Disease Control and Prevention. https://www.cdc.gov/pregnancy/opioids/data.html

WHY IS CALCIUM IMPORTANT

Calcium is the most abundant mineral found in the body. It is the major ingredient in the inorganic component of the bone and takes part in various biochemical reactions. These mechanisms include, the clotting process, neural transmission and muscular contraction which includes the cardiac muscle. It is however essential that the levels of calcium in the body are controlled. Too much calcium will lead to cardiac failure, and too little will lead to tetany, which if severe it can lead to muscular convulsions.

  Vitamin D and the parathyroid hormone can keep these levels in check mainly by mobilising calcium from the bone if it is too low and shunting it be back into the bone if there is too much. Both low and high calcium levels are due to factors involving vitamin D or PTH. Benign high levels of calcium due to too much absorption may lead to calcification of the soft tissue.

    Lack of calcium in the diet can lead to osteoporosis in which the bone is less dense and therefore brittle and weak.  In women, osteoporosis can be due to lack of oestrogens after menopause or oophorectomy. Calcium is usually ubiquitous in diet, but often, a small amount of food provides reasonable amounts, of which dairy products are best.

Physiological Roles of Calcium Ions 

  • Calcium in many different types of cells activate on the membrane, depolarisation and mediate calcium influx in response to action potentials and subthreshold depolarising signals.
  • Calcium entering the cells through the voltage-gated Calcium channels serves as a second messenger of electrical signals which initiates many different cellular events.
  • In the cardiac and smooth muscles, cells activation of the calcium channels initiates contraction directly by increasing cytosolic calcium concentration. 
  • In skeletal muscle cells, the voltage-gated calcium channels in the transverse tubule’s membrane interact directly ryanodine-sensitive calcium release channels in the sarcoplasmic reticulum and activate them to initiate rapid contraction. 
  • In neurons, Voltage-gated calcium channels initiate synaptic transmission
  • In endocrine cells, voltage-gated Calcium channels mediate Calcium ion entry that starts secretion of hormones.

Absorption of Calcium 

Several factors affect the absorption of calcium from the intestine, For example, vitamin D and Parathyroid Hormone. Some foods such as cereals contain phytic acids which combine with calcium rendering it unabsorbable. Oxalic acid, which is found in spinach and rhubarb can also be problematic only when too much is consumed.

Osteoporosis after menopause is by far the most common condition in Western countries caused by a disruption in calcium metabolism. Osteoporosis is not due to lack of calcium per say, but due to lack of estrogens, which are essential in bone metabolism. Estrogen replacement therapy in women postmenopausal can help with osteoporosis, but not without side effects. There is evidence that a moderate amount of calcium supplement together with exercise can help prevent osteoporosis.

Calcium usually as the chloride is given via the IV route to treat severe low levels of calcium and it is also used in cardiac resuscitation.  Calcium ions are essential for myocardial excitation and contraction, coupling and for increasing contractility of the heart. Calcium may be used as a positive inotropic or vasopressor but has no place in the management of arrhythmias unless the arrhythmias are caused by hyperkalaemia, hypocalcaemia, hypermagnesemia or calcium blocker 1.  The Australian Resuscitation Council recommends that calcium not to be given on a routine basis during cardiac arrest. Calcium is however used as an antidote to low blood pressure that is caused by calcium channel blockers. Calcium solutions should not be injected intramuscularly or subcutaneously, because they are extreme irritants and may cause necrosis of the tissue.

Causes of Hypocalcemia

  • Kidney Dysfunction
  • When too much is excreted in urine
  • Inadequate consumption of calcium
  • disorders that decrease calcium absorption
  • Lack of response to a normal level of parathyroid hormone (pseudohypoparathyroidism)No parathyroid glands at birth (for example, in DiGeorge syndrome).
  • A low level of magnesium (hypomagnesemia), which reduces the activity of parathyroid hormoneVitamin D deficiency (due to inadequate consumption or inadequate exposure to sunlight

Symptoms of Hypocalcemia

  • muscle stiffness
  • muscle spasms
  • paresthesias, or feelings of pins and needles, in the extremities
  • changes in mood, such as anxiety, depression, or irritability
  • memory issues
  • hypotension
  • difficulty speaking or swallowing
  • fatigue
  • parkinsonism
  • papilledema, or swelling of the optic disc

