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Bridging anticoagulation therapy with low molecular weight heparin in patients with atrial fibrillation following a stroke is associated with adverse events

Por: Kennedy · R.

Commentary on: Altavilla R, Caso V, Bandini F, et al. Anticoagulation after stroke in patients with atrial fibrillation. Stroke 2019;508:2093–100.

Implications for practice and research

  • Healthcare professionals need to be aware that bridging anticoagulation therapy with low molecular weight heparin (LMWH) in patients with atrial fibrillation following a stroke is associated with a higher rate of recurrent ischaemic and haemorrhagic events compared with patients who do not receive bridging therapy.

  • Strategies to ensure adherence to the guidelines need to be devised and implemented within the clinical setting.

  • Context

    Patients with cardioembolic stroke and non-valvular atrial fibrillation are at a high risk of early stroke recurrence.1 Oral anticoagulation therapy (OAC) in the form of vitamin K antagonists (VKAs) and non–vitamin-K oral anticoagulants (NOACs) are the medical therapy of choice in the secondary prevention of stroke. American Stroke guidelines2 recommend the initiation...

    Coping with multiple morbidities: Asian perspectives to inform culturally appropriate caregiving

    Por: Zhan · X. · Wenchung · W. · Lin · H. · Jingran · L. · Li · B. · Li · M. T. · Tian Fu · R. · Wu · Y. · Wu · X. · Shi · X. · Lee · A. J. · Shengxiao · X.

    Commentary on: Cheng Cheng, Bai Jie, Yang Cong-Yan et al. Patients' experiences of coping with multiple chronic conditions: a qualitative descriptive study. J Clin Nurs, 2019, 28: 4400–11.

    Implications for practice and research

  • Healthcare professionals must acknowledge cultural differences in coping strategies and must communicate effectively to inform caregiving.

  • Further qualitative, descriptive studies are required to explore the needs of patients so this information can inform culturally sensitive and appropriate care.

  • Context

    As prevalence of multiple chronic conditions (MCC) increases, financial, personal and institutional burdens will rise.1 Complexities require more information on polypharmacy, disease management and assessments of impact on service provision.2 This qualitative study3 evaluates how patients cope with their diagnoses and manage their own symptoms. It offers a cultural perspective on the burdens of chronic disease management and presents guidance on coping strategies used in Chinese...

    Nurses should recognise that focusing only on the resolution of physical symptoms may not be enough to overcome the psychosocial implications of living with a chronic disease

    Por: Ma · S.

    Commentary on: Byron C, Cornally N, Burton A, et al. Challenges of living with and managing inflammatory bowel disease: a meta-synthesis of patients’ experiences. J Clin Nurs 2020;29:305–19. doi: 10.1111/jocn.15080.

    Implications for future practice and research

  • Nurses are well situated to coach people living with chronic conditions to recognise and utilise healthy practical and emotional coping strategies.

  • Future research should not only explore how people with inflammatory bowel disease manage the challenges they face but what the scope is for specialist nurse support.

  • Context

    Inflammatory bowel disease (IBD) is a chronic condition of the gastrointestinal tract that is associated with embarrassing signs and symptoms that include rectal bleeding, diarrhoea, faecal urgency and abdominal pain. Byron et al have provided a meta-synthesis of patients experiences with this condition1 and an update on previous work conducted by Kemp et al.2 The authors...

    Paying attention to cultural context matters in advance care planning and palliative care

    Por: Russell · S.

    Commentary on: Lin CP, Evans CJ, Koffman J, et al. What influences patients' decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals. Palliat Med 2019; Epub ahead of print Aug 1. doi:10.1177/0269216319866641.

    Implications for practice and research

  • More evidence is needed to understand the cultural aspects of palliative care.

  • Paying attention to and acting on cultural context facilitate better culturally sensitive, person-centred advance care planning and palliative care.

  • Context

    Advance care planning is largely derived from Western countries,1 with a reliance on Western concepts of autonomy and decision making.2 Much advance care planning research is from the USA, UK and Europe,3 despite significant international cultural differences in the concept of autonomy and decision making.4 5 Lin et al’s1...

