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Sample records for terminally ill patients

  1. [COMMUNICATION WITH TERMINALLY ILL PATIENT].

    PubMed

    2014-12-01

    The communication is a essential therapeutic instrument in every process of relationship in the team patient-family, and mainly in the transmission of bad news. The communication is not just a simple transmission of information. It is a process whose goal is to enable the adaptation of the patient and family to their actual situation and where the "what", "how" and "how much do you want to know", are belonged to the own patient. Along this article, we will expose some thoughts that the team has to take into account when informing the patient. We are going to explain the SPIKES protocol, or its Spanish version EPICEE. 6-step protocol, based on those recommended by the experts to deliver bad news procedures. And finally we'll talk about the conspiracy of silence, one of the most common and difficult situations to handle in day to day due to paternalism by professionals and families, in which they prefer to hide the situation to the patient, thinking it's the best for him. PMID:26121886

  2. Anxiety in Terminally Ill Cancer Patients

    PubMed Central

    Kolva, Elissa; Rosenfeld, Barry; Pessin, Hayley; Breitbart, William; Brescia, Robert

    2011-01-01

    Context Anxiety in terminal cancer is linked to diminished quality of life, yet overall it is poorly understood with regard to prevalence and relationship to other aspects of psychological distress. Objectives This study examines anxiety in terminally ill cancer patients, including the prevalence of anxiety symptoms, the relationship between anxiety and depression, differences in anxiety between participants receiving inpatient palliative care and those receiving outpatient care, and characteristics that distinguish highly anxious from less anxious patients. Methods Participants were 194 patients with terminal cancer. Approximately half (n = 103) were receiving inpatient care in a palliative care facility and half (n = 91) were receiving outpatient care in a tertiary care cancer center. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression, and was administered along with measures of hopelessness, desire for hastened death, and social support. Results Moderately elevated anxiety symptoms were found in 18.6% of participants (n = 36) and 12.4% (n = 24) had clinically significant anxiety symptoms. Level of anxiety did not differ between the two treatment settings. However, participants receiving palliative care reported significantly higher levels of depression and desire for hastened death. A multivariate prediction model indicated that belief in an afterlife, social support, and anxiolytic and antidepressant use were unique, significant predictors of anxiety. Conclusion Severity of anxiety symptoms did not differ between the study sites, suggesting that anxiety may differ from depression and desire for hastened death in the course that it takes over the duration of terminal cancer. PMID:21565460

  3. The Creative Use of Psychotherapy with Terminally Ill AIDS Patients.

    ERIC Educational Resources Information Center

    Fraenkel, William A.

    One clinical psychologist who worked with terminally ill, end-stage Acquired Immune Deficiency Syndrome (AIDS) patients in a hospice type setting experienced more than 150 deaths over an 18-month time period. Many of the patients denied that they had AIDS; some distinguished between having AIDS and testing positive for Human Immunodeficiency Virus…

  4. Assessing Hopelessness in Terminally Ill Cancer Patients: Development of the Hopelessness Assessment in Illness Questionnaire

    PubMed Central

    Rosenfeld, Barry; Pessin, Hayley; Lewis, Charles; Abbey, Jennifer; Olden, Megan; Sachs, Emily; Amakawa, Lia; Kolva, Elissa; Brescia, Robert; Breitbart, William

    2013-01-01

    Hopelessness has become an increasingly important construct in palliative care research, yet concerns exist regarding the utility of existing measures when applied to patients with a terminal illness. This article describes a series of studies focused on the exploration, development, and analysis of a measure of hopelessness specifically intended for use with terminally ill cancer patients. The 1st stage of measure development involved interviews with 13 palliative care experts and 30 terminally ill patients. Qualitative analysis of the patient interviews culminated in the development of a set of potential questionnaire items. In the 2nd study phase, we evaluated these preliminary items with a sample of 314 participants, using item response theory and classical test theory to identify optimal items and response format. These analyses generated an 8-item measure that we tested in a final study phase, using a 3rd sample (n = 228) to assess reliability and concurrent validity. These analyses demonstrated strong support for the Hopelessness Assessment in Illness Questionnaire providing greater explanatory power than existing measures of hopelessness and found little evidence that this assessment was confounded by illness-related variables (e.g., prognosis). In summary, these 3 studies suggest that this brief measure of hopelessness is particularly useful for palliative care settings. Further research is needed to assess the applicability of the measure to other populations and contexts. PMID:21443366

  5. Terminally ill cancer patients' wish to hasten death.

    PubMed

    Kelly, B; Burnett, P; Pelusi, D; Badger, S; Varghese, F; Robertson, M

    2002-07-01

    This exploratory study investigated factors associated with the wish to hasten death among a sample of terminally ill cancer patients. Semi-structured interviews conducted on a total of 72 hospice and home palliative care patients were subjected to qualitative analysis using QSR-NUDIST. The main themes to emerge suggested that patients with a high wish to hasten death had greater concerns with physical symptoms and psychological suffering, perceived themselves to be more of a burden to others, and experienced higher levels of demoralization, while also reporting less confidence in symptom control, fewer social supports, less satisfaction with life experiences and fewer religious beliefs when compared with patients who had a moderate or no wish to hasten death. The implications of these findings will be discussed. PMID:12132547

  6. Analgesia for terminally ill adult patients. Preserve quality of life.

    PubMed

    2011-11-01

    Adequate pain management is crucial in maintaining the best possible quality of life for terminally ill patients. This article examines pain management in the palliative care setting, based on a review of the literature using the standard Prescrire methodology. Accurate pain evaluation, preferably by the patient, is essential for guiding treatment decisions. Some causes of pain are amenable to specific treatments. The expected benefits and harms of the various treatment options and procedures must be weighed on a case by case basis. Quality of life should always be the first priority. The World Health Organization has developed a "three-step analgesic ladder", based on the use of increasingly potent analgesics: step I analgesics include paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs); codeine is the standard step II analgesic; and morphine is the standard step III analgesic. Fentanyl is an alternative to morphine. The daily morphine dose must be determined for each patient. Morphine titration starts with oral doses given every 4 hours, but additional doses can be taken every hour if necessary. Total consumption is then used to calculate the dose required the following day. A sustained-release product can be used to reduce the number of doses required when a consistently effective daily dose has been established. When patients are unable to take morphine orally, it can be given by subcutaneous injection, and by subcutaneous or intravenous infusion. Pumps allow the patient to self-administer morphine on demand. Fentanyl transdermal patches are another option for stable pain. Immediate-release oral forms and injections are useful for preventing or treating breakthrough pain. If morphine requirements increase during treatment, the most likely explanations are exacerbations of pain or an excessively long interval between doses. Pharmacological tolerance and psychological dependence are rare during palliative care. In case of renal failure, the morphine dose should be reduced, sustained-release morphine should be replaced by immediate-release morphine, or morphine should be replaced by fentanyl, as fentanyl metabolism is only slightly affected by renal function. The main adverse effects of morphine are constipation, nausea and vomiting. Drowsiness is frequent at initiation of treatment. Respiratory depression is rare when morphine is introduced gradually. Tricyclic antidepressants and carbamazepine have acceptable harm-benefit balances in patients with neuropathic pain. Cannabinoids are another option but have not been adequately assessed. Localised refractory pain may respond to local anaesthesia, chemical neurolysis or surgical ablation. In practice, it is best to allow patients to control their own analgesic consumption, within limits set by their physician to prevent dosing errors. PMID:22066317

  7. Terminal mental illness: resident experience of patient suicide.

    PubMed

    Reeves, Gloria

    2003-01-01

    Suicide prevention efforts are a major focus of psychiatry residency training. Residents are taught to identify suicide risk factors, monitor for suicidal ideation, and develop crisis stabilization plans for patients at risk for self harm. In contrast, training and support for dealing with suicide completion is often lacking. Although suicide remains a predictable outcome for many patients with severe mental illness, this topic may be avoided or reviewed only with residents who are directly affected by patient suicide. The purpose of this paper is to present a psychiatry resident's experience of dealing with a patient suicide and identify obstacles to developing this aspect of training. Options for "preventative" training in helping trainees deal with this unfortunate outcome of mental illness will be reviewed. PMID:14535611

  8. Illness awareness in terminal cancer patients: an Italian study.

    PubMed

    Corli, O; Apolone, G; Pizzuto, M; Cesaris, L; Cozzolino, A; Orsi, L; Enterri, L

    2009-06-01

    The amount and quality of information and awareness in cancer patients' is a topic frequently debated, but few studies have focussed on terminal patients. This is the objective of the present study that involved two different palliative home-care units in Italy, which recruited 550 terminal cancer patients. Data from patients and their caregivers was prospectively collected with special attention to information patients were provided with when their cancer was diagnosed and patients' awareness of their current health condition. In the case of the information, 67.0% of patients reported they were previously informed about their diagnosis, but only 58.0% seemed to be aware of their terminal condition. The comparison between the caregivers opinions about the level of information provided to the patients and their present awareness and what the patients really know about their own disease shows a high degree of correspondence. Some variables such as age and education level of patients were associated with patient's awareness. PMID:19073780

  9. A Comparative Study of Terminally Ill Hospice and Hospital Patients.

    ERIC Educational Resources Information Center

    Labus, Janet G.; Dambrot, Faye H.

    1986-01-01

    Investigated differences between 28 hospice and 28 hospital patients who died. Comparison found that hospice patients were younger, had more people living in the home, and had shorter disease history. Age, number of people living in the home, and primary cancer site significantly discriminated between hospice and hospital patients and predicted

  10. Palliative Management of Malignant Bowel Obstruction in Terminally Ill Patient

    PubMed Central

    Thaker, Darshit A; Stafford, Bruce C; Gaffney, Luke S

    2010-01-01

    Mr. P was a 57-year-old man who presented with symptoms of bowel obstruction in the setting of a known metastatic pancreatic cancer. Diagnosis of malignant bowel obstruction was made clinically and radiologically and he was treated conservatively (non-operatively)with octreotide, metoclopromide and dexamethasone, which provided good control over symptoms and allowed him to have quality time with family until he died few weeks later with liver failure. Bowel obstruction in patients with abdominal malignancy requires careful assessment. The patient and family should always be involved in decision making. The ultimate goals of palliative care (symptom management, quality of life and dignity of death) should never be forgotten during decision making for any patient. PMID:21811356

  11. The Israeli terminally ill patient law of 2005.

    PubMed

    Jotkowitz, Alan B; Glick, Shimon

    2009-01-01

    Israel, like many other countries, is struggling with numerous bioethical dilemmas due to its cultural and religious diversity. Until recently there was no legal guidance for how to deal with end-of-life issues. However, in 2005 a law was passed regulating the treatment of dying patients. Its most controversial aspect is the distinction it makes between withholding therapy (which is allowed) and withdrawing continuous therapy (which is not allowed). In this formulation, the law attempted to strike a balance between respecting the autonomy of the patient and respecting the sanctity of life. The law respects autonomy by establishing the right of the patient to refuse treatment; it respects the sanctity of life by prohibiting active euthanasia and physician-assisted suicide. However, this compromise was not acceptable to all members of the public advisory body that framed the law. Some argued that there was no moral basis for the distinction between withholding and withdrawing treatment. PMID:20131585

  12. Educational needs of home caregivers of terminally ill patients: literature review.

    PubMed

    Thielemann, P

    2000-01-01

    Hospice care continues to be a rapidly growing philosophy of care at the end of life. One of the fundamental principles of hospice is the role of a primary caregiver to provide for the needs of the terminally ill loved one. Typically, a spouse, adult child, sibling, close friend, or significant other fills this role. Usually, the caregiver has no formal training in caregiving and is learning all aspects of providing for all the needs of the patient. This is an awesome responsibility and quite overwhelming for most caregivers. A research synthesis was completed to assess the educational needs of caregivers of terminally ill patients. The computerized literature search of several databases found very few studies on the educational needs of caregivers. The few studies that have been done have used both quantitative and qualitative approaches, using a variety of assessment tools, looking at several different populations, over varied time periods. In spite of the variety of methods and populations studied, all the studies came to similar conclusions. The needs of the studied caregivers fall into three main categories: needing information on meeting the physical needs of the patients, community resources, and the patient's illness. The findings provide a basis for further research to build a comprehensive educational program that maximizes the role of the caregivers of terminally ill patients. PMID:11883801

  13. Oral health conditions affect functional and social activities of terminally-ill cancer patients

    PubMed Central

    Fischer, D.J.; Epstein, J.B.; Yao, Y.; Wilkie, D.J.

    2013-01-01

    Purpose Oral conditions are established complications in terminally-ill cancer patients. Yet despite significant morbidity, the characteristics and impact of oral conditions in these patients are poorly documented. The study objective was to characterize oral conditions in terminally-ill cancer patients to determine the presence, severity, and the functional and social impact of these oral conditions. Methods This was an observational clinical study including terminally-ill cancer patients (2.53 week life expectancy). Data were obtained via the Oral Problems Scale (OPS) that measures the presence of subjective xerostomia, orofacial pain, taste change, and the functional/social impact of oral conditions and a demographic questionnaire. A standardized oral examination was used to assess objective salivary hypofunction, fungal infection, mucosal erythema, and ulceration. Regression analysis and t test investigated the associations between measures. Results Of 104 participants, most were ?50 years of age, female, and high-school educated; 45% were African American, 43% Caucasian, and 37% married. Oral conditions frequencies were: salivary hypofunction (98%), mucosal erythema (50%), ulceration (20%), fungal infection (36%), and other oral problems (46%). Xerostomia, taste change, and orofacial pain all had significant functional impact; p<.001, p=.042 and p<.001, respectively. Orofacial pain also had a significant social impact (p<.001). Patients with oral ulcerations had significantly more orofacial pain with a social impact than patients without ulcers (p=.003). Erythema was significantly associated with fungal infection and with mucosal ulceration (p<.001). Conclusions Oral conditions significantly affect functional and social activities in terminally-ill cancer patients. Identification and management of oral conditions in these patients should therefore be an important clinical consideration. PMID:24232310

  14. [A study of 31 terminally ill cancer patients who received pure oxycodone injections at home].

    PubMed

    Sasaki, Tsubasa; Kawagoe, Izumi

    2014-11-01

    Since the launch of pure oxycodone injections in May 2012, it has been possible to use oxycodone without opioid rotation. Although an extremely important step showing progress, very few studies regarding the use of pure oxycodone injections have been performed. In this study, we evaluated the safety and efficacy of pure oxycodone injections in 31 terminally ill cancer patients receiving home care. The difficulty in oral oxycodone intake was the main reason for changing to pure oxycodone injections. The mean administered period of subcutaneous pure oxycodone was 5.6 6.7 days. One out of 5 patients receiving pure oxycodone injections complained of worsening sleepiness. However, other symptoms improved. In addition, in cases wherein pure oxycodone injection was the initiating opioid, 1 out of 6 patients showed no improvement of respiratory discomfort, while other symptoms improved. It was difficult to evaluate more patients because of the short period for administration. Although 5 patients experienced skin problems, they were successfully managed by changing the injection site. Of these 5 patients, 2 patients had sensitive skin, with a previous history of alcohol rash. In conclusion, our study suggests that pure oxycodone injections are beneficial over oral oxycodone treatment for terminally ill cancer patients. However, further evaluation of skin problems associated with pure oxycodone injections is required by performing larger studies. PMID:25434442

  15. Ethics of physiotherapy practice in terminally ill patients in a developing country, Nigeria.

    PubMed

    Chigbo, N N; Ezeome, E R; Onyeka, T C; Amah, C C

    2015-12-01

    Physiotherapy has been widely defined as a healthcare profession that assesses, diagnoses, treats, and works to prevent disease and disability through physical means. The World Confederation for Physical Therapy describes physiotherapy as providing services to people and populations to develop, maintain, and restore maximum movement and functional ability throughout the lifespan. Physiotherapists working with terminally ill patients face a myriad of ethical issues which have not been substantially discussed in bioethics especially in the African perspective. In the face of resource limitation in developing countries, physiotherapy seems to be a cost-effective means of alleviating pain and distressing symptoms at the end-of-life, ensuring a more dignified passage from life to death, yet referrals to physiotherapy are not timely. Following extensive literature search using appropriate keywords, six core ethical themes related to physiotherapy in terminally ill patients were identified and using the four principles of bioethics (patient's autonomy, beneficence, nonmaleficence, and justice), an ethical analysis of these themes was done to highlight the ethical challenges of physiotherapists working in a typical African setting such as Nigeria. PMID:26620621

  16. Does Desire for Hastened Death Change in Terminally Ill Cancer Patients?

    PubMed Central

    Rosenfeld, Barry; Pessin, Hayley; Marziliano, Allison; Jacobson, Coleen; Sorger, Brooke; Abbey, Jennifer; Olden, Megan; Brescia, Robert; Breitbart, William

    2014-01-01

    Understanding why some terminally ill patients may seek a hastened death (a construct referred to as desire for hastened death or DHD) is critical to understanding how to optimize quality of life during an individuals final weeks, months or even years of life. Although a number of predictor variables have emerged in past DHD research, there is a dearth of longitudinal research on how DHD changes over time and what factors might explain such changes. This study examined DHD over time in a sample of terminally ill cancer patients admitted to a palliative care hospital. A random sample of 128 patients who completed the Schedule of Attitudes toward Hastened Death (SAHD) at two time points approximately 24 weeks apart participated. Patients were categorized into one of four trajectories based on their SAHD scores at both time points: low (low DHD at T1 and T2), rising (low DHD at T1 and high DHD at T2), falling (high DHD at T1 and low DHD at T2) and high (high DHD at T1 and T2). Among patients who were low at T1, several variables distinguished between those who developed DHD and those who did not: physical symptom distress, depression symptom severity, hopelessness, spiritual well-being, baseline DHD, and a history of mental health treatment. However, these same medical and clinical variables did not distinguish between the falling and high trajectories. Overall, there appears to be a relatively high frequency of change in DHD, even in the last weeks of life. Interventions designed to target patients who are exhibiting subthreshold DHD and feelings of hopelessness may reduce the occurrence of DHD emerging in this population. PMID:24747154

  17. Aggravation of fatigue by steroid therapy in terminally ill patients with cancer.

    PubMed

    Matsuo, Naoki; Yomiya, Kinomi

    2014-05-01

    Steroids are commonly used for fatigue relief in terminally ill cancer patients. However, steroid-induced adverse effects including depression, myopathy, and hyperglycemia may contribute to fatigue. We report our experiences with aggravation of fatigue with steroid use in three cases. Case 1 was a 65-year-old man with advanced gastric cancer. He was started on betamethasone (2 mg/d) for fatigue, but the fatigue worsened due to steroid-induced depression. Discontinuation of steroids and initiation of an antidepressant ameliorated the fatigue. Case 2 was a 68-year-old man with advanced lung cancer. He complained of fatigue. Betamethasone (1 mg/d) was started and alleviated the fatigue. However, when the betamethasone dose was increased to 2 mg/d, the fatigue, with muscle weakness and myalgia, worsened due to steroid-induced myopathy. We therefore switched from betamethasone (2 mg/d) to prednisolone (10 mg /d). The fatigue resolved and the patient returned to his previous condition. Case 3 was a 73-year-old man with recurrent bile duct cancer. He also had diabetes mellitus. He developed fatigue, anorexia and fever. We started betamethasone (1.5 mg/d) for these symptoms, but the fatigue and anorexia worsened due to steroid-induced hyperglycemia. Blood glucose rose to 532 mg/dL. Therefore, insulin therapy was started, and the dose of betamethasone was reduced to 0.5 mg/d. His glucose level decreased to less than 320 mg/dL and he recovered from the fatigue while achieving moderate oral intake. In conclusion, the possibility of steroid-induced secondary fatigue in terminally ill cancer patients should be taken into consideration. PMID:23588576

  18. Cardiopulmonary Resuscitation in Patients With Terminal Illness: An Evidence-Based Analysis

    PubMed Central

    Sehatzadeh, S

    2014-01-01

    Background Cardiopulmonary resuscitation (CPR) was first introduced in 1960 for people who unexpectedly experience sudden cardiac arrest. Over the years, it became routine practice in all institutions to perform CPR for all patients even though, for some patients with fatal conditions, application of CPR only prolongs the dying process through temporarily restoring cardiac function. Objectives This analysis aims to systematically review the literature to provide an accurate estimate of survival following CPR in patients with terminal health conditions. Data Sources A literature search was performed for studies published from January 1, 2004, until January 10, 2014. The search was updated monthly to March 1, 2014. Review Methods Abstracts and full text of studies that met eligibility criteria were reviewed. Reference lists were also examined for any additional relevant studies not identified through the search. Results Cancer patients have lower survival rates following CPR than patients with conditions other than cancer, and cancer patients who receive CPR in intensive care units have one-fifth the rate of survival to discharge of cancer patients who receive CPR in general wards. While the meta-analysis of studies published between 1967 and 2005 reported a lower survival to discharge for cancer patients (6.2%), more recent studies reported higher survival to discharge or to 30-day survival for these patients. Higher survival rates in more recent studies could originate with more “do not attempt resuscitation” orders for patients with end-stage cancer in recent years. Older age does not significantly decrease the rate of survival following CPR while the degree, the type, and the number of chronic health conditions; functional dependence; and multiple CPRs (particularly in advanced age) do reduce survival rates. Emergency Medical Services response time have a significant impact on survival following out-of-hospital CPR. Conclusions Survival after CPR depends on the severity of illness, type and number of health conditions, functional dependence, and multiple CPRs. PMID:26339301

  19. Preparing family caregivers for death and bereavement. Insights from caregivers of terminally ill patients.

    PubMed

    Hebert, Randy S; Schulz, Richard; Copeland, Valire C; Arnold, Robert M

    2009-01-01

    Many family caregivers are unprepared for the death of their loved one and may suffer from worse mental health as a result. We therefore sought to determine the factors that family caregivers believe are important to preparing for death and bereavement. Focus groups and ethnographic interviews were conducted with 33 family caregivers (bereaved or current) of terminally ill patients. The interviews were audiotaped, transcribed, and analyzed using the constant comparative method. Life experiences such as the duration of caregiving/illness, advance care planning, previous experiences with caregiving or death, and medical sophistication all impacted preparedness, or the degree to which a caregiver is ready for the death and bereavement. Regardless of life experiences, however, all caregivers reported medical, practical, psychosocial, and religious/spiritual uncertainty. Because uncertainty was multidimensional, caregivers often needed more than prognostic information in order to prepare. Communication was the primary mechanism used to manage uncertainty. Good communication included clear, reliable information, combined with relationship-centered care from health care providers. Finally, preparedness had cognitive, affective, and behavioral dimensions. To prepare, some caregivers needed information tailored to their uncertainty (cognitive), others needed to "mentally" or "emotionally" prepare (affective), and still others had important tasks to complete (behavioral). In order to better prepare family caregivers for the death of a loved one, health care providers must develop a trusting relationship with caregivers, provide them with reliable information tailored to their uncertainty, and allow time for caregivers to process the information and complete important tasks. PMID:18538977

  20. Teaching Third-Year Medical Students how to Care for Terminally Ill Patients.

    ERIC Educational Resources Information Center

    Martin, Robert W.; Wylie, Norma

    1989-01-01

    A successful seven-day course offered to third-year medical students is an integrated program for teaching them how to deal with terminal illness. The course uses lectures, audiovisual aids, and group and individual sessions to enhance self-awareness and practical application of the material in a clinical setting. (Author/MSE)

  1. 'To call it work somehow demeans it': the social construction of talk in the care of terminally ill patients.

    PubMed

    May, C

    1995-09-01

    The nurse has an important role in helping the terminally ill patient come to terms with the imminence of death. Such work is highly demanding and often stressful, but is work which is accorded a high moral priority by respondents in the study reported in this paper. The paper explores the ways in which nurses work to respond to patients' expressed psychosocial problems and the emphasis that they placed on providing opportunities for patients to speak about their impending death. PMID:7499624

  2. Enzymatic changes in myosin regulatory proteins may explain vasoplegia in terminally ill patients with sepsis.

    PubMed

    Zheng, Wentao; Kou, Yong; Gao, Feng-Lan; Ouyang, Xiu-He

    2016-01-01

    The current study was conducted with the hypothesis that failure of maintenance of the vascular tone may be central to failure of the peripheral circulation and spiralling down of blood pressure in sepsis. Namely, we examined the balance between expression of myosin light chain (MLC) phosphatase and kinase, enzymes that regulate MLCs dephosphorylation and phosphorylation with a direct effect on pharmacomechanical coupling for smooth muscle relaxation and contraction respectively. Mechanical recordings and enzyme immunoassays of vascular smooth muscle lysates were used as the major methods to examine arterial biopsy samples from terminally ill sepsis patients. The results of the present study provide evidence that genomic alteration of expression of key regulatory proteins in vascular smooth muscles may be responsible for the relentless downhill course in sepsis. Down-regulation of myosin light chain kinase (MLCK) and up-regulation of MLCK may explain the loss of tone and failure to mount contractile response in vivo during circulation. The mechanical studies demonstrated the inability of the arteries to develop tone when stimulated by phenylephrine in vitro. The results of our study provide indirect hint that control of inflammation is a major therapeutic approach in sepsis, and may facilitate to ameliorate the progressive cardiovascular collapse. PMID:26772992

  3. Abandonment of terminally ill patients in the Byzantine era. An ancient tradition?

    PubMed Central

    Lascaratos, J; Poulakou-Rebelakou, E; Marketos, S

    1999-01-01

    Our research on the texts of the Byzantine historians and chroniclers revealed an apparently curious phenomenon, namely, the abandonment of terminally ill emperors by their physicians when the latter realised that they could not offer any further treatment. This attitude tallies with the mentality of the ancient Greek physicians, who even in Hippocratic times thought the treatment and care of the terminally ill to be a challenge to nature and hubris to the gods. Nevertheless, it is a very curious attitude in the light of the concepts of the Christian Byzantine physicians who, according to the doctrines of the Christian religion, should have been imbued with the spirit of philanthropy and love for their fellowmen. The meticulous analysis of three examples of abandonment of Byzantine emperors, and especially that of Alexius I Comnenus, by their physicians reveals that this custom, following ancient pagan ethics, in those times took on a ritualised form without any significant or real content. PMID:10390682

  4. Relations between desire for early death, depressive symptoms and antidepressant prescribing in terminally ill patients with cancer.

    PubMed

    Tiernan, E; Casey, P; O'Boyle, C; Birkbeck, G; Mangan, M; O'Siorain, L; Kearney, M

    2002-08-01

    Some patients with advanced cancer express the wish for an early death. This may be associated with depression. We examined the relations between depressive symptoms and desire for early death (natural or by euthanasia or physician-assisted suicide) in 142 terminally ill patients with cancer being cared for by a specialist palliative care team. They completed the Hospital Anxiety and Depression Scale questionnaire and answered four supplementary questions on desire for early death. Only 2 patients expressed a strong wish for death by some form of suicide or euthanasia. 120 denied that they ever wished for early release. The desire for early death correlated with depression scores. Depressive symptoms were common in the whole group but few were on antidepressant therapy. Better recognition and treatment of depression might improve the lives of people with terminal illness and so lessen desire for early death, whether natural or by suicide. PMID:12151487

  5. [Significance of the Moreno therapeutic approach for managing terminally ill patients].

    PubMed

    Frede, U

    1991-08-01

    This article is concerned to describe the significance of the Moreno approach in caring for the incurably ill. The anthropology of Moreno, his therapeutic philosophy and the main attitudes in the encounter with a patient are outlined and discussed with reference to central aspects of the situation of the incurably ill (fear of losing their own autonomy, social death). The possibilities offered by the Moreno approach to therapy in attending these patients are illustrated with examples of the main techniques in psychodrama-therapy: doubling and role-reversal. Above all two functions of doubling appear to be especially important in caring for the incurably ill: that of comprehensive attendance and vicarious action. Possible variations in which the role-reversal can be carried out are specified and discussed as means of helping a patient to have confidence in himself and of helping him to perceive and to develop the intrinsic strength within himself in dealing with his situation. Doubling and role-reversal surely cannot be universal rules in attending the incurably ill, but they are good possibilities to respect and to support the autonomy of the human being and to convert into concrete action the conviction of his right to self-determination which is equally characterized for the therapeutic philosophy of Moreno as well as for attending the incurably ill. PMID:1946905

  6. Coping with Loneliness among the Terminally Ill

    ERIC Educational Resources Information Center

    Rokach, Ami

    2007-01-01

    Loneliness is a universal phenomenon, and its pain is intensified by a diagnosis of a terminal illness. The present study is an investigation of the strategies used by patients with Multiple sclerosis (MS), by individuals diagnosed with cancer, and by the general population to cope with loneliness. Three hundred and twenty nine MS patients, 315

  7. When should managed care firms terminate private benefits for chronically mentally ill patients?

    PubMed

    Gerson, S N

    1994-01-01

    Corporate America's healthcare cost crisis and the country's budget deficit are forcing limits on the resources used to finance healthcare, including mental healthcare. At the same time, the 1990 Americans with Disabilities Act bars discrimination against patients with chronic illnesses, including chronic mental illness. Therefore, corporate benefits managers need guidance on how to ethically and rationally allocate scarce clinical resources to those high-morbidity insureds who utilize disproportionate amounts of these resources. In particular, how should we define the public/private interface: When do patients who repeatedly fail to respond to treatment fall out of the private sector's responsibility? The author, medical director for a leading behavioral healthcare utilization management company, offers the following guidelines recommending reasonable and practical limitations on trials of treatment for seven common categories of difficult psychiatric patients. PMID:10141406

  8. Teaching the Terminally Ill Child.

    ERIC Educational Resources Information Center

    Ainsa, Trisha

    1981-01-01

    Classroom teachers of terminally ill children face potentially difficult, challenging, rewarding and professionally expanding experiences which require an understanding of the basic needs of the dying. Strategies for teaching such children include literature, writing, role playing, magic circle discussions, play therapy, art therapy, counseling,

  9. Random Serum Cortisol as a Predictor for Survival of Terminally Ill Patients With Cancer: A Preliminary Study.

    PubMed

    Kim, Hyo Min; Ha, Kyung Sang; Hwang, In Cheol; Ahn, Hong Yup; Youn, Chang Ho

    2016-04-01

    Although previous research found that serum cortisol levels were associated with cancer prognosis, it is unclear whether this association remains robust even at the very end of life of patients with cancer. We conducted a retrospective chart review of 125 patients with terminal cancer to investigate the role of random serum cortisol levels in predicting the remaining life expectancy. The high random cortisol group had a significantly shorter survival time than the low random cortisol group (7.5 vs 26 days). After adjusting for potential confounders, key factors such as poor performance status, hypoalbuminemia, and high random cortisol level are associated with poor survival. Our results suggest that the random serum cortisol level is an independent predictor of survival time of patients with terminally ill cancer. PMID:25500431

  10. Should physicians withhold life-sustaining care from patients who are not terminally ill?

    PubMed

    Emanuel, E J

    1988-01-16

    Two 1987 New Jersey Supreme Court rulings, In re Farrell and In re Peter, concerning the removal of life-sustaining medical care are discussed. In the United States, competent patients have the right to refuse medical care, including artificially administered nutrition and hydration, and courts also have extended this right to incompetent patients. Two areas of controversy remain: can care be withheld from any patient, or only from the dying, and what criteria determine whether care should be terminated for incompetents? The Farrell case affirmed that competent patients may refuse life-sustaining care at home as well as in the hospital. Peter allowed a friend with a durable power of attorney to authorize removal of the feeding tube of a woman in a permanent vegetative state. Emanuel criticizes the Peter court for distinguishing between patients like Peter and nonvegetative, nonterminal incompetent patients for the purpose of withholding care. PMID:2891943

  11. Death Education and Attitudes toward Euthanasia and Terminal Illness.

    ERIC Educational Resources Information Center

    Nagi, Mostafa H.; Lazerine, Neil G.

    1982-01-01

    Analyzed attitudes of 614 Protestant and Catholic Cleveland clergy toward terminal illness and euthanasia. Clergy responses revealed that, although eager to prolong life, terminally ill patients feared prolonged illness more than death. The controversial nature of euthanasia became more apparent with clergy who had more training in death…

  12. Death Education and Attitudes toward Euthanasia and Terminal Illness.

    ERIC Educational Resources Information Center

    Nagi, Mostafa H.; Lazerine, Neil G.

    1982-01-01

    Analyzed attitudes of 614 Protestant and Catholic Cleveland clergy toward terminal illness and euthanasia. Clergy responses revealed that, although eager to prolong life, terminally ill patients feared prolonged illness more than death. The controversial nature of euthanasia became more apparent with clergy who had more training in death

  13. Bioplastique medialization therapy improves the quality of life in terminally ill patients with vocal cord palsy.

    PubMed

    Alves, C B; Loughran, S; MacGregor, F B; Dey, J I R; Bowie, L J

    2002-10-01

    Unilateral vocal cord palsy can result in a weak breathy voice and an inability to communicate effectively. This study was designed to assess prospectively the efficacy of polymethylsiloxane elastomer (Bioplastique) medialization injection therapy in patients with vocal cord palsy and terminal disease with particular regard to quality of life issues. Patients with unilateral vocal cord palsy secondary to malignant disease were offered Bioplastique injection. A digital voice recording was taken preoperatively and at 1 month, 3 months and 6 months postoperatively. Maximum phonation time (MPT) was recorded at the same intervals, and patients completed two questionnaires: the voice handicap index (VHI) and SF 36 general health questionnaire. Sixteen patients were entered into the study. There was a significant improvement in voice score, MPT, VHI and in three subgroups of the SF 36 at 1 month postoperatively, and the improvement was maintained in the small number who survived to 3 and 6 months. Bioplastique injection for unilateral vocal cord palsy produces a significant improvement in quality of life in addition to measured voice quality in patients with terminal disease. It should be recommended in patients even when the life expectancy is short. PMID:12383303

  14. The Effect of Social Support and Meaning of Life on the Quality-of-Life Care for Terminally Ill Patients.

    PubMed

    Dobrkov, Patricia; P?olkov, Duana; AlTurabi, Layla Khalil; West, Daniel J

    2015-11-01

    This study examines the effect of 2 indicators on quality of life (QOL): social support and meaning of life for terminally ill patients. These 2 indicators are very important from a psychological and spiritual point of view. The findings suggest that there is a statistically significant correlation between meaning of life and QOL (r = .610, P < .001). Results have also demonstrated that more frequent patient visits increase the sense of life fulfillment for dying patients. A significant relationship exists in survival of life meaningfulness and satisfaction with social support. In conclusion, experiencing one's life as meaningful is positively related to the well-being for dying patients. Social support provided by a close relative had a positive influence on the patient's meaning of life and overall life satisfaction. PMID:25106419

  15. Is the clock ticking for terminally ill patients in Israel? Preliminary comment on a proposal for a bill of rights for the terminally ill.

    PubMed

    Barilan, Y M

    2004-08-01

    This paper presents and discusses a recent Israeli proposal to legislate on the rights of the dying patient. A gap exists between elitist biases of the committee proposing the law, and popular values and sentiments. The proposed law divides the dying patients into two groups: "those who wish to go on living" and "those who wish to die". The former will have a right to life prolonging extraordinary care. It is not clear who would foot the bill for this care. Also it is hard to see how this munificence could fail to discriminate against all other patients. Both the secular ethicists and the rabbis involved in drawing up the proposal accepted the assumption that it is good for some terminal patients to die. The rabbis objected, however, to direct and active interventions that shorten life. The solution arrived at was to install timers in the ventilators so as to allow them to expire automatically unless the patient wishes for their resetting. PMID:15289517

  16. Beethoven's terminal illness and death.

    PubMed

    Mai, F M M

    2006-10-01

    There is dispute about the cause of Beethoven's death; alcoholic cirrhosis, syphilis, infectious hepatitis, lead poisoning, sarcoidosis and Whipple's disease have all been proposed. In this article all primary source documents related to Beethoven's terminal illness and death are reviewed. The documents include his letters, the report of his physician Andreas Wawruch, his Conversation Books, the autopsy report, and a new toxicological report of his hair. His terminal illness was characterised by jaundice, ascites, ankle oedema and abdominal pain. The autopsy data indicate that Beethoven had cirrhosis of the liver, and probably also renal papillary necrosis, pancreatitis and possibly diabetes mellitus. His lifestyle for at least the final decade of his life indicated that he overindulged in alcohol in the form of wine. Alcohol was by far the most common cause of cirrhosis at that period. Toxicological analysis of his hair showed that the level of lead was elevated. During the eighteenth and early nineteenth centuries, lead was added illegally to inexpensive wines to sweeten and refresh them. These findings strongly suggest that liver failure secondary to alcoholic cirrhosis, associated with terminal spontaneous bacterial peritonitis, was the cause of death. This was complicated in the end stages by renal failure. If the presence of endogenous lead was verified by analysis of Beethoven's skeletal remains, it would suggest that the lead was derived from wine that he drank. Lead poisoning may account for some of his end-of-life symptoms. There is little clinical or autopsy evidence that Beethoven suffered from syphilis. PMID:17214130

  17. TERMINAL ILLNESS IN AN INDIAN SETTING: PROBLEMS OF COMMUNICATION

    PubMed Central

    Khanna, R.; Singh, R.P.N.

    1988-01-01

    SUMMARY A study of 50 terminally ill cancer patients revealed that 52% were uninformed regarding their diagnosis and prognosis. In almost all cases the relatives had been adequately informed. No less than 82% of the terminally ill patients showed an awareness of the fatal prognosis. Most of the patients found the communication with the doctor and the relatives as unsatisfactory. Comparing this group with another group of non-terminal medically ill patients showed striking differences between the two groups. The findings are compared with those reported from the West and the implications of the above observations discussed. PMID:21927320

  18. Psychosocial Impact of Terminal Chronic Illness.

    ERIC Educational Resources Information Center

    Chubon, Robert A.

    1988-01-01

    Development of a terminal chronic illness creates a spectrum of problems which call for counseling interventions to assist in the individual's adjustment. This overview, intended to raise the consciousness of rehabilitation counselors, outlines the three stages of terminal illness, followed by an examination of resulting lifestyle and relationship

  19. Should doctors inform terminally ill patients? The opinions of nationals and doctors in the United Arab Emirates.

    PubMed Central

    Harrison, A; al-Saadi, A M; al-Kaabi, A S; al-Kaabi, M R; al-Bedwawi, S S; al-Kaabi, S O; al-Neaimi, S B

    1997-01-01

    OBJECTIVES: To study the opinions of nationals (Emiratis) and doctors practising in the United Arab Emirates (UAE) with regard to informing terminally ill patients. DESIGN: Structured questionnaires administered during January 1995. SETTING: The UAE, a federation of small, rich, developing Arabian Gulf states. PARTICIPANTS: Convenience samples of 100 Emiratis (minimum age 15 years) and of 50 doctors practising in government hospitals and clinics. RESULTS: Doctors emerged as consistently less in favour of informing than the Emiratis were, whether the patient was described as almost certain to die during the next six months or as having a 50% chance of surviving, and even when it was specified that the patient was requesting information. In the latter situation, a third of doctors maintained that the patient should not be told. Increasing survival odds reduced the number of doctors selecting to inform; but it had no significant impact on Emiratis' choices. When Emiratis were asked whether they would personally want to be informed if they had only a short time to live, less than half responded in the way they had done to the in principle question. CONCLUSIONS: The doctors' responses are of concern because of the lack of reference to ethical principles or dilemmas, the disregard of patients' wishes and dependency on survival odds. The heterogeneity of Emiratis' responses calls into question the usefulness of invoking norms to explain inter-society differences. In the current study, people's in principle choices did not provide a useful guide to how they said they would personally wish to be treated. PMID:9134491

  20. Enteral and parenteral nutrition support of terminally ill patients: practical and ethical perspectives.

    PubMed

    McCamish, M A; Crocker, N J

    1993-01-01

    The ethics of dealing with the provision of nutrition has been greatly complicated by technological advances. Seventy percent of all deaths in the United States include a decision to forgo some life-sustaining treatment including nutrition support. This article reviews ethical issues in nutrition support, appropriate and inappropriate nutrition support, practical information regarding provision of nutrition, and the development of institutional policies regarding artificial nutrition and hydration. Communication is emphasized in the process of establishing an ethically defensible consensus between patient and caregiver regarding withholding or withdrawing nutrition support. Within this context, withholding and withdrawing this support are considered to have the same ethical significance. Artificial nutrition and hydration is considered medical therapy and can be refused by competent patients and surrogates of incompetent patients under certain circumstances. Patient autonomy is emphasized as a guiding ethical principle. PMID:7806177

  1. Meaning of care for terminally Ill HIV-infected patients by HIV-infected peer caregivers in a simulation-based training program in South Korea.

    PubMed

    Kim, Sunghee; Shin, Gisoo

    2015-01-01

    The purpose of this study was to develop a simulation-based training program for people living with HIV (PLWH) as peer caregivers who would take care of terminally ill, HIV-infected patients. We used qualitative research methods and standardized patients to explore the meaning of caring for patients as peer caregivers. Study participants included 32 patients registered as PLWH at the South Korea Federation for HIV/AIDS. The meanings of peer caregiving were categorized into four dimensions: physical, psychological, relational, and economic. Our study had benefits in knowledge acquisition for caregivers as well as care recipients, empathy with HIV-infected care recipients, improvement in self-esteem and social participation, and financial self-sufficiency to enable independent living for caregivers. The simulation training program for PLWH peer caregivers for terminally ill HIV-infected patients demonstrated value, for both PLWH caregivers and terminally ill HIV-infected patients in South Korea, to improve the quality of care. PMID:26279386

  2. Assessment and management of pain in the terminally ill.

    PubMed

    Dalal, Shalini; Bruera, Eduardo

    2011-06-01

    Regular assessment for the presence of pain and response to pain management strategies should be high priority in terminally ill patients. Pain management interventions are most effective when treatments are individualized based on the various physical and nonphysical components of pain at the end of life, and patients and family are educated and involved in the decision making. Opioids remain the cornerstone of pain management, and adjuvant analgesics and nonpharmacologic options are usually considered after relative stabilization of pain. This article describes the various issues that are pertinent to the assessment and treatment of pain in terminally ill patients. PMID:21628035

  3. Burden to others and the terminally ill.

    PubMed

    Chochinov, Harvey Max; Kristjanson, Linda J; Hack, Thomas F; Hassard, Thomas; McClement, Susan; Harlos, Mike

    2007-11-01

    Studies of patients who are terminally ill consistently identify strong associations between "sense of burden to others" and marked end-of-life distress. However, little research has addressed the issue of burden to others among patients nearing death. The aim of this study was to carefully examine "burden to others" and clarify its relationship with various psychosocial, physical, and existential issues arising in patients who are terminally ill. A cohort of 211 patients with end-stage cancer was assessed, using an assortment of validated psychometrics to document psychosocial, physical, and existential aspects of their end-of-life experience. This included an assessment of their sense of "burden to others." Forty percent of participants indicated a negligible sense of burden to others, scoring within the lowest quarter on an ordinal measure of "burden to others;" 25% scored within the second lowest quarter; 12% within the third quarter; and 23% within the highest or most severe range. The most highly correlated variables with "sense of burden to others" included depression (r=0.460; df=201, P<0.0001), hopelessness (r=0.420; df=199, P<0.0001), and outlook (r=0.362; df=200, P<0.0001). Four variables emerged in a multiple regression analysis predicting burden to others, including hopelessness, current quality of life, depression, and level of fatigue [R(2) adj=0.32, F(6,174)=13.76, P<0.0001]. There was no association between sense of burden to others and actual degree of physical dependency. Feeling a sense of burden to others is common among dying patients. Although 40% of the sample reported little in the way of sense of burden to others, the remainder endorsed higher degrees of burden-related distress, with 23% scoring within the most severe range. The lack of association between "sense of burden to others" and the degree of physical dependency suggests this perception is largely mediated through psychological and existential considerations. Strategies that target meaning and purpose, depression, and level of fatigue could lessen this source of distress and enhance quality, dignity-conserving care. PMID:17616329

  4. Declaration of Venice on terminal illness.

    PubMed

    1983-11-26

    The 27 October 1983 session of the World Medical Association (WMA) in Venice approved a declaration on the physician's obligations to the terminally ill. Reprinted here are the paragraphs concerning the circumstances under which treatment may be withheld and under which artificial means may be used to keep organs active for transplantation. PMID:11652419

  5. Caring for the terminally Ill.

    PubMed

    Bascom, P B; Tolle, S W; Cassel, C K

    1996-05-15

    More than 50% of dying patients do not receive adequate symptomatic relief. Fear of hastening death is the primary reason for physicians' reluctance to prescribe high-dose pain medication. Yet the ethical principle of "double effect" clearly states that palliative care which results in respiratory depression is justified-as long as the goal of management is relief of suffering, rather than death. PMID:8632050

  6. The Creative Use of Psychotherapy with Terminally Ill with AIDS.

    ERIC Educational Resources Information Center

    Fraenkel, William A.