The Symptoms of Severe Hypocalcemia are:

  • seizures
  • arrhythmias
  • congestive heart failure
  • laryngospasms, or seizures of the voice box

Long-Term Symptoms 

  • dry skin
  • brittle nails
  • kidney stones or other calcium deposits in the body
  • dementia
  • cataracts
  • eczema

Food Rich in Calcium 

  • Seeds
  • cheese
  • Yoghurt
  • Beans and Lentils
  • Almonds
  • Whey Protein
  • Figs

Sources 

Zamponi, G. W., Striessnig, J., Koschak, A., & Dolphin, A. C. (2015). The physiology, pathology, and pharmacology of voltage-gated calcium channels and their future therapeutic potential. Pharmacological reviews67(4), 821-870.

Catterall, W. A. (2011). Voltage-Gated Calcium Channels. Cold Spring Harbor Perspectives in Biology3(8), a003947. http://doi.org/10.1101/cshperspect.a003947

War time Sexual violence and International Law

     Rape during war has been documented throughout history. Sexual violence during war is often committed with the intention of terrorising the population. It is done with a purpose of breaking up families, and in some cases, rape, is done with an intention of changing the ethnic makeup of the next generation. Rape is also used to deliberately infect women with HIV or render women from some minority groups from bearing children. For example, over 100,000 women during the Rwandan genocide where raped.  According to figures from the UN, more than 60,000 women were raped during the civil war in Sierra Leone between 1991 and 2002. And more than 200,000 women have been raped since 1998 in the Democratic Republic of Congo.

     In 1999, the International War Crimes Tribunal at Hague heard the horrors of what happened during the Bosnian war. The tribunal heard gang rape, torture and sexual enslavement were committed against Muslim women and girls by the Serbian soldiers during the early days of the Bosnian conflict. Survivors of the rape camps, detail stories of how they had to watch and take turns at being gang-raped by Serbian soldiers, sometimes three times a day. One survivor was only released when she was visibly pregnant, and her rapist told her” go and bare   our Serbian children” (Crime of war, p,369)

    Incidents of rape have continuously been documented in contemporary conflicts with increasing frequency.  Rape is used as a weapon of war to intimidate the enemy, terrorize the community, ethnic cleansing and genocide. Rape has been considered a war crime for centuries and is punishable if convicted. During the American civil war, Abraham Lincoln in 1863 signed into law making rape a capital offence, more recently in the 20th-century rape has been included explicitly to regulate the conduct of war.

     Article 27 of the fourth Geneva convention of 1949 clearly, states that women are to be protected against any attacks on their honor.  Particularly against Rape, enforced prostitution or any form of indecent assault. The most vulnerable during war are the women and the children. Girls are usually raped and tortured, boys are trained as child soldiers, as is the currently the case in Congo and Somalia

Why are war crimes hard to prosecute?

     Firstly, silence, in the past victims of sexual violence have been hesitant to come forward for fear of retribution, this is true for many parts of Congo and Sudan. This is because these countries lack the robust institutions to uphold the rule of law and bring people to justice. In Congo notably, according to the human rights watch, most of the perpetrators of sexual violence were members of the armed forces or other militant groups. That is why it was a step in the right direction when in 2016 the International Criminal Court Convicted  Jean-Pierre Bemba for crimes against humanity. This case was significant because it showed that high-level commanders can be prosecuted for actions committed by their soldiers.

      Secondly, limitations of international law. Under International law, every country has the rights to govern itself. The nation’s sovereignty limits what the ICC can do, the international human rights is a piece of legislation, but it is not binding and can only be enforced when the countries that have signed to the law codify it within the country. Besides the point, not all countries are part of the treaties. So even if the acts committed within a state are crimes against humanity, it is up to that country to allow the ICC to prosecute the people responsible. International law is too easy to ignore because we do not have a world police, that enforces these laws.

     Thirdly, to prove war crimes happened, there must be beyond all reasonable doubt for a guilty verdict to be reached. For example, the Nuremberg trials for the Nazi war criminals where fast because there was overwhelming documented evidence. In contrast to the trial for Slobodan Milosevic which lasted for almost five years. Milosevic faced 66 counts of crimes against humanity, genocide and war crimes that were committed in the Yugoslav, wars which he pleaded not guilty. Milosevic died of a heart attack while in his cell and because of his death the court failed to rule.