    Multicomponent exercise programmes among very elderly hospitalised patients can be safe and effective in reversing functional decline

    Por: Zhang · N.

    Commentary on: Martínez-Velilla N, Casas-Herrero A, Zambom-Ferraresi F, et al. Effect of exercise intervention on functional decline in very elderly patients during acute hospitalization: a randomized clinical trial. JAMA Inter Med 2019;179:28–36.

    Implications for practice and research

  • The proposed exercise programme can provide significant benefit over usual care and improve patient outcomes in the hospital.

  • Future research may look at a larger scale implementation, additional secondary endpoints (hospital readmission, falls and so on) and the combination of this intervention and others known to impact functional decline.

  • Conceptualising functional status as a clinical vital sign is a paradigm shift that would improve outcomes among very elderly patients.

  • Context

    Functional decline is prevalent among older patients who have been hospitalised. During an acute hospitalisation, there may be significant functional decline with non-disabling (and disabling) conditions causing new disability.1 Decline often persists after discharge...

    Fan therapy is a treatment option for relieving of chronic breathlessness

    Por: Ekström · M.

    Commentary on: Swan F, Newey A, Bland M, et al. Airflow relieves chronic breathlessness in people with advanced disease: An exploratory systematic review and meta-analyses. Palliat Med 2019;33:618-633. doi:10.1177/0269216319835393.

    Implications for practice and research

  • Fan therapy and airflow at the face or nasal mucosa might relieve chronic breathlessness.

  • Fan therapy is harmless and could be tried against breathlessness during/after exertion or at rest.

  • Evidence is warranted on the effect using better modes of comparison/blinding, long term effects and on patient acceptability and effectiveness in clinical practice.

  • Context

    Chronic breathlessness,1 is a major cause of suffering in people with severe disease. Treatment includes cardiorespiratory rehabilitation training, supplemental oxygen in hypoxaemia and low dose opioids in selected patients, but is often insufficient and new therapeutic options are needed.2

    Airflow directed at the face using a fan or at the nasal mucosa...

    Study of nurses use of early warning scoring systems for patient deterioration highlights the need to strengthen nurses knowledge and confidence in their clinical judgement in using these tools

    Por: Rehman · S. · Ali · P.

    Commentary on: Wood C, Chaboyer W, Carr P. How do nurses use Early warning scoring systems to detect and act on patient deterioration to ensure patient safety? A scoping review. Int J Nursing Studies 2019;94:166–178.

    Implications for practice and research

  • Educational opportunities involving simulation and reflective practice may help nurses improve their confidence in using their clinical judgement skills, as well as early warning scoring tools to identify and respond to deteriorating patients.

  • Further research is needed to explore nurses’ reluctance to activate the rapid response team when patients meet specific criteria in early warning scoring systems.

  • Context

    The use of early warning scoring tools plays an important role in the identification and management of patients at risk of deterioration1 in acute and non-acute settings.

    However, the use of such tools in the practice setting and especially in non-acute settings, such as...

    Living a life, not an illness: the process of living well with advanced cancer

    Por: Harrison · J. · Devereux · J.

    Commentary on: Arantzamendi M, Garcia-Rueda N, Carvajal A, et al. People with advanced cancer: the process of living well with awareness of dying. Qual Health Res 2018. doi: 10.1177/1049732318816298. [Epub ahead of print 12 Dec 2018].

    Implications for practice and research

  • The process of living well with advanced cancer revolves around an ‘awareness of dying’. This leads to a focus on living a life rather than living an illness.

  • To support development of the theory, future research should explore its applicability in both a family perspective and different cultural contexts.

  • Context

    Little is known about the process of living well with advanced cancer or how to support it.1 The study addresses this by collating the experiences of people living with advanced cancer and comparing them with the ‘Theory of Living Well with Chronic Illness’.2 The authors were familiar with the...

    Undiagnosed delirium is common and difficult to predict among hospitalised patients

    Por: Mitchell · G.