    One clinical psychologist worked with terminally ill, end-stage Acquired Immune Deficiency Syndrome (AIDS) patients in a hospice type setting for an 18-month time period. Interventions included individual psychotherapy, mental status assessments, staff group sessions, and supportive services for families and significant others. During that time,…

  7. The Creative Use of Psychotherapy with Terminally Ill with AIDS.

    ERIC Educational Resources Information Center

    Fraenkel, William A.

    One clinical psychologist worked with terminally ill, end-stage Acquired Immune Deficiency Syndrome (AIDS) patients in a hospice type setting for an 18-month time period. Interventions included individual psychotherapy, mental status assessments, staff group sessions, and supportive services for families and significant others. During that time,

  8. Intentions in wishes to die: analysis and a typology A report of 30 qualitative case studies of terminally ill cancer patients in palliative care

    PubMed Central

    Ohnsorge, K; Gudat, H; Rehmann-Sutter, C

    2014-01-01

    Objective To investigate the variations in and intentions of wishes to die (WTD) of palliative care cancer patients. Methods Thirty terminally ill cancer patients, their caregivers and relatives in a hospice, an oncology palliative care ward of a general hospital, and an outpatient palliative care service. 116 semistructured qualitative interviews analyzed by a combined approach using Grounded Theory and Interpretive Phenomenological Analysis. Results A WTD is dynamic and interactive. Its subjective phenomenology can be described by three aspects: intentions, motivations, and interactions. In this article, we present a typology of the possible intentions. We identified nine different (ideal) types of intentions that WTD statements might have, other than wishing to live and accepting death. Many WTD statements do not imply a desire to hasten death. The intentions of statements differ according to whether a WTD is related to as imaginary or as an action. Often WTD statements contain several partial wishes, which can be in tension with each other and form a dynamic, sometimes unstable equilibrium. Conclusions Terminally ill persons' WTD statements differ in their intention, and deeper knowledge about these differences is ethically relevant. PMID:24706488

  9. An Assessment of the Role of Communication Apprehension in Communicating with the Terminally Ill.

    ERIC Educational Resources Information Center

    Ayres, Joe; Hopf, Tim

    1995-01-01

    Finds that students who reported high communication apprehension (CAs) were less willing to communicate, less willing to volunteer, less willing to work with terminally ill patients, and felt less confident about their communication than low CAs, and disclosed less to terminally ill patients than did people in any other circumstance. (SR)

  10. Coping with terminal illness: the role of hopeful thinking.

    PubMed

    Gum, Amber; Snyder, C R

    2002-12-01

    Using Snyder's theory of hope, the role of hope in the process of dying from a terminal illness is discussed. In this theory, hope is defined as the perceived capability to produce workable routes to desired goals (pathways thinking) and the requisite motivation to use those routes (agency thinking). Strategies by which individuals can maintain and even increase hope during the dying process are described, along with interventions to maintain patients' hope. Directions for future research are suggested. PMID:12685535

  11. Dignity in the terminally ill: a developing empirical model.

    PubMed

    Chochinov, Harvey Max; Hack, Thomas; McClement, Susan; Kristjanson, Linda; Harlos, Mike

    2002-02-01

    Despite use of the term dignity in arguments for and against a patient's self-governance in matters pertaining to death, there is little empirical research on how this term has been used by patients who are nearing death. The objective of this study was to determine how dying patients understand and define the term dignity, in order to develop a model of dignity in the terminally ill. A semi-structured interview was designed to explore how patients cope with their advanced cancer and to detail their perceptions of dignity. Interviews were audiotaped and transcribed verbatim. A consecutive sample of 50 consenting patients with advanced terminal cancer were recruited over a 15-month period of time from an urban extended care hospital housing a specialized unit for palliative care. This unit provides both inpatient services. and coordinates end-of-life care community based programming. Data were analysed using latent content analysis and constant comparison techniques. Four members of the research team independently coded the transcribed data, to develop conceptually meaningful categories of responses. Operational definitions were written for major categories, themes and sub-themes. Three major categories emerged from the qualitative analysis, including illness-related concerns; dignity conserving repertoire; and social dignity inventory. These broad categories and their carefully defined themes and sub-themes form the foundation for an emerging model of dignity amongst the dying. The concept of dignity and the dignity model offer a way of understanding how patients face advancing terminal illness. This will serve to promote dignity and the quality of life of patients nearing death. PMID:11824919

  12. Autonomy and paternalism in geriatric medicine. The Jewish ethical approach to issues of feeding terminally ill patients, and to cardiopulmonary resuscitation.

    PubMed

    Rosin, A J; Sonnenblick, M

    1998-02-01

    Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing nutrition. We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations. PMID:9549682

  13. The Stigma of Dying: Attitudes Toward the Terminally Ill

    ERIC Educational Resources Information Center

    Epley, Rita J.; McCaghy, Charles H.

    1978-01-01

    Using a range of semantic differential adjectives, 233 college students indicated attitudes toward young and old people who were healthy, ill, or terminally ill. Attitudes toward each state of health category separate into three factors: attitudes toward healthy, ill, and dying persons. (Author)

  14. Challenging conversations with terminally ill patients and their loved ones: Strategies to improve giving information in palliative care

    PubMed Central

    Wijk, Helle; Molander, Ulla

    2014-01-01

    Objective: The aim of the study was to explore the skills and strategies employed by professionals when having difficult conversations to provide information to loved ones as part of palliative care. Method: A qualitative design was chosen with in-depth interviews with nurses, assistant nurses and doctors a Hospital in Sweden and were analysed using content analysis. Results: The interviews produced examples of strategies used by professionals when imparting difficult information to patient and loved ones. The results fell into three areas: Who is giving information, Structuring the conversation and Different ways to convey a difficult message. Conclusion: Using conversational skills and strategies in combination with a carefully planned structure appeared to facilitate difficult conversations with patients and loved ones. Further research is required, related to the specific circumstances in which the conversation takes place.

  15. Ethical considerations in critical and terminal illness in the elderly.

    PubMed

    Levenson, S A; List, N D; Zaw-Win, B

    1981-12-01

    In a Baltimore geriatric center and hospital, a program was developed to individualize the treatment of critically and terminally ill patients. Part of this program was an effort to involve the patients themselves in the discussion of their personal wishes, and the provision of a set of guidelines for staff members to help them individualize the care of the patients. Some of the practical problems involved the the application of these ethical ideals are discussed. Merely implementing the protocol helped staff members to become more aware of these complex questions. Physicians should deal forthrightly with "right-to-die" and associated issues. The decision-making should remain in medical hands, and out of the courts and legislatures. PMID:7310039

  16. For patients with terminal chronic illness, does more face-to-face time with a healthcare provider decrease aggressive end-of-life (EOL) care such as ICU admission, feeding tube placement, CPR, or intubation?

    PubMed Central

    Seaberg, Preston; Hamm, Robert M.; McCarthy, Laine H.

    2016-01-01

    Clinical Question For patients with terminal chronic illness, does more face-to-face time with a healthcare provider decrease aggressive end-of-life (EOL) care such as ICU admission, feeding tube placement, CPR, or intubation? Answer Inconclusive. Existing evidence does not provide a conclusive answer to this particular question. While multiple prospective, randomized, controlled trials demonstrate an association between increased patient-provider contact time and decreased aggressive EOL care, interventions in those studies contain multiple confounding elements that preclude isolation of the time factor from the other elements in the interventions. There is a need for research focusing on physician-patient communication time and EOL care. Level of Evidence for the Answer A Search Terms Terminal care, palliative care, terminal illness, communication, patient-provider relations, time factors, life support care, resuscitation orders, enteral nutrition Inclusion Criteria Systematic reviews, meta-analyses, and comparative studies published between 2008 and the current date comparing EOL care or EOL care preferences of patients who spend more face-to-face time with a healthcare provider to those of patients who spend less face-to-face time with a healthcare provider. Exclusion Criteria Studies that do not report the primary outcome of interest (EOL care or EOL care preferences) or that do not measure discussion time or provide interventions that include face-to-face discussion. PMID:25796765

  17. Polyneuropathy in critically ill patients.

    PubMed Central

    Bolton, C F; Gilbert, J J; Hahn, A F; Sibbald, W J

    1984-01-01

    Five patients developed a severe motor and sensory polyneuropathy at the peak of critical illness (sepsis and multiorgan dysfunction complicating a variety of primary illnesses). Difficulties in weaning from the ventilator as the critical illness subsided and the development of flaccid and areflexic limbs were early clinical signs. However, electrophysiological studies, especially needle electrode examination of skeletal muscle, provided the definite evidence of polyneuropathy. The cause is uncertain, but the electrophysiological and morphological features indicate a primary axonal polyneuropathy with sparing of the central nervous system. Nutritional factors may have played a role, since the polyneuropathy improved in all five patients after total parenteral nutrition had been started, including the three patients who later died of unrelated causes. The features allow diagnosis during life, and encourage continued intensive management since recovery from the polyneuropathy may occur. Images PMID:6094735

  18. 42 CFR 418.22 - Certification of terminal illness.

    Code of Federal Regulations, 2011 CFR

    2011-10-01

    ... include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months... clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. (4) The... expectancy of 6 months or less if the terminal illness runs its normal course. (2) Clinical information...

  19. Teachers' Knowledge and Support Systems Regarding Students with Terminal Illness

    ERIC Educational Resources Information Center

    Heller, Kathryn Wolff; Coleman, Mari Beth; Best, Sherwood J.; Emerson, Judith

    2013-01-01

    This study examined teachers' knowledge and support when working with students with terminal illness or having experienced a student death. One hundred and ninety teachers of students with physical or multiple disabilities responded to a 40 item questionnaire that was distributed nationally. Results indicated that teachers have greater knowledge…

  20. Sedation in critically ill patients.

    PubMed

    Oldham, Mark; Pisani, Margaret A

    2015-07-01

    Sedation in the intensive care unit (ICU) is a topic that has been frequently researched, and debate still exists as to what are the best sedative agents for critically ill patients. There is increasing interest in sleep and circadian rhythm disturbances in the ICU and how they may impact on outcomes. In addition to patient-related and ICU environmental factors that likely impact sleep and circadian rhythm in the ICU, sedative and analgesic medications may also play a role. PMID:26118921

  1. Organizational culture in a terminally ill hospital.

    PubMed

    Coustasse, Alberto; Mains, Douglas A; Lykens, Kristine; Lurie, Sue G; Trevino, Fernando

    2007-01-01

    This study analyzed an organizational culture in a community hospital in Texas to measure organizational culture change and its impact on Patient Satisfaction (PS). The study employed primary and secondary data, combining quantitative and qualitative methods for a case study. Participant observation was used and archival data were collected to provide a better understanding of the organizational culture and the context in which change was taking place. This study also applied a "Shared Vision" of the organization as the central process in bringing forth the knowledge shared by members of the community hospital who were both subjects and research participants. The results from the study suggest an increase in PS due to the shared vision of one subculture within the hospital. There were powerful subcultures in this organization based on occupation and specialization, and their interests and functional orientations were not conducive to a systems approach. Hospital management was conducted in "silos" and there was lack of feedback between organizational levels of the hospital, especially in financial management, with organizational dysfunctionality in reacting and adapting to the health care market. PMID:18453135

  2. Lawyer and Counselor as an Interdisciplinary Team Serving the Terminally Ill.

    ERIC Educational Resources Information Center

    Bernstein, Barton E.

    1979-01-01

    Terminally ill patients often have concerns in areas such as estate planning; donation of body parts as anatomical gifts; right to die a natural death; and other questions. The mental health professional should be ready to offer informed data and to serve with the attorney as an interdisciplinary team. (Author)

  3. [Withholding treatment in terminally-ill newborns with Islamic parents].

    PubMed

    Westra, A E; Smit, B J; Willems, D L

    2007-02-24

    End-of-life decisions for terminally-ill newborn infants are usually made with the consent of parents as well as physicians, but may occasionally involve disagreement about which decision is in the best interest of the child. Paediatricians, while acting in accordance with the principle of respecting the autonomy of the parents, may collide with their own motive of avoiding pointless suffering of the infant. Based on their religious beliefs Islamic parents may not consent to an end-of-life decision. Three newborn girls who eventually died had been suffering from a skeletal dysplasia and a serious bronchopulmonary dysplasia, serious intractable deterioration after surgery for necrotising enterocolitis, and trisomy 18 respectively. In the first two cases there was no preceding consensus between parents and physicians and the girls died after more suffering than the paediatrician found acceptable. The physicians should aspire to prevent conflict situations by paying sufficient attention to the differences in beliefs. This demands that physicians understand and respect different beliefs and that they are able to communicate on the subject of these differences. It is important to Islamic parents that the natural course allows Allah to exercise his authority over life and death, and human dignity. Doing the best for the child is often more important than respect for patient or parent autonomy. PMID:17378297

  4. End-of-Life Care for Children with Terminal Illness (For Parents)

    MedlinePLUS

    ... Expect End-of-Life Care for Children With Terminal Illness KidsHealth > Parents > Doctors & Hospitals > Caring for a ... Child > End-of-Life Care for Children With Terminal Illness Print A A A Text Size What's ...

  5. Hyponatremia in critically ill patients

    PubMed Central

    Padhi, Rajesh; Panda, Baikuntha Nath; Jagati, Snehalata; Patra, Subhas Chandra

    2014-01-01

    Context: Hyponatremia is a common electrolyte disturbance in critically ill hence understanding its implications is important. Aims: This study was carried out to ascertain frequency, predisposing conditions and outcome in critically ill patients with hyponatremia on intensive care unit (ICU) admission. Settings and Design: This was an observational, prospective study of a series of ICU patients during a 12-month period. Materials and Methods: The patients were divided into two groups: Hyponatremic (serum sodium < 135 mmol/L) and Eunatremic groups (135-145 mmol/L). Clinical examination included volume status and drug history, biochemistries, clinical diagnosis and cause of hyponatremia. Statistical Analysis Used: Fisher's exact test, unpaired t-tests Wilcoxon ranksum tests, profile-likelihood method, log-rank test and KaplanMeier curves were used. P < 0.05 were considered to be statistically significant. Results: In the hyponatremic group, the frequency of hyponatremia on ICU admission was 34.3%, most were euvolumic, 58.96%. Females comprised of 36.5%. The mean age was 60.4 17.2. The Syndrome of inappropriate Antidiuretic Hormone (SIADH) criteria was met in ninety-one patients (36.25%), peumonia being the leading cause of SIADH. Patients with severe sepsis, elective surgery patients, renal failure and heart failure, cirrhosis of liver and subarachnoid hemorrhage were other more likely etiologic causes (P < 0.05). The hyponatremic group spent a longer time in the ICU (P = 0.02), had longer mechanical ventilator days (P < 0.05) and had an increased mortality rate (P = 0.01). Conclusions: Hyponatremia present on admission to the ICU is independent risk factors for poor prognosis. PMID:24678150

  6. The new Israeli law on the care of the terminally ill: conceptual innovations waiting for implementation.

    PubMed

    Barilan, Y Michael

    2007-01-01

    Israel has recently enacted a law on the care of terminally ill patients. This law, the Patient Nearing Death Act, is the first of its kind in the world. The law divides terminally ill patients--upon their own wishes--into two separate groups: "those who wish their lives be prolonged," and those who do not. Doctors will have to abide by elaborate advanced directives and take into account various sources of information on the presumed wishes of the patient. The law sanctions discontinuation of mechanical ventilation should it become a "cyclical" rather than "continuous" therapy, a provision that has implications for the use of the already available paraPAC ventilators. The law exposes gaps in modern Judaism between the religious law and the attitudes of the observant population with regard to medical ethics. PMID:17951889

  7. What a wish to die can mean: reasons, meanings and functions of wishes to die, reported from 30 qualitative case studies of terminally ill cancer patients in palliative care

    PubMed Central

    2014-01-01

    Background Despite research efforts over recent decades to deepen our understanding of why some terminally ill patients express a wish to die (WTD), there is broad consensus that we need more detailed knowledge about the factors that might influence such a wish. The objective of this study is to explore the different possible motivations and explanations of patients who express or experience a WTD. Methods Thirty terminally ill cancer patients, their caregivers and relatives; from a hospice, a palliative care ward in the oncology department of a general hospital, and an ambulatory palliative care service; 116 semi-structured qualitative interviews analysed using a complementary grounded theory and interpretive phenomenological analysis approach. Results Three dimensions were found to be crucial for understanding and analysing WTD statements: intentions, motivations and social interactions. This article analyses the motivations of WTD statements. Motivations can further be differentiated into (1) reasons, (2) meanings and (3) functions. Reasons are the factors that patients understand as causing them to have or accounting for having a WTD. These reasons can be ordered along the bio-psycho-socio-spiritual model. Meanings describe the broader explanatory frameworks, which explain what this wish means to a patient. Meanings are larger narratives that reflect personal values and moral understandings and cannot be reduced to reasons. Functions describe the effects of the WTD on patients themselves or on others, conscious or unconscious, that might be part of the motivation for a WTD. Nine typical ‘meanings’ were identified in the study, including “to let death put an end to severe suffering”, “to move on to another reality”, and – more frequently– “to spare others from the burden of oneself”. Conclusions The distinction between reasons, meanings and functions allows for a more detailed understanding of the motivation for the WTD statements of cancer patients in palliative care situations. Better understanding is crucial to support patients and their relatives in end-of-life care and decision making. More research is required to investigate the types of motivations for WTD statements, also among non-cancer patients. PMID:25161387

  8. Pharmacokinetics of ranitidine in critically ill patients.

    PubMed Central

    Ilett, K F; Nation, R L; Tjokrosetio, R; Thompson, W R; Oh, T E; Cameron, P D

    1986-01-01

    The plasma pharmacokinetics of ranitidine (50 mg i.v.) have been studied in 17 critically ill patients in an intensive care unit. Measurements of gastric aspirate pH were also made in 16 of these patients. Ranitidine therapy was part of the patients' normal drug regimen. Ranitidine plasma concentration was measured by high performance liquid chromatography and appropriate polyexponential equations were fitted to concentration-time data to enable calculation of relevant pharmacokinetic parameters. Values of the volume of the initial dilution space (median = 89 ml kg-1) and volume of distribution at steady state (median = 1.54 l kg-1) were about 60% of corresponding mean literature values for healthy controls. Plasma clearance (median = 4.22 ml min-1 kg-1) and terminal half-life (median = 4.7 h) were about 2-3 fold less and 2-3 fold greater, respectively, than values for healthy controls. There was wide interpatient variation in all the pharmacokinetic parameters. Renal impairment was considered to be largely responsible for the low plasma clearance. Gastric aspirate pH was measured at 0, 1 and 7 h after ranitidine administration and 58% of samples were found to be above pH 4. Four patients had gastric pH values which were consistently below pH 4 despite average trough plasma ranitidine concentrations equal to or greater than those required for a 50% suppression of gastric acid secretion in normal volunteers. PMID:3964528

  9. Relatives' Perspective on the Terminally Ill Patients Who Died after Euthanasia or Physician-Assisted Suicide: A Retrospective Cross-Sectional Interview Study in the Netherlands

    ERIC Educational Resources Information Center

    Georges, Jean-Jacques; Onwuteaka-Philipsen, Bregje D.; Muller, Martien T.; van der Wal, Gerrit; van der Heide, Agnes; van der Maas, Paul J.

    2007-01-01

    This study used retrospective interviews with 87 relatives to describe the experiences of patients who died by euthanasia or physician-assisted suicide (EAS) in the Netherlands. Most of the patients suffered from cancer (85%). The relatives were most often a partner (63%) or a child (28%) of the patient. Before explicitly requesting EAS most

  10. Relatives' Perspective on the Terminally Ill Patients Who Died after Euthanasia or Physician-Assisted Suicide: A Retrospective Cross-Sectional Interview Study in the Netherlands

    ERIC Educational Resources Information Center

    Georges, Jean-Jacques; Onwuteaka-Philipsen, Bregje D.; Muller, Martien T.; van der Wal, Gerrit; van der Heide, Agnes; van der Maas, Paul J.

    2007-01-01

    This study used retrospective interviews with 87 relatives to describe the experiences of patients who died by euthanasia or physician-assisted suicide (EAS) in the Netherlands. Most of the patients suffered from cancer (85%). The relatives were most often a partner (63%) or a child (28%) of the patient. Before explicitly requesting EAS most…

  11. [Invasive fungal infection in critically ill patients].

    PubMed

    Garnacho-Montero, Jos; Daz-Martn, Ana; Ruiz-Prez De Piappn, Maite; Garca-Cabrera, Emilio

    2012-06-01

    The most common organism implicated in fungal infections in the critically ill patients is Candida spp. C. albicans continues to be the species that causes the largest number of invasive candidiasis. In critically ill patients, Candida spp. are frequently isolated in non-sterile sites. Candida colonization is documented in nearly 60% of non-neutropenic critically ill patients staying more than one week in the ICU. However, only 5% of colonized patients will develop invasive candidiasis. The diagnosis of invasive non-candidemic candidiasis remains elusive in the majority of the patients. Candida in a blood culture should never be viewed as a contaminant and should always prompt treatment initiation. Patients with multifocal colonization with a Candida score >3 should also receive antifungal therapy. Fluconazole is reserved for non-severely ill patients without recent exposure to azoles. The use of an echinocandin is recommended for hemodynamically unstable patients or with a history of recent fluconazole exposure. PMID:22503211

  12. Intentions to work during terminal illness: an exploratory study of antecedent conditions.

    PubMed

    Westaby, James D; Versenyi, Andrea; Hausmann, Robert C

    2005-11-01

    Facing a terminal illness is an unimaginably difficult experience, yet many individuals intend to work despite their prognosis. However, research has not systematically examined the potential antecedents underlying such intentions. Using behavioral intention theory as an underlying framework, this study hypothesized that reasons for working (intrinsic and extrinsic), the will to live, disability severity, accessibility of travel, and age would predict intentions to work during terminal illness. A representative sample of medically diagnosed amyotrophic lateral sclerosis (a.k.a. Lou Gehrig's disease) patients with a mean life expectancy of approximately 3 years participated (mean age=57.8 years). Controlling for length of diagnosis, employment status, and demographic variables, results indicated that intrinsic reasons were particularly strong predictors of intentions, followed by age, disability severity, and accessibility of travel. Exploratory findings also indicated that behavioral intentions were positively related to future employment status, consistent with past theory. ((c) 2005 APA, all rights reserved). PMID:16316283

  13. Creating the final conversations scale: a measure of end-of-life relational communication with terminally ill individuals.

    PubMed

    Generous, Mark Alan; Keeley, Maureen P

    2014-01-01

    Final conversations (FCs) are defined as the communicative interactions, both verbal and nonverbal, that occur between terminally ill patients and relational partners. In this study, the "Final Conversations Scale" was developed and tested. A total of 152 participants that had engaged in final conversations with individuals that were terminally ill completed the newly developed instrument. Factor analysis produced a five-factor structure, including: messages of spirituality/religion; expressions of love; proactive difficult relationship talk; everyday communication; and talk about illness/death. Participants' perceptions of the relational closeness and difficulty with the deceased significantly influenced the individuals' recalled frequency of FCs messages. Practical and scholarly implications focus on the needs of the family members regarding their communication with terminally ill individuals, as well as directions for future research with the FCs Scale. PMID:25148453

  14. Preparation for Counseling Adults with Terminal Illness: Personal and Professional Parallels

    ERIC Educational Resources Information Center

    Manis, Amie A.; Bodenhorn, Nancy

    2006-01-01

    This article presents a review of the literature on counseling adults with terminal illness, particularly the literature on the nature of preparation that counselors and other professionals who attend to the needs of adults with a terminal illness require. The authors review information and findings from philosophical, psychological, practical,

  15. Caregiver Grief in Terminal Illness and Bereavement: A Mixed-Methods Study

    ERIC Educational Resources Information Center

    Waldrop, Deborah P.

    2007-01-01

    Caregivers experience multiple losses during the downhill trajectory of a loved one's terminal illness. Using mixed methods, this two-stage study explored caregiver grief during a terminal illness and after the care recipient's death. Caregiver grief was a state of heightened responsiveness during end-stage care: anxiety, hostility, depression,

  16. Finding Boundaries Inside Prison Walls: Case Study of a Terminally Ill Inmate

    ERIC Educational Resources Information Center

    O'Connor, Mary-Frances

    2004-01-01

    The number of terminally ill prison inmates rises each year. Mental health professionals are uniquely prepared to provide therapy during the end-of-life process with their assessment, training, empathy, and communication skills. This case study examines the six-month therapy of one terminally ill inmate, using a client-centered approach. Drawing

  17. Caregiver Grief in Terminal Illness and Bereavement: A Mixed-Methods Study

    ERIC Educational Resources Information Center

    Waldrop, Deborah P.

    2007-01-01

    Caregivers experience multiple losses during the downhill trajectory of a loved one's terminal illness. Using mixed methods, this two-stage study explored caregiver grief during a terminal illness and after the care recipient's death. Caregiver grief was a state of heightened responsiveness during end-stage care: anxiety, hostility, depression,…

  18. Preparation for Counseling Adults with Terminal Illness: Personal and Professional Parallels

    ERIC Educational Resources Information Center

    Manis, Amie A.; Bodenhorn, Nancy

    2006-01-01

    This article presents a review of the literature on counseling adults with terminal illness, particularly the literature on the nature of preparation that counselors and other professionals who attend to the needs of adults with a terminal illness require. The authors review information and findings from philosophical, psychological, practical,…

  19. Nutritional requirements of the critically ill patient.

    PubMed

    Chan, Daniel L

    2004-02-01

    The presence or development of malnutrition during critical illness has been unequivocally associated with increased morbidity and mortality in people. Recognition that malnutrition may similarly affect veterinary patients emphasizes the need to properly address the nutritional requirements of hospitalized dogs and cats. Because of a lack in veterinary studies evaluating the nutritional requirements of critically ill small animals, current recommendations for nutritional support of veterinary patients are based largely on sound clinical judgment and the best information available, including data from experimental animal models and human studies. This, however, should not discourage the veterinary practitioner from implementing nutritional support in critically ill patients. Similar to many supportive measures of critically ill patients, nutritional interventions can have a significant impact on patient morbidity and may even improve survival. The first step of nutritional support is to identify patients most likely to benefit from nutritional intervention. Careful assessment of the patient and appraisal of its nutritional needs provide the basis for a nutritional plan, which includes choosing the optimal route of nutritional support, determining the number of calories to provide, and determining the composition of the diet. Ultimately, the success of the nutritional management of critically ill dogs and cats will depend on close monitoring and frequent reassessment. PMID:15025191

  20. [Patients' University, illness and learning].

    PubMed

    Tourette-Turgis, Catherine

    2015-10-01

    The Patients' University, a pilot project at the Universit Pierre et Marie Curie, in Paris, enables patients-experts to follow a degree program in patient therapeutic education (University Diploma and Master). Recently, graduate patients and patients directly concerned proposed to co-create a new university certificate for treatment pathway coordinators for breast cancer, rounding out the 120-hour university certificate program on healthcare democracy and meeting the recommendations of the new cancer plan. PMID:26455618

  1. Movement of criticall ill patients within hospital.

    PubMed Central

    Waddell, G

    1975-01-01

    Critically ill patients were observed during routine movement inside the hospital to and from the intensive therapy unit. One patient a month suffered major cardiorespiratory collapse or death as a direct result of movement. Renewed bleeding of a pelvic fracture, cardiac arrhythmia, cardiac embarrassment due to a haemothorax, and cardiovascular decompensation were seen. It was difficult to continue treatment during movement, especially maintaining an airway or providing adequate intermittent positive pressure ventilation. Seventy postoperative patients suffered few ill effects on being moved. Greater awareness of the dangers of moving critically ill patients within hospital is needed. Thorough preparation for the move and adequate maintenance of treatment during movement requires the skill of experienced medical staff. PMID:1092402

  2. Fear of death, death attitudes, and religious conviction in the terminally ill.

    PubMed

    Smith, D K; Nehemkis, A M; Charter, R A

    The way in which an individual's belief system about death affects fear of death (FOD) has been largely neglected in the thanatology literature. The present study addresses the dimension of certainty or uncertainty with which beliefs about death are held and examines the way in which such attitudes might affect the FOD in dying patients. Twenty terminally ill patients were administered three FOD measures and a death perspective scale which assessed eight death attitudes. FOD among the terminally ill at both the conscious and fantasy level was low. Increased age was associated with declining conscious FOD, independent of life expectancy. Of the eight death perspectives, the attitudes toward death as afterlife-of-reward most directly tap the dimension of certainty or uncertainty. A significant curvilinear relationship emerged between this death perspective and FOD, suggesting that beliefs are a less critical determinant of death fear than is the certainty with which these beliefs are held. The study raises research and clinical issues pertinent to understanding FOD in dying patients. PMID:6654612

  3. Delirium management in critically ill patients.

    PubMed

    Calvo-Ayala, Enrique; Khan, Babar

    2013-01-01

    Delirium among critically ill patients is common. Presence of delirium imparts a poorer prognosis to patients, including longer ICU and hospital length of stay, increased risk of institutionalization, higher health related costs, and elevated mortality. Even with such grave consequences, the rates of delirium diagnosis are dire. The importance of early recognition through validated tools and appropriate management of this life-threatening condition cannot be over emphasized. This article provides an overview of delirium pathophysiology, diagnosis, and management with a focus on critically ill patients. PMID:25383387

  4. The expert patient: Illness as practice.

    PubMed

    Edgar, Andrew

    2005-01-01

    This paper responds to the Expert Patient initiative by questioning its over-reliance on instrumental forms of reasoning. It will be suggested that expertise of the patient suffering from chronic illness should not be exclusively seen in terms of a model of technical knowledge derived from the natural sciences, but should rather include an awareness of the hermeneutic skills that the patient needs in order to make sense of their illness and the impact that the illness has upon their sense of self-identity. By appealing to MacIntyre's concepts of "virtue" and "practice", as well as Frank's notion of the "wounded story-teller", it will be argued that chronic illness can be constituted as a practice, by building a culture of honest and courageous story-telling about the experience of chronic suffering. The building of such a practice will renew the cultural resources available to the patient, the physician and the rest of the community in understanding illness and patient-hood. PMID:16215796

  5. Hypomagnesemia in Critically Ill Sepsis Patients

    PubMed Central

    Velissaris, Dimitrios; Karamouzos, Vassilios; Pierrakos, Charalampos; Aretha, Diamanto; Karanikolas, Menelaos

    2015-01-01

    Magnesium (Mg), also known as the forgotten electrolyte, is the fourth most abundant cation overall and the second most abundant intracellular cation in the body. Mg deficiency has been implicated in the pathophysiology of many diseases. This article is a review of the literature regarding Mg abnormalities with emphasis on the implications of hypomagnesemia in critical illness and on treatment options for hypomagnesemia in critically ill patients with sepsis. Hypomagnesemia is common in critically ill patients, and there is strong, consistent clinical evidence, largely from observational studies, showing that hypomagnesemia is significantly associated with increased need for mechanical ventilation, prolonged ICU stay and increased mortality. Although the mechanism linking hypomagnesemia with poor clinical outcomes is not known, experimental data suggest mechanisms contributing to such outcomes. However, at the present time, there is no clear evidence that magnesium supplementation improves outcomes in critically ill patients with hypomagnesemia. Large, well-designed clinical trials are needed to evaluate the role of magnesium therapy for improving outcomes in critically ill patients with sepsis. PMID:26566403

  6. Palliative care for the terminally ill in America: the consideration of QALYs, costs, and ethical issues.

    PubMed

    Yang, Y Tony; Mahon, Margaret M

    2012-11-01

    The drive for cost-effective use of medical interventions has advantages, but can also be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. However, since it is in the nature of end-of-life palliative care that the benefits it brings to its patients are of short duration, it fares poorly under a policy of QALY-maximization. Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness. The use of QALYs in resource allocation means that palliative care will always compete with alternative uses of the same money. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that investing in palliative care makes more sense not only ethically, but also financially. PMID:22071573

  7. Delirium in critically ill patients.

    PubMed

    Jackson, Peter; Khan, Akram

    2015-07-01

    Delirium in the intensive care unit (ICU) is a common diagnosis, with an incidence ranging between 45% and 87%. Delirium represents a significant burden both to the patient and to the health care system, with a 3.2-fold increase in 6-month mortality and annual US health care costs up to $16 billion. In this review, the diagnosis, epidemiology, and risk factors for delirium in the ICU are discussed. The pathophysiology of delirium and evolving prevention and treatment modalities are outlined. PMID:26118922

  8. Management of Infections in Critically Ill Patients

    PubMed Central

    Hranjec, Tjasa

    2014-01-01

    Abstract Background: Critically ill patients have an increased risk of developing infections and infectious complications, sometimes followed by death. Despite a substantial investment of resources in outcomes improvement, optimum treatment for such patients remains unclear for practicing intensivists. Methods: We conducted a review that highlights the most recent developments in the prevention, diagnosis, and management of infection and the evaluation of its outcomes. The review examines the prevention of infection, such as through daily bathing with chlorhexidine and the addition of probiotics to treatment regimens, and questions the previous standards of care, including the monitoring of gastric residuals and treatment of severely ill patients with drotrecogin alfa (activated). It also discusses novel approaches to the treatment of severely ill infected patients with extra-corporeal membrane oxygenation and the earlier normalization of body temperature. Results: The development of new antibiotics continues at a slow pace, with the likelihood that alternative approaches to the management of infection, including changes in the quality of patient care, are producing needed improvements. Conclusions: Clinical outcomes of infection are improving slowly as medical teams strive for better patient care. Lack of reimbursement is unnecessary as a punitive approach to infectious diseases. PMID:24841214

  9. Communication with older, seriously ill patients.

    PubMed

    van Vliet, Liesbeth M; Lindenberger, Elizabeth; van Weert, Julia C M

    2015-05-01

    This article describes effective communication strategies in caring for older, seriously ill patients and their surrogates/caregivers. Specific skills in three core functions are highlighted: (i) empathic communication (ii) information provision and (iii) enabling decision making. Empathy skills include using 'NURSE' statements and assuring a continuous relationship. Tailored information and empathic communication can be used to facilitate information processing and overcome age-related communication barriers. Eliciting patients' goals of care is critical in decision making. Surrogates need assistance when making decisions for patients and often themselves have support and information needs. Suggestions are made to ensure patients' and caregivers' needs are met. PMID:25920057

  10. [Care of the terminal patient].

    PubMed

    Buisn, R; Delgado, J C

    2007-01-01

    In the work of health professions there have always been those who believed that the important thing was to treat all the patients until the final consequences, but there are also those who have considered that the important thing was to treat the patient and when this was not possible, to care for him until the end. Amongst the latter was Cicely Saunders, founder of the Hospices movement. She believed that in the terminal phase of the disease, when there was an increase in the deterioration the patient was to suffer, which also had a great impact on the family and team treating him/her, the aim should change and be replaced by care as the only goal. That care should be redirected towards providing comfort to the patient and his/her family. Because in this phase each positive action carried out on one of them is taken as something that is also positive for the other. The health team must transform itself into a care team. Care as a means and the quality of life and comfort as an end are must be our aims as carers during the final phase of life, as announced by the European Sub-committee of Palliative Care of the EEC, May 5th 1991, when defining palliative care. PMID:18227884

  11. Medication adherence for patients with mental illness.

    PubMed

    Varshney, Upkar; Vetter, Ron

    2012-01-01

    Medication adherence has been studied for some time; however most research has focused on able-bodied patients or the elderly living independently. What has not been studied nearly as much is medication adherence for people with psychiatric or mental illnesses. In this paper, we present a framework that includes the specific challenges in medication adherence for patients with mental illness, algorithms and protocols for evaluating adherence, and some on-going work in developing effective solutions. The architectural framework and associated algorithms leverage the context-aware computing capabilities available on many mobile devices. The system is designed to be able to collect and offer situation-aware information on medication use and adherence for healthcare professionals and other designated persons. PMID:23366355

  12. Families of Critically Ill Patients Need Extra Support, Too

    MedlinePLUS

    ... medlineplus/news/fullstory_156481.html Families of Critically Ill Patients Need Extra Support, Too Tips for coping ... center at Loyola University Health System in Maywood, Ill. Each year, roughly 2.1 million patients are ...

  13. [Anemia and erythropoietin in critically ill patients].

    PubMed

    Baginski, S; Krner, R; Frei, U; Eckardt, K-U

    2003-06-01

    The transfusion of red blood cells is still associated with possible adverse effects and a residual risk of transmission of viral and nonviral diseases. In addition, there is an increasing shortage of blood supply worldwide. These two facts together with the success experienced in the treatment of various types of anemia with recombinant human EPO, have recently led to an increasing interest in the anemia of critically ill patients. As in the anemia of chronic diseases there are several reasons that contribute to the development of anemia in patients on intensive care units: pre-existing anemia, blood loss, reduced red cell life span, impaired iron availability and a direct inhibition of erythropoiesis by inflammatory cytokines. The implications of anemia for the progression and prognosis of critical illness are still unclear and the optimal treatment, including optimal "transfusion triggers" remains controversial. Recombinant human EPO has been proven to be effective in ameliorating the anemia of critical illness in several pilot studies and is currently being tested in larger trials. PMID:12865954

  14. Methylphenidate for Treatment of Depressive Symptoms, Apathy, and Fatigue in Medically Ill Older Adults and Terminally Ill Adults

    PubMed Central

    Hardy, Susan E.

    2009-01-01

    Background Depressive symptoms, apathy, and fatigue are common symptoms among medically ill older adults and patients with advanced disease, and are associated with morbidity and mortality. Methylphenidate has been used to treat these symptoms because of its rapid effect. Objective To review the literature regarding the efficacy and safety of methylphenidate to treat depressive symptoms, apathy, and fatigue in medically ill older adults and in palliative care. Methods English-language articles presenting systematic reviews, clinical trials, or case series describing use of methylphenidate to treat depressive symptoms, fatigue, or apathy in medically ill older adults or in palliative care were identified. The keywords methylphenidate and either depressive, depression, fatigue, or apathy were used to search the Cochrane Database, MEDLINE, PsycINFO, and International Pharmaceutical Abstracts. Included articles addressed depressive symptoms, apathy, or fatigue in 1) older adults (generally age 65 years or older), particularly those with comorbid medical illness; 2) adult patients receiving palliative care; and 3) adults with other chronic illnesses. We excluded articles regarding 1) treatment of depression in healthy young adults; 2) treatment of bipolar disorder or attention-deficit hyperactivity disorder; and 3) treatment of narcolepsy, chronic fatigue syndrome and related disorders. Results 19 controlled trials of methylphenidate in medically ill older adults or in palliative care were identified. Unfortunately, their conflicting results, small size, and poor methodologic quality limit our ability to draw inferences regarding the efficacy of methylphenidate, although the evidence of its safety is stronger. The available evidence suggests possible effectiveness of methylphenidate for depressive symptoms, fatigue, apathy, and cognitive slowing in various medically ill populations. Conclusions In the absence of definitive evidence of effectiveness, trials of low-dose methylphenidate in medically ill adults suffering from depression, apathy, or fatigue with monitoring for response and adverse effects are appropriate. PMID:19281939

  15. Optimizing antimicrobial therapy in critically ill patients

    PubMed Central

    Vitrat, Virginie; Hautefeuille, Serge; Janssen, Cécile; Bougon, David; Sirodot, Michel; Pagani, Leonardo

    2014-01-01

    Critically ill patients with infection in the intensive care unit (ICU) would certainly benefit from timely bacterial identification and effective antimicrobial treatment. Diagnostic techniques have clearly improved in the last years and allow earlier identification of bacterial strains in some cases, but these techniques are still quite expensive and not readily available in all institutions. Moreover, the ever increasing rates of resistance to antimicrobials, especially in Gram-negative pathogens, are threatening the outcome for such patients because of the lack of effective medical treatment; ICU physicians are therefore resorting to combination therapies to overcome resistance, with the direct consequence of promoting further resistance. A more appropriate use of available antimicrobials in the ICU should be pursued, and adjustments in doses and dosing through pharmacokinetics and pharmacodynamics have recently shown promising results in improving outcomes and reducing antimicrobial resistance. The aim of multidisciplinary antimicrobial stewardship programs is to improve antimicrobial prescription, and in this review we analyze the available experiences of such programs carried out in ICUs, with emphasis on results, challenges, and pitfalls. Any effective intervention aimed at improving antibiotic usage in ICUs must be brought about at the present time; otherwise, we will face the challenge of intractable infections in critically ill patients in the near future. PMID:25349478

  16. Antibiotic dose optimization in critically ill patients.

    PubMed

    Cotta, M O; Roberts, J A; Lipman, J

    2015-12-01

    The judicious use of existing antibiotics is essential for preserving their activity against infections. In the era of multi-drug resistance, this is of particular importance in clinical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimization in critically ill patients requires sound knowledge not only of the altered physiology in serious infections - including severe sepsis, septic shock and ventilator-associated pneumonia - but also of the pathogen-drug exposure relationship (i.e. pharmacokinetic/pharmacodynamic index). An important consideration is the fact that extreme shifts in organ function, such as those seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, can have an impact upon drug exposure, and constant vigilance is required when reviewing antibiotic dosing regimens in the critically ill. The use of continuous renal replacement therapy and extracorporeal membrane oxygenation remain important interventions in these patients; however, both of these treatments can have a profound effect on antibiotic exposure. We suggest placing emphasis on the use of therapeutic drug monitoring and dose individualization when optimizing therapy in these settings. PMID:26415688

  17. Lingering terminal illness and family: insights from literature.

    PubMed

    Bertman, S L

    1980-12-01

    Literature invites us to enter into the human dilemma in a manner that is different from but no less penetrating than clinical observation. The writer's craft uncovers realities other than the statistically measurable and objective. In languages far from the strictly literal and closer to indirection, symbolism, and aesthetics, the literary artist probes imagination and consciousness. He presents us with transcripts of conversations replete with intonations, and we thereby become privy to motivations and inner thoughts. The artistry of a piece of fiction, autobiographical essay, poem, or drama propels us into empathetic relationships. We feel with the emotions of the involved dramatis personae; we witness their interactions; we experience their points of view. And by such participation, we, the readers, come to perceive and even refine our own. Themes of chronic illness, dying, and bereavement are certainly not alien to literature. This paper explores several literary moments that may help the professional who is working with these issues to have a broader appreciation of the subtleties of these human experiences. PMID:7274401

  18. Tobacco use treatment in primary care patients with psychiatric illness

    PubMed Central

    Cerimele, Joseph M.; Halperin, Abigail C.; Saxon, Andrew J.