   In 2017 the judges at Hague in a separate trial concluded as follows. 

“The Chamber is not satisfied that there was sufficient evidence presented in this case to find that Slobodan Milosevic agreed with the common plan to permanently remove Bosnian Muslims and Bosnian Croats from Bosnian Serb claimed territory”.

Focus here should be on the word “sufficient”. A not guilty verdict does not always mean that a crime did not occur, and that the defendant is innocent. In some cases, it means that the evidence presented is not enough beyond all reasonable doubt for a guilty verdict to be reached. The burden of proof in murder trials is very high, the burden is always on the plaintiff to prove that the crime happened. Murder trials rarely tell you the truth of what happened, this is partly due to the numerous competing rights, and it also comes down to who has the money and can tell the story consistently.

      Furthermore, International law suffers from lack of funding.  It is not enough to just prosecute high ranking officials, the low level soldiers carrying out the crime have to also be prosecuted. But considering how long and expensive these trials are. It is no wonder most people are not brought to justice, especially in places like Congo and Sudan.  In addition to this point, some countries are not willing to cooperate in giving up the criminals to the ICC. Prosecuting leaders like Jean-Pierre Bemba is hard, but nowhere near as hard as prosecuting people responsible for ethnic cleansing. Ethnic violence still goes on in the deep parts of the Congo, but it is widely under-reported, and as always it is the women and children that are affected most.

Finally, there is no rational basis for why people commit these acts of evil, and while some people get their justice, others don’t. And even those that are prosecuted, it is hard to come up with punishment that fits the crimes committed.

Origins of the HIV and AIDS Pandemic

 The Human Immunodeficiency Virus (HIV) belongs to a family of viruses called the lentiviruses; it is a Retrovirus that causes acquired immunodeficiency syndrome (AIDS), a condition that causes the degeneration of the immune system. This leaves an individual more prone to opportunistic infections and some forms of cancers. HIV/AIDS is transmitted through the contact of infected Blood, semen, vaginal fluid and through breast milk; the most common way that HIV/AIDS is spread through sexual intercourse with an infected person. This paper will look at the history of HIV/AIDS, the distribution, how the HIV/AIDS infects the host and how it targets the immune system (Sharp & Hahn, 2011).

Mode of infection

A conformational change happens after gp120 binds to CD4 cells and must then bind to a second molecule at the surface of the target cells for infection to happen. Specificity of the receptor is dependent on the variant of the gp120 molecules that are expressed on its surface. Because there are several chemokine receptors that are used as co-receptors. Variations in the gp120 molecules determines which CD4 molecules can be infected by the virus, for example, HIV infection and replication through the macrophages use the CCR5 receptors and therefore it does not require high levels of CD4 molecules for infection, while infection and replication through the lymphatic system uses the receptor CXCR4 and requires high levels of CD4.

This important because it shows that the HIV can infect the host using two receptors, CCR5 is thought to be the receptor that the HIV virus uses for the initial infection since people that have a mutation in the CCR5 receptor appear to have some kind of immunity from the virus. If an individual is infected through sexual intercourse, macrophages and dendritic cells stimulate variant of malt, which provides a reservoir both locally and distally and are carried throughout the body. Exposure of the HIV infected cells to the virus promotes viral replication, a switch back to lymph tropic form of stimulation causes the further rapid distribution of the virus throughout the body. Mutation in the gp120 molecules causes the tropism of the virus in an infected person to change over time and cause the alteration of the amino acid sequence.

The virus enters the cells when the gp120 binds to the cell membrane after it binds to the CD4 and it co-receptors it allows the gp41 to penetrate the cell’s membrane and the then inject the viral particles. The cells the HIV virus targets are the CD4 cells, it infects the cells by first attaching to the cells membranes and releases its content into the cells, once in the cells the RNA is transcribed into cDNA by the enzyme reverse transcriptase. The cDNA may remain in the cytoplasm or enter the nucleus where the enzymes integrase, integrates the transcribed RNA into the host genome. Viral replication remains latent for several years while it continues to replicate at low levels.