    Commentary on: Lange P, Lamanna M, Watson R, et al. Undiagnosed delirium is frequent and difficult to predict: results from a prevalence survey of a tertiary hospital. JClin Nurs 2019; 28; 2537–42.

    Implications for practice and research

  • Delirium is common but it is frequently undiagnosed within hospital settings internationally.

  • Older age and dementia are the strongest predictive factors associated with undiagnosed delirium.

  • Validated assessment of all hospitalised patients for delirium is recommended to improve delirium diagnosis among hospitalised patients.

  • Context

    Previous research on delirium prevalence in hospital settings suggests it is a common condition which can affect around 20% of older people.1 Although delirium is both preventable and treatable, healthcare professionals often lack the necessary knowledge and skills regarding delirium prevention, identification and management.2 This has led to high rates of undiagnosed delirium, estimated to be as high as...

    ITU patients with delirium did not benefit from electronic and pharmacist support encouraging the deprescribing of benzodiazepines and anticholinergics

    Por: Donaghy · J.

    Commentary on: D. Campbell, N. L. Perkins, A.J. Khan, et al. Deprescribing in the Pharmacologic Management of Delirium: A Randomized Trial in the Intensive Care Unit. J Am Geriatr Soc 2019;67(4):695–702.

    Implications for practice and research

  • Electronic alerts were used with pharmacist support to suggest alternative medications to benzodiazepines and anticholinergics. This had no effect on the use of these medications or the short-term patient outcomes.

  • Deprescribing interventions can have little influence where prescribing levels are already very low.

  • Context

    Delirium is a syndrome characterised by an acute onset of disturbed consciousness, cognitive function or perception. It is associated with higher mortality, increased rates of dementia and longer hospital stays.1 Consequently, establishing methods of prevention has been identified as an important goal.1 Delirium is a common issue, affecting one-third of hospitalised general medical patients aged 70 and over.2 Campbell et...

    Increased knowledge of oral anticoagulants and treatment satisfaction leads to better adherence to oral anticoagulants in patients with atrial fibrillation

    Por: Schwanda · M. · Gruber · R.

    Commentary on: Smet L, Heggermont WA, Goossens E, et al. Adherence, knowledge, and perception about oral anticoagulants in patients with atrial fibrillation at high risk for thromboembolic events after radiofrequency ablation. J Adv Nurs 2018;74:2577–87.

    Implications for practice and research

  • Increased knowledge about oral anticoagulants (OACs) and treatment satisfaction may increase the adherence to OAC in patients with atrial fibrillation (AF).

  • There is a need for long-term effects of educational interventions regarding adherence and the intake of OAC in patients with AF.

  • Context

    AF occurs frequently and leads to a higher incidence of thromboembolic events and stroke. Therefore, OACs are crucial and recommended. This therapy can be carried out with vitamin K antagonists (VKAs) or non-VKA OAC (NOACs). Both have demonstrated a significant reduction in the risk of thromboembolic events. Additionally, an effective rhythm control strategy, the catheter ablation, is useful and reduces the...

    Best practice for peripheral intravenous catheter replacement

    Por: Hacker Bravo · P.

    Commentary on: Webster J, Osborne S, Rickard CM, et al. Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev 2019;1:CD007798.

    Implications for practice and research

  • No difference was found in rates of catheter-related bloodstream infections (CRBSI), thrombophlebitis, pain or mortality between routine and clinically indicated peripheral intravenous catheter (PIVC) removal and replacement.

  • Routine PIVC change does decrease infiltration and catheter occlusion.

  • Clinically indicated catheter exchange may be a cost-saving measure for healthcare systems.

  • Context

    PIVCs are the most common invasive procedure with each patient receiving an average of two PIVCs during their admission.1 This common device, however, increases risk for BSI/CRBSI with a mortality rate of 12%–25%.2 Many institutions disagree on what best practice recommendations should be. Many institutions including the Centers for Disease Control support the routine removal of PIVCs as a method to decrease the risk...

    Womens experiences of breast cancer reveal the need for a holistic person-centred approach to breast cancer care

    Por: Kerin · U.