    2014-01-01

    The prevalence of smoking is higher in patients with psychiatric illness compared to the general population. Smoking causes chronic illnesses which lead to premature mortality in those with psychiatric illness, is associated with greater burden of psychiatric symptoms, and contributes to the social isolation experienced by individuals with psychiatric disorders. Most patients with psychiatric illness present initially to primary care rather than specialty care settings, and some patients receive care exclusively in the primary care setting. Therefore, family physicians and other primary care clinicians have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses. In this article we review common myths associated with smoking and psychiatric illness, techniques in implementing evidence-based tobacco use treatments, the evidence base for tobacco use treatment for patients with specific psychiatric diagnoses, and factors to consider in treating tobacco use disorders in patients with psychiatric illness. PMID:24808119

  19. 76 FR 38744 - Proposed Information Collection (Application by Insured Terminally Ill Person for Accelerated...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-07-01

    ... stating the life expectancy of the insured person and a statement by the insured on the amount of... terminally ill may request a portion of the face value of his or her Servicemembers' Group Life Insurance (SGLI) or Veterans' Group Life Insurance (VGLI) prior to death. If the insured would like to receive...

  20. Storytelling by Adults Diagnosed with Terminal Illness: Narrative Identifying through Dialogical Research

    ERIC Educational Resources Information Center

    Sauer, Michael Paul

    2012-01-01

    The purpose of this dialogical qualitative research study was to gain insight into the process of storytelling with adults diagnosed with terminal illness as a way of making meaning of their experiences and lives. The study was informed by the conceptual frameworks of story, storytelling, and story listening which are grounded in the theory of…

  1. Ethical Guidelines for Counselors when Working with Clients with Terminal Illness Requesting Physician Aid in Dying

    ERIC Educational Resources Information Center

    Kurt, Layla J.; Piazza, Nick J.

    2012-01-01

    In 2005, the American Counseling Association (ACA) introduced a new ethical standard for counselors working with clients with terminal illness who are considering hastened death options. The authors' purpose is to inform counselors of the Death With Dignity Act and explore relevant ethical guidelines in the "ACA Code of Ethics" (ACA, 2005).

  2. 76 FR 56505 - Agency Information Collection (Application by Insured Terminally Ill Person for Accelerated...

    Federal Register 2010, 2011, 2012, 2013, 2014

    2011-09-13

    ... Benefit (38 CFR 9.14(e)) Activity Under OMB Review AGENCY: Veterans Benefits Administration, Department of... Terminally Ill Person for Accelerated Benefit (38 CFR 9.14(e). OMB Control Number: 2900-0618. Type of Review..., Enterprise Records Service. BILLING CODE 8320-01-P...

  3. Unexpected hypoglycemia in a critically ill patient.

    PubMed

    Bates, David W

    2002-07-16

    Administration of the wrong medication is a serious and understudied problem. Because physicians are not directly involved in the drug administration process, they tend to overlook the possibility of adverse drug events and medication errors in their differential diagnoses of patient illnesses or acute deterioration. This article analyzes the case of a patient with iatrogenic hypoglycemia due to administration of the wrong medication: Insulin instead of heparin was used to flush the patient's arterial line. In addition to assessing the results of the institution's "root-cause analysis" of the factors contributing to this particular adverse event and the institution's response, this article reviews the literature on preventing medication errors. Key strategies that might have been helpful in this case include using checklists for common emergency conditions (such as altered level of consciousness) and automated paging for "panic laboratory values," as well as instituting protocols for medication administration. Changing the system of administering medications by bar coding drugs, with checks of the medication, patient, and provider, could have prevented this accident. Finally, organizations need to strive for a "culture of safety" by providing opportunities to discuss errors and adverse events in constructive, supportive environments and by resisting pressure to find a scapegoat. PMID:12118966

  4. A randomized trial of the cost effectiveness of VA hospital-based home care for the terminally ill.

    PubMed Central

    Hughes, S L; Cummings, J; Weaver, F; Manheim, L; Braun, B; Conrad, K

    1992-01-01

    All admissions to a 1,100-bed Department of Veterans Affairs (VA) hospital were screened to identify 171 terminally ill patients with informal caregivers who were then randomly assigned to VA hospital-based team home care (HBHC, N = 85) or customary care (N = 86). Patient functioning, and patient and caregiver morale and satisfaction with care were measured at baseline, one month, and six months. Health services utilization was monitored over the six-month study period and converted to cost. Findings included no differences in patient survival, activities of daily living (ADL), cognitive functioning, or morale, but a significant increase in patient (p = .02) and caregiver (p = .005) satisfaction with care at one month. A substitution effect of HBHC was seen. Those in the experimental group used 5.9 fewer VA hospital days (p = .03), resulting in a $1,639 or 47 percent per capita saving in VA hospital costs (p = .02). As a result, total per capita health care costs, including HBHC, were $769 or 18 percent (n.s.) lower in the HBHC sample, indicating that expansion of VA HBHC to serve terminally ill veterans would increase satisfaction with care at no additional cost. PMID:1737710

  5. Pharmaconutrition for the obese, critically ill patient.

    PubMed

    Hurt, Ryan T; Frazier, Thomas H; McClave, Stephen A; Cave, Matt C

    2011-09-01

    Obesity is an epidemic that affects approximately 30% of the adult population in the United States. The prevalence of obesity in the critically ill seems to correlate with the rise in obesity in the general population. Delivery of standard enteral nutrition (EN) to patients in the intensive care unit (ICU) has been shown to decrease infectious complications. Obese ICU patients may be at increased risk for infections, ICU length of stay, and ventilation requirements compared to the nonobese. Pharmaconutrition has been shown to decrease many of these negative ICU outcomes. Because of obesity-associated increased ICU risk, provision of certain pharmaconutrients should be considered in obese patients requiring EN therapy. This review examines the evidence for specific nutrients such as green tea, curcumin, sulforaphane, poly-unsaturated fatty acids, L-arginine, L-citrulline, L-leucine, protein, probiotics, magnesium, medium-chain triglycerides, and zinc for the treatment of obesity. These nutrients could potentially be added to current EN formulas or provided as supplements. PMID:21881016

  6. The chronic illness problem inventory: problem-oriented psychosocial assessment of patients with chronic illness.

    PubMed

    Kames, L D; Naliboff, B D; Heinrich, R L; Schag, C C

    1984-01-01

    Two studies are presented which describe the development of a problem-oriented psychosocial screening instrument for use in health care settings. Reliability and validity data are presented on the Chronic Illness Problem Inventory (CIPI) which demonstrate its ability to document accurately patient's specific problems in areas of physical limitations, psychosocial functioning, health care behaviors and marital adjustment. A study is also presented which compares the problems of patients with three distinct chronic illnesses: pain, obesity, and respiratory ailments. Results indicate a significantly greater severity of problems for pain patients and especially patients with multiple pain complaints. Problem areas common to all three illness groups are discussed in the context of providing better comprehensive treatment for chronically ill patients. PMID:6735596

  7. Fear of Death, Mortality Communication, and Psychological Distress among Secular and Religiously Observant Family Caregivers of Terminal Cancer Patients

    ERIC Educational Resources Information Center

    Bachner, Yaacov G.; O'Rourke, Norm; Carmel, Sara

    2011-01-01

    Previous research suggests that caregivers and terminally ill patients face substantial difficulties discussing illness and death. Existing research, however, has focused primarily on the experience of patients. The current study compared responses as well as the relative strength of association between mortality communication, fear of death, and

  8. Fear of Death, Mortality Communication, and Psychological Distress among Secular and Religiously Observant Family Caregivers of Terminal Cancer Patients

    ERIC Educational Resources Information Center

    Bachner, Yaacov G.; O'Rourke, Norm; Carmel, Sara

    2011-01-01

    Previous research suggests that caregivers and terminally ill patients face substantial difficulties discussing illness and death. Existing research, however, has focused primarily on the experience of patients. The current study compared responses as well as the relative strength of association between mortality communication, fear of death, and…

  9. Expanding the Use of Continuous Sedation Until Death: Moving Beyond the Last Resort for the Terminally Ill.

    PubMed

    LiPuma, Samuel H; DeMarco, Joseph P

    2015-01-01

    As currently practiced, the use of continuous sedation until death (CSD) is controlled by clinicians in a way that may deny patients a key choice in controlling their dying process. Ethical guidelines from the American Medical Association and the American Academy of Pain Medicine describe CSD as a "last resort," and a position statement from the American Academy of Hospice and Palliative Medicine describe it as "an intervention reserved for extreme situations." Accordingly, patients must progress to unremitting pain and suffering and reach a last-resort stage before the option to pursue CSD is considered. Alternatively, we present and defend a new guideline in which decisionally capable, terminally ill patients who have a life expectancy of less than six months may request CSD before being subjected to the refractory suffering of a treatment of "last resort." PMID:26132059

  10. Self-Deception in Terminal Patients: Belief System at Stake.

    PubMed

    Echarte, Luis E; Bernacer, Javier; Larrivee, Denis; Oron, J V; Grijalba-Uche, Miguel

    2016-01-01

    A substantial minority of patients with terminal illness hold unrealistically hopeful beliefs about the severity of their disease or the nature of its treatment, considering therapy as curative rather than palliative. We propose that this attitude may be understood as self-deception, following the current psychological theories about this topic. In this article we suggest that the reason these patients deceive themselves is to preserve their belief systems. According to some philosophical accounts, the human belief system (HBS) is constituted as a web with a few stable central nodes - deep-seated beliefs - intimately related with the self. We hypothesize that the mind may possess defensive mechanisms, mostly non-conscious, that reject certain sensory inputs (e.g., a fatal diagnosis) that may undermine deep-seated beliefs. This interpretation is in line with the theory of cognitive dissonance. Following this reasoning, we also propose that HBS-related self-deception would entail a lower cognitive load than that associated with confronting the truth: whereas the latter would engage a myriad of high cognitive functions to re-configure crucial aspects of the self, including the setting of plans, goals, or even a behavioral output, the former would be mostly non-conscious. Overall, we believe that our research supports the hypothesis that in cases of terminal illness, (self-)deceiving requires less effort than accepting the truth. PMID:26903921

  11. Self-Deception in Terminal Patients: Belief System at Stake

    PubMed Central

    Echarte, Luis E.; Bernacer, Javier; Larrivee, Denis; Oron, J. V.; Grijalba-Uche, Miguel

    2016-01-01

    A substantial minority of patients with terminal illness hold unrealistically hopeful beliefs about the severity of their disease or the nature of its treatment, considering therapy as curative rather than palliative. We propose that this attitude may be understood as self-deception, following the current psychological theories about this topic. In this article we suggest that the reason these patients deceive themselves is to preserve their belief systems. According to some philosophical accounts, the human belief system (HBS) is constituted as a web with a few stable central nodes – deep-seated beliefs – intimately related with the self. We hypothesize that the mind may possess defensive mechanisms, mostly non-conscious, that reject certain sensory inputs (e.g., a fatal diagnosis) that may undermine deep-seated beliefs. This interpretation is in line with the theory of cognitive dissonance. Following this reasoning, we also propose that HBS-related self-deception would entail a lower cognitive load than that associated with confronting the truth: whereas the latter would engage a myriad of high cognitive functions to re-configure crucial aspects of the self, including the setting of plans, goals, or even a behavioral output, the former would be mostly non-conscious. Overall, we believe that our research supports the hypothesis that in cases of terminal illness, (self-)deceiving requires less effort than accepting the truth. PMID:26903921

  12. Attitudes toward euthanasia among Polish physicians, nurses and people who have no professional experience with the terminally ill.

    PubMed

    Glebocka, A; Gawor, A; Ostrowski, F

    2013-01-01

    Euthanasia is an issue that generates an extensive social debate. Euthanasia is generally classified as either active or passive. The former is usually defined as taking specific steps to cause the patient's death, while the latter is described as withdrawal of medical treatment with the deliberate intention of bringing the patient's life to an end. The dispute on euthanasia involves a multitude of aspects including religious, legal, cultural, ethical, medical, and spiritual issues. The purpose of the present study was to examine the views of medical professionals toward the highly controversial issue of euthanasia. Accordingly, the research has been conducted among a group of Polish nurses and physicians working in Intensive Care and Oncology Units. Their views have been compared to those of the control group, which included the members of the general public, who do not work in medical profession. It was expected that the education and training and the day-to-day exposure to vegetative patients might influence the views of medical personnel concerning euthanasia. The research demonstrated that the members of all groups supported liberal views. Conservative views were not popular among the respondents. The physicians turned out to be the least conservative group. The survey has also demonstrated that there is a broad consensus that informational and psychological support should be provided to terminally ill patients and their relatives. The attitude toward the passive form of euthanasia seems to have broad support. In particular doctors tend to approve this form of bringing a terminally ill patient's life to an end. The active euthanasia is regarded with much less favor and physicians, in particular, appear to disapprove of it. PMID:23836005

  13. [Home care for terminal patients and information technology].

    PubMed

    Hasegawa, Keiko; Gokita, Tomoko; Fujimoto, Yoshie; Souma, Mariko; Yamazaki, Shunji; Ooshima, Hitoshi; Takabayashi, Katsuhiko

    2002-12-01

    An electronic medical record sharing system, which supports management of terminally ill patients at home, was developed in Matsudo City as a trial project. The system interconnects several facilities including four general practitioners (GPs), a visiting nurse center and a supporting municipal hospital. It provides the latest patients' information from GPs to the municipal hospital in case of the acute change of the patients' condition and their transfer. Using this system the discussion between GPs and visiting nurses became much more fruitful than we had expected, while some doctors did not use the system because of their computer literacy. Problems in the system security and privacy protection as well as clarification of users' responsibility remain to be solved. A more expanded system is now being developed as a new enterprise of Matsudo Medical Association following this system. PMID:12536825

  14. Thrombo-prophylaxis in acutely ill medical and critically ill patients

    PubMed Central

    Saigal, Saurabh; Sharma, Jai Prakash; Joshi, Rajnish; Singh, Dinesh Kumar

    2014-01-01

    Thrombo-prophylaxis has been shown to reduce the incidence of pulmonary embolism (PE) and mortality in surgical patients. The purpose of this review is to find out the evidence-based clinical practice criteria of deep vein thrombosis (DVT) prophylaxis in acutely ill medical and critically ill patients. English-language randomized controlled trials, systematic reviews, and meta-analysis were included if they provided clinical outcomes and evaluated therapy with low-dose heparin or related agents compared with placebo, no treatment, or other active prophylaxis in the critically ill and medically ill population. For the same, we searched MEDLINE, PUBMED, Cochrane Library, and Google Scholar. In acutely ill medical patients on the basis of meta-analysis by Lederle et al. (40 trials) and LIFENOX study, heparin prophylaxis had no significant effect on mortality. The prophylaxis may have reduced PE in acutely ill medical patients, but led to more bleeding events, thus resulting in no net benefit. In critically ill patients, results of meta-analysis by Alhazzani et al. and PROTECT Trial indicate that any heparin prophylaxis compared with placebo reduces the rate of DVT and PE, but not symptomatic DVT. Major bleeding risk and mortality rates were similar. On the basis of MAGELLAN trial and EINSTEIN program, rivaroxaban offers a single-drug approach to the short-term and continued treatment of venous thrombosis. Aspirin has been used as antiplatelet agent, but when the data from two trials the ASPIRE and WARFASA study were pooled, there was a 32% reduction in the rate of recurrence of venous thrombo-embolism and a 34% reduction in the rate of major vascular events. PMID:24987238

  15. The pharmacologic approach to the critically ill patient

    SciTech Connect

    Chernow, B. )

    1988-01-01

    This book contains papers addressing the pharmacologic approach to the critically ill patient. Chapter topics include: Radiation injury; Red cell substitutes: a current appraisal; and Psychopharmacology in the ICU.

  16. Doctor-Patient Emails Can Help the Chronically Ill

    MedlinePLUS

    ... gov/medlineplus/news/fullstory_156514.html Doctor-Patient Emails Can Help the Chronically Ill Online communications reduced ... the ability to communicate with their doctor via email may improve their health, new research suggests. The ...

  17. Brain dysfunction in patients with chronic critical illness.

    PubMed

    Girard, Timothy D

    2012-06-01

    Critically ill patients frequently experience acute brain dysfunction in the form of coma or delirium, both of which are common during acute and chronic critical illness (CCI). These manifestations of brain dysfunction are associated with numerous adverse outcomes during acute critical illness, including prolonged hospitalization, increased healthcare costs, and increased mortality. The prognosis of CCI patients with coma or delirium has not yet been thoroughly studied, but preliminary studies suggest this population is at high risk for detrimental outcomes associated with acute brain dysfunction. Additionally, a high percentage of patients who survive acute or CCI suffer from long-term brain dysfunction, which manifests primarily as memory deficits and executive dysfunction and is predicted by brain dysfunction in the ICU. Interventions directed at reducing the burden of brain dysfunction during critical illness have shown promise in studies of patients with acute critical illness, but these therapies have yet to be studied during CCI. Thus, multicenter randomized trials are needed to determine which interventions are most effective for such patients. Until these data are available, management strategies that have been proven beneficial during acute critical illness-such as reduction of sedative exposure, especially to benzodiazepines, and early use of physical and occupational therapy-should be employed during the treatment of patients with CCI. PMID:22663969

  18. Nutritional Therapy for Critically Ill Patients.

    PubMed

    Martindale, Robert G; Warren, Malissa; Diamond, Sarah; Kiraly, Laszlo

    2015-01-01

    Nutrition therapy provided early in the critical care setting has been shown to improve outcome. Appropriate and early nutrition interventions can attenuate the hyperdynamic systemic response and depressed immune reaction to injury, serious illness and major surgery. Controversies limit the uniform application and potential benefits of nutrition, including failure to accurately predict who will 'need' nutritional intervention, lack of consensus on what the optimal enteral formulation is, overreliance on parenteral nutrition, failure to maximize the use of early enteral nutrition (EN), and how much and how best to feed the morbidly obese population. Despite challenges and inconsistencies in today's critical care setting, specialized nutrition has evolved from metabolic 'support' during critical illness to a primary therapeutic intervention designed, individualized and focused to achieve metabolic optimization and mitigation of stress-induced immune and hyperdynamic systemic responses. Nutrition should be considered early and commenced after initial resuscitation has taken place. This is most effectively accomplished with the use of protocols that aggressively promote early EN, and will result in lower mortality and a reduction in major complications. Though the complexity of the heterogeneous critically ill population will always be challenging, we are developing a better understanding of immunity, metabolic needs and catabolism associated with intensive care unit admissions. PMID:26544877

  19. The support needs of terminally ill people living alone at home: a narrative review

    PubMed Central

    Aoun, Samar M.; Breen, Lauren J.; Howting, Denise

    2014-01-01

    Context: The number of terminally ill people who live alone at home and without a caregiver is growing and exerting pressure on the stretched resources of home-based palliative care services. Objectives: We aimed to highlight the unmet support needs of terminally ill people who live alone at home and have no primary caregiver and identify specific models of care that have been used to address these gaps. Methods: We conducted a narrative review of empirical research published in peer-reviewed journals in English using a systematic approach, searching databases 2002–2013. This review identified 547 abstracts as being potentially relevant. Of these, 95 were retrieved and assessed, with 37 studies finally reviewed. Results: Majority of the studies highlighted the reduced likelihood of this group to be cared for and die at home and the experiences of more psychosocial distress and more hospital admissions than people with a primary caregiver. Few studies reported on the development of models of care but showed that the challenges faced by this group may be mitigated by interventions tailored to meet their specific needs. Conclusion: This is the first review to highlight the growing challenges facing community palliative care services in supporting the increasing number of people living alone who require care. There is a need for more studies to examine the effectiveness of informal support networks and suitable models of care and to provide directions that will inform service planning for this growing and challenging group. PMID:25750828

  20. Pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients.

    PubMed

    Chin, T W; Vandenbroucke, A; Fong, I W

    1995-01-01

    Current dosage regimens of trimethoprim-sulfamethoxazole used to treat Pneumocystis carinii pneumonia in AIDS patients have been based on data from healthy subjects or patients without AIDS. The clearance and absorption characteristics of the drugs may potentially be different between patients with and without AIDS. This study was conducted to assess the pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients treated for P. carinii pneumonia. Patients received trimethoprim at 15 mg/kg of body weight and sulfamethoxazole at 75 mg/kg of body weight daily intravenously in three to four divided doses and were switched to the oral route when the regimen was tolerated. Serum samples for determination of drug concentrations were obtained over 12 h after intravenous and oral dosing. The pharmacokinetics of trimethoprim and sulfamethoxazole were compared in eight critically ill versus nine non-critically ill male patients and were as follows, respectively: clearance, 1.88 +/- 0.44 versus 1.73 +/- 0.64 ml/min/kg for trimethoprim and 0.40 +/- 0.12 versus 0.34 +/- 0.11 ml/min/kg for sulfamethoxazole; volume of distribution, 1.6 +/- 0.5 versus 1.5 +/- 0.5 liters/kg for trimethoprim and 0.5 +/- 0.3 versus 0.4 +/- 0.1 liters/kg for sulfamethoxazole; and half-life, 10.9 +/- 7.4 versus 11.3 +/- 4.0 h for trimethoprim, and 15.5 +/- 9.5 versus 14.3 +/- 4.7 h for sulfamethoxazole. No significant differences (P > 0.05) were observed between patient groups, although there was wide intersubject variability. Absorption appeared to be similar between the critically ill and non-critically patients: bioavailability was 97.5% +/- 22.4% versus 101.8% +/- 22.7% for trimethoprim and 86.2% +/- 17.9% versus 99.1% +/- 20.5% for sulfamethoxazole, respectively. Because of the similar pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients, the two groups of patients may receive similar dosages. Dosage adjustment does not appear to be required when switching from the intravenous to the oral route. PMID:7695325

  1. Assessment and treatment of hyperglycemia in critically ill patients

    PubMed Central

    Viana, Marina Veroza; Moraes, Rafael Barberena; Fabbrin, Amanda Rodrigues; Santos, Manoella Freitas; Gerchman, Fernando

    2014-01-01

    Hyperglycemia is a commonly encountered issue in critically ill patients in the intensive care setting. The presence of hyperglycemia is associated with increased morbidity and mortality, regardless of the reason for admission (e.g., acute myocardial infarction, status post-cardiovascular surgery, stroke, sepsis). However, the pathophysiology and, in particular, the treatment of hyperglycemia in the critically ill patient remain controversial. In clinical practice, several aspects must be taken into account in the management of these patients, including blood glucose targets, history of diabetes mellitus, the route of nutrition (enteral or parenteral), and available monitoring equipment, which substantially increases the workload of providers involved in the patients' care. This review describes the epidemiology, pathophysiology, management, and monitoring of hyperglycemia in the critically ill adult patient. PMID:24770692

  2. Care of the Terminally Ill from Religious Perspectives: Role of Palliative and Hospice Care

    PubMed Central

    Mir, Tanveer

    2012-01-01

    Health care should make an attempt to understand the different religious principles that affect end-of-life decisions in patient care. With advanced illness, defining an ethical framework is essential to understanding sensitive issues. Compassionate care is crucial in all end-of-life care settings. Physician awareness is a key principle in inculcating the religious values of patients. Cultural and religious awareness on the part of the health-care team is needed to provide patients with effective end-of-life palliative and hospice care. PMID:23610503

  3. Management of pain, agitation, and delirium in critically ill patients.

    PubMed

    Pandharipande, Pratik P; Patel, Mayur B; Barr, Juliana

    2014-01-01

    Pain, agitation, and delirium (PAD) are common in critically ill patients. Consequently, analgesic and sedative medications are frequently administered to critically ill patients to treat PAD, to improve synchrony with mechanical ventilation, and to decrease the physiological stress response. However, prolonged, continuous deep sedation of intensive care unit (ICU) patients is associated with numerous adverse outcomes, including longer durations of mechanical ventilation, prolonged ICU stays, acute brain dysfunction, and an increased risk of death. The 2013 ICU PAD Guidelines were developed to provide a clear, evidence-based road map for clinicians to better manage PAD in critically ill patients. Significant knowledge gaps in these areas still remain, but if widely adopted, the PAD Guidelines can help bridge these gaps and will be transformative in terms of their impact on ICU care. Strong evidence indicates that linking PAD management strategies with ventilator weaning, early mobility, and sleep hygiene in ICU patients will result in significant synergistic benefits to patient care and reductions in costs. An interdisciplinary team-based approach, using proven process improvement strategies, and ICU patient and family activation and engagement, will help ensure successful implementation of the ICU PAD Care Bundle in ICUs. This paper highlights the major recommendations of the 2013 ICU PAD Guidelines. We hope this review will help ICU physicians and other health care providers advance the management of PAD in critically ill patients, and improve patients' clinical outcomes. PMID:24424616

  4. Difficulties of Diabetic Patients in Learning about Their Illness.

    ERIC Educational Resources Information Center

    Bonnet, Caroline; Gagnayre, Remi; d'Ivernois, Jean Francois

    2001-01-01

    Examines the difficulties experienced by diabetic patients in learning about their illness. Diabetic people (N=138) were questioned by means of a closed answer questionnaire. Results reveal that patients easily acquired manual skills, yet numerous learning difficulties were associated with the skills required to solve problems and make decisions,

  5. Difficulties of Diabetic Patients in Learning about Their Illness.

    ERIC Educational Resources Information Center

    Bonnet, Caroline; Gagnayre, Remi; d'Ivernois, Jean Francois

    2001-01-01

    Examines the difficulties experienced by diabetic patients in learning about their illness. Diabetic people (N=138) were questioned by means of a closed answer questionnaire. Results reveal that patients easily acquired manual skills, yet numerous learning difficulties were associated with the skills required to solve problems and make decisions,…

  6. Screening and Management of Delirium in Critically Ill Patients.

    PubMed

    Farina, Nicholas; Smithburger, Pamela; Kane-Gill, Sandra

    2015-09-01

    Delirium is highly prevalent in the critically ill population and has been associated with numerous negative outcomes including increased mortality. The presentation of a delirious patient in the intensive care unit (ICU) is characterized by a fluctuating cognitive status and inattention that varies dramatically among patients. Delirium can present in 3 different motoric subtypes: hyperactive, hypoactive, and mixed. Two tools, the Intensive Care Delirium Screening Checklist and Confusion Assessment ICU, are validated and recommended for the detection of delirium in critically ill patients. The identification of delirium in a critically ill patient should be facilitated using one of these tools. An intermediate form of delirium known as subsyndromal delirium also exists, although the significance of this syndrome is largely unknown. Another phenomenon known as sedation-related delirium has been recently described, although more research is needed to understand its significance. Patients in the ICU are exposed to many risk factors for developing delirium; controlling these risk factors is essential for preventing delirium development in critically ill patients. Nonpharmacologic interventions have been shown to prevent patients from developing delirium. Prevention is crucial because once delirium develops pharmacologic therapy is limited. PMID:26715799

  7. Shoshin Beriberi in Critically-Ill patients: case series.

    PubMed

    Dabar, George; Harmouche, Carine; Habr, Bassem; Riachi, Moussa; Jaber, Bertrand

    2015-01-01

    Thiamine plays a fundamental role in cellular metabolism. The classical syndrome caused by thiamine deficiency is beriberi, and its fulminant variant, once considered an uncommon finding, is now encountered among the critically ill.We present a case series of four critically ill non-septic non-alcoholic patients with severe lactic acidosis and refractory cardio-circulatory collapse caused by acute fulminant beriberi, which drastically responded to thiamine administration.In critical care settings, increased awareness of this life-threatening but reversible condition is a requirement, especially among patients receiving parenteral nutrition and those with unexplained recalcitrant lactic acidosis. PMID:25982313

  8. Development of the University of Pittsburgh Medical Center policy for the care of terminally ill patients who may become organ donors after death following the removal of life support.

    PubMed

    DeVita, M A; Snyder, J V

    1993-06-01

    In the mid 1980s it was apparent that the need for organ donors exceeded those willing to donate. Some University of Pittsburgh Medical Center (UPMC) physicians initiated discussion of possible new organ donor categories including individuals pronounced dead by traditional cardiac criteria. However, they reached no conclusion and dropped the discussion. In the late 1980s and the early 1990s, four cases arose in which dying patients or their families requested organ donation following the elective removal of mechanical ventilation. Controversy surrounding these cases precipitated open discussion of the use of organ donors pronounced dead on the basis of cardiac criteria. Prolonged deliberations by many committees in the absence of precedent ultimately resulted in what is, to our knowledge, the country's first policy for organ donation following elective removal of life support. The policy is intricate and conservative. Care was taken to include as many interested parties as possible in an effort to achieve representative and broad based support. This paper describes the development of the UPMC policy on non-heart-beating organ donation. PMID:10126526

  9. Pulmonary penetration of piperacillin and tazobactam in critically ill patients

    PubMed Central

    Felton, TW; McCalman, K; Malagon, I; Isalska, B; Whalley, S; Goodwin, J; Bentley, AM; Hope, WW

    2014-01-01

    Pulmonary infections in critically ill patients are common and associated with high morbidity and mortality. Piperacillin-tazobactam is a frequently used therapy in critically ill patients with pulmonary infection. Antibiotic concentrations in the lung reflect target site antibiotic concentrations in patients with pneumonia. The aim of this study was to assess the plasma and intra-pulmonary pharmacokinetics (PK) of piperacillin-tazobactam in critically ill patients administered standard piperacillin-tazobactam regimens. A population PK model was developed to describe plasma and intra-pulmonary piperacillin and tazobactam concentrations. The probability of piperacillin exposures reaching pharmacodynamic endpoints and the impact of pulmonary permeability on piperacillin and tazobactam pulmonary penetration was explored. The median piperacillin and tazobactam pulmonary penetration ratio was 49.3% and 121.2%, respectively. Pulmonary piperacillin and tazobactam concentration were unpredictable and negatively correlated to pulmonary permeability. Current piperacillin-tazobactam regimens may be insufficient to treat pneumonia caused by piperacillin-tazobactam susceptible organisms in some critically ill patients. PMID:24926779

  10. Sedation and analgesia in critically ill neurologic patients.

    PubMed

    Makii, Jason M; Mirski, Marek A; Lewin, John J

    2010-10-01

    Critically ill neurologic patients can pose a challenge when it comes to providing sedation and analgesia, primarily with the balance of maintaining sedation to provide patient comfort while still allowing a neurological examination. Determination of the optimal agent requires assessment and understanding of the underlying requirement for sedation: provision of analgesia, anxiolysis, or treatment of delirium. Pharmacological options exist that can affect individual or multiple underlying sedation requirements. Numerous evaluation tools exist to monitor the efficacy of sedation as well as help clinicians titrate agents to predefined goals; these tools allow the safe administration of drugs that can otherwise have serious adverse effects. Sedation regimens must ultimately be individualized to each patient to account for differences in pharmacokinetics and dynamics of the various agents, and this is particularly true in sedating neurologically injured patients. The agents frequently used to provide sedation and analgesia in the critically ill neurologic patient will be reviewed. PMID:21507849

  11. Spiritual Care For Jewish Patients Facing A Life Threatening Illness

    PubMed Central

    Bluman, Rabbi Olga F.; Klein, Linda; Thomas, Jay; Ferrell, Betty

    2013-01-01

    Providing biopsychosocial/spiritual care for patients facing a life threatening illness can be complex, and this complexity can be amplified when a patient identifies as Jewish. A common but incorrect assumption is that a person who identifies him or herself as Jewish abides by the tenets of the Jewish religion. However, many Jews consider themselves Jewish in an ethnic or cultural sense rather than connected to a religion or belief in God. This case report presents an ethnic/cultural Jew with a life threatening illness of advanced lung cancer. Despite evidence of spiritual/existential suffering, this patient declined spiritual care. From an analysis of this case and clinical experience, we suggest exploratory questions that clinicians can use in response to common questions or statements made by such patients. This exploration may lead to a chaplain referral and we highlight interventions that chaplains and clinicians may find helpful as they come alongside Jewish patients. PMID:23614173

  12. Citrate Pharmacokinetics in Critically Ill Patients with Acute Kidney Injury

    PubMed Central

    Zhu, Qiuyu; Liu, Junfeng; Qian, Jing; You, Huaizhou; Gu, Yong; Hao, Chuanming; Jiao, Zheng; Ding, Feng

    2013-01-01

    Introduction Regional citrate anticoagulation (RCA) is gaining popularity in continous renal replacement therapy (CRRT) for critically ill patients. The risk of citrate toxicity is a primary concern during the prolonged process. The aim of this study was to assess the pharmacokinetics of citrate in critically ill patients with AKI, and used the kinetic parameters to predict the risk of citrate accumulation in this population group undergoing continuous veno-venous hemofiltration (CVVH) with RCA. Methods Critically ill patients with AKI (n?=?12) and healthy volunteers (n?=?12) were investigated during infusing comparative dosage of citrate. Serial blood samples were taken before, during 120 min and up to 120 min after infusion. Citrate pharmacokinetics were calculated and compared between groups. Then the estimated kinetic parameters were applied to the citrate kinetic equation for validation in other ten patients CVVH sessions with citrate anticoagulation. Results Total body clearance of citrate was similar in critically ill patients with AKI and healthy volunteers (648.04347.00 L/min versus 686.64353.60 L/min; P?=?0.624). Basal and peak citrate concentrations were similar in both groups (p?=?0.423 and 0.247, respectively). The predicted citrate curve showed excellent fit to the measurements. Conclusions Citrate clearance is not impaired in critically ill patients with AKI in the absence of severe liver dysfunction. Citrate pharmacokinetic data can provide a basis for the clinical use of predicting the risk of citrate accumulation. Trial Registration ClinicalTrials.gov Identifier NCT00948558 PMID:23824037

  13. Parenteral Nutrition in the Critically Ill Patient

    PubMed Central

    Ziegler, Thomas R.

    2011-01-01

    A 67-year-old woman with type 2 diabetes mellitus undergoes extensive resection of the small bowel and right colon with a jejunostomy and colostomy because of mesenteric ischemia. In the surgical intensive care unit, severe systemic inflammatory response syndrome with possible sepsis develops. The patient is treated with volume resuscitation, vasopressor support, mechanical ventilation, broad-spectrum antibiotics, and intravenous insulin infusion. Low-dose tube feedings are initiated postoperatively through a nasogastric tube. However, these feedings are discontinued after the development of escalating vasopressor requirements, worsening abdominal distention, and increased gastric residual volume, along with an episode of emesis. The hospital nutritional-support service is consulted for feeding recommendations. A discussion with the patient's family reveals that during the previous 6 months, she lost approximately 15% of her usual body weight and decreased her food intake because of abdominal pain associated with eating. Her preoperative body weight was 51 kg (112 lb), or 90% of her ideal body weight. The physical examination reveals mild wasting of skeletal muscle and fat. Blood tests show hypomagnesemia, hypophosphatemia, and normal hepatic and renal function. Central venous parenteral nutrition is recommended. PMID:19741230

  14. Precipitating Factors of Acute Illness in Patients with Chronic Disease

    PubMed Central

    Munroe, D. S.

    1965-01-01

    The precipitating causes of acute illness in patients with chronic organic disease can often be prevented, reversed or controlled. The various kinds of precipitating factors are described, and their anticipation and the prompt institution of remedial measures are emphasized. PMID:5843867

  15. Alcohol-Use Disorders in the Critically Ill Patient

    PubMed Central

    Jones, Drew G.; Sessler, Curtis N.; Zilberberg, Marya D.; Weaver, Michael F.

    2010-01-01

    Alcohol abuse and dependence, referred to as alcohol-use disorders (AUDs), affect 76.3 million people worldwide and account for 1.8 million deaths per year. AUDs affect 18.3 million Americans (7.3% of the population), and up to 40% of hospitalized patients have AUDs. This review discusses the development and progression of critical illness in patients with AUDs. In contrast to acute intoxication, AUDs have been linked to increased severity of illness in a number of studies. In particular, surgical patients with AUDs experience higher rates of postoperative hemorrhage, cardiac complications, sepsis, and need for repeat surgery. Outcomes from trauma are worse for patients with chronic alcohol abuse, whereas burn patients who are acutely intoxicated may not have worse outcomes. AUDs are linked to not only a higher likelihood of community-acquired pneumonia and sepsis but also a higher severity of illness and higher rates of nosocomial pneumonia and sepsis. The management of sedation in patients with AUDs may be particularly challenging because of the increased need for sedatives and opioids and the difficulty in diagnosing withdrawal syndrome. The health-care provider also must be watchful for the development of dangerous agitation and violence, as these problems are not uncommonly seen in hospital ICUs. Despite studies showing that up to 40% of hospitalized patients have AUDs, relatively few guidelines exist on the specific management of the critically ill patient with AUDs. AUDs are underdiagnosed, and a first step to improving patient outcomes may lie in systematically and accurately identifying AUDs. PMID:20923804

  16. Metabolic syndrome in patients with severe mental illness in Gorgan

    PubMed Central

    Kamkar, Mohammad Zaman; Sanagoo, Akram; Zargarani, Fatemeh; Jouybari, Leila; Marjani, Abdoljalal

    2016-01-01

    Background: Metabolic syndrome is commonly associated with cardiovascular diseases and psychiatric mental illness. Hence, we aimed to assess the metabolic syndrome among severe mental illness (SMI). Materials and Methods: The study included 267 patients who were referred to the psychiatric unit at 5th Azar Education Hospital of Golestan University of Medical Sciences in Gorgan, Iran. Results: The mean waist circumference, systolic and diastolic blood pressure, triglyceride and fasting blood glucose levels were significantly higher in the SMI with metabolic syndrome, but the high density lipoprotein (HDL)-cholesterol was significantly lower. The prevalence of metabolic syndrome in SMI patients was 20.60%. There were significant differences in the mean of waist circumference, systolic (except for women) and diastolic blood pressure, triglyceride, HDL-cholesterol and fasting blood glucose in men and women with metabolic syndrome when compared with subjects without metabolic syndrome. The prevalence of metabolic syndrome in SMI women was higher than men. The most age distribution was in range of 30-39 years old. The most prevalence of metabolic syndrome was in age groups 50-59 years old. The prevalence of metabolic syndrome was increased from 30 to 59 years old. Conclusion: The prevalence of metabolic syndrome in patients with SMI in Gorgan is almost similar to those observed in Asian countries. The prevalence of metabolic syndrome was lower than western countries. These observations may be due to cultural differences in the region. It should be mention that the families of mental illness subjects in our country believe that their patients must be cared better than people without mental illness. These findings of this study suggest that mental illness patients are at risk of metabolic syndrome. According to our results, risk factors such as age and gender differences may play an important role in the presence of metabolic syndrome. In our country, women do less physical activity than men; therefore, the incidence of metabolic syndrome is higher among women.