Along mRNA strand is produced by transcribing the provirus that is spliced at the ends for the synthesis of different proteins. The first two protein made are tat and rev, tat enters the nucleus where it acts on transcription factors by binding to the LTR region this increases the rate of viral transcription. Rev also sticks to the nucleus of and to the rev the binding of rev to the responsive unit of the transcript increase RNA transport to the cytoplasm.

In the second wave of viral replication the viral core and envelope are produced and in third step un-spliced RNA is carried to the cytoplasm where it serves as a pattern for the synthesis of other viral particles. CD4 cells are released from the cells and this often leads to the cell lysing. Macrophages and dendritic cells are often not killed hence they serve as the carrier that transports the virus to other parts of the body. Dendritic cells carry the virus on the surface while macrophages allow low levels of production of HIV. Further infection and replication happen when infected macrophages and T cells are stimulated by either an antigen or cytokines.

Replication

After the virus enters the host cells and the RNA is reverse transcribed and intergraded into the DNA of the host cells. It remains latent for several years and replicates as the host cell replicates and an estimate of over 10 billion different HIV viruses are produced in an average infected person. HIV produces many different copies of the virus when it replicates because unlike normal DNA replication it does not have proofreading capabilities when there is a mutation during the replication process. The high mutation rate of HIV when it replicates is the main reason why it is doing hard to find treatments and its ability to change its surface antigens means that the immune system cannot recognise it fast.

Initial infection

The initial infection is characterised by flu-like symptoms, during this time the virus is in peripheral blood, this is followed by a significant drop in the number of circulating CD4T cells. The immune system responds by generating cytotoxic T lymphocytes (CLTs) and antibodies specific to the virus, these CLTs are also responsible for the drop in the number of CD4 T cells.

This is a stage in the infection that an individual presents the antibodies that are specific to HIV proteins, what follows is the partial recovery in of the CD4 cells. The distribution of the virus to the lymphoid tissue and to the rest of the body is done by the Macrophages and dendritic cells.

Latent phase

The high mutation of the virus makes it hard for the immune system to get rid of the virus even though the immune response is standard, for example, the latent phase of the virus can last for as long as 15 years. While the virus replicates, there is a slow decline in the number of CD4 cells.

The main location for infection is the lymph node that is why the number of virus-infected T cells in the peripheral blood remains constant. The presentation of the virus at the surface of the cells is done by the follicular dendritic cells which also act as a reservoir for the virus. Follicular Hyperplasia and lymphadenopathy happen due to continues presentation of the virus to the B and T cells, which eventually leads to degradation of the lymph nodes.

A number of factors contribute to the death of the T cells, the first one is the production of the virus in the cells, and the second one that the cells that are infected seem to be prone to programmed cell death, the third one is that CTLs kill some of the infected cells and finally CD4 T cells that are not infected are killed by bystander ADCC like mechanisms which are brought about by the binding of soluble gp120and anti gp120 to the surface of CD4 cells. During latent phase, the number of CD8 cells is more than the number of CD4 cells and AIDS starts when the levels of the CD4 t cells become low (HIV Replication Cycle,2019)

Crisis phase (AIDS)

Aids is usually diagnosed through the count of CD4 T cells, below 14% usually indicates that a person has AIDS which is characterised by the development of unusual cancer, optimistic infection and the general wasting syndrome which represents that the Virus has spread to the central nervous system.

The slow drop in the CD4 T cells count leaves an individual; prone to infection and activation of virally infected B and T cells further exacerbates immune deficiencies through the stimulation of viral transduction progeny and mutation in the CD8 cells that kill virally infected cells makes it hard for the immune system to detect the virus.

Distribution

There are two forms of the HIV virus, HIV1 and HIV2, HIV1 is more virulent than HIV 2 this explains why HIV2 is mainly restricted to North Africa. The map above highlights the distribution of the HIV/AIDS.

Origins

    There are two main theories that explain the origin of HIV/AIDs. The first one is the bushmeat practice theory of the people in Africa.  Based on the information that HIV is directly related to the simian immunodeficiency virus (SIV) that is found in chimpanzees’ scientists have theorised that SIV may have mutated to HIV in Africa through continuous exposure of SIV.

Discovery

The initial description of HIV/AIDS was in 1981 when unusual cases of pneumonia were reported among previously healthy homosexual males in America. This was followed by the recognition of an aggressive form of Kaposi’s sarcoma, since the first reported case thereof HIV/AIDS in 1981 there are now over 30 million people infected worldwide.