    Commentary on: Smit A, Coetzee BJ, Roomaney R, et al. Women’s stories of living with breast cancer: a systematic review and meta-synthesis of qualitative evidence. Soc Sci Med 2019; 222:231–45. doi: 10.1016/j.socscimed.2019.01.020

    Implications for practice and research

  • Findings illustrate the physical, psychosocial and emotional impact of breast cancer on women.

  • A holistic, person-centred approach to breast cancer care is required before, during and after active cancer treatment has been terminated.

  • The proposed trajectory of breast cancer framework will enable future researchers to consider breast cancer experiences relative to particular breast cancer time-points.

  • Context

    Breast cancer is reported to be the most common type of cancer in women.1 There are distinct histological subtypes; luminal A, luminal B, basal-like and human epidermal growth factor receptor 2 (HER2) enriched.2 Improved molecular understanding has facilitated the development of targeted treatments. Disease stage and...

    Over-confidence in cardiac devices can create a barrier in engaging patients in advance care planning and discussions around device deactivation

    Por: Elliott · K.

    Commentary on: Hadler RA, Goldstein NE, Bekelman DB, et al. "Why Would I Choose Death?": A Qualitative Study of Patient Understanding of the Role and Limitations of Cardiac Devices. J Cardiovasc Nurs 2019;34:275–82. doi: 10.1097/JCN.0000000000000565.

    Implications for practice and research

  • Stage II-IV heart failure patients with cardiac devices may overestimate their device’s ability to prevent further deterioration and death. This may become a barrier to engaging in advance care planning.

  • Further research is required to evaluate best methods of engaging these patients in discussions around advance care planning and device deactivation.

  • Context

    Guidelines for managing patients with heart failure indicate that discussions about the condition, treatment options and advance care planning should be discussed at an early stage of the disease.1 Prior to implanting a cardiac device, clinicians should be discussing when device deactivation might become appropriate.2–4...

    Tele-health-monitoring may decrease emergency room visits and hospitalisation in patients with COPD

    Por: OConnor · S.

    Commentary on: Hong Y and Lee SH. Effectiveness of tele-monitoring by patient severity and intervention type in chronic obstructive pulmonary disease patients: a systematic review and meta-analysis. Int J Nurs Stud 2019;92:1–15.

    Implications for practice and research

  • Monitoring patients’ health remotely at home using technology has been gaining in popularity for a number of years.

  • Evidence suggests that tele-monitoring may have the potential to reduce emergency room visits and hospitalisation for patients with chronic obstructive pulmonary disease (COPD), particularly those with high disease severity.

  • More rigorously conducted trials of tele-monitoring in patients with  COPD are required to determine clinical and cost-effectiveness.

  • Context

    COPD is a long-term, debilitating, respiratory condition that impacts the lives of millions of people worldwide. Poor management of COPD can lead to hospital admissions, increased healthcare costs and poorer outcomes for patients and their families.1 A range of interventions are...

    Supporting family in their search for meaning and purpose during unexpected ICU admission improves coping, resilience and psychological outcomes

    Commentary on: Wong, P, Liamputtong P, Koch S, et al. Searching for meaning: a grounded theory of family resilience in adult ICU. J Clin Nurs 2018;28:781–91. Doi: 10.111/jocn.14673

    Implications for practice and research

  • To be resilient, families of intensive care unit (ICU) patients must be supported to seek and understand information, advocate for their loved one and find personal meaning and purpose in the admission.

  • Future research is needed to understand the best psychosocial interventions for family during ICU admission.

  • Context

    Intensive care units (ICUs) are evolving to function with increased family involvement. However, unchecked family involvement in the ICU can place a family at risk for psychological problems including anxiety, depression and if severe enough, postintensive care syndrome family (PICS-F). These risk factors may be lessened if a patient and family-centred care (PFCC) model is used. The foundation for PFCC involves dignity and respect, collaboration, information sharing...

    Patient-reported improvement in pain with pregabalin for painful diabetic neuropathy and postherpetic neuralgia is promising but needs further investigation

    Por: Cox · F.