  17. Effects of ambulance transport in critically ill patients.

    PubMed Central

    Waddell, G; Scott, P D; Lees, N W; Ledingham, I M

    1975-01-01

    Two groups of critically ill patients were transferred by ambulance from other hospitals to a central intensive therapy unit. The effect of transport was reviewed retrospectively in 46 patients and prospectively in 20 patients. Of the 46 patients reviewed retrospectively six became hypotensive, six became hypertensive, and seven developed delayed hypotension. One patient developed fits and six out of 13 patients had a rise in arterial PCO-2 of 1-6-4-1 kPa (12-31 mm Hg). Of the 20 patients reviewed prospectively, one patient became hypertensive due to overtransfusion, one had a fit, but none became hypotensive. Three out of four cases of delayed hypotension were related to starting intermittent positive pressure ventilation. Arterial PCO-2 fell in one patient and arterial PCO-2 rose in two, each change being related to changed oxygen therapy or narcotics. There were no changes in other cardiovascular or respiratory indices, body temperature, or urine production. Earlier transfer, resuscitation before transfer, continuing medical care during the journey, and hence a slower smoother journey seemed to be important factors in the management of these patients. Our findings, may have important implications in the future regional organization of the care of critically ill patients. PMID:1090329

  18. Optimizing nutrition therapy to enhance mobility in critically ill patients.

    PubMed

    Cherry-Bukowiec, Jill R

    2013-01-01

    Critically ill patients are at high risk of malnutrition and lean body mass loss. Screening for malnutrition and performing detailed assessment of energy needs should be routine for patients admitted to intensive care units. Providing adequate calorie and protein provisions can attenuate muscle loss in many at-risk patients. Enteral nutrition is associated with decreased risks of morbidity and infections and is therefore preferred to parenteral nutrition in hemodynamically stable patients with favorable anatomy. Judicious use of steroids and paralytics in combination with adequate glucose control may decrease the risk of developing critical illness polyneuromyopathy. There is growing evidence for the potential immune-enhancing benefits of many micronutrients and vitamins in the critically ill, but more research is needed to determine which nutrients are most effective in which disease processes and what dosing regimens are safe and effective. Elderly, obese, and very young patients pose unique challenges for nutrition therapy and early mobility programs. Pairing early mobility programs with optimal nutrition therapy can help reduce morbidity, limit muscle loss, and speed recovery in intensive care unit patients. PMID:23221439

  19. Bleeding complications in critically ill patients with liver cirrhosis

    PubMed Central

    Cho, Jaeyoung; Choi, Sun Mi; Yu, Su Jong; Park, Young Sik; Lee, Chang-Hoon; Lee, Sang-Min; Yim, Jae-Joon; Yoo, Chul-Gyu; Kim, Young Whan; Han, Sung Koo; Lee, Jinwoo

    2016-01-01

    Background/Aims: Patients with liver cirrhosis (LC) are at risk for critical events leading to Intensive Care Unit (ICU) admission. Coagulopathy in cirrhotic patients is complex and can lead to bleeding as well as thrombosis. The aim of this study was to investigate bleeding complications in critically ill patients with LC admitted to a medical ICU (MICU). Methods: All adult patients admitted to our MICU with a diagnosis of LC from January 2006 to December 2012 were retrospectively assessed. Patients with major bleeding at the time of MICU admission were excluded from the analysis. Results: A total of 205 patients were included in the analysis. The median patient age was 62 years, and 69.3% of the patients were male. The most common reason for MICU admission was acute respiratory failure (45.4%), followed by sepsis (27.3%). Major bleeding occurred in 25 patients (12.2%). The gastrointestinal tract was the most common site of bleeding (64%), followed by the respiratory tract (20%). In a multivariate analysis, a low platelet count at MICU admission (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and sepsis (OR, 8.35; 95% CI, 1.04 to 67.05) were independent risk factors for major bleeding. The ICU fatality rate was significantly greater among patients with major bleeding (84.0% vs. 58.9%, respectively; p = 0.015). Conclusions: Major bleeding occurred in 12.2% of critically ill cirrhotic patients admitted to the MICU. A low platelet count at MICU admission and sepsis were associated with an increased risk of major bleeding during the MICU stay. Further study is needed to better understand hemostasis in critically ill patients with LC. PMID:26805633

  20. Psychiatric complications in the critically ill cardiac patient.

    PubMed Central

    Sanders, K M; Cassem, E H

    1993-01-01

    Psychiatric consultation to the critically ill cardiac patient focuses on several common problems: anxiety, delirium, depression, personality reactions, and behavioral disturbances. A review of the causes and treatment of anxiety in the coronary care unit is followed by a discussion of delirium in the critically ill cardiac patient. A description of delirium associated with the use of the intraaortic balloon pump and its treatment with high doses of intravenous haloperidol is also included. After the initial crisis has been stabilized in the critical care unit, the premorbid personality traits of the patient may emerge as behavioral disturbances--particularly as the duration of stay increases. The use of psychiatric consultation completes the discussion. PMID:8219821

  1. Increased incidence of diuretic use in critically ill obese patients?,??

    PubMed Central

    de Louw, Emma J.; Sun, Pepijn O.; Lee, Joon; Feng, Mengling; Mark, Roger G.; Celi, Leo Anthony; Mukamal, Kenneth J.; Danziger, John

    2015-01-01

    Objective Sodium retention occurs commonly in cardiac and liver disease, requiring the administration of diuretics to restore fluid balance. Whether obesity is associated with sodium retention has not been fully evaluated. Methods In a large single-center cohort of critically ill patients, we evaluated whether admission body mass index was associated with the administration of either oral or intravenous diuretics during the intensive care unit (ICU) stay. Main results Of 7724 critically ill patients, 3946 (51.1%) were prescribed diuretics during the ICU stay. Overweight, class I obesity, and class II/III obesity were associated with a 1.35 (95% confidence interval [CI], 1.201.53; P < .001), 1.56 (95% CI, 1.351.80; P < .001), and 1.91 (95% CI, 1.612.26; P < .001) adjusted risk of receiving diuretics within the ICU, respectively. In adjusted analysis, a 5-kg/m2 increment of body mass index was associated with a 1.19 (95% CI, 1.141.23; P < .001) increased adjusted risk of within-ICU diuretics. Among those patients receiving loop diuretics, obese patients received significantly larger daily diuretic doses. Conclusion Critically ill obese patients are more likely to receive diuretics during their stay in the ICU and to receive higher dosages of diuretics. Our data suggest that obesity is an independent risk factor for sodium retention. PMID:25721030

  2. Thirst in Critically Ill Patients: From Physiology to Sensation

    PubMed Central

    Arai, Shoshana; Stotts, Nancy; Puntillo, Kathleen

    2013-01-01

    Critically ill patients often have distressful episodes of severe thirst, but the underlying complex biochemical, neurohormonal regulatory controls that regulate this primal sensation have rarely been addressed by clinicians. Subtle changes in plasma osmolality are the most potent stimulus for thirst. In response to increases in osmolality, osmoreceptors activate release of the neurohormone vasopressin (also known as antidiuretic hormone). The released vasopressin acts on the kidneys to conserve water to correct the hyperosmolar state. If this compensatory mechanism is unsuccessful, thirst arises to promote drinking. Thirst induced by marked volume loss, in contrast, is more closely related to the volemic and pressure changes regulated by the renin-angiotensin aldosterone system. Understanding the physiological mechanisms of thirst will help in understanding the pathophysiological consequences of underlying thirst-related disease and treatments in critically ill patients. Further clinical research is needed to elucidate the multiple inhibitory and excitatory neurohormonal stimuli that motivate patients’ intense desire for water. PMID:23817822

  3. Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients

    PubMed Central

    2011-01-01

    Background Recognizing infection is crucial in immunocompromised patients with organ dysfunction. Our objective was to assess the diagnostic accuracy of procalcitonin (PCT) in critically ill immunocompromised patients. Methods This prospective, observational study included patients with suspected sepsis. Patients were classified into one of three diagnostic groups: no infection, bacterial sepsis, and nonbacterial sepsis. Results We included 119 patients with a median age of 54 years (interquartile range [IQR], 42-68 years). The general severity (SAPSII) and organ dysfunction (LOD) scores on day 1 were 45 (35-62.7) and 4 (2-6), respectively, and overall hospital mortality was 32.8%. Causes of immunodepression were hematological disorders (64 patients, 53.8%), HIV infection (31 patients, 26%), and solid cancers (26 patients, 21.8%). Bacterial sepsis was diagnosed in 58 patients and nonbacterial infections in nine patients (7.6%); 52 patients (43.7%) had no infection. PCT concentrations on the first ICU day were higher in the group with bacterial sepsis (4.42 [1.60-22.14] vs. 0.26 [0.09-1.26] ng/ml in patients without bacterial infection, P < 0.0001). PCT concentrations on day 1 that were > 0.5 ng/ml had 100% sensitivity but only 63% specificity for diagnosing bacterial sepsis. The area under the receiver operating characteristic (ROC) curve was 0.851 (0.78-0.92). In multivariate analyses, PCT concentrations > 0.5 ng/ml on day 1 independently predicted bacterial sepsis (odds ratio, 8.6; 95% confidence interval, 2.53-29.3; P = 0.0006). PCT concentrations were not significantly correlated with hospital mortality. Conclusion Despite limited specificity in critically ill immunocompromised patients, PCT concentrations may help to rule out bacterial infection. PMID:21864380

  4. Dying at home: nursing of the critically and terminally ill in private care in Germany around 1900.

    PubMed

    Nolte, Karen

    2009-06-01

    Over the last twenty years, 'palliative care' has evolved as a special nursing field in Germany. Its historic roots are seen in the hospices of the Middle Ages or in the hospice movement of the twentieth century. Actually, there are numerous everyday sources to be found about this subject from the nineteenth century. The article at hand deals with the history of nursing the terminally ill and dying in domestic care in the nineteenth century. Taking care of and nursing the dying was part of everyday routine in the nursing care as practiced by the deaconesses and sisters in those days. Mit der Seelenpflege bei den unheilbar Kranken und Sterbenden schufen die Kaiserswerther Diakonissen sich einen von Arzten unabhngigen Kompetenzbereich. Meine Analysen zur Privatpflege zeigen jedoch darber hinaus, dass die in ihrer Aufmerksamkeit auf das Mutterhaus ausgerichteten Diakonissen auch in Leibespflege sehr viel unabhngiger von den Arzten zu agieren schienen als die freien Krankenschwestern. The article takes a look not only at the actual nursing activities but also at the relationship between the sisters and their patients and their relatives and the family doctor. On the basis of the recorded letters which the nurses wrote to the deaconess motherhouse in Kaiserswerth, it is also possible to analyze how the deaconesses communicated and reflected their actions at the deathbed. PMID:19453359

  5. Pain Relief Advice May Help ER Patients with Terminal Cancer

    MedlinePLUS

    ... who received usual care in the emergency department. Palliative care is a type of therapy for very ill patients with the goal of offering support and pain relief without attempting to cure the underlying cause ...

  6. The experience of Chinese immigrant women in caring for a terminally ill family member in Australia.

    PubMed

    Heidenreich, Mary T; Koo, Fung Kuen; White, Kate

    2014-01-01

    The Chinese community, a heterogeneous, highly visible non-English speaking ethnic group in Australia, remains mostly hidden and underrepresented in palliative care service delivery along with participation in health research despite being the fastest growing such group in the country. There is a lack of Australian research information concerning the impact of migration on the caregiving experience of women carers within the Chinese cultural framework and the Australian palliative care context. This paper aims to explore the influence of Chinese cultural norms and immigration on the experience of immigrant women of Chinese ancestry caring for a terminally ill family member at home in Sydney. This study also seeks to identify factors that may present access barriers to palliative care support services. A qualitative approach was used in this study. Data were collected from semi-structured interviews with five home-based Chinese women carers and were analysed using thematic analysis. Findings identified that the participants found being a carer is a lonely and isolating experience. Sources of isolation and loneliness included social isolation experienced as a solitary carer without meaningful family and social relationships; loss of familiar cultural understandings and family values; and emotional isolators expressed in response to the physical and emotional role commitment and other constraints. The study results suggest the need for palliative care educational programmes designed to help nurses to understand the impact of cultural background within the palliative care context. Results also indicate that health care professionals should provide culturally appropriate and competent palliative care services, sensitive to the diverse socio-cultural influences and individual needs of Chinese migrants. PMID:25632724

  7. Concepts of trust among patients with serious illness.

    PubMed

    Mechanic, D; Meyer, S

    2000-09-01

    This paper examines conceptions of trust among three groups of respondents diagnosed with either breast cancer, Lyme disease or mental illness. Interviews were carried out using an open-ended interview guide to explore how patients made assessments of trust in their doctors and health care plans. The guide followed a conceptual approach that asked questions about competence, agency/fiduciary responsibility, control, disclosure and confidentiality. Respondents were given ample opportunity to raise other areas of concern. The data were organized using the NUDIST software package for the analysis of non-numerical and unstructured qualitative data. Patients viewed trust as an iterative process and commonly tested their physicians against their knowledge and expectations. Interpersonal competence, involving caring, concern and compassion, was the most common aspect of trust reported, with listening as a central focus. Most patient comments referred to learnable skills and not simply to personality characteristics. Technical competence also received high priority but was often assessed by reputation or interpersonal cues. Patients were much concerned that doctors be their agents and fight for their interests with health care plans. Disclosure and confidentiality were less common concerns; most patients anticipated that doctors would be honest with them and respect their confidences. Patients' responses also appeared to vary by their disease, their socio-demographic characteristics, their involvement with self-help groups, and how their illness conditions unfolded. PMID:10975226

  8. Amicus Curiae brief for the United States Supreme Court on mental health, terminal illness, and assisted death.

    PubMed

    Miller, Pamela J; Werth, James L

    2005-01-01

    The Supreme Court will hear the case of Gonzales v. Oregon in the fall of 2005 to determine if prescriptions written under Oregon's Death with Dignity law violate the Controlled Substances Act. The Attorney General of the United States also believes that hastening death is a public health danger because of the vulnerability of people with terminal illness, primarily because of the possibility of depression. PMID:17387073

  9. Pain and Agitation Management in Critically Ill Patients.

    PubMed

    Stephens, Julie; Wright, Michael

    2016-03-01

    Pain and agitation may be difficult to assess in a critically ill patient. Pain is best assessed by self-reporting pain scales; but in patients who are unable to communicate, behavioral pain scales seem to have benefit. Patients' sedation level should be assessed each shift and preferably by a validated ICU tool, such as the RASS or SAS scale. Pain is most appropriately treated with the use of opiates, and careful consideration should be given to the pharmacokinetic and pharmacodynamic properties of various analgesics to determine the optimal agent for each individual patient. Sedation levels should preferably remain light or with the use of a daily awakening trial. Preferred treatment of agitation is analgosedation with the addition of nonbenzodiazepine sedatives if necessary. There are risks associated with each agent used in the treatment of pain and agitation, and it is important to monitor patients for effectiveness, signs of toxicity, and adverse drug reactions. PMID:26897427

  10. [Endoscopic treatment in critically ill patients with upper gastrointestinal bleeding].

    PubMed

    Kheladze, Z S; Dzhaiani, S V; Tsutskiridze, B N; Kheladze, Zv Z; Chakhunashvili, G K; Chakhunashvili, D K

    2010-03-01

    The goal of the current research was to ascertain the optimal methods of an endoscopic haemostasis in critical care patients with GDB. The research was conducted on critically ill patients. The different endoscopic methods of treatment: injectional hemostasis, irrigation with local hemostatics, thermo coagulation, and combined method were used. Treatment with injectional hemostasis resulted in hemostasis in 75% of patients. Irrigation with local hemostatics was conducted using the local hemostatic agent caprofer and (or) 10% solution of epsylonaminocapronal acid. The final hemostasis was achieved in the 90% of the cases; bleeding was stopped in 85% of the cases when the hemorrhages occurred from chronic ulcers. The effect of thermo coagulation method was 80-85%. Combined method of treatment (combination of the irrigation with caprofer and thermo coagulation) helped to achieve 95% of the final hemostasis in critically ill patients. The achieved results certify that the combined use of caprofer and method of electro coagulation in critical care patients with GDB is very perspective. Simultaneously with this, it is also recommended to use anti-segregation therapy with blockers of proton pomp and boosting the defense of the mucous tissue with high doses of mucogen. PMID:20413810

  11. Profiles of physician practice and patient severity of illness.

    PubMed Central

    Horn, S D; Horn, R A; Moses, H

    1986-01-01

    We report on a study that examined physician practice profiles using two methods of patient classification: the Severity of Illness Index and diagnosis-related groups (DRGs). When used together with conventional management information and DRGs, the Severity of Illness Index permitted useful comparisons to be made among physicians; differences in both case-mix and severity could be estimated. In 37 per cent of the physicians studied, we found differences of more than $10,000 in the apparent impact of a physician on the hospital's financial position, depending on whether one controlled for severity or not. The extent to which these differences in impact could be due to quality of care differences is an area for future research. However, the findings that 37 per cent of the physicians in the study may be wrongly identified as over- or under-utilizers suggest long-term public health consequences of preparing physician profiles based on unadjusted DRGs. PMID:3083704

  12. Outcomes of critically ill cancer patients with Acinetobacter baumannii infection

    PubMed Central

    amendys-Silva, Silvio A; Correa-Garca, Paulina; Garca-Guilln, Francisco J; Gonzlez-Herrera, Mara O; Prez-Alonso, Amrico; Texcocano-Becerra, Julia; Herrera-Gmez, Angel; Cornejo-Jurez, Patricia; Meneses-Garca, Abelardo

    2015-01-01

    AIM: To describe the intensive care unit (ICU) outcomes of critically ill cancer patients with Acinetobacter baumannii (AB) infection. METHODS: This was an observational study that included 23 consecutive cancer patients who acquired AB infections during their stay at ICU of the National Cancer Institute of Mexico (INCan), located in Mexico City. Data collection took place between January 2011, and December 2012. Patients who had AB infections before ICU admission, and infections that occurred during the first 2 d of ICU stay were excluded. Data were obtained by reviewing the electronic health record of each patient. This investigation was approved by the Scientific and Ethics Committees at INCan. Because of its observational nature, informed consent of the patients was not required. RESULTS: Throughout the study period, a total of 494 critically ill patients with cancer were admitted to the ICU of the INCan, 23 (4.6%) of whom developed AB infections. Sixteen (60.9%) of these patients had hematologic malignancies. Most frequent reasons for ICU admission were severe sepsis or septic shock (56.2%) and postoperative care (21.7%). The respiratory tract was the most frequent site of AB infection (91.3%). The most common organ dysfunction observed in our group of patients were the respiratory (100%), cardiovascular (100%), hepatic (73.9%) and renal dysfunction (65.2%). The ICU mortality of patients with 3 or less organ system dysfunctions was 11.7% (2/17) compared with 66.6% (4/6) for the group of patients with 4 or more organ system dysfunctions (P = 0.021). Multivariate analysis identified blood lactate levels (BLL) as the only variable independently associated with in-ICU death (OR = 2.59, 95%CI: 1.04-6.43, P = 0.040). ICU and hospital mortality rates were 26.1% and 43.5%, respectively. CONCLUSION: The mortality rate in critically ill patients with both HM, and AB infections who are admitted to the ICU is high. The variable most associated with increased mortality was a BLL ? 2.6 mmol/L in the first day of stay in the ICU. PMID:26261778

  13. Bilateral Diaphragmatic Paralysis in a Patient With Critical Illness Polyneuropathy

    PubMed Central

    Chen, Hsuan-Yu; Chen, Hung-Chen; Lin, Meng-Chih; Liaw, Mei-Yun

    2015-01-01

    Abstract Bilateral diaphragmatic paralysis (BDP) manifests as respiratory muscle weakness, and its association with critical illness polyneuropathy (CIP) was rarely reported. Here, we present a patient with BDP related to CIP, who successfully avoided tracheostomy after diagnosis and management. A 71-year-old male presented with acute respiratory failure after sepsis adequately treated. Repeated intubation occurred because of carbon dioxide retention after each extubation. After eliminating possible factors, septic shock-induced respiratory muscle weakness was suspected. Physical examination, a nerve conduction study, and chest ultrasound confirmed our impression. Pulmonary rehabilitation and reconditioning exercises were arranged, and the patient was discharged with a diagnosis of BDP. The diagnosis of BDP is usually delayed, and there are only sporadic reports on its association with polyneuropathy, especially in patients with preserved limb muscle function. Therefore, when physicians encounter patients that are difficult to wean from mechanical ventilation, CIP associated with BDP should be considered in the differential diagnosis. PMID:26252301

  14. Plasma pharmacokinetics of antimicrobial agents in critically ill patients.

    PubMed

    Pea, Federico

    2013-02-01

    Prompt optimal antimicrobial treatment in critically ill patients is mandatory and must be achieved not only in terms of spectrum of activity, but also in terms of exposure at the infection site. Plasma profile of antimicrobial agents may represent a valid surrogate marker of drug exposure and allow to identify the correct dosage for a given drug. However, in the critically ill patients the pharmacokinetic behavior of antimicrobials may be altered by some very peculiar pathophysiological conditions, so that dosages significantly different from those used in clinically stable patients or from those originally studied in healthy volunteers for regulatory purposes may often be needed in order to ensure optimal plasma drug exposure in such population. This is especially true for hydrophilic antimicrobials (aminoglycosides, beta-lactams, glycopeptides, lipopeptides, echinocandins, fluconazole, acyclovir, ganciclovir) whose volume of distribution and clearance may be significantly altered by these conditions. These aspects are particularly relevant in patients with severe sepsis or with septic shock for whom the time for being considered as a special population to be studied apart from the general population has probably come. From the healthcare system perspective, this means that individualization of antimicrobial therapy by means of a real time therapeutic drug monitoring coupled with clinical pharmacological advice should be considered an invaluable tool for optimizing antimicrobial therapy and for the containment of microbial resistance in this setting. PMID:22946868

  15. Nutritional risk assessment in critically ill cancer patients: systematic review

    PubMed Central

    Fruchtenicht, Ana Valéria Gonçalves; Poziomyck, Aline Kirjner; Kabke, Geórgia Brum; Loss, Sérgio Henrique; Antoniazzi, Jorge Luiz; Steemburgo, Thais; Moreira, Luis Fernando

    2015-01-01

    Objective To systematically review the main methods for nutritional risk assessment used in critically ill cancer patients and present the methods that better assess risks and predict relevant clinical outcomes in this group of patients, as well as to discuss the pros and cons of these methods according to the current literature. Methods The study consisted of a systematic review based on analysis of manuscripts retrieved from the PubMed, LILACS and SciELO databases by searching for the key words “nutritional risk assessment”, “critically ill” and “cancer”. Results Only 6 (17.7%) of 34 initially retrieved papers met the inclusion criteria and were selected for the review. The main outcomes of these studies were that resting energy expenditure was associated with undernourishment and overfeeding. The high Patient-Generated Subjective Global Assessment score was significantly associated with low food intake, weight loss and malnutrition. In terms of biochemical markers, higher levels of creatinine, albumin and urea were significantly associated with lower mortality. The worst survival was found for patients with worse Eastern Cooperative Oncologic Group - performance status, high Glasgow Prognostic Score, low albumin, high Patient-Generated Subjective Global Assessment score and high alkaline phosphatase levels. Geriatric Nutritional Risk Index values < 87 were significantly associated with mortality. A high Prognostic Inflammatory and Nutritional Index score was associated with abnormal nutritional status in critically ill cancer patients. Among the reviewed studies that examined weight and body mass index alone, no significant clinical outcome was found. Conclusion None of the methods reviewed helped to define risk among these patients. Therefore, assessment by a combination of weight loss and serum measurements, preferably in combination with other methods using scores such as Eastern Cooperative Oncologic Group - performance status, Glasgow Prognostic Score and Patient-Generated Subjective Global Assessment, is suggested given that their use is simple, feasible and useful in such cases. PMID:26270855

  16. Assessing Patients' Palliative Care Needs in the Final Stages of Illness During Hospitalization.

    PubMed

    Buzgova, Radka; Sikorova, Lucie; Jarosova, Darja

    2016-03-01

    This study aimed to explore the palliative care needs of inpatients in the final stages of illness and to analyze the factors that influence them. The survey comprised 349 inpatients in the terminal stage of disease. Needs were assessed with the Patient Needs Assessment in Palliative Care (PNAP) questionnaire; mental status was evaluated using the Hospital Anxiety and Depression Scale (HADS) questionnaire. The importance of needs varied with respect to patients' diagnosis, age, gender, religion, and their levels of anxiety and depression. Most frequently, predictors of needs importance were lower age, poorer functional status, higher anxiety, and lower depression scores. Unmet needs were more likely to be indicated by nonreligious patients with better functional status and higher anxiety and depression scores. PMID:25361612

  17. Focus on peripherally inserted central catheters in critically ill patients

    PubMed Central

    Cotogni, Paolo; Pittiruti, Mauro

    2014-01-01

    Venous access devices are of pivotal importance for an increasing number of critically ill patients in a variety of disease states and in a variety of clinical settings (emergency, intensive care, surgery) and for different purposes (fluids or drugs infusions, parenteral nutrition, antibiotic therapy, hemodynamic monitoring, procedures of dialysis/apheresis). However, healthcare professionals are commonly worried about the possible consequences that may result using a central venous access device (CVAD) (mainly, bloodstream infections and thrombosis), both peripherally inserted central catheters (PICCs) and centrally inserted central catheters (CICCs). This review aims to discuss indications, insertion techniques, and care of PICCs in critically ill patients. PICCs have many advantages over standard CICCs. First of all, their insertion is easy and safe -due to their placement into peripheral veins of the arm- and the advantage of a central location of catheter tip suitable for all osmolarity and pH solutions. Using the ultrasound-guidance for the PICC insertion, the risk of hemothorax and pneumothorax can be avoided, as well as the possibility of primary malposition is very low. PICC placement is also appropriate to avoid post-procedural hemorrhage in patients with an abnormal coagulative state who need a CVAD. Some limits previously ascribed to PICCs (i.e., low flow rates, difficult central venous pressure monitoring, lack of safety for radio-diagnostic procedures, single-lumen) have delayed their start up in the intensive care units as common practice. Though, the recent development of power-injectable PICCs overcomes these technical limitations and PICCs have started to spread in critical care settings. Two important take-home messages may be drawn from this review. First, the incidence of complications varies depending on venous accesses and healthcare professionals should be aware of the different clinical performance as well as of the different risks associated with each type of CVAD (CICCs or PICCs). Second, an inappropriate CVAD choice and, particularly, an inadequate insertion technique are relevant-and often not recognized-potential risk factors for complications in critically ill patients. We strongly believe that all healthcare professionals involved in the choice, insertion or management of CVADs in critically ill patients should know all potential risk factors of complications. This knowledge may minimize complications and guarantee longevity to the CVAD optimizing the risk/benefit ratio of CVAD insertion and use. Proper management of CVADs in critical care saves lines and lives. Much evidence from the medical literature and from the clinical practice supports our belief that, compared to CICCs, the so-called power-injectable peripherally inserted central catheters are a good alternative choice in critical care. PMID:25374804

  18. Focus on peripherally inserted central catheters in critically ill patients.

    PubMed

    Cotogni, Paolo; Pittiruti, Mauro

    2014-11-01

    Venous access devices are of pivotal importance for an increasing number of critically ill patients in a variety of disease states and in a variety of clinical settings (emergency, intensive care, surgery) and for different purposes (fluids or drugs infusions, parenteral nutrition, antibiotic therapy, hemodynamic monitoring, procedures of dialysis/apheresis). However, healthcare professionals are commonly worried about the possible consequences that may result using a central venous access device (CVAD) (mainly, bloodstream infections and thrombosis), both peripherally inserted central catheters (PICCs) and centrally inserted central catheters (CICCs). This review aims to discuss indications, insertion techniques, and care of PICCs in critically ill patients. PICCs have many advantages over standard CICCs. First of all, their insertion is easy and safe -due to their placement into peripheral veins of the arm- and the advantage of a central location of catheter tip suitable for all osmolarity and pH solutions. Using the ultrasound-guidance for the PICC insertion, the risk of hemothorax and pneumothorax can be avoided, as well as the possibility of primary malposition is very low. PICC placement is also appropriate to avoid post-procedural hemorrhage in patients with an abnormal coagulative state who need a CVAD. Some limits previously ascribed to PICCs (i.e., low flow rates, difficult central venous pressure monitoring, lack of safety for radio-diagnostic procedures, single-lumen) have delayed their start up in the intensive care units as common practice. Though, the recent development of power-injectable PICCs overcomes these technical limitations and PICCs have started to spread in critical care settings. Two important take-home messages may be drawn from this review. First, the incidence of complications varies depending on venous accesses and healthcare professionals should be aware of the different clinical performance as well as of the different risks associated with each type of CVAD (CICCs or PICCs). Second, an inappropriate CVAD choice and, particularly, an inadequate insertion technique are relevant-and often not recognized-potential risk factors for complications in critically ill patients. We strongly believe that all healthcare professionals involved in the choice, insertion or management of CVADs in critically ill patients should know all potential risk factors of complications. This knowledge may minimize complications and guarantee longevity to the CVAD optimizing the risk/benefit ratio of CVAD insertion and use. Proper management of CVADs in critical care saves lines and lives. Much evidence from the medical literature and from the clinical practice supports our belief that, compared to CICCs, the so-called power-injectable peripherally inserted central catheters are a good alternative choice in critical care. PMID:25374804

  19. Patient and spouse illness beliefs and quality of life in prostate cancer patients

    PubMed Central

    Wu, Lisa M.; Mohamed, Nihal E.; Winkel, Gary; Diefenbach, Michael A.

    2015-01-01

    Objective Among married prostate cancer (PC) patients, the spouse is often the primary provider of emotional support and personal care. However, few studies have investigated spouses illness beliefs (i.e., about disease duration and treatment control) and their impact on patients quality of life (QOL). Spouses beliefs about disease duration (timeline) were hypothesised to mediate relationships between spouses treatment control beliefs and patients QOL six months later. Methods Fifty-three patients, who underwent localised treatment for PC, and their spouses, completed an illness beliefs measure (the revised Illness Perception Questionnaire). Patients completed a QOL measure (the Functional Assessment of Cancer Therapy General) six months later. Results Spouse timeline beliefs mediated the association between spouse treatment control beliefs and patient QOL six months later (total indirect effect = ?0.71, 95% CI 0.02-2.03). That is, spouse beliefs that the treatment would control their loved one's illness led to beliefs that the disease would be of shorter duration, which in turn led to improved patient QOL six months later. This relationship did not occur with patients beliefs. Conclusions Results highlight the important influence of spouse illness beliefs over time on patient QOL with implications for clinical care and dyadic research. PMID:22971045

  20. Ischemic Stroke in Critically Ill Patients with Malignancy

    PubMed Central

    Suh, Gee Young; Yang, Jeong Hoon; Lee, Daesang; Park, Jinkyeong; Cho, Joongbum; Chung, Chi Ryang; Park, Chi-Min; Jeon, Kyeongman

    2016-01-01

    Background Cerebrovascular diseases are a frequent cause of neurological symptoms in patients with cancer. The clinical characteristics of ischemic stroke (IS) in patients with cancer have been reported in several studies; however, limited data are available regarding critically ill patients with cancer who develop IS during their stay in the intensive care unit (ICU). Methods All consecutive patients who underwent brain magnetic resonance imaging (MRI) for suspicion of IS with acute abnormal neurologic symptoms or who developed signs of IS while in the ICU were retrospectively evaluated. We compared the clinical characteristics and diffusion-weighted imaging (DWI) lesion patterns between patients finally diagnosed as having or not having IS. Results Over the study period, a total of 88 patients underwent brain MRI for suspicion of IS, with altered mental status in 55 (63%), hemiparesis in 28 (32%), and seizure in 20 (23%). A total of 43 (49%) patients were ultimately diagnosed with IS. Multiple DWI lesions (41%) were more common than single lesions (8%). The etiologies of IS were not determined in the majority of patients (n = 27, 63%). In the remaining 16 (37%) patients, the most common aetiology of IS was cardioembolism (n = 8), followed by large-vessel atherosclerosis (n = 3) and small-vessel occlusion (n = 2). However, brain metastases were newly diagnosed in only 7 (8%) patients. Univariate comparison of the baseline characteristics between patients with or without IS did not reveal any significant differences in sex, malignancy type, recent chemotherapy, vascular risk factors, or serum D-dimer levels at the time of suspicion of IS. Thrombotic events were more common in the IS group than in the non-IS group (P = 0.028). However, patients who were ultimately diagnosed with IS had more hemiparesis symptoms at the time of suspicion of IS (P = 0.001). This association was significant even after adjusting for potentially confounding factors (adjusted odds ratio 5.339; 95% confidence interval, 1.521–19.163). Conclusions IS developed during ICU stays in critically ill patients with cancer have particular features that may be associated with cancer-related mechanism. PMID:26751213

  1. Role of the Open Abdomen in Critically Ill Patients.

    PubMed

    Beckman, Marshall; Paul, Jasmeet; Neideen, Todd; Weigelt, John A

    2016-04-01

    An open abdomen is common used in critically ill patients to temporize permanent abdominal closure. The most common reason for leaving the abdomen open by reopening a laparotomy, not closing, or creating a fresh laparotomy is the abdominal compartment syndrome. The open abdomen technique is also used in damage control operations and intra-abdominal sepsis. Negative pressure wound therapy may be associated with better outcomes than other temporary abdominal closure techniques. The open abdomen is associated with many early and late complications, including infections, gastrointestinal fistulas, and ventral hernias. Clinicians should be vigilant regarding the development of these complications. PMID:27016166

  2. Coagulation and complement system in critically ill patients.

    PubMed

    Helling, H; Stephan, B; Pindur, G

    2015-09-01

    Activation of coagulation and inflammatory response including the complement system play a major role in the pathogenesis of critical illness. However, only limited data are available addressing the relationship of both pathways and its assessment of a predictive value for the clinical outcome in intense care medicine. Therefore, parameters of the coagulation and complement system were studied in patients with septicaemia and multiple trauma regarded as being exemplary for critical illness. 34 patients (mean age: 51.38 years (16.57), 15 females, 19 males) were investigated at day 1 of admittance to the intensive care unit (ICU). Leukocytes, complement factors C3a and C5a were significantly (p?< ?0.0500) higher in sepsis than in trauma, whereas platelet count and plasma fibrinogen were significantly lower in multiple trauma. Activation markers of coagulation were elevated in both groups, however, thrombin-antithrombin-complex was significantly higher in multiple trauma. DIC scores of 5 were not exceeded in any of the two groups. Analysing the influences on mortality (11/34; 32.35% ), which was not different in both groups, non-survivors were significantly older, had significantly higher multiple organ failure (MOF) scores, lactate, abnormal prothrombin times and lower C1-inhibitor activities, even more pronounced in early deaths, than survivors. In septic non-survivors protein C was significantly lower than in trauma. We conclude from these data that activation of the complement system as part of the inflammatory response is a significant mechanism in septicaemia, whereas loss and consumption of blood components including parts of the coagulation and complement system is more characteristic for multiple trauma. Protein C in case of severe reduction might be of special concern for surviving in sepsis. Activation of haemostasis was occurring in both diseases, however, overt DIC was not confirmed in this study to be a leading mechanism in critically ill patients. MOF score, lactate, C1-inhibitor and prothrombin time have been the only statistically significant predictors for lethal outcome suggesting that organ function, microcirculation, haemostasis and inflammatory response are essential elements of the pathomechanism and clinical course of diseases among critically ill patients. PMID:26410872

  3. Inter-hospital transport of critically ill patients; expect surprises

    PubMed Central

    2012-01-01

    Introduction Inter-hospital transport of critically ill patients is increasing. When performed by specialized retrieval teams there are less adverse events compared to transport by ambulance. These transports are performed with technical equipment also used in an Intensive Care Unit (ICU). As a consequence technical problems may arise and have to be dealt with on the road. In this study, all technical problems encountered while transporting patients with our mobile intensive care unit service (MICU) were evaluated. Methods From March 2009 until August 2011 all transports were reviewed for technical problems. The cause, solution and, where relevant, its influence on protocol were stated. Results In this period of 30 months, 353 patients were transported. In total 55 technical problems were encountered. We provide examples of how they influenced transport and how they may be resolved. Conclusion The use of technical equipment is part of intensive care medicine. Wherever this kind of equipment is used, technical problems will occur. During inter-hospital transports, without extra personnel or technical assistance, the transport team is dependent on its own ability to resolve these problems. Therefore, we emphasize the importance of having some technical understanding of the equipment used and the importance of training to anticipate, prevent and resolve technical problems. Being an outstanding intensivist on the ICU does not necessarily mean being qualified for transporting the critically ill as well. Although these are lessons derived from inter-hospital transport, they may also apply to intra-hospital transport. PMID:22326110

  4. Update in the management of critically ill burned patients.

    PubMed

    Lorente, J A; Amaya-Villar, R

    2016-01-01

    The management of critically ill burn patients is challenging. These patients have to be managed in specialized centers, where the expertise of physicians and nursing personnel guarantees the best treatment. Mortality of burn patients has improved over the past decades due to a better understanding of burn shock pathophysiology, optimal surgical management, infection control and nutritional support. Indeed, a more aggressive resuscitation, early excision and grafting, the judicious use of topical antibiotics, and the provision of an adequate calorie and protein intake are key to attain best survival results. General advances in critical care have also to be implemented, including protective ventilation, glycemic control, selective decontamination of the digestive tract, and implementation of sedation protocols. PMID:26746126

  5. Echocardiographic Hemodynamic Monitoring in the Critically Ill Patient

    PubMed Central

    Romero-Bermejo, Francisco J; Ruiz-Bailn, Manuel; Guerrero-De-Mier, Manuel; Lpez-lvaro, Julin

    2011-01-01

    Echocardiography has shown to be an essential diagnostic tool in the critically ill patient's assessment. In this scenario the initial fluid therapy, such as it is recommended in the actual clinical guidelines, not always provides the desired results and maintains a considerable incidence of cardiorrespiratory insufficiency. Echocardiography can council us on these patients' clinical handling, not only the initial fluid therapy but also on the best-suited election of the vasoactive/inotropic treatment and the early detection of complications. It contributes as well to improving the etiological diagnosis, allowing one to know the heart performance with more precision. The objective of this manuscript is to review the more important parameters that can assist the intensivist in theragnosis of hemodynamically unstable patients. PMID:22758613

  6. An assessment tool for acutely ill medical patients.

    PubMed

    Gleeson, Margaret; Kellett, John; Cowan, Mairead; Casey, Marie

    This article reports the implementation and impact of a standardized systematic evidence-based predictive score for the initial assessment of acutely ill medical patients. The Simple Clinical Score (SCS) was introduced in the A&E department and the medical floor of the authors' hospital between June 2007 and July 2008. The SCS was well received by the staff - 67% felt it greatly improved patient assessment and was very valuable for ensuring appropriate placement of the patient after admission and improved the quality of care. This article describes the change process, the pilot evaluation and the training programme undertaken during the implementation of the SCS. It is hoped that this experience will be of value to other project teams who are undertaking similar initiatives. PMID:19448581

  7. Ultrasound-guided percutaneous tracheostomy in critically ill obese patients

    PubMed Central

    2012-01-01

    Introduction The purpose of this study was to evaluate the feasibility of ultrasound (US)-guided percutaneous tracheostomy (PCT) and the incidence of complications in critically ill, obese patients. Methods Fifty consecutive patients were included in a prospective study in two surgical and critical care medicine departments. Obesity was defined as a body mass index (BMI) of at least 30 kg/m2. The feasibility of PCT and the incidence of complications were compared in obese patients (n = 26) and non-obese patients (n = 24). Results are expressed as the median (25th-75th percentile) or number (percentage). Results The median BMIs were 34 kg/m2 (32-38) in the obese patient group and 25 kg/m2 (24-28) in the non-obese group (p < 0.001). The median times for tracheostomy were 10 min (8-14) in non-obese patients and 9 min (5-10) in obese-patients (p = 0.1). The overall complication rate was similar in obese and non-obese patient groups (35% vs. 33%, p = 0.92). Most complications were minor (hypotension, desaturation, tracheal cuff puncture and minor bleeding), with no differences between obese and non-obese groups. Bronchoscopic inspection revealed two cases of granuloma (8%) in obese patients. One non-obese patient developed a peristomal skin infection, which was treated with intravenous antibiotics. Ultrasound-guided PCT was possible in all enrolled patients and there were no surgical conversions or deaths. Conclusions This study demonstrated that US-guided PCT is feasible in obese patients with a low complication rate. Obesity may not constitute a contra-indication for US-guided PCT. A US examination provides information on cervical anatomy and hence modifies and guides choice of the PCT puncture site. Trial registration ClinicalTrials.gov: NCT01502657. PMID:22390815

  8. Communication with patients suffering from serious physical illness.

    PubMed

    Grassi, Luigi; Caruso, Rosangela; Costantini, Anna

    2015-01-01

    Communication is the corner stone of the relationship with the patient in all medical settings with the main aims of creating a good inter-personal relationship, exchanging information, and making treatment-related decisions. In a rapidly changing cultural and social context, the paternalistic approach of doctors knowing the best and deciding what should be done for a patient has been replaced by a shared decision-making approach, with patients being advised to educate themselves, ask questions and influence the course of the discussion with their doctors. Thus, a need for an improvement in the communication skills of physicians is extremely important for patients affected by serious physical illness (e.g. cancer, HIV infection, multiple sclerosis, amyotrophic lateral sclerosis). Certain attitudes, behaviour and skills (e.g. capacity to impart confidence, being empathetic, providing a 'human touch', relating on a personal level, being forthright, being respectful, and being thorough) are part of effective communication. However, some specific aspects influencing doctor-patient communication and relationships, such as personality variables, coping and attachment styles, as well as cultural factors, should also be taken in to account. The development of training curricula to help doctors acquire proper skills in communication is mandatory, since research has shown that training in communication may facilitate the effectiveness of a doctor-patient relationship and the patient's satisfaction with care and give a general sense of humanity, which is easily lost in a biotechnologically oriented medicine. PMID:25832510

  9. The epidemiology of bacteriuria and candiduria in critically ill patients.

    PubMed

    Aubron, C; Suzuki, S; Glassford, N J; Garcia-Alvarez, M; Howden, B P; Bellomo, R

    2015-02-01

    An observational study was conducted to describe the epidemiology of bacteriuria and candiduria in the intensive care unit (ICU), and the occurrence of blood stream infection (BSI) associated with ICU-acquired positive urine culture. Between 2006 and 2011, 444 episodes of either bacteriuria or candiduria defined by positive urine culture (microorganisms ⩾105 c.f.u./ml) occurred in 406 patients. Three hundred and seventy-seven (85%) were hospital-acquired including 221 which were ICU-acquired (6·4 ± 0·8 episodes/1000 ICU days). Escherichia coli was the most common bacteria of both community- and ICU-acquired bacteriuria/candiduria (49·2% and 29%, respectively). Candida spp. represented 55% (129/236) of pathogens responsible for ICU-acquired positive urine cultures. Patients with ICU-acquired candiduria had greater illness severity at ICU admission than those with ICU-acquired bacteriuria (APACHE III score 79 ± 25 vs. 66 ± 31, P = 0·0015). BSI associated with ICU-acquired positive urine culture occurred in 0·15/1000 ICU days and was more often due to Candida. In this study, Candida was the most common pathogen responsible for ICU-acquired positive urine cultures and illness severity was a risk factor for candiduria in the study population. PMID:24762978

  10. Use of inotropes and vasopressor agents in critically ill patients

    PubMed Central

    Bangash, Mansoor N; Kong, Ming-Li; Pearse, Rupert M

    2012-01-01

    Inotropes and vasopressors are biologically and clinically important compounds that originate from different pharmacological groups and act at some of the most fundamental receptor and signal transduction systems in the body. More than 20 such agents are in common clinical use, yet few reviews of their pharmacology exist outside of physiology and pharmacology textbooks. Despite widespread use in critically ill patients, understanding of the clinical effects of these drugs in pathological states is poor. The purpose of this article is to describe the pharmacology and clinical applications of inotropic and vasopressor agents in critically ill patients. LINKED ARTICLES This article is commented on by Bracht et al., pp. 20092011 and De Backer and Scolletta, pp. 20122014 of this issue. To view Bracht et al. visit http://dx.doi.org/10.1111/j.1476-5381.2011.01776.x and to view De Backer and Scolletta visit http://dx.doi.org/10.1111/j.1476-5381.2011.01746.x PMID:21740415

  11. Comparisons of the Judgments of National Experts and Texas Teachers on Knowledge, Attitudes and Behavior Appropriate for Elementary Teachers of Terminally Ill Students.