 When AIDS was first discovered it seemed to be restricted to gay men, drug user and Haitians that lived in the United States and if AIDS was confined to these high-risk population the rest of America felt safe. This however changed when a child contracted AIDS after she was blood transfused. Later that year there were reported cases among bisexual men and women, after these cases no one was denying that AIDS was spreading to the rest of the population.

 In 1982 scientists in France led by Lu Montaginer and Froncoise Barre- sinoussi isolated a new virus from an AIDS sufferer. Later in 1984 workers at the cancer institute in America also announced that they had managed to isolate the virus that causes AIDS they called it (HTLVIII) which means the human T cells virus which was later named as human immunodeficiency virus. The causes of AIDS were not identified until three years later, and soon after that the genome was sequenced, and the clinical tests were developed (Sharp & Hahn, 2011).

The list below highlights the HIV/AIDS timeline

  • 1981 – 108 cases of AIDS reported in the US
  • June – five gay men in los angles
  • July – eight gay men reported with severe immunodeficiency
  • December – cases of AIDS in intravenous drug users
  • December – the first AIDs case reported in United Kingdom
  • By 1982 around 593 cases of AIDS were reported and with the morbidity of 243
  • June – a cluster of AIDS cases in California suggest an infectious agent
  • 1982 – Acquired immunodeficiency was given as the new name
  • December – a 20 months year old baby dies of AIDS due to multiple transfusions
  • By 1983 the mortality had gone up to 759 people
  • 1094 the mortality had gone up to 6,993
  • November CD4 molecules on the T cells identified as the receptor for the virus
  • by 1986 the mortality had gone up to about 16000, and in May of the same year the name human immunodeficiency virus was given to the virus that causes AIDS

Structure

 HIV can be divided in two the HIV1 and HIV1; they can be described as an enveloped retrovirus that belongs to a family of virus called the lentivirus. The viral particle contains two strains of identical RNA and three enzymes called integrase, protease and reverse transcriptase.

These are packaged into p24 core antigen with a p7 nucleoprotein and p9. All these are surrounded by a p17 matrix protein. Antigens presenting cells like dendritic cells, macrophages as well as the CD4+T cells are potential targets for the virus because they display CD4 makers on their surface. This is because the viral envelop that is derived from the host cell display viral glycoprotein gp120 and gp41, the gp120 which is covalently bonded to gp41 is very important for infection.

References

Richard coico, G. s. (2009). immunology a short course john Wiley & sons

S, J. (2007). Diagnosis of HIV-1 Infection in Children Younger Than 18 Months in the United States. Journal of American academy of paediatrics. from http://pediatrics.aappublications.org/content/120/6/e1547/F1.full

The Molecular Structure of HIV. (1998). from http://www.yale.edu/bio243/HIV/hivstructure.html

The HIV Genome. (1998). from http://www.yale.edu/bio243/HIV/genome.htmlA brief history of HIV. (2008). from http://www.can.org.au/Pages/HIV/History.aspx

Kramski a, A. S. a., A.P.R. Johnston b, G.F. Lichtfuss c,d, S. Jegaskanda a, R. De Rose a,, & Stratov a, A. D. K. f., M.A. French g, R.J. Center a, A. Jaworowski c,d,e, S.J. Kent a,. (2012). Role of monocytes in mediating HIV-specific antibody-dependent

Cellular cytotoxicity, Journal of Immunological Methods.

Richard coico, G. s. (2009). immunology a short course john Wiley & sons

S, J. (2007). Diagnosis of HIV-1 Infection in Children Younger Than 18 Months in the United States. Journal of American academy of paediatrics.

HIV Replication Cycle | NIH: National Institute of Allergy and Infectious Diseases. (n.d.). Retrieved May 1, 2020, from http://www.niaid.nih.gov/diseases-conditions/hiv-replication-cycle

Sharp, P. M., & Hahn, B. H. (2011). Origins of HIV and the AIDS Pandemic. Cold Spring Harbor Perspectives in Medicine:, 1(1). https://doi.org/10.1101/cshperspect.a006841

Communication Challenges in Palliative Care

  

       Palliative care is an approach to care that focuses on improving the quality of life of patients and their families facing the issues that are associated with life-threatening chronic incurable illnesses (Jarrell, 2016). It is important to note that palliative care does not mean end of life care and patients can be on palliative for years before they die (Wallerstedt et al., 2019). Palliative care has four stages namely, Stable, deteriorating, unstable and terminal. Palliative care management plan must be made in collaboration with patients and their families in order to achieve optimal care (Hui & Bruera, 2016).  