    Commentary on: Derry S, Bell RF, Straube S, et al. Pregabalin for neuropathic pain in adults. Cochrane Database Syst Rev 2019:CD007076. doi: 10.1002/14651858.CD007076.pub3.

    Implications for practice and research

  • There is moderate quality evidence that pregabalin is more effective than placebo for postherpetic neuralgia, painful diabetic neuropathy and post-traumatic neuropathic pain.

  • There is no evidence to support its use in HIV neuropathy nor central neuropathic pain.

  • Future studies require greater sample sizes and clearer methodology.

  • There is a need to identify patients who would benefit from pregabalin therapy.

  • Context

    Pregabalin is licensed to treat neuropathic pain which is defined as pain caused by a lesion or disease of the somatosensory nervous system.1 Neuropathic pain effects up to 10% of the population2 and includes postherpetic neuralgia (PHN) and painful diabetic neuropathy (PDN). The impact can be disabling and lead to higher healthcare...

    Select groups of older adults may benefit from emergency-based short-stay unit admission, as compared to standard medical admission

    Por: Kerin · U.

    Commentary on: Strøm C, Rasmussen LS, Löwe AS, et al. Short-stay unit hospitalisation vs. standard care outcomes in older internal medicine patients-a randomised clinical trial. Age Ageing 2018;47:810-817. doi: 10.1093/ageing/afy090.


  • Preliminary data suggests emergency-based, short-stay units reduced: functional decline, adverse events, readmission rates and hospital stays.

  • Short-stay units reported similar 90-day mortality rates to standard medical admissions.

  • Multicentre international studies are required.

  • Future research should include a cost-analysis and powered studies to detect minimal differences in 90-day mortality.

  • Context

    In most countries, demand exceeds availability of acute healthcare resources.1 An aged population with complex biopsychosocial needs are an increasing healthcare challenge.2 Older adults regularly require extended periods of hospitalisation, and are more at risk of developing adverse, hospital-acquired sequelae.2 3

    Short-stay units (SSU) are speculated to be cost-effective facilities with the potential to...

    Harm-benefit analysis: treatment of mild hypertension in low-risk individuals

    Por: Kean · T.

    Commentary on: Sheppard et al. Benefits and harms of antihypertensive treatment in low-risk patients with mild hypertension. JAMA Internal Medicine

    Implications for practice and research

  • A risk-based approach that includes tailored targets and comorbidity may be optimal in the management of hypertension.1

  • Research to examine risk-over-time as a prognostic indicator in the development of cardiovascular disease (CVD) in low-risk patients may provide greater insight into the benefit of treating mild hypertension in these individuals.1

  • Context

    Hypertension, a growing global burden, affects one-quarter of the world’s population.1–3 Uncontrolled hypertension can lead to life-threatening sequelae, decreased quality of life and increased expenditures by health systems.1–3 Evidence-based guidelines, a mainstay of modern practice, feature prominently in clinical decision-making.3 4 Yet, some guidelines can spur controversy.

    Sheppard et...

    Opioid users reflect on their experiences responding to suspected opioid overdoses using take-home naloxone

    Por: Donaghy · J.

    Commentary on: Neale J, Brown C, Campbell ANC, et al. How competent are people who use opioids at responding to overdoses? Qualitative analyses of actions and decisions taken during overdose emergencies. Addiction. 2018 Nov 26. doi: 10.1111/add.14510.

    Implications for practice and research

  • Opioid users described using take-home naloxone (THN) to deliver emergency treatment to victims of opioid overdose.

  • Insights from opioid users who have responded to overdoses could improve THN.

  • This study provides a foundation for research exploring the competency of individuals delivering first-line treatment to opioid overdose victims.

  • Context

    In the USA, opioid overdose accounted for 42 249 deaths during 2016. Respiratory depression caused by opioid overdose can be reversed by the timely administration of naloxone. THN programmes supply naloxone and advice in responding to opioid overdose crisis to non-medical professionals.1 Current provision does not appear to meet the clinical need.