    ERIC Educational Resources Information Center

    Coates, Nancy Jane

    Prominent professionals who had worked with seriously ill children were identified through an automated literature search. The Delphi technique was used to identify components and reach expert consensus on knowledge, attitudes and behavior appropriate for teachers of terminally ill children. Comparisons were then made between the consensus and

  12. Liver dysfunction associated with artificial nutrition in critically ill patients

    PubMed Central

    Grau, Teodoro; Bonet, Alfonso; Rubio, Mercedes; Mateo, Dolores; Farré, Mercé; Acosta, José Antonio; Blesa, Antonio; Montejo, Juan Carlos; de Lorenzo, Abelardo García; Mesejo, Alfonso

    2007-01-01

    Introduction Liver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients. Methods We conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l. Results Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05). Conclusion TPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect. PMID:17254321

  13. Antiretroviral Therapy Outcomes in Patients with Severe Mental Illness.

    PubMed

    Karstaedt, Alan S; Kooverjee, Sadhna; Singh, Lucille; Jeenah, Yasmien; Jonsson, Gregory

    2015-01-01

    A retrospective cohort analysis was performed to describe outcomes and retention in care on antiretroviral therapy (ART) of 53 patients with severe mental illness (SMI). Diagnoses were psychosis secondary to HIV (24 patients), psychosis not otherwise specified (12), mania with or without psychosis (9), depression with psychotic features (4), and schizophrenia and bipolar mood disorder (2 each). The median baseline CD4 count was 66/mm(3) and viral load was 5.4 log10 copies/mL. Thirteen (25%) patients were lost to follow-up (10 within 6 months), 3 were transferred out, and 3 died. By week 96, 29 (85%) of 34 (64%) patients still in care had a viral load <400 copies/mL and 26 (76%) a viral load <25 copies/mL. Median CD4 count increased to 307/mm(3). Twenty-seven of 34 patients discontinued antipsychotic medication. Patients with SMI and advanced HIV infection responded well to ART. The first 6 months was important for retention in care. PMID:26173943

  14. Cytomegalovirus Reactivation in Critically-Ill Immunocompetent Patients

    PubMed Central

    Limaye, Ajit P.; Kirby, Katharine A.; Rubenfeld, Gordon D.; Leisenring, Wendy M.; Bulger, Eileen M.; Neff, Margaret J.; Gibran, Nicole S.; Huang, Meei-Li; Santo, Tracy K.; Corey, Lawrence; Boeckh, Michael

    2009-01-01

    Context Cytomegalovirus (CMV) infection is associated with adverse clinical outcomes in immunosuppressed persons, but the incidence and association of CMV reactivation with adverse outcomes in persons lacking evidence of immunosuppression (immunocompetent) with critical illness have not been well-defined. Objective To determine the association of CMV reactivation with intensive care unit (ICU) and hospital length of stay in critically-ill immunocompetent persons. Methods We prospectively assessed CMV plasma DNAemia by real-time PCR twice weekly and clinical outcomes in a cohort of CMV seropositive, immunocompetent adults admitted to an ICU. Clinical parameters were assessed by personnel blinded to CMV PCR results. Risk factors for CMV reactivation and association with hospital and ICU length of stay (LOS) were assessed by multivariable logistic regression and proportional odds models. Setting Six ICUs at two separate hospitals at a large tertiary care academic medical center between 20042006. Participants A total of 120 critically-ill, CMV seropositive adults lacking evidence of immunosuppression. Main Outcome Measures Association of CMV reactivation with prolonged hospital length of stay or death. Results The primary composite endpoint of continued hospitalization (n=35) or death (n=10) at 30 days occurred in 45 (35%) of the 120 patients. CMV viremia at any level or > 1,000 copies/ml occurred in 33% (39 of 120, 95% confidence interval [CI] 24%41%) and 20% (24 of 120, 95% CI 13%28%), at a median of 12 days (range 357) and 26 days (range 956), respectively. By logistic regression, CMV infection at any level (adjusted OR: 4.3 [1.611.9], p = 0.005), >1,000 copies/ml (adjusted OR 13.9 [3.260], p < 0.001), or average CMV area under the curve [AUC] (adjusted OR 2.1 [1.33.2], p < 0.001), was independently associated with hospitalization or death by 30 days. In multivariable partial proportional odds models, both CMV seven-day moving average (OR 5.1 (2.99.1) p < 0.0001) and CMV AUC (OR 3.2 (2.14.7), p < 0.0001) were independently associated with a hospital LOS ?14 days. Conclusions These preliminary findings suggest that reactivation of CMV occurs frequently in critically-ill immunocompetent patients and is associated with prolonged hospitalization or death. A controlled trial of CMV prophylaxis in this setting is warranted. PMID:18647984

  15. Scoring Systems in Assessing Survival of Critically Ill ICU Patients

    PubMed Central

    Sekulic, Ana D.; Trpkovic, Sladjana V.; Pavlovic, Aleksandar P.; Marinkovic, Olivera M.; Ilic, Aleksandra N.

    2015-01-01

    Background The aim of this study was to determine which of the most commonly used scoring systems for evaluation of critically ill patients in the ICU is the best and simplest to use in our hospital. Material/Methods This prospective study included 60 critically ill patients. After admittance to the ICU, APACHE II, SAPS II, and MPM II0 were calculated. During further treatment in the ICU, SOFA and MPM II were calculated at 24 h, 48 h, and 72 h and 7 days after admittance using laboratory and radiological measures. Results In comparison with survivors, non-survivors were older (p<0.01) and spent significantly more days on mechanical ventilation (p<0.01). ARDS was significantly more common in patients who survived compared to those who did not (chi-square=7.02, p<0.01), which is not the case with sepsis (chi-square=0.388, p=0.53). AUROC SAPS II was 0.690, and is only slightly higher than the other 2 AUROC incipient scoring systems, MPM II and APACHE II (0.654 and 0.623). The APACHE II has the highest specificity (81.8%) and MPM II the highest sensitivity (85.2%). MPM II7day AUROC (1.0) shows the best discrimination between patients who survived and those who did not. MPM II48 (0.836), SOFA72 (0.821) and MPM II72 (0.817) also had good discrimination scores. Conclusions APACHE II and SAPS II measured on admission to the ICU were significant predictors of complications. MPM II7day has the best discriminatory power, followed by SOFA7day and MPM II48. MPM II7day has the best calibration followed by SOFA7day and APACHE II. PMID:26336861

  16. Characteristics of patients with schizophrenia who do not believe they are mentally ill.

    PubMed

    Pyne, J M; Bean, D; Sullivan, G

    2001-03-01

    The purpose of this study was to use a very simple self-report measure to identify patients who did not believe they were mentally ill and describe their characteristics. The study included 177 inpatients and outpatients with schizophrenia. Multivariate regression methods analyzed the relationship between illness belief and sociodemographic, clinical, and attitudinal factors. Thirty-seven percent of subjects did not believe they were mentally ill. Younger age, fewer depressive symptoms, lower perceived medication efficacy, greater satisfaction with current mental health, and less concern about mental illness stigma were associated with not believing one was mentally ill. Outpatients with fewer hospitalizations were less likely to believe they were ill. Inpatients with more hospitalizations were less likely to believe they were ill and had poor medication adherence. Readily identifying patients who do not believe they are mentally ill may be useful to clinicians and policymakers when matching at-risk patients with adherence interventions. PMID:11277350

  17. Adaptation to different noninvasive ventilation masks in critically ill patients*

    PubMed Central

    da Silva, Renata Matos; Timenetsky, Karina Tavares; Neves, Renata Cristina Miranda; Shigemichi, Liane Hirano; Kanda, Sandra Sayuri; Maekawa, Carla; Silva, Eliezer; Eid, Raquel Afonso Caserta

    2013-01-01

    OBJECTIVE: To identify which noninvasive ventilation (NIV) masks are most commonly used and the problems related to the adaptation to such masks in critically ill patients admitted to a hospital in the city of So Paulo, Brazil. METHODS: An observational study involving patients ? 18 years of age admitted to intensive care units and submitted to NIV. The reason for NIV use, type of mask, NIV regimen, adaptation to the mask, and reasons for non-adaptation to the mask were investigated. RESULTS: We evaluated 245 patients, with a median age of 82 years. Acute respiratory failure was the most common reason for NIV use (in 71.3%). Total face masks were the most commonly used (in 74.7%), followed by full face masks and near-total face masks (in 24.5% and 0.8%, respectively). Intermittent NIV was used in 82.4% of the patients. Adequate adaptation to the mask was found in 76% of the patients. Masks had to be replaced by another type of mask in 24% of the patients. Adequate adaptation to total face masks and full face masks was found in 75.5% and 80.0% of the patients, respectively. Non-adaptation occurred in the 2 patients using near-total facial masks. The most common reason for non-adaptation was the shape of the face, in 30.5% of the patients. CONCLUSIONS: In our sample, acute respiratory failure was the most common reason for NIV use, and total face masks were the most commonly used. The most common reason for non-adaptation to the mask was the shape of the face, which was resolved by changing the type of mask employed. PMID:24068269

  18. Cytokines and metabolic patterns in pediatric patients with critical illness.

    PubMed

    Briassoulis, George; Venkataraman, Shekhar; Thompson, Ann

    2010-01-01

    It is not known if cytokines, which are cell-derived mediators released during the host immune response to stress, affect metabolic response to stress during critical illness. The aim of this prospective study was to determine whether the metabolic response to stress is related to the inflammatory interleukin-6 (IL-6), 10 (IL-10), and other stress mediators' responses and to assess their relationships with different feeding patterns, nutritional markers, the severity of illness as assessed by the Multiple Organ System Failure (MOSF), the Pediatric Risk of Mortality Score (PRISM), systemic inflammatory response syndrome (SIRS), and mortality in critically ill children. Patients were classified as hypermetabolic, normometabolic, and hypometabolic when the measured resting energy expenditures (REE) were >110%, 90-110% and, <90% of the predicted basal metabolic rate, respectively. The initial predominance of the hypometabolic pattern (48.6%) declined within 1 week of acute stress (20%), and the hypermetabolic patterns dominated only after 2 weeks (60%). Only oxygen consumption (VO(2)) and carbon dioxide production (VCO(2)) (P < .0001) but none of the cytokines and nutritional markers, were independently associated with a hypometabolic pattern. REE correlated with the IL-10 but not PRISM. In the presence of SIRS or sepsis, CRP, IL-6, IL-10, Prognostic Inflammatory and Nutritional Index (NI), and triglycerides--but not glucose, VO(2), or VCO(2) increased significantly. High IL-10 levels (P = .0000) and low measured REE (P = .0000) were independently associated with mortality (11.7%), which was higher in the hypometabolic compared to other metabolic patterns (P < .005). Our results showed that only VO(2) and VCO(2), but not IL-6 or IL-10, were associated with a hypometabolic pattern which predominated the acute phase of stress, and was associated with increased mortality. Although in SIRS or sepsis, the cytokine response was reliably reflected by increases in NI and triglycerides, it was different from the metabolic (VO(2), VCO(2)) or glucose response. PMID:20490277

  19. A comparison of patients with illness phobia and panic disorder.

    PubMed

    Noyes, R; Wesner, R B; Fisher, M M

    1992-01-01

    Fourteen subjects with illness phobia, a subtype of hypochondriasis, were compared with an equal number of subjects with panic disorder who had been matched for age and sex. The illness phobic subjects differed from panic subjects in not having spontaneous panic attacks or agoraphobic symptoms, the characteristic features of panic disorder. The onset of illness phobia was related to experience with illness in half the subjects. Half of the illness phobic subjects also had family histories of anxiety disorders. The results suggest that illness phobia is distinct from panic disorder and that it is a disorder in which environmental and genetic factors are etiologically important. PMID:1539109

  20. Delirium in critically ill patients: epidemiology, pathophysiology, diagnosis and management.

    PubMed

    Zaal, Irene J; Slooter, Arjen J C

    2012-07-30

    Delirium is commonly observed in critically ill patients and is associated with negative outcomes. The pathophysiology of delirium is not completely understood. However, alterations to neurotransmitters, especially acetylcholine and dopamine, inflammatory pathways and an aberrant stress response are proposed mechanisms leading to intensive care unit (ICU) delirium. Detection of delirium using a validated delirium assessment tool makes early treatment possible, which may improve prognosis. Patients at high risk of delirium, especially those with cognitive decline and advanced age, should be identified in the first 24 hours of admission to the ICU. Whether these high-risk patients benefit from haloperidol prophylaxis deserves further study. The effectiveness of a multicomponent, non-pharmacological approach is shown in non-ICU patients, which provides proof of concept for use in the ICU. The few studies on this approach in ICU patients suggest that the burden of ICU delirium may be reduced by early mobility, increased daylight exposure and the use of earplugs. In addition, the combined use of sedation, ventilation, delirium and physical therapy protocols can reduce the frequency and severity of adverse outcomes and should become part of routine practice in the ICU, as should avoidance of deliriogenic medication such as anticholinergic drugs and benzodiazepines. Once delirium develops, symptomatic treatment with antipsychotics is recommended, with haloperidol being the drug of first choice. However, there is limited evidence on the safety and effectiveness of antipsychotics in ICU delirium. PMID:22804788

  1. Plasma Catalytic Iron, AKI, and Death among Critically Ill Patients

    PubMed Central

    Rajapurkar, Mohan; Lele, Suhas S.; Mukhopadhyay, Banibrata; Waikar, Sushrut S.

    2014-01-01

    Background and objectives Catalytic iron has been hypothesized to be a key mediator of AKI. However, the association between plasma catalytic iron levels and AKI has not been well studied in humans. Design, settings, participants, & measurements A single-center, prospective, nonconsecutive cohort study of 121 critically ill patients admitted to intensive care units (ICUs) between 2008 and 2012 was performed. Plasma catalytic iron, free hemoglobin, and other iron markers were measured on ICU days 1 and 4. The primary end point was in-hospital mortality or AKI requiring RRT. Secondary end points included mortality (assessed during hospitalization, at 30 days, and 1 year) and incident AKI, defined by modified Kidney Disease Improving Global Outcomes criteria. Results ICU day 1 plasma catalytic iron levels were higher among patients who reached the primary end point (median, 0.74 mol/l [interquartile range, 0.313.65] versus 0.29 mol/l [0.220.46]; P<0.01). ICU day 1 plasma catalytic iron levels were associated with number of packed red blood cell transfusions before ICU arrival (rs=0.29; P<0.001) and plasma free hemoglobin levels on ICU day 1 (rs=0.32; P<0.001). Plasma catalytic iron levels on ICU day 1 were significantly associated with in-hospital mortality or AKI requiring RRT, even after adjusting for age, enrollment eGFR, and number of packed red blood cell transfusions before ICU arrival (13 events; adjusted odds ratio per 1-SD higher ln[catalytic iron], 3.33; 95% confidence interval, 1.79 to 6.20). ICU day 1 plasma catalytic iron levels were also significantly associated with incident AKI, RRT, hospital mortality, and 30-day mortality. Conclusions Among critically ill patients, elevated plasma catalytic iron levels on arrival to the ICU are associated with a greater risk of incident AKI, RRT, and hospital mortality. PMID:25189925

  2. The behavioral toxicity of bromocriptine in patients with psychiatric illness.

    PubMed

    Perovich, R M; Lieberman, J A; Fleischhacker, W W; Alvir, J

    1989-12-01

    Dopamine agonists may be useful in the treatment of neuroleptic-induced hyperprolactinemia and movement disorders; it is a treatment approach that has been avoided for fear of inducing or exacerbating psychotic symptoms. The risks of giving dopamine agonists to psychiatric patients have been well documented in the literature. To further evaluate the psychotogenic effects of bromocriptine, a dopamine receptor agonist, we conducted a double-blind study in which 16 psychiatrically stable patients were treated for tardive dyskinesia with neuroleptics plus high doses of bromocriptine (N = 11) or placebo (N = 5) for 10 weeks. The diagnoses included schizophrenia, schizoaffective disorder, and major depression with psychotic features. Patients were evaluated weekly with the Brief Psychiatric Rating Scale and the Clinical Global Impression Scale during the 10-week treatment phase and for 8 weeks after medication was withdrawn. There were no statistically significant differences between active and placebo groups in behavioral ratings at baseline, week 10, and week 18. These results are compared with the findings of previous studies in which bromocriptine was given to psychiatric patients. Although the literature suggests that bromocriptine can induce or exacerbate psychosis in psychiatric patients, this occurs primarily in those with a psychotic diathesis and who are not currently receiving neuroleptic medication. Other important factors include the dose of bromocriptine, duration of treatment, and the clinical state of the patient at the time bromocriptine treatment is initiated. These results suggest that bromocriptine can be safely used in patients at risk for psychotic illnesses as long as patients are clinically stable and maintained on neuroleptics. PMID:2574194

  3. Population Pharmacokinetics of Fosfomycin in Critically Ill Patients.

    PubMed

    Parker, Suzanne L; Frantzeskaki, Frantzeska; Wallis, Steven C; Diakaki, Chryssa; Giamarellou, Helen; Koulenti, Despoina; Karaiskos, Ilias; Lipman, Jeffrey; Dimopoulos, George; Roberts, Jason A

    2015-10-01

    This study describes the population pharmacokinetics of fosfomycin in critically ill patients. In this observational study, serial blood samples were taken over several dosing intervals of intravenous fosfomycin treatment. Blood samples were analyzed using a validated liquid chromatography-tandem mass spectrometry technique. A population pharmacokinetic analysis was performed using nonlinear mixed-effects modeling. Five hundred fifteen blood samples were collected over one to six dosing intervals from 12 patients. The mean (standard deviation) age was 62 (17) years, 67% of patients were male, and creatinine clearance (CLCR) ranged from 30 to 300 ml/min. A two-compartment model with between-subject variability on clearance and volume of distribution of the central compartment (Vc) described the data adequately. Calculated CLCR was supported as a covariate on fosfomycin clearance. The mean parameter estimates for clearance on the first day were 2.06 liters/h, Vc of 27.2 liters, intercompartmental clearance of 19.8 liters/h, and volume of the peripheral compartment of 22.3 liters. We found significant pharmacokinetic variability for fosfomycin in this heterogeneous patient sample, which may be explained somewhat by the observed variations in renal function. PMID:26239990

  4. [Delirium and delirium management in critically ill patients].

    PubMed

    Kersten, A; Reith, S

    2016-02-01

    Delirium in critically ill patients is a common entity in the intensive care unit (ICU) and is an expression of the cerebral organ dysfunction of the patient. The hallmark signs are disturbed consciousness and cognition in combination with inattentiveness and alterations in perception, which are manifested within a time interval of hours to days during treatment on the ICU. Delirium has been shown to have negative effects on patient short-term and long-term outcome parameters and increases morbidity and mortality. Despite its significance in many cases delirium remains inadequately diagnosed during routine treatment by ICU personnel. There are two validated and easily applicable scales for the standardized diagnosis of delirium: the confusion assessment method for the ICU (CAM-ICU) and the intensive care delirium screening checklist (ICDSC). These are simple to apply by medical as well as non-medical personnel. The therapy of delirium is mostly determined by non-pharmacological measures aiming at early identification, reorientation and mobilization of the patient, improving cerebral activity and establishing adequate wake-sleep cycles. There is only sparse evidence for pharmacological treatment of delirium; however, the choice of sedative agent has a proven effect on the incidence and duration of delirium in the ICU. PMID:26795215

  5. Management of delirium in adult critically ill patients: an overview.

    PubMed

    Banh, Hoan Linh

    2012-01-01

    Delirium is a common manifestation of acute, reversible, brain dysfunction in critically ill patients. It is associated with increased morbidity and mortality in the intensive care unit (ICU). Detection and prevention of risk factors for delirium is critical. Daily assessment for delirium should be part of the treatment strategies. Although, non-pharmacologic treatment have been successful, often, pharmacologic intervention is necessary. Currently, there are no approved medications indicated for the treatment of ICU delirium. The objective of this review article is to provide a comprehensive overview of non-pharmacologic and pharmacologic options for the treatment of ICU delirium. This article is open to POST-PUBLICATION REVIEW. Registered readers (see "For Readers") may comment by clicking on ABSTRACT on the issue's contents page. PMID:23106953

  6. Candida glabrata candidemia: An emerging threat in critically ill patients

    PubMed Central

    Gupta, Ashish; Gupta, Anu; Varma, Amit

    2015-01-01

    Background: Candidemia is an important nosocomial blood stream infection in critically ill patients. Although several studies have addressed candidemia, very few have reviewed the impact of Candida glabrata candidemia in Intensive Care Unit (ICU) patients. Materials and Methods: The medical records of ICU patients between 2006 and 2010 were reviewed retrospectively. The epidemiology, clinical features and mortality related risk factors among our adult ICU patients were seen. Results: Among 144 episodes of candidemia, C. glabrata (n = 26; 18.05%) was the third most common species isolated. The incidence of C. glabrata candidemia was 0.21/1000 ICU admissions. The most common risk factors were prior exposure to broad spectrum antibiotics (100%), central venous catheter (100%), mechanical ventilation (76.9%), diabetes mellitus (50%), age >65 years (46.15%). Urine (23%) was the most common source of C. glabrata candidemia. Overall in hospital 30 days mortality rate due to C. glabrata fungemia was 53.8%. Patients who were treated with fluconazole showed better outcome than patients treated with amphotericin B. Renal failure requiring hemodialysis was the significantly associated with mortality in our study. Conclusion: Candida glabrata was the 3rd most common Candida causing candidemia in our ICUs with a incidence of 0.21/1000 ICU admissions. The outcome of ICU acquired C. glabrata candidemia was poor with 30 days mortality rate of 53.8%. Renal failure requiring hemodialysis was the only risk factor associated with mortality. Further studies are required to identify the other risk factors associated with mortality in C. glabrata candidemia. PMID:25810610

  7. Does Mental Illness Stigma Contribute to Adolescent Standardized Patients' Discomfort With Simulations of Mental Illness and Adverse Psychosocial Experiences?

    ERIC Educational Resources Information Center

    Hanson, Mark D.; Johnson, Samantha; Niec, Anne; Pietrantonio, Anna Marie; High, Bradley; MacMillan, Harriet; Eva, Kevin W.

    2008-01-01

    Objective: Adolescent mental illness stigma-related factors may contribute to adolescent standardized patients' (ASP) discomfort with simulations of psychiatric conditions/adverse psychosocial experiences. Paradoxically, however, ASP involvement may provide a stigma-reduction strategy. This article reports an investigation of this hypothetical…

  8. Synchronization of Cardio-Respiratory Dynamics in Critically Ill Patients.

    NASA Astrophysics Data System (ADS)

    Burykin, Anton; Buchman, Timothy

    2008-03-01

    We studied changes in cardio-respiratory synchronization and dynamics of cardiovascular system during transition from mechanical ventilation to spontaneous respiration in critically ill patients. This observational study exploits a standard clinical practice---the spontaneous breathing trial (SBT). The SBT consists of a period of mechanical ventilation, followed by a period of spontaneous breathing, followed by resumption of mechanical ventilation. We collected continuous respiratory, cardiac (EKG), and blood pressure signals of mechanically ventilated patients before, during and after SBT. The data were analyzed by means of spectral analysis, phase dynamics, and entropy measures. Mechanical ventilation appears to affect not only the lungs but also the cardiac and vascular systems. Spontaneous cardiovascular rhythms are entrained by the mechanical ventilator and are drawn into synchrony. Sudden interruption of mechanical ventilation causes gross desynchronization, which is restored by reinstitution of mechanical ventilation. The data suggest (1) therapies intended to support one organ system may propagate unanticipated effects to other organ systems and (2) sustained therapies may adversely affect recovery of normal organ system interactions.

  9. Teaching medical students about communicating with patients with major mental illness.

    PubMed

    Iezzoni, Lisa I; Ramanan, Radhika A; Lee, Stacey

    2006-10-01

    Persons with major mental illness often have chronic diseases and poor physical health. Therefore, all practicing physicians should learn about communicating effectively with these patients. Few efforts to teach medical students communication skills have specifically targeted patients with major mental illness. Indeed, most of the limited literature on this topic is decades old, predating significant scientific advances in cognitive neuroscience and psychiatric therapeutics and changes in social policies regarding major mental illness. To gather preliminary insight into training needs, we interviewed 13 final-year students from 2 Boston medical schools. Students' observations coalesced around 4 themes: fears and anxieties about interacting with persons with major mental illness; residents "protecting" students from patients with major mental illness; lack of clinical maturity; and barriers to learning during psychiatry rotations. Educational researchers must explore ways to better prepare young physicians to communicate effectively with patients with major mental illness. PMID:16970561

  10. Teaching Medical Students about Communicating with Patients with Major Mental Illness

    PubMed Central

    Iezzoni, Lisa I; Ramanan, Radhika A; Lee, Stacey

    2006-01-01

    Persons with major mental illness often have chronic diseases and poor physical health. Therefore, all practicing physicians should learn about communicating effectively with these patients. Few efforts to teach medical students communication skills have specifically targeted patients with major mental illness. Indeed, most of the limited literature on this topic is decades old, predating significant scientific advances in cognitive neuroscience and psychiatric therapeutics and changes in social policies regarding major mental illness. To gather preliminary insight into training needs, we interviewed 13 final-year students from 2 Boston medical schools. Students' observations coalesced around 4 themes: fears and anxieties about interacting with persons with major mental illness; residents protecting students from patients with major mental illness; lack of clinical maturity; and barriers to learning during psychiatry rotations. Educational researchers must explore ways to better prepare young physicians to communicate effectively with patients with major mental illness. PMID:16970561

  11. Fear of death, mortality communication, and psychological distress among secular and religiously observant family caregivers of terminal cancer patients.

    PubMed

    Bachner, Yaacov G; O'Rourke, Norm; Carmel, Sara

    2011-02-01

    Previous research suggests that caregivers and terminally ill patients face substantial difficulties discussing illness and death. Existing research, however, has focused primarily on the experience of patients. The current study compared responses as well as the relative strength of association between mortality comunication, fear of death, and psychological distress (i.e., depressive symptomatology, emotional exhaustion) among secular and religiously observant family caregivers of terminally ill cancer patients. A total of 236 participants were recruited over 18 months within the first year of caregiver bereavement. Retrospectively reported mortality communication was statistically greater among secular caregivers; in contrast, both fear of death and depressive symptoms were greater among the religiously observant. Path analyses subsequently revealed notable differences between groups. Among secular caregivers, a significant inverse relationship between mortality communication and the two indices of caregiver distress emerged. In contrast, the association between mortality communication and psychological distress among the religious was moderated by these caregivers' fear of death. The results of this study suggest that fear of death is a significant predictor of psychological distress among religiously observant caregivers of terminal cancer patients (i.e., fear of their own death as elicited by the caregiving role). Fostering morality communication between secular caregivers and patients would appear to be one means of reducing the likelihood of clinically significant psychological distress. This may be insufficient among religiously observant caregivers, however, for whom fear of death may first need to be redressed. PMID:24501834

  12. Predictive value of an abnormal hepatobiliary scan in patients with severe intercurrent illness

    SciTech Connect

    Kalff, V.; Froelich, J.W.; Lloyd, R.; Thrall, J.H.

    1983-01-01

    Ten patients had severe intercurrent illness and the gallbladder could not be seen on a hepatobiliary scan. In 4, surgery and pathological examination showed that the gallbladder was normal; 1 had chronic cholecystitis and 5 had acute acalculous cholecystitis. This study indicates that a positive hepatobiliary scan may not be indicative of acute gallbladder disease in the seriously ill patient.

  13. Body Consciousness, Illness-Related Impairment, and Patient Adherence in Hemodialysis.

    ERIC Educational Resources Information Center

    Christensen, Alan J.; And Others

    1996-01-01

    Examined the joint effects of private body consciousness (PBC) and degree of illness-related physical impairment on treatment regimen adherence in a sample of 52 hemodialysis patients. Predicted the effect of PBC on adherence would vary as a function of patients' level of illness-related physical impairment. Results are discussed in terms of

  14. Illness perception of dropout patients followed up at bipolar outpatient clinic, Turkey.

    PubMed

    Oflaz, Serap; Guveli, Hulya; Kalelioglu, Tevfik; Akyazı, Senem; Yıldızhan, Eren; Kılıc, Kasım Candas; Basyigit, Sehnaz; Ozdemiroglu, Filiz; Akyuz, Fatma; Gokce, Esra; Bag, Sevda; Kurt, Erhan; Oral, Esat Timucin

    2015-06-01

    Dropout is a common problem in the treatment of psychiatric illnesses including bipolar disorders (BD). The aim of the present study is to investigate illness perceptions of dropout patients with BD. A cross sectional study was done on the participants who attended the Mood Disorder Outpatient Clinic at least 3 times from January 2003 through June 2008, and then failed to attend clinic till to the last one year, 2009, determined as dropout. Thirty-nine dropout patients and 39 attendent patients with BD were recruited for this study. A sociodemographic form and brief illness perception questionnaire were used to capture data. The main reasons of patients with BD for dropout were difficulties of transport (31%), to visit another doctor (26%), giving up drugs (13%) and low education level (59%) is significant for dropout patients. The dropout patients reported that their illness did not critically influence their lives, their treatment had failed to control their illnesses, they had no symptoms, and that their illness did not emotionally affect them. In conclusion, the nonattendance of patients with serious mental illness can result in non-compliance of therapeutic drug regimens, and a recurrence of the appearance symptoms. The perception of illness in dropout patients with BD may be important for understanding and preventing nonattendance. PMID:25921931

  15. Speculations on the origin of the ill-effects associated with the use of visual display terminals.

    PubMed

    Mawson, A R

    1985-05-21

    There are increasing reports of a wide variety of unexplained ill-effects associated with the occupational use of visual display terminals (VDTs); these include psychological complaints such as headache, irritability, and fatigue, musculoskeletal pains, dry or burning eyes, deteriorating eyesight, cataracts, facial dermatitis, and pregnancy abnormalities. Many VDTs emit near-ultraviolet (UV-A) radiation in amounts ranging from 200 to 1500 times less than the present U.S. safety standard of 1.0 X 10(-3) W/cm2. Although the possibility of a radiation hazard from VDTs is widely discounted, various points of circumstantial evidence are marshalled in this paper in support of the hypothesis that prolonged exposure to even these low amounts of UV-A radiation may result in progressive increases in sensitivity to UV-A and in cumulative biologic damage. It is further proposed that UV-A produces the ill-effects by catabolizing vitamin A in skin and plasma into highly active metabolites, the gradual accumulation of which results in an endogenous form of vitamin A intoxication. In addition to producing the skin and systemic effects of hypervitaminosis A, these metabolites presumably enter the fetal circulation, leading to pregnancy abnormalities similar to those associated with high doses of the vitamin for the treatment of skin disorders. PMID:4033154

  16. Illness beliefs of leprosy patients: use of medical anthropology in clinical practice.

    PubMed

    Neylan, T C; Nelson, K E; Schauf, V; Scollard, D M

    1988-06-01

    Illness beliefs of 61 patients identified as having leprosy were assessed by Kleinman's Explanatory Model Format. Our patients used a wide variety of etiologic theories which were grouped in categories such as venereal disease, heredity, dangerous food, sin, karma, and humoral disorders. Despite efforts at patient education, very few patients adopted the concept of bacterial infection to explain their illness. The patients identified their illness with a variety of different labels, some of which had associations with particular symptoms. Leprosy was perceived and experienced more as a series of acute disorders not necessarily related to one another. The various theories of illness were instrumental in directing treatment choices which included a number of indigenous healing practices. Such information may be useful in improving patient care and compliance by providing practitioners with interpretive strategies for communicating with their patients. PMID:3411165

  17. Chronic illness and the physician-patient relationship: a response to the Hastings Center's "ethical challenges of chronic illness".

    PubMed

    Moros, D A; Rhodes, R; Baumrin, B; Strain, J J

    1991-04-01

    The following article is a response to the position paper of the Hastings Center, "Ethical Challenges of Chronic Illness", a product of their three year project on Ethics and Chronic Care. The authors of this paper, three prominent bioethicists, Daniel Callahan, Arthur Caplan, and Bruce Jennings, argue that there should be a different ethic for acute and chronic care. In pressing this distinction they provide philosophical grounds for limiting medical care for the elderly and chronically ill. We give a critical survey of their position and reject it as well as any attempt to characterize the physician-patient relationship as a commercial contract. We emphasize, as central features of good medical practice, a commitment to be the patient's agent and a determination to acquire and be guided by knowledge. These commitments may sometimes conflict with efforts to have the physician serve as an instrument of social and economic policies limiting medical care. PMID:1905745

  18. Causal Attribution and Illness Perception: A Cross-Sectional Study in Mexican Patients with Psychosis

    PubMed Central

    Gómez-de-Regil, Lizzette

    2014-01-01

    Health psychology researchers have begun to focus greater attention on people's beliefs about health/illness since these beliefs can clearly affect behavior. This cross-sectional study aimed at (1) identifying the most common factors psychotic patients attribute their illness to and (2) assessing the association between causal attribution and illness perception (cognitive, emotional, and comprehensibility dimensions). Sixty-two patients (56.5% females) who had been treated for psychosis at a public psychiatric hospital in Mexico answered the Angermeyer and Klusmann Illness Attribution Scale and the Brief Illness Perception Questionnaire. Results showed that most patients attributed psychosis onset to social factors and that attribution to their personality might have an overwhelmingly negative effect on their lives. Acknowledging psychotic patient attributional beliefs and considering them in clinical practice could improve treatment efficacy and overall recovery success. This is particularly important in psychosis, since symptoms are often severe and/or persistent and require long-term treatment. PMID:25525628

  19. Causal attribution and illness perception: a cross-sectional study in Mexican patients with psychosis.

    PubMed

    Gmez-de-Regil, Lizzette

    2014-01-01

    Health psychology researchers have begun to focus greater attention on people's beliefs about health/illness since these beliefs can clearly affect behavior. This cross-sectional study aimed at (1) identifying the most common factors psychotic patients attribute their illness to and (2) assessing the association between causal attribution and illness perception (cognitive, emotional, and comprehensibility dimensions). Sixty-two patients (56.5% females) who had been treated for psychosis at a public psychiatric hospital in Mexico answered the Angermeyer and Klusmann Illness Attribution Scale and the Brief Illness Perception Questionnaire. Results showed that most patients attributed psychosis onset to social factors and that attribution to their personality might have an overwhelmingly negative effect on their lives. Acknowledging psychotic patient attributional beliefs and considering them in clinical practice could improve treatment efficacy and overall recovery success. This is particularly important in psychosis, since symptoms are often severe and/or persistent and require long-term treatment. PMID:25525628

  20. Belief in supernatural causes of mental illness among Malay patients: impact on treatment.

    PubMed

    Razali, S M; Khan, U A; Hasanah, C I

    1996-10-01

    The concept of aetiology of mental illness in 134 Malay patients was investigated by means of a 20-item checklist. About 53% of the patients attributed their illnesses to supernatural agents. Witchcraft and possession by evil spirits were regarded as common causes of illness. The number of patients who believed in supernatural causes of their mental illness was significantly higher among those who had consulted bomohs (Malay traditional healers) than among those who had not consulted them. The belief that mental illness is caused by supernatural agents is firmly held by bomohs, who reinforce this notion in those who seek their advice. Belief in supernatural causes of mental illness was not significantly associated with age, gender, level of education or occupation of the patients. Patients who believed in supernatural causes of mental illness were also found to show poor drug compliance, and the number of such patients at 6 months follow-up was significantly lower than the corresponding figure for those who did not believe in supernatural causes. The importance of understanding the patients' cultural background when treating psychiatric patients is highlighted. PMID:8911557

  1. Assessing Patient Management Plans of Doctors and Medical Students: An Illness Script Perspective

    ERIC Educational Resources Information Center

    Monajemi, Alireza; Schmidt, Henk G.; Rikers, Remy M. J. P.

    2012-01-01

    Introduction: Illness script theory offers explanations for expert-novice differences in clinical reasoning. However, it has mainly focused on diagnostic (Dx) performance, while patient management (Mx) has been largely ignored. The aim of the present study was to show the role of Mx knowledge in illness script development and how it relates to…

  2. Assessing Patient Management Plans of Doctors and Medical Students: An Illness Script Perspective

    ERIC Educational Resources Information Center

    Monajemi, Alireza; Schmidt, Henk G.; Rikers, Remy M. J. P.

    2012-01-01

    Introduction: Illness script theory offers explanations for expert-novice differences in clinical reasoning. However, it has mainly focused on diagnostic (Dx) performance, while patient management (Mx) has been largely ignored. The aim of the present study was to show the role of Mx knowledge in illness script development and how it relates to

  3. Unexpected events occurring during the intra-hospital transport of critically ill ICU patients

    PubMed Central

    Venkategowda, Pradeep M.; Rao, Surath M.; Mutkule, Dnyaneshwar. P.; Taggu, Alai. N.

    2014-01-01

    Background: Intra-hospital transport of critically ill patients is a challenging task. However, despite the improvements in intra-hospital transport practices, adverse event incidents remain high and constitute a significant risk for the transport of the critically ill ICU patients. Objectives: To observe the number and types of unexpected-events (UEs) occurring during intra-hospital transport of critically ill ICU patients. Interventions provided along with outcome. Materials and Methods: This was a prospective observational study of 254 intra-hospital critically-ill ICU patients of our hospital transported for diagnostic purposes during April 2012 - March 2013. The escorting intensivist completed the data of unexpected events during transport. Results: A total of 254 patients were observed prospectively for UEs during intra-hospital transfer of critically ill patients. The overall UEs observed were 139 among 64 patients. Among the UEs which occurred, the maximum were miscellaneous causes [89 (64.00%)] like oxygen probe [38 (27.33%)] or ECG lead displacement [27 (19.42%)]. Major events like fall in spo2 >5% observed in 15 (10.79%) patients, BP variation > 20% from baseline in 22 (15.82%) patients, altered mental status in 5 (3.59%), and arrhythmias in 6 (4.31%) patients. Among 64 (100%) patients with UEs, 3 (2.15%) patients with serious adverse events have been aborted from transport. Conclusion: Unexpected-events (UEs) are common during transport of critically ill ICU patients and these adverse events can be reduced when critically ill patients are accompanied by intensivist/medically qualified person during transport and following strict transport guidelines. PMID:24987233

  4. Therapeutic touch and the terminally ill: healing power through the hands.

    PubMed

    Snyder, J R

    1997-01-01

    I hope it has become apparent that the use of Therapeutic Touch can be a useful addition to more conventional hospice treatments. Also, it can be a very rewarding and fulfilling experience for the patient. It has been so for me. I feel extremely fortunate to have been given the opportunity of introducing Therapeutic Touch into the Allegheny Hospice, a program of Allegheny General Hospital in Pittsburgh, Pennsylvania. We are still in the early stages of implementation. Currently, we are initiating a research program to accomplish the following with respect to Therapeutic Touch: Demonstrate that Therapeutic Touch does, in fact, yield the same results when performed in a hospice setting as when performed in other settings established by prior research. Establish the degree to which drug levels can be reduced (if any) by the introduction of Therapeutic Touch into the treatment regimen and still maintain an acceptable level of pain control. Demonstrate that the quality of life can be improved for the patients and their families through the use of Therapeutic Touch over the current treatment methods not using Therapeutic Touch. Establish sufficient documentation for respective insurance providers to justify future payment for this treatment. It is envisioned that this program will be accomplished later this year. Our hospice organization is a very dynamic one, dedicated to bringing the best possible care to our patients. In addition to the aforementioned Therapeutic Touch research program, we have just embarked on another research effort to determine the advantages of using a "Low Pressure Air Mattress" to reduce the incidence and severity of skin breakdown. This has the potential to improve the quality of life not only of the patient but also of the care giver. In this day and age when many seem to have severely neglected the sick and elderly, there is a great opportunity for creative, compassionate people to become involved in hospice programs around the country. In so doing, you could render an invaluable service to your fellow, man, and, at the same time, achieve a deep sense of fulfillment. Anyone wishing to become involved in a hospice program or interested in learning Therapeutic Touch may contact me at Allegheny Hospice, a Allegheny Center, 6th floor, Pittsburgh, Pa., 15212. PMID:9295408

  5. A retrospective study of clinical profile and outcomes of critically ill patients with heat-related illness

    PubMed Central

    Kalaiselvan, MS; Renuka, MK; Arunkumar, AS

    2015-01-01

    Background and Aims: Heat-related illness (HRI) due to high ambient temperatures is a common feature during the Indian summer. HRI often results in Intensive Care Unit (ICU) admissions and are associated with significant morbidity and mortality. However, published report on the effects of HRI among the Indian population is lacking. This study was undertaken to identify the profile of patients admitted to ICU with clinical features of HRI and study their clinical outcomes. Methods: This was a retrospective case series of patients admitted with features of HRI during the summer of 2012 in our multidisciplinary ICU. Data on demographics, co-morbid illness, admission severity of illness (Acute Physiology and Chronic Health Evaluation II [APACHE II]), organ failure scores (Sequential Organ Failure Assessment [SOFA]) and neuroimaging studies were collected. Outcome data studied included mortality, ICU length of stay (LOS), ventilator days and hospital LOS. Statistical analysis was performed using Student's t-test, Chi-square test and multivariate analysis. Results: Twenty-six patients met the diagnostic criteria for HRI. Fifteen were males. The mean age was 53.12 18.6 years. Mean APACHE II score was 19.6 7.7 and mean SOFA score was 7.5 2.6. The common presenting symptoms were fever with neurological impairment (100%) and gastrointestinal symptoms (30%). Major organ systems involvement include neurological (100%), renal (57%), hepatic (34%) and coagulation abnormalities (26%). Most common metabolic abnormality noted was hyponatraemia (73%). Magnetic resonance imaging findings suggestive of heat stroke were seen in 5 of 26 patients. Mortality rate was 34%. 8 of 17 survivors had residual neurological impairment. Conclusion: HRI carries a high mortality and significant neurological morbidity. PMID:26755836

  6. Immediate intralipid clearance from plasma in critically ill patients after a single-dose injection

    SciTech Connect

    Lindh, A.; Roessner, S.

    1987-09-01

    Plasma fractional removal rates (k2) of Intralipid injected in parallel with /sup 125/I albumin were analyzed in five healthy males and nine critically ill patients. The k2 values of critically ill patients were similar to those of healthy subjects. However, the initial plasma concentrations of Intralipid calculated by extrapolation to zero-time (y0) were markedly different. The mean y0 value in the critically ill patients was 43% that of healthy subjects. No plasma loss of /sup 125/I albumin occurred throughout the test. Intralipid to /sup 125/I albumin plasma concentration ratios during the removal phase paralleled the curves obtained from the iv fat tolerance test. This suggests that these ratios depend on Intralipid clearance rather than leakage from the circulation. The immediate loss of Intralipid suggests that the pulmonary vasculature, the first capillary bed through which the emulsion passes, could be the site where a substantial uptake of the emulsion occurs in critically ill patients.