      This paper aims to explore the communication challenges that clinicians in palliative/end of life care face. It will also explore the importance of good communication in providing dignity and respect to people on palliative care. And will end by looking at the reason communication is very important to improving nursing practice.  

      In Australia, from 2012- 17 the number of palliative care-related hospitalisation increased by 25%, from about 61,600 to almost 77,400. Between 2016-17, 51.6% of the patients who died as an admitted patient had been palliative during their   hospitalisation. The steady growth in the levels of hospitalisation in Australia, can likely be put down to the increase and the aging of the Australia population. Also, the increase in the levels of chronic, and incurable illnesses (Australian Institute of health, 2019).   

Importance to Nursing Practice   

      Firstly, Communication is arguably the most important skills in palliative nursing. Patients centred communication is important to a nurse as it enables the patient and their families make informed decision that are consistent with their own values, goals and preferences (Warmling & de Souza, 2018). (Macpherson, 2018) Found that many physicians find palliative care discussions difficult, this is due to the lack of training in communication interaction, difficulties dealing with emotions and fear of taking away the patient’s hope. Even with a clear knowledge of the whole palliative process, and a willingness to facilitate the discussion, clinicians face tensions between, respecting the needs of the patient, avoid undermining cultural values and meeting the needs of the children. 

        Secondly, having an open-ended dialogue when residents are first admitted to care homes is important, as it provides a clear framework of what sort of medical interventions clinicians can make when the patient becomes critical (Hack et al., 2017). This is normally done through an Advanced Care Directive, an ACD details the needs and wants of the resident should they become critical, and the medical interventions that can be pursued. However even if an ACD is available, accessibility to it is very difficult, because either the doctors, nurses or families are not aware it exists. Moreover, ACD’s are dependent on the current condition of the resident/patient (Page, 2019).  

      (Brighton & Bristowe, 2016) Found that poor communication among clinicians can often lead to poor assessment, evaluation and management of patient symptoms. This is especially true when caring for people with major cognitive decline, like dementia and Alzheimer’s. Advanced care directives are supposed to give clinicians a decision-making framework for when patients deteriorate. But an ACD, only gives guidance for the gradual deterioration of patients and specific guidelines on whether to resuscitate. They are, however, very vague when it comes to medical emergencies where the patient does not die but the outcome significantly takes away the right of the patient to die with dignity and respect. For individuals without a valid ACD, clinicians normally wait until there is a drastic change in the functional status of the patient. That can either be brought on by a fall, stroke or flue, in order to have a conversation about palliative care/end of life care (Carr & Luth, 2017).   

      Furthermore, the more multicultural the Australian society becomes, the harder it will be to provide person centred care. This is because different cultures have different ways they deal with palliative care.  Differences may relate to whether the most usual cultural approach to end of life care is family based or focused on the autonomy of the patient.  Since nurses spend the most time with the patients they are better placed to advocate and know the dislikes and the needs of the patients and their families (Modares & Matei, 2018). 

     To conclude, good communication is important to improving practice in palliative care as it allows clinicians to provide person centred care. It also allows nurses to provide that meets the needs of the patient and their families.  Additional education after graduation is required among nurses in order to effectively communicate with people on palliative care.

References

Jarrell, J. A. (2016). Palliative Care. In Care of Adults with Chronic Childhood Conditions (pp. 355-362). Springer, Cham. 

Wallerstedt, B., Benzein, E., Schildmeijer, K., & Sandgren, A. (2019). What is palliative care? Perceptions of healthcare professionals. Scandinavian journal of caring sciences, 33(1), 77-84. 

Hui, D., & Bruera, E. (2016). Integrating palliative care into the trajectory of cancer care. Nature reviews Clinical oncology, 13(3), 159. 

Australian Institute of Health and Welfare. (2019). Palliative care services in Australia. Retrieved from https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia 

Warmling, L., & de Souza, P. A. (2018). The Importance of Communication among the Members of the Nursing Team. Creative Education, 9(06), 993. 

Macpherson, C. (2018). Difficulties for a practitioner preparing a family for the death of a parent: A narrative inquiry. Mortality, 23(3), 247-260. 

Page, D. (2019). THE BARRIERS TO COMPLETING AN ADVANCE DIRECTIVE: THE PERSPECTIVES OF HEALTHCARE PROFESSIONALS. https://doi.org/10.17615/nevz-rm58

Hack, J., Buecking, B., Lopez, C. L., Ruchholtz, S., & Kühne, C. A. (2017). Advance directives in clinical practice: Living will, healthcare power of attorney and care directive. Zeitschrift fur Rheumatologie, 76(5), 425-433.

Brighton LJ, Bristowe K, Communication in palliative care: talking about the end of life, before the end of life, Postgraduate Medical Journal 2016;92:466-470.

Deborah Carr, PhD, Elizabeth A Luth, PhD, Advance Care Planning: Contemporary Issues and Future Directions, Innovation in Aging, Volume 1, Issue 1, 1 March 2017, igx012, https://doi.org/10.1093/geroni/igx012

Modares, M., & Matei, A. C. (2018). End of life care in a multicultural framework: to treat or not to treat. University of Toronto Medical Journal, 95(3), 43-33.

What Everyone Must Know About OBESITY

Obesity is a condition that is associated with excessive levels of body fat, obesity is considered a major health problem in Western Countries. Between 2014 and 2015 a staggering 63.4% of the population was overweight. This is an increase of 19% from 1995. In the same period, there was about 22,700 hospital separation involving one or more weight loss procedure, seven of eight of these procedures happened in private hospitals. 79% of these where for female patients. Figures also indicate that from 2005-2006 to 2014-25 weight loss surgeries more than doubled from about 9,300 to 22,700 (Gupta et al., 2016).

In Australia and other industrialised countries, there is a growing concern for the rising levels of childhood obesity. Recent figures indicate that 28% of children and adolescents are considered overweight or obese. In some minority groups, such as Aboriginal and Torres Strait Islanders, the figures appear to be even higher. In children, being overweight can lead to several short and long-term consequences. For example, low self-esteem, depression, body image issues and can increase the risk of individuals developing eating disorders (Sainsbury, Hendy, Magnusson, & Colagiuri, 2018).

    The World Health Organisation has classified obesity as a global epidemic. Overweight or obese people have higher rates of cardiovascular diseases, diabetes mellitus and cancer. Other problems that are associated with obesity include gastro-oesophageal reflux disease, sleep disorders and chronic joint pain. In some countries, the morbidity and mortality for obese people are second only to smoking cigarettes. The causes of obesity are complex and involve a combination of genetics, physiological and lifestyle factors.

      Regulation of Food Intake

  In humans there are two feeding centres which are both located in the hypothalamus, one is associated with hunger and stimulates eating. The other is associated with a sense of fullness and inhibits eating. The hunger centre is always active, but it is intermittently inhibited by the satiety centre. These centres respond to the noradrenaline signals, paracrine signals, blood nutrient levels and psychosocial factors. Stimuli that can trigger eating are numerous, for example, teste and smell, low blood sugar levels, some drugs such as marijuana and low ambient temperatures (Houben, Dassen, & Jansen, 2016).

    Another essential substance that regulates hunger is a hormone that is secreted by the stomach called Ghrelin. It helps to stimulate appetite, causing you to digest more food and store more fat. It also appears to help control insulin release and play a protective role in cardiovascular health. The levels of Ghrelin in the blood fluctuate during the day but are quite elevated prior to a meal and then decreases afterwards. Obese individuals tend to have lower levels of Ghrelin, whereas people with anorexia tend to have higher levels. What is interesting is that the speed to which Ghrelin drops can be influenced by the type of foods that are consumed (Pradhan, Samson, & Sun, 2013).

On the other hand, there are several chemical mediators that suppress appetite and reduce food intake. The monoamine neurotransmitter noradrenaline and serotonin tend to inhibit eating. Another hormone (CCK) is secreted in response to triglycerides in the gastrointestinal tract. It rapidly stimulates the satiety centres of the hypothalamus to stop eating. Some researchers have indicated that eating disorder like Bulimia may be associated with impaired CCK secretion (Al Shukor, Raes, Van Camp, & Smagghe, 2015).