  7. Attitudes of Malaysian general hospital staff towards patients with mental illness and diabetes

    PubMed Central

    2011-01-01

    Background The context of the study is the increased assessment and treatment of persons with mental illness in general hospital settings by general health staff, as the move away from mental hospitals gathers pace in low and middle income countries. The purpose of the study was to examine whether general attitudes of hospital staff towards persons with mental illness, and extent of mental health training and clinical experience, are associated with different attitudes and behaviours towards a patient with mental illness than towards a patients with a general health problem - diabetes. Methods General hospital health professionals in Malaysia were randomly allocated one of two vignettes, one describing a patient with mental illness and the other a patient with diabetes, and invited to complete a questionnaire examining attitudes and health care practices in relation to the case. The questionnaires completed by respondents included questions on demographics, training in mental health, exposure in clinical practice to people with mental illness, attitudes and expected health care behaviour towards the patient in the vignette, and a general questionnaire exploring negative attitudes towards people with mental illness. Questionnaires with complete responses were received from 654 study participants. Results Stigmatising attitudes towards persons with mental illness were common. Those responding to the mental illness vignette (N = 356) gave significantly lower ratings on care and support and higher ratings on avoidance and negative stereotype expectations compared with those responding the diabetes vignette (N = 298). Conclusions Results support the view that, in the Malaysian setting, patients with mental illness may receive differential care from general hospital staff and that general stigmatising attitudes among professionals may influence their care practices. More direct measurement of clinician behaviours than able to be implemented through survey method is required to support these conclusions. PMID:21569613

  8. Pharmacokinetics of Caspofungin in Critically Ill Patients on Continuous Renal Replacement Therapy

    PubMed Central

    Weiler, Stefan; Seger, Christoph; Pfisterer, Hartwig; Stienecke, Eva; Stippler, Florian; Welte, Ren; Joannidis, Michael; Griesmacher, Andrea

    2013-01-01

    Caspofungin pharmacokinetics was assessed in 27 critically ill patients, including 7 on continuous venovenous hemofiltration (CVVH), 8 on continuous venovenous hemodialysis (CVVHD), and 13 not requiring continuous renal replacement therapy (CRRT). Caspofungin exposure during CRRT was very similar to that of the control group and comparable to that in healthy volunteers. Caspofungin clearance by CRRT was very low. Therefore, the standard dosage of caspofungin is probably adequate for critically ill patients undergoing CVVH or CVVHD. PMID:23733471

  9. Does hemodynamic monitoring complement conventional methods of assessment in the critically ill cardiac patient?

    PubMed Central

    Holder, D A

    1979-01-01

    Conventional clinical methods give qualitative information about left ventricular function in the critically ill patient. However, the information gathered from the physical examination and noninvasive methods is subject to important pitfalls with respect to both its nonspecificity and interobserver variability. The advent of hemodynamic monitoring has highlighted these difficulties and provided more quantitative information that is relevant in both diagnosis and treatment of the critically ill patient. PMID:497980

  10. Immunoinflammatory Response in Critically Ill Patients: Severe Sepsis and/or Trauma

    PubMed Central

    Popovic, Nada; Djordjevic, Dragan

    2013-01-01

    Immunoinflammatory response in critically ill patients is very complex. This review explores some of the new elements of immunoinflammatory response in severe sepsis, tumor necrosis factor-alpha in severe acute pancreatitis as a clinical example of immune response in sepsis, immune response in severe trauma with or without secondary sepsis, and genetic aspects of host immuno-inflammatory response to various insults in critically ill patients. PMID:24371374

  11. Violent victimization of adult patients with severe mental illness: a systematic review

    PubMed Central

    Latalova, Klara; Kamaradova, Dana; Prasko, Jan

    2014-01-01

    The aims of this paper are to review data on the prevalence and correlates of violent victimization of persons with severe mental illness, to critically evaluate the literature, and to explore possible approaches for future research. PubMed/MEDLINE and PsycINFO databases were searched using several terms related to severe mental illness in successive combinations with terms describing victimization. The searches identified 34 studies. Nine epidemiological studies indicate that patients with severe mental illness are more likely to be violently victimized than other community members. Young age, comorbid substance use, and homelessness are risk factors for victimization. Victimized patients are more likely to engage in violent behavior than other members of the community. Violent victimization of persons with severe mental illness has long-term adverse consequences for the course of their illness, and further impairs the quality of lives of patients and their families. Victimization of persons with severe mental illness is a serious medical and social problem. Prevention and management of victimization should become a part of routine clinical care for patients with severe mental illness. PMID:25336958

  12. Psychometric Evaluation of the Internalized Stigma of Mental Illness Scale for Patients with Mental Illnesses: Measurement Invariance across Time

    PubMed Central

    Chang, Chih-Cheng; Wu, Tsung-Hsien; Chen, Chih-Yin; Wang, Jung-Der; Lin, Chung-Ying

    2014-01-01

    Background The current investigation examined the psychometric properties of the Internalized Stigma of Mental Illness (ISMI) scale in a sample of patients with mental illness. In addition to the internal consistency, test-retest reliability, and concurrent validity that previous studies have tested for the ISMI, we extended the evaluation to its construct validity and measurement invariance using confirmatory factor analysis (CFA). Methods Three hundred forty-seven participants completed two questionnaires (i.e., the ISMI and the Depression and Somatic Symptoms Scale [DSSS]), and 162 filled out the ISMI again after 50.23±31.18 days. Results The results of this study confirmed the frame structure of the ISMI; however, the Stigma Resistance subscale in the ISMI seemed weak. In addition, internal consistency, test-retest reliability, and concurrent validity were all satisfactory for all subscales and the total score of the ISMI, except for Stigma Resistance (α = 0.66; ICC = 0.52, and r = 0.02 to 0.06 with DSSS). Therefore, we hypothesize that Stigma Resistance is a new concept rather than a concept in internalized stigma. The acceptable fit indices supported the measurement invariance of the ISMI across time, and suggested that people with mental illness interpret the ISMI items the same at different times. Conclusion The clinical implication of our finding is that clinicians, when they design interventions, may want to use the valid and reliable ISMI without the Stigma Resistance subscale to evaluate the internalized stigma of people with mental illness. PMID:24887440

  13. A patient-centered research agenda for the care of the acutely ill older patient.

    PubMed

    Wald, Heidi L; Leykum, Luci K; Mattison, Melissa L P; Vasilevskis, Eduard E; Meltzer, David O

    2015-05-01

    Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training. PMID:25877486

  14. Complex and dynamic times of being chronically ill: Beyond disease trajectories of patients with ulcerative colitis.

    PubMed

    Shubin, Sergei; Rapport, Frances; Seagrove, Anne

    2015-12-01

    This article contributes to health research literature by problematizing the linear, sequential and intelligible understanding of time in the studies of illness. Drawing on the work of Martin Heidegger, it attempts to overcome the problem of considering the time of illness as either a framework controlling patients' experiences or a mind-dependent feature of their lives. The paper offers a conceptual analysis of the stories of ulcerative colitis patients from a recent clinical trial to present temporalities of illness as both objective and subjective, relational and dynamic. We attend to a combination of temporalities related to the ambiguous unfolding of illness and patients' relationships with such an unpredictable world of changing bodies, medical practices and temporal norms. Furthermore, our analysis reveals openness of times and considers ulcerative colitis patients as constantly evolving beings, with multiple possibilities brought about by illness. The paper highlights co-existence of times and considers patients' lives as incorporating a multiplicity of futures, presents and pasts. It concludes with conceptual observations about the consequences of developing complex approaches to illness in health research, which can better highlight the situatedness of patients and their multi-dimensional temporal foundations. PMID:26560409

  15. Personality Change Pre- to Post- Loss in Spousal Caregivers of Patients with Terminal Lung Cancer

    PubMed Central

    Hoerger, Michael; Chapman, Benjamin P.; Prigerson, Holly G.; Fagerlin, Angela; Mohile, Supriya G.; Epstein, Ronald M.; Lyness, Jeffrey M.; Duberstein, Paul R.

    2015-01-01

    Personality is relatively stable in adulthood but could change in response to life transitions, such as caring for a spouse with a terminal illness. Using a case-control design, spousal caregivers (n=31) of patients with terminal lung cancer completed the NEO-FFI twice, 1.5 years apart, before and after the patients death. A demographically-matched sample of community controls (n=93) completed the NEO-FFI on a similar timeframe. Based on research and theory, we hypothesized that bereaved caregivers would experience greater changes than controls in interpersonal facets of extraversion (sociability), agreeableness (prosocial, nonantagonistic), and conscientiousness (dependability). Consistent with hypotheses, bereaved caregivers experienced an increase in interpersonal orientation, becoming more sociable, prosocial, and dependable (Cohens d = .48?.67), though there were no changes in nonantagonism. Changes were not observed in controls (ds ? .11). These initial findings underscore the need for more research on the effect of life transitions on personality. PMID:25614779

  16. Abnormal illness behavior of patients with functional somatic symptoms: relation to psychiatric disorders.

    PubMed

    Guo, Y; Kuroki, T; Koizumi, S

    2001-01-01

    Functional somatic symptoms are highly associated with hypochondriasis, anxiety, and depressive disorders. Despite the absence of an organic disorder, underlying psychological distress of patients with functional somatic symptoms may result in abnormal illness behavior such as inadequate treatment seeking or overuse of medical services. Using the Illness Behavior Questionnaire (IBQ), we examined the illness behavior of Japanese patients visiting a general medicine clinic whose physical symptoms were considered functional. We used the General Health Questionnaire-30 to classify patients with functional somatic symptoms as those with and without psychological distress. Patients with distress (n=35) reported more physical complaints and higher IBQ scores than did patients without distress (n=22). The IBQ profile of patients with psychological distress was identical to that of patients diagnosed with either hypochondriasis or major depression. The illness behavior of patients without psychological distress was indistinguishable from that of patients whose physical symptoms were attributed to organic disease. These results further support the hypothesis that functional somatic symptoms may be associated with hypochondriasis and major depression, the pathology of which may contribute to the development of abnormal illness behavior. PMID:11543849

  17. Correlations Between Awareness of Illness (Insight) and History of Addiction in Heroin-Addicted Patients

    PubMed Central

    Maremmani, Angelo Giovanni Icro; Rovai, Luca; Rugani, Fabio; Pacini, Matteo; Lamanna, Francesco; Bacciardi, Silvia; Perugi, Giulio; Deltito, Joseph; DellOsso, Liliana; Maremmani, Icro

    2012-01-01

    In a group of 1066 heroin addicts, who were seeking treatment for opioid agonist treatment, we looked for differences in historical, demographic, and clinical characteristics, between patients with different levels of awareness of illness (insight). The results showed that, in the cohort studied, a majority of subjects lacked insight into their heroin-use behavior. Compared with the impaired-insight group, those who possessed insight into their illness showed significantly greater awareness of past social, somatic, and psychopathological impairments, and had a greater number of past treatment-seeking events for heroin addiction. In contrast with other psychiatric illnesses, the presence of awareness appears to be related to the passing of time and to the worsening of the illness. Methodologies to improve the insight of patients should, therefore, be targeted more directly on patients early in their history of heroin dependence, because the risk of lack of insight is greatest during this period. PMID:22787450

  18. Understanding the suffering of a patient with an illness: signs, context and strategies.

    PubMed

    Hueso Montoro, Csar; Siles Gonzlez, Jos; Amezcua, Manuel; Bonill de Las Nieves, Candela; Pastor Montero, Sonia; Celdrn Maas, Miriam

    2012-01-01

    The aim of this study is to understand the suffering of a patient with an illness, by using a secondary research method, that is, a qualitative meta-study. The primary data source of the meta-study includes "biographical reports". This project is based on a case study, in which the first-hand experiences of a patient with an illness were collected. The findings of the reports were compiled using the Archivos de la Memoria collection of the Index Foundation (Granada, Spain) and journals specialized in editing these materials. A selection of 20 biographical reports was targeted. The results of the meta-study show that suffering is a multidimensional process within a framework of ambiguous feelings. The suffering involves family and social network participation. Patients develop a range of strategies to overcome the illness. One of the effects is the fear of illness relapse or worsening. PMID:22991127

  19. Internalized Stigma of Mental Illness among Schizophrenic Patients and Their Families (Comparative Study)

    ERIC Educational Resources Information Center

    Mahmoud, Sahar; Zaki, Rania A.

    2015-01-01

    This study was a comparative study aiming to assess the extent of internalized stigma of mental illness among patients with schizophrenia & identify stigma as perceived by family members caring schizophrenic patients. The study was conducted in two settings 1st clinic was outpatient clinic for psychiatric patient affiliated to Abbasia…

  20. Rehabilitation of Critical Illness Polyneuropathy and Myopathy Patients: An Observational Study

    ERIC Educational Resources Information Center

    Novak, Primoz; Vidmar, Gaj; Kuret, Zala; Bizovicar, Natasa

    2011-01-01

    Critical illness polyneuropathy and myopathy (CIPNM) frequently develops in patients hospitalized in intensive care units. The number of patients with CIPNM admitted to inpatient rehabilitation is increasing. The aim of this study was to comprehensively evaluate the outcome of their rehabilitation. Twenty-seven patients with CIPNM were included in…

  1. Rehabilitation of Critical Illness Polyneuropathy and Myopathy Patients: An Observational Study

    ERIC Educational Resources Information Center

    Novak, Primoz; Vidmar, Gaj; Kuret, Zala; Bizovicar, Natasa

    2011-01-01

    Critical illness polyneuropathy and myopathy (CIPNM) frequently develops in patients hospitalized in intensive care units. The number of patients with CIPNM admitted to inpatient rehabilitation is increasing. The aim of this study was to comprehensively evaluate the outcome of their rehabilitation. Twenty-seven patients with CIPNM were included in

  2. Characteristic illness behaviour in assault patients: DATES syndrome.

    PubMed Central

    Shepherd, J P; Peak, J D; Haria, S; Sleeman, F

    1995-01-01

    Violent crime has become a public health issue, not least because the needs of victims have been neglected in the criminal justice system. Since this group suffer more psychological distress than victims of accidents, we compared illness experience in 433 adult assault victims with paired victims of accidents in a case control study. In the 10 year period prior to injury, there was a significant excess of hospital contacts in the assault group in relation to trauma, elective surgery and drug abuse but not to other psychiatric or medical conditions. This spectrum of disorders constitutes a previously unrecognized syndrome in young adults, probably representing the manifestations of antisocial personality. PMID:7769600

  3. Supporting Cancer Patients in Illness Management: Usability Evaluation of a Mobile App

    PubMed Central

    Kaufman, David R; Ruland, Cornelia M

    2014-01-01

    Background Mobile phones and tablets currently represent a significant presence in people’s everyday lives. They enable access to different information and services independent of current place and time. Such widespread connectivity offers significant potential in different app areas including health care. Objective Our goal was to evaluate the usability of the Connect Mobile app. The mobile app enables mobile access to the Connect system, an online system that supports cancer patients in managing health-related issues. Along with symptom management, the system promotes better patient-provider communication, collaboration, and shared decision making. The Connect Mobile app enables access to the Connect system over both mobile phones and tablets. Methods The study consisted of usability tests of a high fidelity prototype with 7 cancer patients where the objectives were to identify existing design and functionality issues and to provide patients with a real look-and-feel of the mobile system. In addition, we conducted semistructured interviews to obtain participants’ feedback about app usefulness, identify the need for new system features and design requirements, and measure the acceptance of the mobile app and its features within everyday health management. Results The study revealed a total of 27 design issues (13 for mobile apps and 14 for tablet apps), which were mapped to source events (ie, errors, requests for help, participants' concurrent feedback, and moderator observation). We also applied usability heuristics to identify violations of usability principles. The majority of violations were related to enabling ease of input, screen readability, and glanceability (15 issues), as well as supporting an appropriate match between systems and the real world (7 issues) and consistent mapping of system functions and interactions (4 issues). Feedback from participants also showed the cancer patients’ requirements for support systems and how these needs are influenced by different context-related factors, such as type of access terminal (eg, desktop computer, tablet, mobile phone) and phases of illness. Based on the observed results, we proposed design and functionality recommendations that can be used for the development of mobile apps for cancer patients to support their health management process. Conclusions Understanding and addressing users’ requirements is one of the main prerequisites for developing useful and effective technology-based health interventions. The results of this study outline different user requirements related to the design of the mobile patient support app for cancer patients. The results will be used in the iterative development of the Connect Mobile app and can also inform other developers and researchers in development, integration, and evaluation of mobile health apps and services that support cancer patients in managing their health-related issues. PMID:25119490

  4. Endocrine effects of vasopressin in critically ill patients.

    PubMed

    Sharshar, Tarek; Annane, Djillali

    2008-06-01

    Vasopressin, also called antidiuretic hormone, is a 9 amino-acid peptide, synthesized from a precursor containing neurophysin II, by neurones from the supra-optic and peri-ventricular nuclei, and then stored in the posterior hypophysis. Vasopressin regulates plasmatic osmolality and volaemia via V2 receptors at the levels of the kidney, and vascular smooth muscle tone via V1a arterial receptors. Both its synthesis and release from hypophysis vesicles depend on variations in plasma osmolality, volaemia, and arterial blood pressure. In addition, vasopressin interacts with the main hormonal systems involved in the response to stress, including the hypothalamic-pituitary adrenal axis, other anterior pituitary hormones, mainly prolactin and growth hormone, the renin-angiotensin system, and regulates insulin synthesis and glucose metabolism. Interestingly, during critical illness, exogenous administration of vasopressin showed little effects on the circulating levels of these various hormones, except an increase in prolactin. The absence of endocrine effects of vasopressin during critical illness is unclear and may relate to an already maximal hormonal stimulation or to down-regulation of vasopressin receptors. PMID:18683473

  5. [What information do patients with schizophrenia have about their illness and treatment?].

    PubMed

    Ferreri, M; Rouillon, F; Nuss, P; Bazin, N; Farah, S; Djaballah, K; Gerard, D

    2000-01-01

    Improved compliance with antipsychotic medication is a major issue in schizophrenic management. For this purpose educational programs have been used, but up to now, little or no information has been gathered or published in France concerning schizophrenic patients' opinion on information they have about their disease and their treatment. Thus we conducted a survey in concert with 78 psychiatrists from the French psychiatric health service. From this cross sectional survey we assessed 336 outpatients (male: 72%; mean age: 36 +/- 10.4 years) with schizophrenia according to the DSM IV (paranoid sub type: 57%, disorganized: 12%, catatonic: 1%, undifferentiated: 12%, residual: 18%). The mean duration of the illness was 11.6 years (sd: 8.5) and the mean duration of the follow up with the same psychiatrist was 5.4 years (sd: 5.1). Patients completed a questionnaire which assessed their level of information on mental illness and treatment. The diagnosis of schizophrenia has been told to their patients by 39% of the psychiatrists, and treatment has been explained to the patients by 96% of the practitioners. Results indicate less than half of the patients (45%) felt ill, only 46% thought they knew their illness well or very well (nevertheless only 31% of them named spontaneously the diagnosis of schizophrenia or psychosis), and 61% considered that they had been given sufficient information. Most of the patients (79%) were persuaded that their treatment was useful, and 75% of patient were completely satisfied with their treatment. Surprisingly 92% reported taking their medication regularly. Most patients think that a high level of information about their illness (74%) and treatment (79%) help them to cope better with their schizophrenia. Analysis performed according to patients characteristics indicated that paranoid patients felt more ill (p = 0.035) than others, thought to know less about their illness (p = 0.0065), and were less satisfied with their treatment (p = 0.04) and their level of information (p = 0.03). Patients with a duration of their illness longer than 10 years were more convinced of the utility of their treatment (p = 0.02) and had debated more on the choice of their treatment with their psychiatrist (p = 0.047). Patients older than 35 years were more satisfied with their information (p = 0.002). More patients with atypical antipsychotics accepted to take their treatment on a regular basis (p = 0.035) compared to patients under classical neuroleptics. This survey underlines that mental health consumers' opinions can be obtained even in the field of schizophrenia, and argues in favour of further such investigations. It also highlights the need for educational programs on schizophrenia and antipsychotic medications. PMID:11192802

  6. Adipose tissue alterations in critical illness: a paradox as to patient outcomes.

    PubMed

    Wade, Charles E

    2013-01-01

    Adipocyte morphological changes in critically ill patients have been reported, potentially providing beneficial effects. Marques and colleagues reported that these morphological adipocyte changes, as well as accumulation of M2 phenotype macrophages, occur irrespective of nutritional status in the critically ill. The present study provides insight into the alterations that occur, although further studies are needed to fully understand the role that adipose tissue plays in the critically injured. PMID:24053887

  7. Illness Perception in Primary Cutaneous T-cell Lymphomas: What Patients Believe About Their Disease.

    PubMed

    Eder, Johanna; Kammerstätter, Martina; Erhart, Friedrich; Mairhofer-Muri, Daniela; Trautinger, Franz

    2016-03-01

    There is currently no information available on illness perception in primary cutaneous T-cell lymphomas (CTCL). The aim of this study was therefore to gather initial information on disease understanding and interpretation in patients with CTCL. Consecutive patients from a hospital-based primary cutaneous lymphoma ward completed the Revised Illness Perception Questionnaire (IPQ-R) on 2 consecutive visits. A total of 24 patients with different variants of CTCL were included in the study. Patients experienced their condition as being long-lasting, but not fundamentally affecting their lives. Patients had poor belief in personal control, but strong belief in treatment control. They did not show a good understanding of their disease, and had a moderately negative emotional response to their illness. In conclusion, the IPQ-R provides a feasible and reproducible tool for measurement and better understanding of illness perception in patients with CTCL. Knowledge of patients' attitudes towards their disease should enable optimization of the patient-physician relationship and patient care. PMID:26392387

  8. Acute delirium in a critically ill patient may be a wolf in sheep’s clothing

    PubMed Central

    Lemyze, Malcolm; Favory, Raphael; Alves, Isabelle; Mathieu, Daniel

    2009-01-01

    Acute delirium is a commonly encountered problem in the intensive care unit (ICU), which has a myriad of causes and contributes to poor outcomes. We present the case of an alcoholic critically ill patient who developed prolonged acute ICU delirium wrongly diagnosed as sedation and alcohol withdrawal. Protracted vomiting, swallowing disorders and continuous aspirations prevented him from enteral feeding and discontinuation of mechanical ventilation. After several days, it became clear that the patient had been misdiagnosed. Fortunately, nystagmus and ophthalmoplegia then allowed the recognition of Wernicke’s encephalopathy, confirmed by cerebral MRIs. After thiamine supplementation, his state improved but he was discharged only on day 32. Wernicke’s encephalopathy is an acute reversible neuropsychiatric emergency, which is falsely considered as uncommon, and is largely misdiagnosed, especially in critically ill patients. Thiamine should be systematically given to all critically ill alcoholic patients, especially those with protracted vomiting. PMID:21686461

  9. Acute delirium in a critically ill patient may be a wolf in sheep's clothing.

    PubMed

    Lemyze, Malcolm; Favory, Raphael; Alves, Isabelle; Mathieu, Daniel

    2009-01-01

    Acute delirium is a commonly encountered problem in the intensive care unit (ICU), which has a myriad of causes and contributes to poor outcomes. We present the case of an alcoholic critically ill patient who developed prolonged acute ICU delirium wrongly diagnosed as sedation and alcohol withdrawal. Protracted vomiting, swallowing disorders and continuous aspirations prevented him from enteral feeding and discontinuation of mechanical ventilation. After several days, it became clear that the patient had been misdiagnosed. Fortunately, nystagmus and ophthalmoplegia then allowed the recognition of Wernicke's encephalopathy, confirmed by cerebral MRIs. After thiamine supplementation, his state improved but he was discharged only on day 32. Wernicke's encephalopathy is an acute reversible neuropsychiatric emergency, which is falsely considered as uncommon, and is largely misdiagnosed, especially in critically ill patients. Thiamine should be systematically given to all critically ill alcoholic patients, especially those with protracted vomiting. PMID:21686461

  10. Acceptance of illness and satisfaction with life among malaria patients in rivers state, Nigeria

    PubMed Central

    2014-01-01

    Background Health condition is one of the basic factors affecting satisfaction with life, and the level of illness acceptance. The purpose of the study was to analyse the level of illness acceptance, the level of satisfaction with life among malaria patients, and the level of trust placed in the physician and the nurse. Methods The study employs the method of diagnostic survey based on standardised AIS and SWLS scales, as well as Anderson and Dedricks PPTS and PNTS scales. Results The average AIS level was 12 points, while the average level of SwL at the SWLS scale was 16.5 points. The average level of trust in the physician and the nurse amounted to 50.6 points and 51.4 points, respectively. The correlation between the level of illness acceptance and self-evaluated satisfaction with life was statistically significant, with R?=?0.56. The marital status influenced the level of illness acceptance with p?illness acceptance with p?patients did not accept their illness, while the level of satisfaction with life was low. The majority of respondents trusted their physician and nurse. There is a statistically significant correlation between the level of illness acceptance and the self-evaluated satisfaction with life. The marital status had a statistically significant effect on the acceptance of illness and the satisfaction with life. The individuals who had a job demonstrated higher levels of quality of life and illness acceptance. PMID:24885562

  11. Bedside percutaneous tracheostomy experience with 72 critically ill patients.

    PubMed

    Kahveci, S F; Goren, S; Kutlay, O; Ozcan, B; Korfali, G

    2000-11-01

    Tracheostomy is necessary in intensive care unit (ICU) patients requiring prolonged mechanical ventilation. As an alternative to the standard surgical method, percutaneous techniques are available. Seventy-two patients were electively selected for percutaneous tracheostomy (PCT) in a nine-bed combined medical-surgical intensive care unit. PCT was performed at bedside with the Portex Percutaneous Tracheostomy Kit that uses the Griggs technique. The procedure time and early complications were recorded. The procedure was successful in all patients. The average duration of placement was 7.4 min. There were no tracheostomy-related deaths. Major bleeding occurred in three patients and required surgical intervention. In one patient, minor bleeding occurred at the stoma site that resolved with applied pressure. Wound infections were treated with local antiseptics in two patients. These findings suggest that PCT is a simple, quick and safe procedure. PMID:11029567

  12. Biomarkers in Hepatic Disease: A Review Focused on Critically Ill Patients.

    PubMed

    Kubilay, Nejla Zeynep; Sengel, Buket Erturk; Wood, Kenneth E; Layon, A Joseph

    2016-02-01

    The ability to make a diagnosis early and appropriately is paramount for the survival of the critically ill ICU patient. Along with the myriad physical examination and imaging modalities available, biomarkers provide a window on the disease process. Herein we review hepatic biomarkers in the context of the critical care patient. PMID:25324195

  13. Dental Hygiene Students' Preparation for Treatment of Patients with Mental Illnesses.

    ERIC Educational Resources Information Center

    Lemon, Sherry; Reveal, Marge

    1991-01-01

    A survey of 138 dental hygiene programs gathered information on didactic and clinical experiences for preparing students to treat patients with mental illnesses. Although most curricula addressed the issue, inadequate time was allotted. Over half did not provide oral care to these patients; few felt the community's need was met. (MSE)

  14. Physicians' Nonverbal Rapport Building and Patients' Talk About the Subjective Component of Illness.

    ERIC Educational Resources Information Center

    Duggan, Ashley P.; Parrott, Roxanne L.

    2001-01-01

    Considers how physicians' nonverbal communication is sometimes associated with patients' affective satisfaction. Examines the relationship between physicians' nonverbal rapport building and patients' disclosure of information related to the subjective component of illness. Considers implications for understanding the role of physicians' nonverbal

  15. Physicians' Nonverbal Rapport Building and Patients' Talk About the Subjective Component of Illness.

    ERIC Educational Resources Information Center

    Duggan, Ashley P.; Parrott, Roxanne L.

    2001-01-01

    Considers how physicians' nonverbal communication is sometimes associated with patients' affective satisfaction. Examines the relationship between physicians' nonverbal rapport building and patients' disclosure of information related to the subjective component of illness. Considers implications for understanding the role of physicians' nonverbal…

  16. Surveillance of 16 respiratory viruses in patients with influenza-like illness in Nanjing, China.

    PubMed

    Huo, Xiang; Qin, Yuanfang; Qi, Xian; Zu, Rongqiang; Tang, Fenyang; Li, Liang; Hu, Zhibin; Zhu, Fengcai

    2012-12-01

    Much less is known about the etiology of influenza-like illness in China. A continuous surveillance of 16 respiratory viruses was conducted from November 2010 to October 2011 of outpatients with influenza-like illness in Nanjing, China. The two largest general hospitals and a provincial virus laboratory in Nanjing participated in this study. Throat swabs were collected from outpatients during medical visits for influenza-like illness and were tested for 16 respiratory viruses using PCR. Three hundred seventeen viruses were detected in samples from 246 (50.6%) patients with influenza-like illness. The viruses found mostly commonly were influenza, rhinovirus, hCoV HKU1, and adenovirus. The identification rates of respiratory viruses differed significantly among different sampling seasons (P = 0.0002). The rates of influenza A and hCoV HKU1 were much higher during the influenza-like illness winter peak than during the influenza-like illness summer peak and other months. Co-infections were detected in 57 (11.7%) patients and were found most commonly in adults older than 60 years. RSV was detected in 5.9% and 2.6% of patients who were 0-5 and 6-15 years old, respectively, but was not detected in other age groups. This study confirmed that multiple respiratory viruses may circulate concurrently in the population and account for a large proportion of influenza-like illness. In addition to influenza virus, hCoV HKU1 may be associated with the influenza-like illness winter peak in Nanjing, China. PMID:23080506

  17. Palliative care versus euthanasia. The German position: the German General Medical Council's principles for medical care of the terminally ill.

    PubMed

    Sahm, S W

    2000-04-01

    In September 1998 the Bundesärztekammer, i.e., the German Medical Association, published new principles concerning terminal medical care. Even before publication, a draft of these principles was very controversial, and prompted intense public debate in the mass media. Despite some of the critics' suspicions that the principles prepared the way for liberalization of active euthanasia, euthanasia is unequivocally rejected in the principles. Physician-assisted suicide is considered to violate professional medical rules. In leaving aside some of the notions customarily used in the euthanasia debate, e.g., passive euthanasia, the principles emphasize the obligation of physicians to offer and the right of patients to receive palliative care. The principles explicitly list modalities of basic treatment that are indispensable in all cases, such as the obligation to satisfy hunger and thirst. This statement is meant to resolve the dispute on nutrition and hydration at the end of life, as it shifts the focus of care from maintaining physiological parameters to satisfying subjective needs. For patients in a persistent vegetative state, artificial feeding is held to be obligatory. Yet, the principles make reference to recent German jurisdiction which permit the stopping of artificial feeding if it is in accordance with the patient's presumed will. Additionally, the wording concerning this issue is found to remain unclear. Patients' autonomy is strengthened by explicitly welcoming advance directives as a means to ascertain patients' wills. The principles mark some changes compared to earlier documents. They deserve careful analysis and should be considered in the international debate on issues concerning the end of life. PMID:10833136

  18. [Economic considerations in critically ill intensive care patients].

    PubMed

    Kremer, B; Hckstdt, A; Wawersik, J

    1996-01-01

    Since 1992 the data for all patients referred to our ICU have been entered on computer and analyzed for parameters relevant to therapeutic effectiveness on the one hand and cost-containment on the other. The analysis of data for 5424 patients concerning APACHE II-score, age, number of ICU days, time of mechanical ventilation and/or hemodialysis, cardio-respiratory complications and insufficiency, ICU discharge date and hospital discharge date demonstrates a profile or our intensive care services using all resources efficiently. The data revealed no ethically acceptable parameter or necessity to include economic considerations in medical decisions which had to be taken for individual patients and situations. PMID:9101860

  19. Congregate living for the mentally ill: patients as tenants.

    PubMed

    Burger, A S; Kimelman, L; Lurie, A; Rabiner, C J

    1978-09-01

    The authors describe an apartment-living project for chronic mental patients released from the Hillside Division of the Long Island Jewish-Hillside Medical Center. The apartments, which are rented by the hospital and sublet to the patients, are located in modern, well-maintained high-rise buildings within commuting distance from the hospital. To avoid creating a psychiatric ghetto, the project rents no more than two apartments in buildings of a hundred or more units. The hospital was able to rent the apartments by assuring the landlords that the hospital would be a financially responsible tenant and that staff would be in continuing contact with the patients, would be available to the landlords if problems arose, and would remove troublesome tenants. Some of the problems encountered by the patients in the program are described, as are guidelines for selecting those who have a reasonable chance of benefiting from such a program. PMID:208956

  20. Use of complementary and alternative therapies to promote sleep in critically ill patients.

    PubMed

    Richards, Kathy; Nagel, Corey; Markie, Megan; Elwell, Jean; Barone, Claudia

    2003-09-01

    The efficacy of complementary and alternative therapies for sleep promotion in critically ill patients is largely unexamined. We found only seven studies (three on environmental interventions and one each on massage, music therapy, therapeutic touch, and, melatonin) that examined the effect of complementary and alternative therapies. A number of studies, however, have shown that massage, music therapy. and therapeutic touch promote relaxation and comfort in critically ill patients, which likely leads to improved sleep. Massage, music therapy, and therapeutic touch are safe for critically ill patients and should be routinely applied by ICU nurses who have received training on how to administer these specialized interventions. Environmental interventions, such as reducing noise, playing white noise such as ocean sounds, and decreasing interruptions to sleep for care, also are safe and logical interventions that ICU nurses should use to help patients sleep. Progressive muscle relaxation has been extensively studied and shown to be efficacious for improving sleep in persons with insomnia; however, progressive muscle relaxation requires that patients consciously attend to relaxing specific muscle groups and practice these techniques, which may be difficult for critically 11 patients. We do not currently recommend aromatherapy and alternative sedatives, such as valerian and melatonin, for sleep promotion in critically ill patients because the safety of these substances is unclear. In summary, we recommend that ICU nurses implement music therapy, environmental interventions, therapeutic touch, and relaxing massage to promote sleep in critically ill patients. These interventions are safe and may improve patient sleep, although randomized controlled trials are needed to test their efficacy. Aromatherapy and alternative sedatives require further investigation to determine their safety and efficacy. PMID:12943139

  1. Ketoconazole hepatotoxicity in a patient treated for environmental illness and systemic candidiasis

    SciTech Connect

    Brusko, C.S.; Marten, J.T. )

    1991-12-01

    Environmental illness, a hypothesized disease caused by exposure to substances such as combustion products, pesticides, food additives, and Candida albicans, is discussed. The case of a patient with environmental illness and systemic candidiasis for six weeks with ketoconazole, liver enzyme concentrations increased. One month after discontinuation of ketoconazole, the liver enzyme concentrations decreased; however, over the next five months, liver enzymes and bilirubin increased. The patient developed encephalopathy and eventually was transferred to a medical center for possible liver transplant. A review of the literature pertaining to ketoconazole hepatotoxicity is also presented.16 references.

  2. [A religious sect, its mental ill patients, its physician and its psychiatrists].

    PubMed

    Bourgeois, M; Khaleff, M; Labrousse, D

    1975-01-01

    A religious Sect (Jhovah witness), its mental patients, its doctor and its psychiatrists. The authors study religious sects, specially Jhovoah witness. Such 15 mentally ill patients among this group have been treated at the psychiatric clinic. The fact that they are members of a community, sharing the same religious faith, and having in common severe rules of life, is considered as having a pathogenic or beneficial effect. One of them, physician, explain their opinion of mental illness : they believe in biological factors and discard any psychotherapeutic mean. PMID:1163915

  3. Management of critically ill patients with type 2 diabetes: The need for personalised therapy

    PubMed Central

    Kar, Palash; Jones, Karen L; Horowitz, Michael; Deane, Adam M

    2015-01-01

    Critical illness in patients with pre-existing diabetes frequently causes deterioration in glycaemic control. Despite the prevalence of diabetes in patients admitted to hospital and intensive care units, the ideal management of hyperglycaemia in these groups is uncertain. There are data that suggest that acute hyperglycaemia in critically ill patients without diabetes is associated with increased mortality and morbidity. Exogenous insulin to keep blood glucose concentrations < 10 mmol/L is accepted as standard of care in this group. However, preliminary data have recently been reported that suggest that chronic hyperglycaemia may result in conditioning, which protects these patients against damage mediated by acute hyperglycaemia. Furthermore, acute glucose-lowering to < 10 mmol/L in patients with diabetes with inadequate glycaemic control prior to their critical illness appears to have the capacity to cause harm. This review focuses on glycaemic control in critically ill patients with type 2 diabetes, the potential for harm from glucose-lowering and the rationale for personalised therapy. PMID:26069718

  4. Anemia and blood transfusion in the critically ill patient: role of erythropoietin

    PubMed Central

    2004-01-01

    Critically ill patients receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all patients admitted to intensive care units receive at least 1 red blood cell (RBC) unit during their stay, and the average is close to 5 RBC units. RBC transfusion is not risk free. There is little evidence that 'routine' transfusion of stored allogeneic RBCs is beneficial to critically ill patients. The efficacy of perioperative recombinant human erythropoietin (rHuEPO) has been demonstrated in a variety of elective surgical settings. Similarly, in critically ill patients with multiple organ failure, rHuEPO therapy will also stimulate erythropoiesis. In a randomized, placebo-controlled trial, therapy with rHuEPO resulted in a significant reduction in RBC transfusions. Despite receiving fewer RBC transfusions, patients in the rHuEPO group had a significantly greater increase in hematocrit. Strategies to increase the production of RBCs are complementary to other approaches to reduce blood loss in the intensive care unit, and they decrease the transfusion threshold in the management of all critically ill patients. PMID:15196323

  5. Vitamin D deficiency is independently associated with mortality among critically ill patients

    PubMed Central

    Moraes, Rafael Barberena; Friedman, Gilberto; Wawrzeniak, Iuri Christmann; Marques, Leonardo S.; Nagel, Fabiano Mrcio; Lisboa, Thiago Costa; Czepielewski, Mauro Antonio

    2015-01-01

    OBJECTIVE: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients. METHOD: In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity. RESULTS: Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity. CONCLUSIONS: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients. PMID:26039948

  6. Building trustworthy relationships with critically ill patients and families.

    PubMed

    Rushton, Cynda Hylton; Reina, Michelle L; Reina, Dennis S

    2007-01-01

    A difficult case study involving repeated health crises and irreversible organ dysfunction illustrates the challenges critical care professionals face in caring for patients and their families. In such cases, trust is especially fragile, and coexists with its counterpart, betrayal. The Reina Trust & Betrayal Model defines 3 types of Transactional Trust. The first, Competence Trust, or the Trust of Capability, requires that clinicians practice humility, engage in inquiry, honor the patient's choices, and express compassion. The second, Contractual Trust, or the Trust of Character, demands that clinicians keep agreements, manage expectations, establish boundaries, and encourage mutually serving expectations. The third, Communication Trust, or the Trust of Disclosure, must be rooted in respect and based on truth-telling. Particularly in life-and-death situations, communication requires honesty and clarity. Each type of trust involves specific behaviors that build trust and can guide critical care professionals as they interact with patients and their families. PMID:17284945

  7. Pharmacokinetics of liposomal amphotericin B (Ambisome) in critically ill patients.

    PubMed Central

    Heinemann, V; Bosse, D; Jehn, U; Kähny, B; Wachholz, K; Debus, A; Scholz, P; Kolb, H J; Wilmanns, W

    1997-01-01

    The liposomal formulation of amphotericin B (AmBisome) greatly reduces the acute and chronic side effects of the parent drug. The present study describes the pharmacokinetic characteristics of AmBisome applied to 10 patients at a dose of 2.8 to 3.0 mg/kg of body weight and compares them to the pharmacokinetics observed in 6 patients treated with amphotericin B deoxycholate at the standard dose of 1.0 mg/kg. Interpatient variabilities of amphotericin B peak concentrations (Cmax) and areas under concentration-time curves (AUC) were 8- to 10-fold greater for patients treated with AmBisome than for patients treated with amphotericin B deoxycholate. At the threefold greater dose of AmBisome, median Cmaxs were 8.4-fold higher (14.4 versus 1.7 microg/ml) and median AUCs exceeded those observed with amphotericin B deoxycholate by 9-fold. This was in part explained by a 5.7-fold lower volume of distribution (0.42 liters/kg) in AmBisome-treated patients. The elimination of amphotericin B from serum was biphasic for both formulations. However, the apparent half-life of elimination was twofold shorter for AmBisome (P = 0.03). Neither hemodialysis nor hemofiltration had a significant impact on AmBisome pharmacokinetics as analyzed in one patient. In conclusion, the liposomal formulation of amphotericin B significantly (P = 0.001) reduces the volume of drug distribution, thereby allowing for greater drug concentrations in serum. The low toxicity of AmBisome therefore cannot readily be explained by its serum pharmacokinetics. PMID:9174183

  8. The economic impact of the insured patients with severe chronic and acute illnesses: a qualitative approach

    PubMed Central

    Aji, Budi; Yamamoto, Shelby Suzanne; Sauerborn, Rainer

    2014-01-01

    Background Little research has focused on the economic hardship among the insured with severe illnesses and high treatment costs, in particular, the consequence of poorer insurance coverage for high-cost illnesses. Therefore, we presented the case for identifying the experiences of insured patients with severe chronic and acute illnesses. This study identified a qualitative understanding of the economic impact of severe chronic and acute illnesses and household strategies to deal with high treatment costs. Design Interviews were conducted with 19 insured households of three different health insurance programs with a family member that had been hospitalized for severe chronic or acute illnesses in either Banyumas or Margono Sukarjo hospitals in Banyumas, Central Java, Indonesia. A thematic analysis was applied to guide the interpretation of the data. Results Insured households with a family member that had been hospitalized for severe chronic and acute illnesses were greatly affected by the high treatment costs. Four major issues emerged from this qualitative study: insured patients are still burdened with high out-of-pocket payments, households adopt various strategies to cope with the high cost of treatments, households experience financial hardships, and positive and negative perceptions of the insured regarding their health insurance coverage for acute and chronic illnesses. Conclusions Askes and Jamsostek patients faced financial burdens from high cost sharing for hospital amenities, non-covered drugs, and treatments and other indirect costs. Meanwhile, Jamkesmas beneficiaries faced no financial burden for related medical services but were rather burdened with indirect costs for the carers. Households relied on internal resources to cover hospital bills as the first strategy, which included the mobilization of savings, sale of assets, and borrowing of money. External support was tapped secondarily and included financial support from extended family members, donations from neighbors and the community, and additional benefits from employers. However, insured households overall had positive perceptions of insurance. PMID:25308817

  9. Impaired High-Density Lipoprotein Anti-Oxidant Function Predicts Poor Outcome in Critically Ill Patients

    PubMed Central

    Schrutka, Lore; Goliasch, Georg; Meyer, Brigitte; Wurm, Raphael; Koller, Lorenz; Kriechbaumer, Lukas; Heinz, Gottfried; Pacher, Richard; Lang, Irene M

    2016-01-01

    Introduction Oxidative stress affects clinical outcome in critically ill patients. Although high-density lipoprotein (HDL) particles generally possess anti-oxidant capacities, deleterious properties of HDL have been described in acutely ill patients. The impact of anti-oxidant HDL capacities on clinical outcome in critically ill patients is unknown. We therefore analyzed the predictive value of anti-oxidant HDL function on mortality in an unselected cohort of critically ill patients. Method We prospectively enrolled 270 consecutive patients admitted to a university-affiliated intensive care unit (ICU) and determined anti-oxidant HDL function using the HDL oxidant index (HOI). Based on their HOI, the study population was stratified into patients with impaired anti-oxidant HDL function and the residual study population. Results During a median follow-up time of 9.8 years (IQR: 9.2 to 10.0), 69% of patients died. Cox regression analysis revealed a significant and independent association between impaired anti-oxidant HDL function and short-term mortality with an adjusted HR of 1.65 (95% CI 1.22–2.24; p = 0.001) as well as 10-year mortality with an adj. HR of 1.19 (95% CI 1.02–1.40; p = 0.032) when compared to the residual study population. Anti-oxidant HDL function correlated with the amount of oxidative stress as determined by Cu/Zn superoxide dismutase (r = 0.38; p<0.001). Conclusion Impaired anti-oxidant HDL function represents a strong and independent predictor of 30-day mortality as well as long-term mortality in critically ill patients. PMID:26978526

  10. Modalities of Invasive Arterial Pressure Monitoring in Critically Ill Patients

    PubMed Central

    Jacq, Gwenalle; Gritti, Karine; Carr, Ccile; Fleury, Nadge; Lang, Annie; Courau-Courtois, Josette; Bedos, Jean-Pierre; Legriel, Stephane

    2015-01-01

    Few studies assessed modalities of invasive arterial pressure monitoring (IAPM). We evaluated effects on measured values of various combinations of transducer level, catheter access site, and patient position. Prospective observational study in consecutive adults admitted to a French intensive care unit in 2009 to 2011 and fulfilling our inclusion criteria. Four combinations (BE) of transducer level, catheter access site, and patient position were compared with a reference combination (A) (A: patient supine with all catheters in the same plane and a single transducer level (M) for zero point reference (Z) aligned on the phlebostatic axis; B: 45 head-of-bed elevation with M and Z aligned on the phlebostatic axis; C: 45 head-of-bed elevation with M aligned on the catheter access site and Z on the phlebostatic axis; D: 45 head-of-bed elevation with M and Z aligned on the catheter access site; and E: 45 head-of-bed elevation with M aligned on the phlebostatic axis and Z on the catheter access site). We included 103 patients, 68 men and 35 women, with a median age of 69 years (interquartile range [IQR], 5678); at inclusion, 91 (88.3%) received mechanical ventilation, 45 (43.7%) catecholamines, and 66 (64.1%) sedation. The IAPM access site was femoral in 49 (47.6%) and radial in 54 (52.4%) patients, with 62 of 103 (60.2%) catheters on the right side. Measured absolute mean arterial pressure values were significantly higher with 3 study combinations (CE) than with the reference combination (A). After adjustment, the differences versus A (median, 83 [IQR, 7492]?mm Hg) remained significant for D (median, 91 [IQR, 85100]?mm Hg, P?patients in the 45 head-of-bed elevation position, aligning the Z on the phlebostatic axis provides values that are not significantly different from those obtained using the reference supine modality. PMID:26426625

  11. Heart-related anxieties in relation to general anxiety and severity of illness in cardiology patients.

    PubMed

    Muschalla, Beate; Glatz, Johannes; Linden, Michael

    2014-01-01

    Absence of an adequate reason for anxiety is a criterion for pathological anxiety. However, the presence of danger or fear-provoking stimuli may even be a risk factor for anxiety and does not exclude that there is additionally pathological anxiety too. The question is, to what degree can heart-related anxiety be explained by the severity of illness or trait anxiety? Two hundred and nine patients (37.8% women) from a cardiology inpatient unit completed the Heart-Anxiety-Questionnaire, Progression-Anxiety-Questionnaire, Job-Anxiety-Scale and the State-Trait-Anxiety-Inventory. The severity of cardiac illness was rated by the treating cardiologists using the Multidimensional Severity of Morbidity Rating. Time absent from work due to sickness was assessed as an indicator for illness-related impairment. Heart anxiety was significantly related to progression anxiety and, to a lesser extent, trait anxiety and indicators of subjective symptoms of somatic illness. No association was found with medical ratings for prognosis, multimorbidity, or reduction in life expectancy. Heart-related anxiety is a symptom of an anxiety disorder. Although partially dependent on subjective suffering, it cannot be explained by the severity of medical illness. Treatment of health-related anxieties should focus on how to cope with subjective symptoms of illness. PMID:23473360

  12. Feeding critically ill patients the right 'whey': thinking outside of the box. A personal view.

    PubMed

    Marik, Paul E

    2015-12-01

    Atrophy of skeletal muscle mass is an almost universal problem in survivors of critical illness and is associated with significant short- and long-term morbidity. Contrary to common practice, the provision of protein/amino acids as a continuous infusion significantly limits protein synthesis whereas intermittent feeding maximally stimulates skeletal muscle synthesis. Furthermore, whey-based protein (high in leucine) increases muscle synthesis compared to soy or casein-based protein. In addition to its adverse effects on skeletal muscle synthesis, continuous feeding is unphysiological and has adverse effects on glucose and lipid metabolism and gastrointestinal function. I propose that critically ill patients' be fed intermittently with a whey-based formula and that such an approach is likely to be associated with better glycemic control, less hepatic steatosis and greater preservation of muscle mass. This paper provides the scientific basis for my approach to intermittent feeding of critically ill patients. PMID:26055186

  13. Reduced Responsiveness of Blood Leukocytes to Lipopolysaccharide Does not Predict Nosocomial Infections in Critically Ill Patients.

    PubMed

    van Vught, Lonneke A; Wiewel, Maryse A; Hoogendijk, Arie J; Scicluna, Brendon P; Belkasim-Bohoudi, Hakima; Horn, Janneke; Schultz, Marcus J; van der Poll, Tom

    2015-08-01

    Critically ill patients show signs of immune suppression, which is considered to increase vulnerability to nosocomial infections. Whole-blood stimulation is frequently used to test the function of the innate immune system. We here assessed the association between whole-blood leukocyte responsiveness to lipopolysaccharide (LPS) and subsequent occurrence of nosocomial infections in critically ill patients admitted to the intensive care unit (ICU). All consecutive critically ill patients admitted to the ICU between April 2012 and June 2013 with two or more systemic inflammatory response syndrome criteria and an expected length of ICU stay of more than 24 h were enrolled. Age- and sex-matched healthy individuals were included as controls. Blood was drawn the first morning after ICU admission and stimulated ex vivo with 100 ng/mL ultrapure LPS for 3 h. Tumor necrosis factor-α, interleukin-1β (IL-1β), and IL-6 were measured in supernatants. Seventy-three critically ill patients were included, of whom 10 developed an ICU-acquired infection. Compared with healthy subjects, whole-blood leukocytes of patients were less responsive to ex vivo stimulation with LPS, as reflected by strongly reduced tumor necrosis factor-α, IL-1β, and IL-6 levels in culture supernatants. Results were not different between patients who did and those who did not develop an ICU-acquired infection. The extent of reduced LPS responsiveness of blood leukocytes in critically ill patients on the first day after ICU admission does not relate to the subsequent development of ICU-acquired infections. These results argue against the use of whole-blood stimulation as a functional test applied early after ICU admission to predict nosocomial infection. PMID:25895151

  14. Redox Changes Induced by General Anesthesia in Critically Ill Patients with Multiple Traumas

    PubMed Central

    Papurica, Marius; Rogobete, Alexandru Florin; Sandesc, Dorel; Dumache, Raluca; Nartita, Radu; Sarandan, Mirela; Cradigati, Alina Carmen; Luca, Loredana; Vernic, Corina; Bedreag, Ovidiu Horea

    2015-01-01

    The critically ill polytrauma patient is a constant challenge for the trauma team due to the complexity of the complications presented. Intense inflammatory response and infections, as well as multiple organ dysfunctions, significantly increase the rate of morbidity and mortality in these patients. Moreover, due to the physiological and biochemical imbalances present in this type of patients, the bioproduction of free radicals is significantly accelerated, thus installing the oxidative stress. In the therapeutic management of such patients, multiple surgical interventions are required and therefore they are being subjected to repeated general anesthesia. In this paper, we want to present the pathophysiological implications of oxidative stress in critically ill patients with multiple traumas and the implications of general anesthesia on the redox mechanisms of the cell. We also want to summarize the antioxidant treatments able to reduce the intensity of oxidative stress by modulating the biochemical activity of some cellular mechanisms. PMID:26693352

  15. Imprecision in medical communication: study of a doctor talking to patients with serious illness.

    PubMed Central

    Skelton, J R; Murray, J; Hobbs, F D

    1999-01-01

    Uncertainty is believed to be a central feature in illness experiences. Conversations between a consultant hematologist and 61 seriously ill patients were transcribed, entered on a database and scrutinized for patterns of language uncertainty by linguistic concordancing analysis. Transcripts were then discussed in detail with the hematologist, and techniques of protocol analysis were used to gain insight into his thought processes during consultations. The main findings were that the doctor used many more expressions of uncertainty than did patients: that evaluative terms were widely used to reassure rather than to worry patients; and that patients and doctor together used certain key terms ambiguously, in a manner which allowed the doctor to feel that facts were not misrepresented while perhaps permitting the patient to feel reassured. PMID:10692882

  16. The Role of Time-Limited Trials in Dialysis Decision Making in Critically Ill Patients.

    PubMed

    Scherer, Jennifer S; Holley, Jean L

    2016-02-01

    Technologic advances, such as continuous RRT, provide lifesaving therapy for many patients. AKI in the critically ill patient, a fatal diagnosis in the past, is now often a survivable condition. Dialysis decision making for the critically ill patient with AKI is complex. What was once a question solely of survival now is nuanced by an individual's definition of quality of life, personal values, and short- and long-term prognoses. Clinical evaluation of AKI in the critically ill is multifaceted. Treatment decision making requires consideration of the natural evolution of the patient's AKI within the context of the global prognosis. Situations are often marked by prognostic uncertainty and clinical unknowns. In the face of these uncertainties, establishment of patient-directed therapies is imperative. A time-limited trial of continuous RRT in this setting is often appropriate but difficult to execute. Using patient preferences as a clinical guide, a proper time-limited trial requires assessment of prognosis, elicitation of patient values, strong communication skills, clear documentation, and often, appropriate integration of palliative care services. A well conducted time-limited trial can avoid interprofessional conflict and provide support for the patient, family, and staff. PMID:26450932

  17. Atrial fibrillation is an independent predictor of mortality in critically ill patients

    PubMed Central

    Shaver, Ciara M.; Chen, Wei; Janz, David R.; May, Addison K.; Darbar, Dawood; Bernard, Gordon R.; Bastarache, Julie A.; Ware, Lorraine B.

    2016-01-01

    Objective Atrial fibrillation (AF) has been associated with increased mortality in critically-ill patients. We sought to determine whether AF in the intensive care unit (ICU) is an independent risk factor for death. A secondary objective was to determine if patients with new-onset AF have different risk factors or outcomes compared to patients with a previous history of AF. Design Prospective observational cohort study. Setting Medical and general surgical ICUs in a tertiary academic medical center. Patients 1,770 critically-ill patients requiring at least 2 days in the ICU. Interventions None. Measurements Demographics, medical history, development of AF, fluid balance, echocardiographic findings, medication administration, and hospital mortality were collected during the first four days of ICU admission. Main Results AF occurred in 236 (13%) patients (Any AF). Of these, 123 patients (7%) had no prior AF (New-onset AF) while the remaining 113 (6%) had Recurrent AF. Any AF was associated with male gender, Caucasian race, increased age, cardiac disease, organ failures, and disease severity. Patients with Any AF had increased mortality compared to those without AF (31% vs. 17%, p <0.001) and Any AF was independently associated with death (OR 1.62, 95% CI 1.14-2.29, p=0.007) in multivariable analysis controlling for severity of illness and other confounders. The association of AF with death was magnified in patients without sepsis (OR 2.92, 95% CI 1.52-5.60, p=0.001). Treatment for AF had no effect on hospital mortality. New-onset AF and Recurrent AF were each associated with increased mortality. New-onset AF, but not Recurrent AF, was associated with increased diastolic dysfunction and vasopressor use and a greater cumulative positive fluid balance. Conclusions AF in critical illness, whether new-onset or recurrent, is independently associated with increased hospital mortality, especially in patients without sepsis. PMID:26154932

  18. Individualization of Piperacillin Dosing for Critically Ill Patients: Dosing Software To Optimize Antimicrobial Therapy

    PubMed Central

    Felton, T. W.; Roberts, J. A.; Lodise, T. P.; Van Guilder, M.; Boselli, E.; Neely, M. N.

    2014-01-01

    Piperacillin-tazobactam is frequently used for empirical and targeted therapy of infections in critically ill patients. Considerable pharmacokinetic (PK) variability is observed in critically ill patients. By estimating an individual's PK, dosage optimization Bayesian estimation techniques can be used to calculate the appropriate piperacillin regimen to achieve desired drug exposure targets. The aim of this study was to establish a population PK model for piperacillin in critically ill patients and then analyze the performance of the model in the dose optimization software program BestDose. Linear, with estimated creatinine clearance and weight as covariates, Michaelis-Menten (MM) and parallel linear/MM structural models were fitted to the data from 146 critically ill patients with nosocomial infection. Piperacillin concentrations measured in the first dosing interval, from each of 8 additional individuals, combined with the population model were embedded into the dose optimization software. The impact of the number of observations was assessed. Precision was assessed by (i) the predicted piperacillin dosage and by (ii) linear regression of the observed-versus-predicted piperacillin concentrations from the second 24 h of treatment. We found that a linear clearance model with creatinine clearance and weight as covariates for drug clearance and volume of distribution, respectively, best described the observed data. When there were at least two observed piperacillin concentrations, the dose optimization software predicted a mean piperacillin dosage of 4.02 g in the 8 patients administered piperacillin doses of 4.00 g. Linear regression of the observed-versus-predicted piperacillin concentrations for 8 individuals after 24 h of piperacillin dosing demonstrated an r2 of >0.89. In conclusion, for most critically ill patients, individualized piperacillin regimens delivering a target serum piperacillin concentration is achievable. Further validation of the dosage optimization software in a clinical trial is required. PMID:24798288

  19. Fluid and electrolyte overload in critically ill patients: An overview

    PubMed Central

    Besen, Bruno Adler Maccagnan Pinheiro; Gobatto, André Luiz Nunes; Melro, Lívia Maria Garcia; Maciel, Alexandre Toledo; Park, Marcelo

    2015-01-01

    Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renal protection from endogenous and exogenous substances, for the safe dilution of medications and as “maintenance” fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities (hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit length-of-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit. PMID:25938027

  20. Illness representations, psychological distress and non-cardiac chest pain in patients attending an emergency department

    PubMed Central

    Webster, R.; Norman, P.; Goodacre, S.; Thompson, A.R.; McEachan, R.R.C.

    2014-01-01

    Objective: Many patients who attend an emergency department (ED) with chest pain receive a diagnosis of non-cardiac chest pain (NCCP), and often suffer poor psychological outcomes and continued pain. This study assessed the role of illness representations in explaining psychological distress and continued chest pain in patients attending an ED. Methods: ED NCCP patients (N = 138) completed measures assessing illness representations, anxiety, depression and quality of life (QoL) at baseline, and chest pain at one month. Results: Illness representations explained significant amounts of the variance in anxiety (Adj. R² = .38), depression (Adj. R² = .18) and mental QoL (Adj. R² = .36). A belief in psychological causes had the strongest associations with outcomes. At one month, 28.7% of participants reported experiencing frequent pain, 13.2% infrequent pain and 58.1% no pain. Anxiety, depression and poor QoL, but not illness representations, were associated with continued chest pain. Conclusions: The findings suggest that (i) continued chest pain is related to psychological distress and poor QoL, (ii) interventions should be aimed at reducing psychological distress and improving QoL and (iii) given the associations between perceived psychological causes and psychological distress/QoL, NCCP patients in the ED might benefit from psychological therapies to manage their chest pain. PMID:24831735

  1. Hospice Comics: Representations of Patient and Family Experience of Illness and Death in Graphic Novels.

    PubMed

    Czerwiec, Mk; Huang, Michelle N

    2014-08-20

    Non-fiction graphic novels about illness and death created by patients and their loved ones have much to teach all readers. However, the bond of empathy made possible in the comic form may have special lessons for healthcare providers who read these texts and are open to the insights they provide. PMID:25138207

  2. Pretherapy Expectations and Definitions of Mental Illness among Minority and Low-Income Patients.

    ERIC Educational Resources Information Center

    Acosta, Frank X.

    1979-01-01

    Notes similarities and differences of pretherapy expectations for psychotherapists, length of time in therapy, and definitions of mental illness among 44 Mexican American and 48 Anglo American low income out-patients at an East Los Angeles mental health clinic. (SB)

  3. Adults Living with Limited Literacy and Chronic Illness: Patient Education Experiences

    ERIC Educational Resources Information Center

    King, Judy; Taylor, Maurice C.

    2010-01-01

    The purpose of this study was to investigate how Canadian adults living with limited literacy and chronic illness made meaning of their patient education experiences. The study used a hermeneutic phenomenological research design and employed three data sources over a nine-month period. Data was interpreted and analyzed as it was collected,

  4. Relationship Between Upper Respiratory Tract Influenza Test Result and Clinical Outcomes Among Critically Ill Influenza Patients

    PubMed Central

    Reddy, Krishna P.; Bajwa, Ednan K.; Parker, Robert A.; Onderdonk, Andrew B.; Walensky, Rochelle P.

    2016-01-01

    Among critically ill patients with lower respiratory tract (LRT)-confirmed influenza, we retrospectively observed worse 28-day clinical outcomes in upper respiratory tract (URT)-negative versus URT-positive subjects. This finding may reflect disease progression and highlights the need for influenza testing of both URT and LRT specimens to improve diagnostic yield and possibly inform prognosis. PMID:26966696

  5. Adults Living with Limited Literacy and Chronic Illness: Patient Education Experiences

    ERIC Educational Resources Information Center

    King, Judy; Taylor, Maurice C.

    2010-01-01

    The purpose of this study was to investigate how Canadian adults living with limited literacy and chronic illness made meaning of their patient education experiences. The study used a hermeneutic phenomenological research design and employed three data sources over a nine-month period. Data was interpreted and analyzed as it was collected,…

  6. Pharmacological and nonpharmacological management of delirium in critically ill patients.

    PubMed

    Hipp, Dustin M; Ely, E Wesley

    2012-01-01

    Delirium is a common yet under-diagnosed syndrome of acute brain dysfunction, which is characterized by inattention, fluctuating mental status, altered level of consciousness, or disorganized thinking. Although our recognition of risk factors for delirium has progressed, our understanding of the underlying pathophysiologic mechanisms remains limited. Improvements in monitoring and assessment for delirium (particularly in the intensive care setting) have resulted in validated and reliable tools such as arousal scales and bedside delirium monitoring instruments. Once delirium is recognized and the modifiable risk factors are addressed, the next step in management (if delirium persists) is often pharmacological intervention. The sedatives, analgesics, and hypnotics most often used in the intensive care unit (ICU) to achieve patient comfort are all too frequently deliriogenic, resulting in a longer duration of ICU and hospital stay, and increased costs. Therefore, identification of safe and efficacious agents to reduce the incidence, duration, and severity of ICU delirium is a hot topic in critical care. Recognizing that there are no medications approved by the Food and Drug Administration (FDA) for the prevention or treatment of delirium, we chose anti-psychotics and alpha-2 agonists as the general pharmacological focus of this article because both were subjects of relatively recent data and ongoing clinical trials. Emerging pharmacological strategies for addressing delirium must be combined with nonpharmacological approaches (such as daily spontaneous awakening trials and spontaneous breathing trials) and early mobility (combined with the increasingly popular approach called: Awakening and Breathing Coordination, Delirium Monitoring, Early Mobility, and Exercise [ABCDE] of critical care) to develop evidence-based approaches that will ensure safer and faster recovery of the sickest patients in our healthcare system. PMID:22270810

  7. Recommendations to Facilitate Expanded Access to Investigational Therapies for Seriously Ill Patients.

    PubMed

    Jerome, Rebecca N; Edwards, Terri L; Boswell, Haley C; Bernard, Gordon R; Harris, Paul A; Pulley, Jill M

    2016-03-01

    When clinical trial enrollment is not an option for seriously ill patients whose illnesses have not responded to approved treatment options, those patients and their physicians may consider gaining access to investigational therapies through a pathway established by the Food and Drug Administration (FDA) called expanded access. However, recent events have highlighted the challenging dynamics involved in accessing investigational therapies through expanded access that include a complex interplay of factors involving the patient, physician, drug company, FDA, and, increasingly, social media.The authors offer several potential strategies to streamline what is otherwise an arduous process for all involved. (1) The drug company should prospectively determine whether it will establish an expanded access program for specific drugs. (2) A central clearinghouse for companies should support registration of expanded access drugs for suitable patients. (3) The determination of whether a patient fits criteria would be made by an independent review board of clinicians. (4) An independent coordinating center is needed; academic health centers are ideally suited for that role. (5) Adequate financing of the costs of therapy need to be in place to make expanded access a reality, given frequent lack of payer coverage for therapies. (6) Further enhancement of regulatory pathways, approaches, or rules would promote expanded access. (7) Patients should explicitly acknowledge the limited data available. (8) There should be a shared, secure, technical platform to facilitate expanded access.All the authors' strategies present important prospects for improving treatment options for the most seriously ill patients. PMID:26445080

  8. Retrospective review on obstetric cases of critically ill and dead patients in Dongguan.

    PubMed

    Shen, Li-Han; Fang, Yun-Yong; Zheng, Yan-Bing; Xiao, Li-Juan; Huang, Su-Ran; Liu, Xi-Zhen; Cai, Li-Hua

    2015-03-01

    This retrospective analysis was set to understand the epidemiological status of the critically ill obstetric patients in Dongguan city, Guangdong, China. Understanding the risk factors for the death cases can provide scientific evidences for future preventive strategies to decrease the maternal mortality rate. This retrospective included the statistical data and clinical data on the cases of critically ill and dead obstetric patients admitted to Dongguan People's Hospital and Dongguan Maternal & Child Health Hospital from September 1st, 2009 to August 31st, 2013. Data included numbers of the critically ill maternal and obstetric women, common obstetric and maternal comorbidities and complications in the critically ill patients, the basic characteristics of maternal and obstetric deaths, records of regular prenatal examinations, the time intervals between onset of acute symptoms and ICU admission, blood purification, and the acute physiology and chronic health evaluation II (APACHE II) score. During the 5-year period, there were increasing trend of critically ill pregnant and obstetric patients, and the prevalence rate of critically ill obstetric patients was 8.99-9.28 %. The most common obstetric causes of admission were massive postpartum hemorrhage (63.54 %), followed by pregnancy-associated hypertension (15.85 %) and placenta previa (8.92 %). The most common non-obstetric causes of admission were acute heart failure (1.98 %). In the observed period, 20 critically ill obstetric patients died in these two hospitals (mortality rate 0.24 %, 20/8,129). The mean age of dead women was (30.3 6.6) years old and mean gestational age was (30.1 9.3) weeks. 75 % of the patient had more than two pregnancies. Over 90 % of the patients received education below junior high school level. 85 % of the patients were non-Dongguan natives and regular prenatal care rate was only 15 % on dead cases. The most common causes of death were pregnancy-associated hypertension, acute heart failure, and massive postpartum hemorrhage. The dead patients experienced longer interval between onset of acute symptoms and ICU admission (media = 62.5 h), higher APACHE II score (25.4 5.4), and lower blood purification treatment rate (10 %). The incidence of critically ill pregnant and obstetric patients is high in Dongguan city. The group of dead obstetric patients, the majority of which were non-Dongguan natives, usually experienced above-average pregnancies, lower educational level, lower regular prenatal care rate, and longer interval between onset of acute symptoms and ICU admission. Critically ill obstetric patients may benefit from publicized informed relevant education, government-supported health care, preventative interventions of critical obstetric and medical complications, timely ICU admission after onset of acute symptoms, and the enhanced support of organ functions within the ICU. PMID:25315638

  9. DANGER IN THE INTENSIVE CARE UNIT: DAMPS IN CRITICALLY ILL PATIENTS.

    PubMed

    Timmermans, Kim; Kox, Matthijs; Scheffer, Gert Jan; Pickkers, Peter

    2016-02-01

    Danger-associated molecular patterns (DAMPs) that are released by injured, threatened, or dead cells, or that originate from the extracellular matrix, influence the immune system. This is of great relevance in critically ill patients, in whom trauma or surgery-related cell damage, hypoxia, ischemia, and infections can result in extensive release of DAMPs. As many patients at the intensive care unit suffer from immune system-related complications, DAMPs could serve as markers for the prognosis of these patients and represent possible therapeutic targets. In the present review, we provide an overview of several well known DAMPs (high-mobility group box 1, heat-shock proteins, s100 proteins, nucleic acids, and hyaluronan) and their effects on the immune system. Furthermore, we discuss the role of DAMPs as markers or therapeutic targets in several conditions frequently encountered in critically ill patients, such as sepsis, trauma, ventilator-induced lung injury, and cardiac arrest. PMID:26513703

  10. Assessing Capacity in Psychiatric Patients With Acute Medical Illness Who Refuse Care

    PubMed Central

    Spike, Jeffrey P.

    2014-01-01

    Three cases are presented that demonstrate the difficulty of assessing medical decision-making capacity in patients with psychiatric illness who are refusing care. Health professionals often assess capacity differently in practice. Provided their patients have some understanding of their illness and have some plans for meeting basic needs, psychiatrists are often inclined to give patients the freedom to refuse care even if they do not exhibit a full understanding of the medical facts of their case and why they are refusing it. Adult medicine physicians, in contrast, are inclined to require patients to state a more complete understanding of the benefits and burdens of evaluation and treatment before allowing them to refuse care when their refusals might result in adverse medical outcomes. The 3 cases exemplify the tension between these approaches and highlight the role of hospital ethics consultation in addressing this conflict. PMID:25834754

  11. Families of chronically mentally ill patients: their structure, coping resources, and tolerance for deviant behavior.

    PubMed

    Axelrod, J; Geismar, L; Ross, R

    1994-11-01

    The attitudes of families toward caring for a mentally ill member in the home are explored through in-depth interviews with 105 families of chronically ill psychiatric patients from a public and a private hospital. Family readiness, defined as having the ability and the willingness to supervise the patient, was measured by the St. Paul Scale of Family Functioning and the Tolerance of Deviant Behavior Scale. Findings revealed a significant relationship between the respondent's belief in his or her ability to manage the behavior of the patient and willingness to accept the patient into the home as measured by tolerance for deviant behavior. No significant relationships were found between family resources, level of functioning, income, or community connectedness. Implications for practice and study limitations are discussed. PMID:7813965

  12. The impact of stigma of mental illness in a Canadian community: a survey of patients experiences.

    PubMed

    Oleniuk, Ashley; Duncan, C Randy; Tempier, Raymond

    2013-02-01

    We examined stigma experiences and its impact among patients (n = 41) hospitalized for mental illness. We studied their characteristics contributing to the expectation, intensity, and frequency of stigma they could experience. Opinions were compared on the Experiences with the Stigma of Mental Illness scale measuring stigma experiences and impact. There were differences on perceived stigma in: being 19 years or younger at first symptom or treatment, having had one previous psychiatric hospitalizations and having attended one or more outpatient sessions. Those having attended outpatient sessions, being previously hospitalized or younger suffered more impact. PMID:22052428

  13. Anemia and transfusion in critically ill pediatric patients: a review of etiology, management, and outcomes.

    PubMed

    Sloniewsky, Daniel

    2013-04-01

    This article describes the incidence and etiology of anemia in critically ill children. In addition, the article details the pathophysiology and clinical ramifications of anemia in this population. The use of transfused packed red blood cells as a therapy for anemia in critically ill patients is also discussed, including the indications for and complications associated with this practice as well as potential reasons for these complications. Finally, the article lists some therapeutic practices that may lessen the risks associated with transfusion, and briefly discusses the use of blood substitutes. PMID:23537677

  14. [Pulmonary-renal crosstalk in the critically ill patient].

    PubMed

    Donoso F, Alejandro; Arriagada S, Daniela; Cruces R, Pablo

    2015-01-01

    Despite advances in the development of renal replacement therapy, mortality of acute renal failure remains high, especially when occurring simultaneously with distant organic failure as it is in the case of the acute respiratory distress syndrome. In this update, birideccional deleterious relationship between lung and kidney on the setting of organ dysfunction is reviewed, which presents important clinical aspects of knowing. Specifically, the renal effects of acute respiratory distress syndrome and the use of positive-pressure mechanical ventilation are discussed, being ventilator induced lung injury one of the most common models for studying the lung-kidney crosstalk. The role of renal failure induced by mechanical ventilation (ventilator-induced kidney injury) in the pathogenesis of acute renal failure is emphasized. We also analyze the impact of the acute renal failure in the lung, recognizing an increase in pulmonary vascular permeability, inflammation, and alteration of sodium and water channels in the alveolar epithelial. This conceptual model can be the basis for the development of new therapeutic strategies to use in patients with multiple organ dysfunction syndrome. PMID:26338439

  15. Disseminated enteroinvasive aspergillosis in a critically ill patient without severe immunocompromise

    PubMed Central

    Fieber, Jennifer H.; Atladóttir, Jórunn; Solomon, Daniel G.; Maerz, Linda L.; Reddy, Vikram; Mitchell-Richards, Kisha; Longo, Walter E.

    2013-01-01

    Invasive aspergillosis (IA) is a rapidly progressive and often fatal infectious disease described classically in patients who are highly immunocompromised. However, there has been increasing evidence that IA may affect critically ill patients without traditional risk factors. We present a case of a 47-year-old man without conventional risk factors for IA who presented with impending sepsis and proceeded to have a complicated hospital course with a postmortem diagnosis of invasive gastrointestinal aspergillosis of the small bowel. PMID:24968426

  16. Disseminated enteroinvasive aspergillosis in a critically ill patient without severe immunocompromise.

    PubMed

    Fieber, Jennifer H; Atladóttir, Jórunn; Solomon, Daniel G; Maerz, Linda L; Reddy, Vikram; Mitchell-Richards, Kisha; Longo, Walter E

    2013-01-01

    Invasive aspergillosis (IA) is a rapidly progressive and often fatal infectious disease described classically in patients who are highly immunocompromised. However, there has been increasing evidence that IA may affect critically ill patients without traditional risk factors. We present a case of a 47-year-old man without conventional risk factors for IA who presented with impending sepsis and proceeded to have a complicated hospital course with a postmortem diagnosis of invasive gastrointestinal aspergillosis of the small bowel. PMID:24968426

  17. Self-Management: Enabling and empowering patients living with cancer as a chronic illness

    PubMed Central

    McCorkle, Ruth; Ercolano, Elizabeth; Lazenby, Mark; Schulman-Green, Dena; Schilling, Lynne S.; Lorig, Kate; Wagner, Edward H.

    2010-01-01

    With recent improvements in early detection, diagnosis and treatment of cancer, people with cancer are living longer, and their cancer may be managed as a chronic illness. Cancer as a chronic illness places new demands on patients and families to manage their own care, and it challenges old paradigms that oncology's work is done after treatment. As a chronic illness, however, cancer care occurs on a continuum that stretches from prevention to the end of life, with early detection, diagnosis, treatment, and survivorship in between. In this paper, we review self-management interventions that enable patients and families to participate in managing their care along this continuum. We review randomized controlled trials of self-management interventions with cancer patients and families in the treatment, survivorship, and end-of-life phases of the cancer-care continuum. We also present the Chronic Care Model as a model of care that oncology practices can use to enable and empower patients and families to engage in self-management. We conclude that, the need for a common language by which to speak about self-management and a common set of self-management actions for cancer care notwithstanding, oncology practices can now build strong relationships with their patients and formulate mutually-agreed upon care plans that enable and empower patients to care for themselves in the way they prefer. PMID:21205833

  18. Duplex directed caval filter insertion in multi-trauma and critically ill patients.

    PubMed

    Sato, D T; Robinson, K D; Gregory, R T; Gayle, R G; Parent, F N; DeMasi, R J; Meier, G H; Sorrell, K A; Goff, C D; Weireter, L J; Riblet, J L

    1999-07-01

    This study was undertaken to determine the safety and feasibility of inferior vena cava (IVC) filter insertion at the bedside using duplex imaging in multi-trauma and/or critically ill patients. From February 1996 to August 1997, 53 multi-trauma and/or critically ill patients, who were in the intensive care unit and referred for an IVC filter, were prospectively evaluated for possible duplex directed caval filter (DDCF) insertion. Screening IVC duplex scans were performed in all patients. Satisfactory ultrasound visualization in 46 patients (87%) allowed attempted DDCF insertion. All procedures were percutaneously performed at the bedside using Vena Tech IVC filters. The results from this series showed that DDCF insertion can be safely and rapidly performed at the bedside in multi-trauma or critically ill patients. The procedure is dependent on satisfactory visualization of the IVC by duplex ultrasonography, which was possible in 45 out of 53 (85%) patients. Insertion at the bedside substantially reduces the procedural cost and avoids the need for transport, radiation exposure, and intravenous contrast. PMID:10398732

  19. Low dose adrenocorticotropic hormone test and adrenal insufficiency in critically ill acquired immunodeficiency syndrome patients

    PubMed Central

    Shashidhar, P. K.; Shashikala, G. V.

    2012-01-01

    Context: Prevalence of adrenal insufficiency (AI) is not uncommon in HIV infected population. However, AI is rarely diagnosed in clinical practice because many patients have non-specific symptoms and signs. Critical illness in such patients further complicates the evaluation of adrenal function. A 1μgm ACTH test can be used for diagnosis, since it results in more physiological levels of ACTH. A serum cortisol of <18 μg/dL, 30 or 60-minutes after ACTH test has been accepted as indicative of AI, but many experts advocate the normal cortisol response should exceed 25 μg/dL, in critically ill patients. Aim: To determine the prevalence of AI in critically ill AIDS patients, by using 1 μg ACTH test and also, to compare the diagnostic criteria for adrenal insufficiency between cortisol response of <18 μg/dL and <25 μg/dL. Settings and Design: This prospective study was done in the Department of Medicine. Materials and Methods: After taking blood for basal plasma cortisol from AIDS affected fifty adult men and women aged over 18 yrs, 1 μg ACTH was given intravenously, and blood samples were again collected at 30 and 60 minutes for plasma cortisol estimation. Statistical analysis: It was done by Mann-Whitney test. Results: Prevalence of AI was 74% (37 patients) and 92% (46 patients), when the peak stimulated cortisol level of <18 μg/dL and <25 μg/dL, respectively, was used. Conclusion: AI is more prevalent in critically ill AIDS patients. Hence, this test can be performed for early intervention and better management. PMID:22629505

  20. Screening and risk factors of exocrine pancreatic insufficiency in critically ill adult patients receiving enteral nutrition

    PubMed Central

    2013-01-01

    Introduction Malnutrition is a frequent problem associated with detrimental clinical outcomes in critically ill patients. To avoid malnutrition, most studies focus on the prevention of inadequate nutrition delivery, whereas little attention is paid to the potential role of exocrine pancreatic insufficiency (EPI). In this trial, we aim to evaluate the prevalence of EPI and identify its potential risk factors in critically ill adult patients without preexisting pancreatic diseases. Methods In this prospective cross-sectional study, we recruited 563 adult patients with critical illnesses. All details of the patients were documented, stool samples were collected three to five days following the initiation of enteral nutrition, and faecal elastase 1 (FE-1) concentrations were assayed using an enzyme-linked immunosorbent assay kit. Blood samples were also taken to determine serum amylase and lipase activity. Results The percentages of recruited patients with EPI (FE-1 concentration <200 ?g/g) and severe EPI (FE-1 concentration <100 ?g/g) were 52.2% and 18.3%, respectively. The incidences of steatorrhea were significantly different (P < 0.05) among the patients without EPI, with moderate EPI (FE-1 concentration = 100 to 200 ?g/g) and severe EPI (FE-1 concentration < 100 ?g/g). Both multivariate logistic regression analysis and z-tests indicated that the occurrence of EPI was closely associated with shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis. Conclusions More than 50% of critically ill adult patients without primary pancreatic diseases had EPI, and nearly one-fifth of them had severe EPI. The risk factors for EPI included shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis. Trial registration NCT01753024 PMID:23924602

  1. Perspectives of Decisional Surrogates and Patients Regarding Critical Illness Genetic Research

    PubMed Central

    Freeman, Bradley D.; Bolcic-Jankovic, Dragana; Kennedy, Carie R.; LeBlanc, Jessica; Eastman, Alexander; Barillas, Jennifer; Wittgen, Catherine M.; indsey, Kathryn; Mahmood, Rumel S.; Clarridge, Brian R.

    2015-01-01

    Background Critical illness research is challenging due to disease severity and because patients are frequently incapacitated. Surrogates called upon to provide consent might not accurately represent patient preferences. Though commonplace, genetic data collection adds complexity in this context. We undertook this investigation to understand whether surrogate decision makers would be receptive to permitting participation in a critical illness genetics study and whether their decision making was consistent with that of the patient represented. Methods We invited individuals identified as surrogates for critically ill adults, if required, as well as patients once recovered to participate in a survey designed to understand attitudes about genetic research. Associations between dependent (receptivity to participation, concordance of responses) and independent variables were tested using bivariate and multivariate logistic regression analyses. Results Most of the entire surrogate sample (n=439) reported familiarity with research, including genetic research; tended to view research as useful; and were receptive to allowing their family member participate (with 39.6% and 38.1% stating that this would be very and somewhat likely, respectively) even absent direct benefit. Willingness to participate was similar comparing genetic and non-genetic studies (?2 [1,n=439]=0.00127, p=0.972), though respondents expressed worry regarding lack of confidentiality of genetic data. Responses were concordant in 70.8% of the 192 surrogate-patient pairs analyzed. In multivariate analysis, African American race was associated with less receptivity to genetic data collection (p<0.05). No factors associated with concordance of surrogate-patient response were identified. Conclusions Surrogates receptivity to critical illness research was not influenced by whether the study entailed collection of genetic data. While more than two-thirds of surrogate-patient responses for participation in genetics research were concordant, concerns expressed regarding genetic data often related to breach of confidentiality. Emphasizing safeguards in place to minimize such breeches might prove an effective strategy for enhancing recruitment.

  2. Surviving Critical Illness: The Acute Respiratory Distress Syndrome as Experienced by Patients and Their Caregivers

    PubMed Central

    Cox, Christopher E.; Docherty, Sharron L.; Brandon, Debra H.; Whaley, Christie; Attix, Deborah K.; Clay, Alison S.; Dore, Daniel V.; Hough, Catherine L.; White, Douglas B.; Tulsky, James A.

    2009-01-01

    Objective Survivors of the acute respiratory distress syndrome (ARDS), a systemic critical illness, often report poor quality of life based on responses to standardized questionnaires. However, the experiences of ARDS survivors have not been reported. Our objective was to characterize the effects of critical illness in the daily lives and functioning of ARDS survivors. Design, Setting, and Patients We recruited consecutively 31 ARDS survivors and their informal caregivers from medical and surgical intensive care units of an academic medical center and a community hospital. Eight patients died before completing interviews. We conducted semi-structured interviews with 23 ARDS survivors and 24 caregivers three to nine months after ICU admission, stopping enrollment after thematic saturation was reached. Transcripts were analyzed using Colaizzi’s qualitative methodology to identify significant ways in which survivors’ critical illness experience impacted their lives. Measurements and Main Results Participants related five key elements of experience as survivors of ARDS: pervasive memories of critical care, day to day impact of new disability, critical illness defining the sense of self, relationship strain and change, and ability to cope with disability. Survivors described remarkable disability that persisted for months. Caregivers’ interviews revealed substantial strain from caregiving responsibilities, as well as frequent symptom minimization by patients. Conclusions The diverse and unique experiences of ARDS survivors reflect the global impact of severe critical illness. We have identified symptom domains important to ARDS patients that are not well represented in existing health outcomes measures. These insights may aid the development of targeted interventions to enhance recovery and return of function after ARDS. PMID:19865004

  3. Comparison of the RIFLE, AKIN and KDIGO criteria to predict mortality in critically ill patients

    PubMed Central

    Levi, Talita Machado; de Souza, Srgio Pinto; de Magalhes, Janine Garcia; de Carvalho, Mrcia Sampaio; Cunha, Andr Luiz Barreto; Dantas, Joo Gabriel Athayde de Oliveira; Cruz, Marlia Galvo; Guimares, Yasmin Laryssa Moura; Cruz, Constana Margarida Sampaio

    2013-01-01

    Objective Acute kidney injury is a common complication in critically ill patients, and the RIFLE, AKIN and KDIGO criteria are used to classify these patients. The present study's aim was to compare these criteria as predictors of mortality in critically ill patients. Methods Prospective cohort study using medical records as the source of data. All patients admitted to the intensive care unit were included. The exclusion criteria were hospitalization for less than 24 hours and death. Patients were followed until discharge or death. Student's t test, chi-squared analysis, a multivariate logistic regression and ROC curves were used for the data analysis. Results The mean patient age was 64 years old, and the majority of patients were women of African descent. According to RIFLE, the mortality rates were 17.74%, 22.58%, 24.19% and 35.48% for patients without acute kidney injury (AKI) in stages of Risk, Injury and Failure, respectively. For AKIN, the mortality rates were 17.74%, 29.03%, 12.90% and 40.32% for patients without AKI and at stage I, stage II and stage III, respectively. For KDIGO 2012, the mortality rates were 17.74%, 29.03%, 11.29% and 41.94% for patients without AKI and at stage I, stage II and stage III, respectively. All three classification systems showed similar ROC curves for mortality. Conclusion The RIFLE, AKIN and KDIGO criteria were good tools for predicting mortality in critically ill patients with no significant difference between them. PMID:24553510

  4. Management of acute cholecystitis in critically ill patients: contemporary role for cholecystostomy and subsequent cholecystectomy.