Role of Leptin

    Leptin is a hormone that is released from the fat cells located in the adipose tissue, leptin helps regulate and alter long-term food intake and expenditure, not just from meal to meal. The primary design for leptin is to help the body maintain weight. Because leptin comes from the fat cells, the levels of leptin in an individual is directly connected to the fat composition of the body. If the individual ads fat the levels of leptin increase. Leptin helps inhibit hunger and regulate energy balance so that the body does not trigger hunger responses when the body needs energy. When the levels of leptin fall, as is the case in people who lose weight, it can trigger an increase in huge appetite and food cravings.

   In normal circumstances when the body is functioning well, excess fat cells will produce leptin which will trigger the hypothalamus to lower the appetite. This allows the body to deep into the fat stores to feed itself. In obese individuals, they have too much leptin in the blood. This can cause leptin resistance, where the body is no longer sensitive to the hormone. Low levels of leptin do happen, but this is rare, this is called congenital leptin deficiency. In Congenital leptin deficiency, the body does not produce leptin. And without leptin, the body thinks it has fat and this causes intense uncontrollable hunger and food intake. Congenital leptin deficiency often manifests in severe childhood obesity and delayed puberty (Park & Ahima, 2015).    

The internet is saturated with countless weight loss and super diet programs, each one of them promising faster weight loss results. But by far the best way to lose weight is by setting a sustainable and realistic program involving diet and exercise. Foods that should be avoided within reason and depending on your lifestyle are simple carbohydrates, processed sugars and processed meats. According to dietitians, sudden spurts of exercises use carbohydrate stores, whereas steady exercises use fat stores.

An Individual’s body mass is a product of their total energy intake and expenditure. An individual is said to be in energy balance when the food intake equals the energy that is consumed by the body cells. When this occurs, an individual will neither gain weight or lose weight. Assuming that the daily fluid intake and output stay the same.

Daily changes in the total energy intake and expenditure do happen, but if the individual manages to maintain this energy balance the total body weight will be maintained. The rate of energy expenditure determines the rate of usage by the body, it can be measured as oxygen consumption and body temperature. Factors that increase metabolism include physical activity, sympathetic nervous system stimulation and raised body temperature (Dhurandhar et al., 2015).

Suggestion for safe and effective weight loss

Do not crash diet, you will most likely regain the lost weight

Aim for small slow loses of around 1Kg per week

Cut down on dietary fats especially saturated fats and increase the general intake of fruits and vegetables.

Exercise at least three days a week, or generally increase your overall physical activity.

Sources.

Al Shukor, N., Raes, K., Van Camp, J., & Smagghe, G. (2015). Analysis of interaction of phenolic compounds with the cholecystokinin signaling pathway to explain effects on reducing food intake. Paper presented at the 20th National symposium of Applied Biological Sciences (NSABS 2015).

Dhurandhar, N. V., Schoeller, D., Brown, A. W., Heymsfield, S. B., Thomas, D., Sørensen, T. I., . . . Group, E. B. M. W. (2015). Energy balance measurement: when something is not better than nothing. International Journal of Obesity, 39(7), 1109.

Gupta, N., Heiden, M., Aadahl, M., Korshøj, M., Jørgensen, M. B., & Holtermann, A. (2016). What is the effect on obesity indicators from replacing prolonged sedentary time with brief sedentary bouts, standing and different types of physical activity during working days? A cross-sectional accelerometer-based study among blue-collar workers. PLoS ONE, 11(5), e0154935.

Houben, K., Dassen, F. C., & Jansen, A. (2016). Taking control: Working memory training in overweight individuals increases self-regulation of food intake. Appetite, 105, 567-574.

Park, H.-K., & Ahima, R. S. (2015). Physiology of leptin: energy homeostasis, neuroendocrine function and metabolism. Metabolism, 64(1), 24-34.

Pradhan, G., Samson, S. L., & Sun, Y. (2013). Ghrelin: much more than a hunger hormone. Current opinion in clinical nutrition and metabolic care, 16(6), 619-624. doi:10.1097/MCO.0b013e328365b9be

Sainsbury, E., Hendy, C., Magnusson, R., & Colagiuri, S. (2018). Public support for government regulatory interventions for overweight and obesity in Australia. BMC Public Health, 18(1), 513.