    PubMed

    Morse, Bryan C; Smith, J Brandon; Lawdahl, Richard B; Roettger, Richard H

    2010-07-01

    The diagnosis of acute cholecystitis in critically ill patients carries a high mortality rate. Although decompression and drainage of the gallbladder through a cholecystostomy tube may be used as a temporary treatment of acute cholecystitis in this population, there is still some debate about the management of the tube and the subsequent need for a cholecystectomy. This series evaluates the clinical course and outcomes of critically ill patients who underwent the insertion of cholecystostomy tubes for the initial treatment of acute cholecystitis. This is a retrospective review of critically ill patients admitted to the hospital intensive care unit who were diagnosed with acute cholecystitis and underwent a cholecystostomy tube as a temporary treatment for the disease. Patients were identified through the Greenville Hospital System electronic medical records coding database. Medical records were reviewed for demographic data, diagnoses, imaging, complications, and outcomes. From January 2002 through June 2008, 50 patients were identified for the study. The mean age was 72 +/- 11 years, and the majority (66%) were men. The following comorbidities were found: severe cardiovascular disease (40 patients), respiratory failure (30 patients), and multisystem organ dysfunction (30 patients). The mean intensive care unit length of stay (LOS) was 16 +/- 9 days, and the mean hospital LOS was 28 +/- 27 days. At 30 days, the morbidity associated with the cholecystostomy tube itself was 4 per cent, but overall in-hospital morbidity and mortality rates were 62 and 50 per cent, respectively. Of the 25 patients who survived longer than 30 days, 12 retained their cholecystostomy tubes until they underwent cholecystectomy (four open, seven laparoscopic). All of the remaining 13 patients had their cholecystostomy tubes removed, and eight developed recurrent cholecystitis. Of these patients with recurrent of cholecystitis, five had cholecystectomy or repeat cholecystostomy, but the remaining three patients died. Although this is a small patient population, these data suggest that, in critically ill patients, cholecystostomy tubes should remain in place until the patient is deemed medically suitable to undergo cholecystectomy. Removal of the cholecystostomy tube without subsequent cholecystectomy is associated with a high incidence of recurrent cholecystitis and devastating consequences. PMID:20698375

  5. Quality indicators on the use of antimicrobials in critically ill patients.

    PubMed

    Vera, P; Palomar, M; lvarez-Lerma, F

    2014-12-01

    Quality indicators have been applied to many areas of health care in recent years, including intensive care. However, they have not been specifically developed and validated for antimicrobial use in critically ill patients. Antimicrobials play a key role in intensive care units not only in the prognosis of each individual patient, but also in the development of resistance and changes in the flora in this setting. Evaluating the use of these agents is complex in the intensive care unit, however, because the indications vary greatly and antimicrobial treatment is often changed during admission. We designed and developed specific quality indicators regarding the use of antimicrobials in critically ill patients admitted to the intensive care unit. These indicators are proposed as a tool for application in intensive care units to detect problems in the use of antimicrobials. Future trials are needed, however, to validate these indicators in a large population over time. PMID:25241269

  6. Nutrition therapy in critically ill patients- a review of current evidence for clinicians.

    PubMed

    Ridley, Emma; Gantner, Dashiell; Pellegrino, Vincent

    2015-08-01

    The provision of nutrition to critically ill patients is internationally accepted as standard of care in intensive care units (ICU). Nutrition has the potential to positively impact patient outcomes, is relatively inexpensive compared to other commonly used treatments, and is increasingly identified as a marker of quality ICU care. Furthermore, we are beginning to understand its true potential, with positive and deleterious consequences when it is delivered inappropriately. As with many areas of medicine the evidence is rapidly changing and often conflicting, making interpretation and application difficult for the individual clinician. This narrative review aims to provide an overview of the major evidence base on nutrition therapy in critically ill patients and provide practical suggestions. PMID:25616601

  7. Muscle chemistry of critically ill surgical patients and the effects of a course of intravenous nutrition.

    PubMed

    King, R F; Collins, J P; Morgan, D B; Hill, G L

    1978-07-01

    The water, electrolyte and nitrogen contents of muscle were measured in 15 critically ill surgical patients before and after a course (approximately 2 weeks) of intravenous nutrition and in 8 normal individuals. The muscle from the surgical patients contained a significantly increased ratio of water to fat-free dry weight (P less than 0.01) due to an increase in the proportion of extracellular to intracellular water, and this was not corrected by intravenous nutrition. These changes could be due to an accumulation of extracellular fluid alone or to a loss of cell cytoplasm or a loss of whole muscle fibres. Intracellular chemistry was normal in the ill surgical patients and was not changed by intravenous nutrition. PMID:96905

  8. Candidemia in the critically ill: initial therapy and outcome in mechanically ventilated patients

    PubMed Central

    2013-01-01

    Background Mortality among critically ill patients with candidemia is very high. We sought to determine whether the choice of initial antifungal therapy is associated with survival among these patients, using need for mechanical ventilatory support as a marker of critical illness. Methods Cohort analysis of outcomes among mechanically ventilated patients with candidemia from the 24 North American academic medical centers contributing to the Prospective Antifungal Therapy (PATH) Alliance registry. Patients were included if they received either fluconazole or an echinocandin as initial monotherapy. Results Of 5272 patients in the PATH registry at the time of data abstraction, 1014 were ventilated and concomitantly had candidemia, with 689 eligible for analysis. 28-day survival was higher among the 374 patients treated initially with fluconazole than among the 315 treated with an echinocandin (66% versus 51%, P?patients with albicans infection (hazard ratio .62, 95% CI .44.88). While not statistically significant, fluconazole appeared to be associated with higher mortality among patients infected with glabrata (HR 1.13, 95% CI .701.84). Conclusions Among ventilated patients with candidemia, those receiving fluconazole as initial monotherapy were significantly more likely to survive than those treated with an echinocandin. This difference persisted after adjustment for non-treatment factors. PMID:24172136

  9. Hemoglobin levels and transfusions in neurocritically ill patients: a systematic review of comparative studies

    PubMed Central

    2012-01-01

    Introduction Accumulating evidence suggests that, in critically ill patients, a lower hemoglobin transfusion threshold is safe. However, the optimal hemoglobin level and associated transfusion threshold remain unknown in neurocritically ill patients. Methods We conducted a systematic review of comparative studies (randomized and nonrandomized) to evaluate the effect of hemoglobin levels on mortality, neurologic function, intensive care unit (ICU) and hospital length of stay, duration of mechanical ventilation, and multiple organ failure in adult and pediatric neurocritically ill patients. We searched MEDLINE, The Cochrane Central Register of Controlled Trials, Embase, Web of Knowledge, and Google Scholar. Studies focusing on any neurocritical care conditions were included. Data are presented by using odds ratios for dichotomous outcomes and mean differences for continuous outcomes. Results Among 4,310 retrieved records, six studies met inclusion criteria (n = 537). Four studies were conducted in traumatic brain injury (TBI), one in subarachnoid hemorrhage (SAH), and one in a mixed population of neurocritically ill patients. The minimal hemoglobin levels or transfusion thresholds ranged from 7 to 10 g/dl in the lower-Hb groups and from 9.3 to 11.5 g/dl in the higher-Hb groups. Three studies had a low risk of bias, and three had a high risk of bias. No effect was observed on mortality, duration of mechanical ventilation, or multiple organ failure. In studies reporting on length of stay (n = 4), one reported a significant shorter ICU stay (mean, -11.4 days (95% confidence interval, -16.1 to -6.7)), and one, a shorter hospital stay (mean, -5.7 days (-10.3 to -1.1)) in the lower-Hb groups, whereas the other two found no significant association. Conclusions We found insufficient evidence to confirm or refute a difference in effect between lower- and higher-Hb groups in neurocritically ill patients. Considering the lack of evidence regarding long-term neurologic functional outcomes and the high risk of bias of half the studies, no recommendation can be made regarding which hemoglobin level to target and which associated transfusion strategy (restrictive or liberal) to favor in neurocritically ill patients. PMID:22471943

  10. Impact of supplementation with amino acids or their metabolites on muscle wasting in patients with critical illness or other muscle wasting illness: a systematic review.

    PubMed

    Wandrag, L; Brett, S J; Frost, G; Hickson, M

    2015-08-01

    Muscle wasting during critical illness impairs recovery. Dietary strategies to minimise wasting include nutritional supplements, particularly essential amino acids. We reviewed the evidence on enteral supplementation with amino acids or their metabolites in the critically ill and in muscle wasting illness with similarities to critical illness, aiming to assess whether this intervention could limit muscle wasting in vulnerable patient groups. Citation databases, including MEDLINE, Web of Knowledge, EMBASE, the meta-register of controlled trials and the Cochrane Collaboration library, were searched for articles from 1950 to 2013. Search terms included 'critical illness', 'muscle wasting', 'amino acid supplementation', 'chronic obstructive pulmonary disease', 'chronic heart failure', 'sarcopenia' and 'disuse atrophy'. Reviews, observational studies, sport nutrition, intravenous supplementation and studies in children were excluded. One hundred and eighty studies were assessed for eligibility and 158 were excluded. Twenty-two studies were graded according to standardised criteria using the GRADE methodology: four in critical care populations, and 18 from other clinically relevant areas. Methodologies, interventions and outcome measures used were highly heterogeneous and meta-analysis was not appropriate. Methodology and quality of studies were too varied to draw any firm conclusion. Dietary manipulation with leucine enriched essential amino acids (EAA), ?-hydroxy-?-methylbutyrate and creatine warrant further investigation in critical care; EAA has demonstrated improvements in body composition and nutritional status in other groups with muscle wasting illness. High-quality research is required in critical care before treatment recommendations can be made. PMID:24807079

  11. Content Analysis of the Dreams of Dying Patients.

    ERIC Educational Resources Information Center

    Groth-Marnat, Gary

    1987-01-01

    Investigated dream content of 104 dreams from nine terminally ill patients with estimated life expectancy of one year or less. Found differences between dreams of terminally ill and dreams of physically healthy individuals, suggesting an adaptive withdrawal and process of social and emotional disengagement by terminally ill individuals. (Author/NB)

  12. [Patient-provider communication in chronic illness: current state of research in selected areas].

    PubMed

    Farin, E

    2010-10-01

    Communication between patient and providers is extremely important, especially for the treatment of chronically ill patients, characterized by a biopsychosocial disease model. This article presents an overview of the current status of research on patient-provider communication in 3 selected areas: the communication preferences of chronically ill persons, the correlation between communication and relevant endpoints, and interventions to improve patient-provider communication. One major result of the research is that patients display a rather high degree of inter- and intra-individual variability with respect to the preference of certain communication styles (e.g. patient participation); there are differences among them, and they develop varying preferences in the course of their illness. However, communicative behavior of the provider that is generally perceived by many patients to be positive can also be identified: affective behavior (for example, asking the patient about his/her feelings, being sensitive to these feelings and responding to them), providing information in an understandable, proactive manner, and attempting to understand the patient's perceptions, expectations, and cognitive concepts. Successful communication requires a certain congruence between the patient's communication preferences and the provider's behavior. It has been sufficiently documented in literature that successful communication leads to greater adherence. The correlation to patient satisfaction is not documented quite as clearly but has often been shown. The findings vary with respect to the improvement in the patient's health status. The effectiveness of communication training for providers has been documented quite well regarding the immediate endpoints in patient-provider interaction (e.g., patient-oriented behavior); the evidence with respect to medium-term endpoints such as patient satisfaction varies, also due to the number of possible operationalizations of the endpoints. Supplementing provider training with communication-related training for patients appears to be an important and useful method as many studies have shown that the behavior of providers can be influenced using relatively simple measures that start with the patient. There is a need for further development of research on patient-provider communication, in particular with respect to a more solid theoretical basis, integration of methods including qualitative and quantitative methods, self-evaluations, and interaction analyses, and also concerning conducting more longitudinal studies. PMID:20963669

  13. Predictive Factors for Hospitalization of Patients with Heat Illness in Yamaguchi, Japan

    PubMed Central

    Yamamoto, Takahiro; Todani, Masaki; Oda, Yasutaka; Kaneko, Tadashi; Kaneda, Kotaro; Fujita, Motoki; Miyauchi, Takashi; Tsuruta, Ryosuke

    2015-01-01

    The objective of the study was to investigate the predictive factors for the hospitalization of patients who presented with mild to moderate heat illness at an emergency department. We conducted a retrospective survey of hospitals with an emergency department in Yamaguchi Prefecture, Japan. The survey questionnaire entries included patient age, sex, use of an ambulance, vital signs, blood examination conducted at the emergency department, the length of hospitalization, and outcome. We analyzed the predictive factors for hospitalization in patients with heat illness. A total of 127 patients were analyzed. Of these, 49 (37%) were admitted, with 59% discharged on the day following admission. In univariate analysis, the following inpatient characteristics were predictive for hospitalization: old age, low Glasgow Coma Scale score, elevated body temperature, increased serum C-reactive protein, and increased blood urea nitrogen. In logistic regression multivariate analysis, the following were predictive factors for hospitalization: age of ? 65 years (odds ratio (OR) 4.91; 95% confidence interval (CI) 1.4217.00), body temperature (OR 1.97; 95% CI 1.143.41), Glasgow Coma Scale (OR 0.40; 95% CI 0.160.98), and creatinine (OR 2.92; 95% CI 1.236.94). The results suggest that the elderly with hyperthermia, disturbance of consciousness, and elevated serum creatinine have an increased risk for hospitalization with heat illness. PMID:26393633

  14. Higher Plasma Pyridoxal Phosphate Is Associated with Increased Antioxidant Enzyme Activities in Critically Ill Surgical Patients

    PubMed Central

    Cheng, Chien-Hsiang; Huang, Shih-Chien; Chiang, Ting-Yu; Wong, Yueching

    2013-01-01

    Critically ill patients experience severe stress, inflammation and clinical conditions which may increase the utilization and metabolic turnover of vitamin B-6 and may further increase their oxidative stress and compromise their antioxidant capacity. This study was conducted to examine the relationship between vitamin B-6 status (plasma and erythrocyte PLP) oxidative stress, and antioxidant capacities in critically ill surgical patients. Thirty-seven patients in surgical intensive care unit of Taichung Veterans General Hospital, Taiwan, were enrolled. The levels of plasma and erythrocyte PLP, serum malondialdehyde, total antioxidant capacity, and antioxidant enzyme activities (i.e., superoxide dismutase (SOD), glutathione S-transferase, and glutathione peroxidase) were determined on the 1st and 7th days of admission. Plasma PLP was positively associated with the mean SOD activity level on day 1 (r = 0.42, P < 0.05), day 7 (r = 0.37, P < 0.05), and on changes (Δ (day 7 − day 1)) (r = 0.56, P < 0.01) after adjusting for age, gender, and plasma C-reactive protein concentration. Higher plasma PLP could be an important contributing factor in the elevation of antioxidant enzyme activity in critically ill surgical patients. PMID:23819116

  15. Predictive Factors for Hospitalization of Patients with Heat Illness in Yamaguchi, Japan.

    PubMed

    Yamamoto, Takahiro; Todani, Masaki; Oda, Yasutaka; Kaneko, Tadashi; Kaneda, Kotaro; Fujita, Motoki; Miyauchi, Takashi; Tsuruta, Ryosuke

    2015-09-01

    The objective of the study was to investigate the predictive factors for the hospitalization of patients who presented with mild to moderate heat illness at an emergency department. We conducted a retrospective survey of hospitals with an emergency department in Yamaguchi Prefecture, Japan. The survey questionnaire entries included patient age, sex, use of an ambulance, vital signs, blood examination conducted at the emergency department, the length of hospitalization, and outcome. We analyzed the predictive factors for hospitalization in patients with heat illness. A total of 127 patients were analyzed. Of these, 49 (37%) were admitted, with 59% discharged on the day following admission. In univariate analysis, the following inpatient characteristics were predictive for hospitalization: old age, low Glasgow Coma Scale score, elevated body temperature, increased serum C-reactive protein, and increased blood urea nitrogen. In logistic regression multivariate analysis, the following were predictive factors for hospitalization: age of ? 65 years (odds ratio (OR) 4.91; 95% confidence interval (CI) 1.42-17.00), body temperature (OR 1.97; 95% CI 1.14-3.41), Glasgow Coma Scale (OR 0.40; 95% CI 0.16-0.98), and creatinine (OR 2.92; 95% CI 1.23-6.94). The results suggest that the elderly with hyperthermia, disturbance of consciousness, and elevated serum creatinine have an increased risk for hospitalization with heat illness. PMID:26393633

  16. Early experience with continuous arteriovenous hemofiltration in critically ill pediatric patients.

    PubMed

    Leone, M R; Jenkins, R D; Golper, T A; Alexander, S R

    1986-12-01

    The applicability of continuous arteriovenous hemofiltration (CAVH) for renal replacement therapy was evaluated in three infants and two young children with catastrophic medical and surgical illnesses. In the first four patients, CAVH was used in conjunction with either peritoneal or hemodialysis. In the fifth patient, CAVH was the sole renal replacement therapy employed; in this critically ill anuric infant, we were best able to evaluate the ability of CAVH to continuously control fluid, electrolyte, and acid-base balance, and allow the administration of adequate parenteral nutrition. The difficulties encountered were related to anticoagulation, establishment of adequate vascular access, and selection of an appropriate hemofilter for the performance of the technique. Despite the application of suction-assistance, we were unable to effectively employ a prototype pediatric hemofilter to attain a level of plasma ultrafiltration consistent with the objectives of therapy. However, we were able to effectively and safely employ an adult hemofilter for these purposes; modifications were made in the adult hemofilter system before its application in the smallest pediatric patients. Our experience suggests that, even in critically ill infants, CAVH can be successfully applied as an effective renal replacement therapy. However, further experience is required before its potential impact on patient survival can be assessed. PMID:3780250

  17. Age of red blood cells and transfusion in critically ill patients

    PubMed Central

    2013-01-01

    Red blood cells (RBC) storage facilitates the supply of RBC to meet the clinical demand for transfusion and to avoid wastage. However, RBC storage is associated with adverse changes in erythrocytes and their preservation medium. These changes are responsible for functional alterations and for the accumulation of potentially injurious bioreactive substances. They also may have clinically harmful effects especially in critically ill patients. The clinical consequences of storage lesions, however, remain a matter of persistent controversy. Multiple retrospective, observational, and single-center studies have reported heterogeneous and conflicting findings about the effect of blood storage duration on morbidity and/or mortality in trauma, cardiac surgery, and intensive care unit patients. Describing the details of this controversy, this review not only summarizes the current literature but also highlights the equipoise that currently exists with regard to the use of short versus current standard (extended) storage duration red cells in critically ill patients and supports the need for large, randomized, controlled trials evaluating the clinical impact of transfusing fresh (short duration of storage) versus older (extended duration of storage) red cells in critically ill patients. PMID:23316800

  18. Personal prayer in patients dealing with chronic illness: a review of the research literature.

    PubMed

    Jors, Karin; Bssing, Arndt; Hvidt, Niels Christian; Baumann, Klaus

    2015-01-01

    Background. Prayer is commonly used among patients for health purposes. Therefore, this review focused on three main questions: (1) why do people turn to prayer in times of illness?, (2) what are the main topics of their prayers?, and (3) how do they pray? Method. We undertook a systematic review of the literature by searching the databases PubMed, Medline, and PsycINFO. The following inclusion criteria were used: (1) participants in the study were patients dealing with an illness, (2) the study examined the use of private rather than intercessory prayer, and (3) the content and purpose of prayer rather than its effects were investigated. Results. 16 articles were included in the final review. Participants suffered from a variety of chronic diseases, mostly cancer. Five main categories for the reasons and topics of prayer were found: (1) disease-centered prayer, (2) assurance-centered prayer, (3) God-centered prayer, (4) others-centered prayer, and (5) lamentations. Among these, disease-centered prayer was most common. Conclusions. Although most patients with chronic diseases do pray for relief from their physical and mental suffering, the intention of their prayers is not only for healing. Rather, prayer can be a resource that allows patients to positively transform the experience of their illness. PMID:25815041

  19. Hemodynamic Monitoring in the Critically Ill Patient – Current Status and Perspective

    PubMed Central

    Sakka, Samir G.

    2015-01-01

    In the critically ill patient, early and effective hemodynamic management including fluid therapy and administration of vasoactive drugs to maintain vital organ perfusion and oxygen delivery is mandatory. Understanding the different approaches in the management of critically ill patients during the resuscitation and further management is essential to initiate adequate context- and time-specific interventions. Treatment of hemodynamic variables to achieve a balance between organ oxygen delivery and consumption is the cornerstone. In general, cardiac output is considered a major determinant of oxygen supply and thus its monitoring is regarded helpful. However, indicators of oxygen requirements are equally necessary to assess adequacy of oxygen supply. Currently, more and more less or even totally non-invasive monitoring systems have been developed and clinically introduced, but require validation in this particular patient population. Cardiac output monitors and surrogates of organ oxygenation only enable to adequately guide management, as patient’s outcome is determined by acquisition and interpretation of accurate data, and finally suitable management decisions. This mini-review presents the currently available techniques in the field of hemodynamic monitoring in critically ill patients and briefly summarizes their advantages and limitations. PMID:26284244

  20. Personal Prayer in Patients Dealing with Chronic Illness: A Review of the Research Literature

    PubMed Central

    Jors, Karin; Baumann, Klaus

    2015-01-01

    Background. Prayer is commonly used among patients for health purposes. Therefore, this review focused on three main questions: (1) why do people turn to prayer in times of illness?, (2) what are the main topics of their prayers?, and (3) how do they pray? Method. We undertook a systematic review of the literature by searching the databases PubMed, Medline, and PsycINFO. The following inclusion criteria were used: (1) participants in the study were patients dealing with an illness, (2) the study examined the use of private rather than intercessory prayer, and (3) the content and purpose of prayer rather than its effects were investigated. Results. 16 articles were included in the final review. Participants suffered from a variety of chronic diseases, mostly cancer. Five main categories for the reasons and topics of prayer were found: (1) disease-centered prayer, (2) assurance-centered prayer, (3) God-centered prayer, (4) others-centered prayer, and (5) lamentations. Among these, disease-centered prayer was most common. Conclusions. Although most patients with chronic diseases do pray for relief from their physical and mental suffering, the intention of their prayers is not only for healing. Rather, prayer can be a resource that allows patients to positively transform the experience of their illness. PMID:25815041

  1. Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management.

    PubMed

    Sutton, Lynsey J; Jutel, Annemarie

    2016-02-01

    Management of alcohol withdrawal in critically ill patients is a challenge. The alcohol consumption histories of intensive care patients are often incomplete, limiting identification of patients with alcohol use disorders. Abrupt cessation of alcohol places these patients at risk for alcohol withdrawal syndrome. Typically benzodiazepines are used as first-line therapy to manage alcohol withdrawal. However, if patients progress to more severe withdrawal or delirium tremens, extra adjunctive medications in addition to benzodiazepines may be required. Sedation and mechanical ventilation may also be necessary. Withdrawal assessment scales such as the Clinical Institute of Withdrawal Assessment are of limited use in these patients. Instead, general sedation-agitation scales and delirium detection tools have been used. The important facets of care are the rapid identification of at-risk patients through histories of alcohol consumption, management with combination therapies, and ongoing diligent assessment and evaluation. (Critical Care Nurse. 2016;36[1]:28-39). PMID:26830178

  2. Effect of Parenteral Selenium Supplementation in Critically Ill Patients: A Systematic Review and Meta-Analysis

    PubMed Central

    Huang, Ting-Shuo; Shyu, Yu-Chiau; Chen, Huang-Yang; Lin, Li-Mei; Lo, Chia-Ying; Yuan, Shin-Sheng; Chen, Pei-Jer

    2013-01-01

    Background It is currently unclear whether parenteral selenium supplementation should be recommended in the management of critically ill patients. Here we conducted a systematic review and meta-analysis to assess the efficacy of parenteral selenium supplementation on clinical outcomes. Methods/Principal Findings Randomized trials investigating parenteral selenium supplementation administered in addition to standard of care to critically ill patients were included. CENTRAL, Medline, EMBASE, the Science Citation Index, and CINAHL were searched with complementary manual searches. The primary outcome was all-cause mortality. Trials published in any language were included. Two authors independently extracted data and assessed trial quality. A third author was consulted to resolve disagreements and for quality assurance. Twelve trials were included and meta-analysis was performed on nine trials that recruited critically ill septic patients. These comprised 965 participants in total. Of these, 148 patients (30.7%) in the treatment groups, and 180 patients (37.3%) in control groups died. Parenteral selenium treatment significantly reduced all-cause mortality in critically ill patients with sepsis (relative risk [RR] 0.83, 95% CI 0.700.99, p?=?0.04, I2?=?0%). Subgroup analyses demonstrated that the administration schedule employing longer duration (RR 0.77, 95% CI 0.630.94, p?=?0.01, I2?=?0%), loading boluses (RR 0.73, 95% CI 0.580.94, p?=?0.01, I2?=?0%) or high-dose selenium treatment (RR 0.77, 95% CI 0.610.99, p?=?0.04, I2?=?0%) might be associated with a lower mortality risk. There was no evidence of adverse events. Conclusions/Significance Parenteral selenium supplementation reduces risk of mortality among critically ill patients with sepsis. Owing to the varied methodological quality of the studies, future high-quality randomized trials that directly focus on the effect of adequate-duration of parenteral selenium supplementation for severe septic patients are needed to confirm our results. Clinicians should consider these findings when treating this high-risk population. Systematic Review Registration PROSPERO 2011; CRD42011001768 PMID:23372722

  3. Continuous arteriovenous hemofiltration in the critically ill patient. Clinical use and operational characteristics.

    PubMed

    Lauer, A; Saccaggi, A; Ronco, C; Belledonne, M; Glabman, S; Bosch, J P

    1983-10-01

    Continuous arteriovenous hemofiltration is an extracorporeal technique for the treatment of fluid overload and electrolyte disturbances and for the removal of urea nitrogen. This technique is especially applicable in critically ill patients with hemodynamic instability. A special filter and modified hemodialysis blood lines can easily and rapidly be attached to a patient. No special blood access is needed. Fluids and solutes are removed from the patient by ultrafiltration. A net filtration pressure inside the filter causes an ultrafiltrate to form. The extracorporeal circuit can be kept in place for hours or days. PMID:6625376

  4. Procalcitonin Clearance for Early Prediction of Survival in Critically Ill Patients with Severe Sepsis

    PubMed Central

    Mat Nor, Mohd Basri; Md Ralib, Azrina

    2014-01-01

    Introduction. Serum procalcitonin (PCT) diagnosed sepsis in critically ill patients; however, its prediction for survival is not well established. We evaluated the prognostic value of dynamic changes of PCT in sepsis patients. Methods. A prospective observational study was conducted in adult ICU. Patients with systemic inflammatory response syndrome (SIRS) were recruited. Daily PCT were measured for 3 days. 48 h PCT clearance (PCTc-48) was defined as percentage of baseline PCT minus 48 h PCT over baseline PCT. Results. 95 SIRS patients were enrolled (67 sepsis and 28 noninfectious SIRS). 40% patients in the sepsis group died in hospital. Day 1-PCT was associated with diagnosis of sepsis (AUC 0.65 (95% CI, 0.55 to 0.76)) but was not predictive of mortality. In sepsis patients, PCTc-48 was associated with prediction of survival (AUC 0.69 (95% CI, 0.53 to 0.84)). Patients with PCTc-48 > 30% were independently associated with survival (HR 2.90 (95% CI 1.22 to 6.90)). Conclusions. PCTc-48 is associated with prediction of survival in critically ill patients with sepsis. This could assist clinicians in risk stratification; however, the small sample size, and a single-centre study, may limit the generalisability of the finding. This would benefit from replication in future multicentre study. PMID:24719759

  5. Predictors of mortality in patients with serious mental illness and co-occurring type 2 diabetes.

    PubMed

    Brown, Clayton; Leith, Jaclyn; Dickerson, Faith; Medoff, Deborah; Kreyenbuhl, Julie; Fang, Lijuan; Goldberg, Richard; Potts, Wendy; Dixon, Lisa

    2010-05-15

    Persons with serious mental illness (SMI) have higher rates of chronic medical conditions such as type 2 diabetes and mortality than the general population. We assessed demographic and health related factors in the prediction of all-cause mortality among SMI patients with diabetes and a comparison group of diabetic patients without SMI. From 1999 to 2002, 201 patients with type 2 diabetes and SMI were recruited from community mental health centers and 99 persons with type 2 diabetes and no identified mental illness were recruited from nearby primary clinics. Deaths over an average seven-year period after baseline assessment were identified using the Social Security Administration's Death Master File. Twenty-one percent in each group died over follow-up. Age, smoking status, duration of diabetes, and diabetes-related hospitalization in the 6months prior to baseline assessment predicted mortality in all patients. Among the non-SMI patients, those who were prescribed insulin had over a four-fold greater odds of mortality whereas this association was not found in the SMI patients. Diabetes likely contributes to mortality in persons with SMI. Providers need to be especially vigilant regarding mortality risk when patients require hospitalization for diabetes and as their patients age. Smoking cessation should also be aggressively promoted. PMID:20163874

  6. Assisted suicide in the care of mentally ill patients: the Lucio Magri's case.

    PubMed

    Frati, Paola; Gulino, Matteo; Mancarella, Paola; Cecchi, Rossana; Ferracuti, Stefano

    2014-01-01

    A year after Mario Monicelli's suicide, the death of another famous person in Italy, Lucio Magri, reawakened the Italian debate on social, ethical and juridical issues in end-of-life decisions. Unlike Monicelli, Lucio Magri decided to end his own life in Switzerland with the help of a physician because his mental illness rendered his life unbearable. Both Monicelli and Magri suffered from a severe depression. The authors analyze the ethical issues regarding the right to die for mentally ill patients and neurological disabled patients, discussing the decision-making autonomy in persons suffering from severe depression. The role of the psychiatry in the management of end-of-life decision requests is considered along with pros and cons of suicide prevention and rationale suicide. PMID:24365684

  7. Clustering analysis to identify distinct spectral components of encephalogram burst suppression in critically ill patients.

    PubMed

    Zhou, David W; Westover, M Brandon; McClain, Lauren M; Nagaraj, Sunil B; Bajwa, Ednan K; Quraishi, Sadeq A; Akeju, Oluwaseun; Cobb, J Perren; Purdon, Patrick L

    2015-08-01

    Millions of patients are admitted each year to intensive care units (ICUs) in the United States. A significant fraction of ICU survivors develop life-long cognitive impairment, incurring tremendous financial and societal costs. Delirium, a state of impaired awareness, attention and cognition that frequently develops during ICU care, is a major risk factor for post-ICU cognitive impairment. Recent studies suggest that patients experiencing electroencephalogram (EEG) burst suppression have higher rates of mortality and are more likely to develop delirium than patients who do not experience burst suppression. Burst suppression is typically associated with coma and deep levels of anesthesia or hypothermia, and is defined clinically as an alternating pattern of high-amplitude "burst" periods interrupted by sustained low-amplitude "suppression" periods. Here we describe a clustering method to analyze EEG spectra during burst and suppression periods. We used this method to identify a set of distinct spectral patterns in the EEG during burst and suppression periods in critically ill patients. These patterns correlate with level of patient sedation, quantified in terms of sedative infusion rates and clinical sedation scores. This analysis suggests that EEG burst suppression in critically ill patients may not be a single state, but instead may reflect a plurality of states whose specific dynamics relate to a patient's underlying brain function. PMID:26737967

  8. Mimivirus is not a frequent cause of ventilator-associated pneumonia in critically ill patients.

    PubMed

    Vanspauwen, M J; Schnabel, R M; Bruggeman, C A; Drent, M; van Mook, W N K A; Bergmans, D C J J; Linssen, C F M

    2013-10-01

    Acanthamoeba polyphaga mimivirus (APMV) belongs to the amoebae-associated microorganisms. Antibodies to APMV have been found in patients with pneumonia suggesting a potential role as a respiratory pathogen. In addition, positive serology for APMV was associated with an increased duration of mechanical ventilation and intensive care unit stay in patients with ventilator-associated pneumonia. The aim of the present study was to assess the presence of APMV in bronchoalveolar lavage fluid samples of critically ill patients suspected of ventilator-associated pneumonia. The study was conducted in the intensive care unit of the Maastricht University Medical Centre. All consecutive bronchoalveolar lavage fluid samples obtained between January 2005 and October 2009 from patients suspected of ventilator-associated pneumonia were eligible for inclusion. All samples were analyzed by real-time PCR targeting the APMV. A total of 260 bronchoalveolar lavage fluid samples from 214 patients (139 male, 75 female) were included. Bacterial ventilator-associated pneumonia was confirmed microbiologically in 105 out of 260 (40%) suspected episodes of ventilator-associated pneumonia (86 patients). The presence of APMV DNA could not be demonstrated in the bacterial ventilator-associated pneumonia positive or in the bacterial ventilator-associated pneumonia negative bronchoalveolar lavage fluid samples. Although suspected, APMV appeared not to be present in critically ill patients suspected of ventilator-associated pneumonia, and APMV does not seem to be a frequent cause of ventilator-associated pneumonia. PMID:23861144

  9. Ventilator-associated pneumonia in critically ill patients with intensive antibiotic usage

    PubMed Central

    Bor, Canan; Demirag, Kubilay; Okcu, Ozlem; Cankayali, Ilkin; Uyar, Mehmet

    2015-01-01

    Objective: Ventilator-associated pneumonia (VAP) is an infection with high mortality and morbidity that prolongs the length of stay in the intensive care unit (ICU) and hospitalisation. VAP is one of the most common infections in critically ill patients. This study aimed to prospectively determine the VAP rate and associated factors in critically ill patients with intensive antibiotic usage during a one-year period. Methods: In total, 125 out of 360 patients admitted to the intensive care unit during the one-year study period (September 2010-2011) were included for follow-up for VAP diagnosis. Demographic data, APACHE II scores, diagnoses on admission, clinical pulmonary infection scores (CPIS), CRP, procalcitonin, risk factors for infection, time to VAP diagnosis, and bacteriological culture results were recorded. All data were assessed in terms of ICU, hospital and 28-day mortality. Results: In total, 56 (45%) out of 125 patients were diagnosed with VAP. In addition, 91% of patients diagnosed with VAP were administered antibiotics before diagnosis. In the VAP patients, the mortality rates were 48, 68 and 71% for 28-day, ICU and hospital mortality, respectively. Conclusion: The coexistence of clinical and microbiological parameters should not be sought when diagnosing VAP in patients who use antibiotics intensively. VAP can be diagnosed when CPIS?6 in cases with sufficient microbiological evidence. This strategy may decrease mortality by preventing a delay in therapy.

  10. Population Pharmacokinetics in China: The Dynamics of Intravenous Voriconazole in Critically Ill Patients with Pulmonary Disease.

    PubMed

    Chen, Wenying; Xie, Hui; Liang, Fenghua; Meng, Dongmei; Rui, Jianzhong; Yin, Xueyan; Zhang, Tiantian; Xiao, Xianglin; Cai, Shaohui; Liu, Xiaoqing; Li, Yimin

    2015-01-01

    Pharmacokinetic research in China on the use of voriconazole in critically ill adult patients with different pulmonary diseases remains to be explored. This study evaluated the population pharmacokinetics of the use of voriconazole (VRC) in critically ill patients to determine covariate effects on VRC pharmacokinetics by NONMEM, which could further optimize VRC dosing in this population. A one-compartment model with first-order absorption and elimination best fit the data, giving 4.28?L/h clearance and 93.4?L volume of distribution of VRC. The model variability, described as an approximate percentage coefficient of interindividual variability in clearance and volume of distribution, was 72.94% and 26.50%, respectively. A significant association between Cmin and drug response or grade 2 hepatotoxicity was observed (p=0.002, <0.001, respectively, 1.5-4.0?g/mL) via logistic multivariate regression. Monte Carlo simulations at 100, 150, 200, and 250?mg dosage predicted effectiveness at 45.99%, 99.76%, 98.76%, and 67.75% within the 1.5-4.0?g/mL range, suggesting that a 150 or 200?mg intravenous dose twice daily is best suited to achieve the target steady state trough concentration range in critically ill patients with pulmonary disease. PMID:26133710

  11. Optimal care and design of the tracheal cuff in the critically ill patient.

    PubMed

    Jaillette, Emmanuelle; Martin-Loeches, Ignacio; Artigas, Antonio; Nseir, Saad

    2014-01-01

    Despite the increasing use of non-invasive ventilation and high-flow nasal-oxygen therapy, intubation is still performed in a large proportion of critically ill patients. The aim of this narrative review is to discuss recent data on long-term intubation-related complications, such as microaspiration, and tracheal ischemic lesions. These complications are common in critically ill patients, and are associated with substantial morbidity and mortality. Recent data suggest beneficial effects of tapered cuffed tracheal tubes in reducing aspiration. However, clinical data are needed in critically ill patients to confirm this hypothesis. Polyurethane-cuffed tracheal tubes and continuous control of cuff pressure could be beneficial in preventing microaspiration and ventilator-associated pneumonia (VAP). However, large multicenter studies are needed before recommending their routine use. Cuff pressure should be maintained between 20 and 30 cmH2O to prevent intubation-related complications. Tracheal ischemia could be prevented by manual or continuous control of cuff pressure. PMID:24572178

  12. Patients Perspectives on Stigma of Mental Illness (an Egyptian Study in a Private Hospital)

    PubMed Central

    Sidhom, Emad; Abdelfattah, Ahmed; Carter, Julie M.; El-Dosoky, Ahmed; El-Islam, Mohamed Fakhr

    2014-01-01

    The present study is concerned with the stigma of mental illness. It examines the subjective element of the experience of stigma among a sample of in-patients with different mental disorders. The sample was taken from consecutive admissions of in-patients meeting International Classification of Diseases, 10th revision (ICD-10) criteria for mental disorders who had capacity to decide on participation in the study and were willing to respond to the structured interview. The study was undertaken in an Egyptian private psychiatric hospital. The structured clinical interview included aspects of the emotional, behavioral, and cognitive effects of having a psychiatric diagnosis on in-patients with various diagnostic labels in an Egyptian psychiatric hospital. It also studied whether this effect changes with specific disorders, total duration of illness, or sociodemographic variables as gender, age, or educational level. The study illustrated the core items of stigmatization attached to the diagnosis of mental illness (1), which more than half of the participants responded affirmatively. The study aimed to explore the most prevailing aspects of stigma or social disadvantage; hoping that this may offer a preliminary guide for clinicians to address these issues in their practice. PMID:25505426

  13. Optimal care and design of the tracheal cuff in the critically ill patient

    PubMed Central

    2014-01-01

    Despite the increasing use of non-invasive ventilation and high-flow nasal-oxygen therapy, intubation is still performed in a large proportion of critically ill patients. The aim of this narrative review is to discuss recent data on long-term intubation-related complications, such as microaspiration, and tracheal ischemic lesions. These complications are common in critically ill patients, and are associated with substantial morbidity and mortality. Recent data suggest beneficial effects of tapered cuffed tracheal tubes in reducing aspiration. However, clinical data are needed in critically ill patients to confirm this hypothesis. Polyurethane-cuffed tracheal tubes and continuous control of cuff pressure could be beneficial in preventing microaspiration and ventilator-associated pneumonia (VAP). However, large multicenter studies are needed before recommending their routine use. Cuff pressure should be maintained between 20 and 30 cmH2O to prevent intubation-related complications. Tracheal ischemia could be prevented by manual or continuous control of cuff pressure. PMID:24572178

  14. Recommendations for the intra-hospital transport of critically ill patients

    PubMed Central

    2010-01-01

    Introduction This study was conducted to provide Intensive Care Units and Emergency Departments with a set of practical procedures (check-lists) for managing critically-ill adult patients in order to avoid complications during intra-hospital transport (IHT). Methods Digital research was carried out via the MEDLINE, EMBASE, CINAHL and HEALTHSTAR databases using the following key words: transferring, transport, intrahospital or intra-hospital, and critically ill patient. The reference bibliographies of each of the selected articles between 1998 and 2009 were also studied. Results This review focuses on the analysis and overcoming of IHT-related risks, the associated adverse events, and their nature and incidence. The suggested preventive measures are also reviewed. A check-list for quick execution of IHT is then put forward and justified. Conclusions Despite improvements in IHT practices, significant risks are still involved. Basic training, good clinical sense and a risk-benefit analysis are currently the only deciding factors. A critically ill patient, prepared and accompanied by an inexperienced team, is a risky combination. The development of adapted equipment and the widespread use of check-lists and proper training programmes would increase the safety of IHT and reduce the risks in the long-term. Further investigation is required in order to evaluate the protective role of such preventive measures. PMID:20470381

  15. Investigational tests and treatments performed in terminal stage cancer patients in two weeks before death: Turkish oncology group (TOG) study.

    PubMed

    Trker, ?brahim; Kmrc, ?eref; Ar?can, Ali; Doruk, Hatice; zy?lkan, zgr; Co?kun, Hasan ?enol; Colak, Dil?en; gl avu?o?lu, Emel; Ata, Alper; Sezer, Ahmet; Ye?il ?nk?r, Havva; ?enler, Filiz Cay; Arpac?, Fikret

    2014-12-01

    Although more palliative care is necessary for terminally ill cancer patients, excess investigational tests, invasive procedures, and treatments are given instead. Between November 2009 and December 2013, six hundred and twenty-four patients with end-stage cancer who were died at inpatient setting evaluated retrospectively. Patients' characteristics, sites of tumor and metastasis, tests and invasive procedures, treatments performed in the last 2 weeks before death were collected from the hospital files and analyzed. Median age of 624 patients was 58 (range 16-96) years. More than half of the patients (370, 59.3%) were men. The most frequent cancer sites were gastrointestinal (GI) system (32.2%), lung (24.0%), and breast (11.1%). Frequent metastatic sites were liver (34.8%), bone (31.5%), lung (23.3%), and/or brain (16.9%). Causes of death were respiratory failure, infections, and/or liver failure in 49.9, 23.9, and 19.4% of patients, respectively. Radiological tests performed in the last 2 weeks before death were ultrasonography, computed tomography, magnetic resonance imaging, bone scan in 25.6, 16.3, 11.4, and 3.8% of patients, respectively. Treatments received were intravenous (i.v) serum infusion, blood transfusion, total parenteral nutrition (TPN), human albumin infusion in 55.9, 44.1, 34.9, and 9.5% of patients, respectively. Invasive procedures such as invasive pain relief, terminal sedation, and chemotherapy performed in 12.6, 4.4, and 10.0% of patients, respectively. Central venous catheter application, paracentesis, thoracentesis, and GI endoscopy were applied in 41.7, 9.8, 5.6, and 3.4% of the patients, respectively. Radiological tests, invasive procedures, TPN, and human albumin transfusion were used excessively in terminal stage cancer patients in our medical oncology inpatient clinics. Invasive pain relief and terminal sedation were still underused in our cancer clinics. There is an urgent need in developing national palliative care program to improve the understanding of end-of-life care in our medical oncology clinics. PMID:25412940

  16. A comparison of adherence to hypoglycemic medications between Type 2 diabetes patients with and without serious mental illness.

    PubMed

    Kreyenbuhl, Julie; Leith, Jaclyn; Medoff, Deborah R; Fang, Lijuan; Dickerson, Faith B; Brown, Clayton H; Goldberg, Richard W; Potts, Wendy; Dixon, Lisa B

    2011-06-30

    Inadequate self-management of chronic medical conditions like Type 2 diabetes may play a role in the poor health status of individuals with serious mental illnesses. We compared adherence to hypoglycemic medications and blood glucose control between 44 diabetes patients with a serious mental illness and 30 patients without a psychiatric illness. The two groups did not differ in their ability to manage a complex medication regimen as assessed by a performance-based measure of medication management capacity. However, significantly fewer patients with a mental illness self-reported nonadherence to their hypoglycemic regimens compared to those without a mental illness. Although individuals with mental illnesses also had better control of blood glucose, this metabolic parameter was not correlated with adherence to hypoglycemic medications in either patient group. The experience of managing a chronic mental illness may confer advantages to individuals with serious mental illnesses in the self-care of co-occurring medical conditions like Type 2 diabetes. PMID:21459458

  17. Clinical associations of host genetic variations in the genes of cytokines in critically ill patients.

    PubMed

    Belopolskaya, O B; Smelaya, T V; Moroz, V V; Golubev, A M; Salnikova, L E

    2015-06-01

    Host genetic variations may influence a changing profile of biochemical markers and outcome in patients with trauma/injury. The objective of this study was to assess clinical associations of single nucleotide polymorphisms (SNPs) in the genes of cytokines in critically ill patients. A total of 430 patients were genotyped for SNPs in the genes of pro- (IL1B, IL6, IL8) and anti-inflammatory (IL4, IL10, IL13) cytokines. The main end-points were sepsis, mortality and adult respiratory distress syndrome (ARDS). We evaluated the dynamic levels of bilirubin, blood urea nitrogen, creatine kinase, creatinine and lactate dehydrogenase in five points of measurements (between 1 and 14 days after admission) and correlated them with SNPs. High-producing alleles of proinflammatory cytokines protected patients against sepsis (IL1B -511A and IL8 -251A) and mortality (IL1B -511A). High-producing alleles of anti-inflammatory cytokines IL4 -589T and IL13 431A (144Gln) were less frequent in ARDS patients. The carriers of IL6 -174C/C genotypes were prone to the increased levels of biochemical markers and acute kidney and liver insufficiency. Genotype-dependent differences in the levels of biochemical indicators gradually increased to a maximal value on the 14th day after admission. These findings suggest that genetic variability in pro- and anti-inflammatory cytokines may contribute to different clinical phenotypes in patients at high risk of critical illness. PMID:25619315

  18. Narcissistic rage: The Achilles' heel of the patient with chronic physical illness.

    PubMed

    Hyphantis, Thomas; Almyroudi, Augustina; Paika, Vassiliki; Goulia, Panagiota; Arvanitakis, Konstantinos

    2009-01-01

    Based on the psychoanalytic reading of Homer's Iliad whose principal theme is "Achilles' rage" (the semi-mortal hero invulnerable in all of his body except for his heel, hence "Achilles' heel" has come to mean a person's principal weakness), we aimed to assess whether "narcissistic rage" has an impact on several psychosocial variables in patients with severe physical illness across time. In 878 patients with cancer, rheumatological diseases, multiple sclerosis, inflammatory bowel disease, and glaucoma, we assessed psychological distress (SCL-90 and GHQ-28), quality of life (WHOQOL-BREF), interpersonal difficulties (IIP-40), hostility (HDHQ), and defense styles (DSQ). Narcissistic rage comprised DSQ "omnipotence" and HDHQ "extraverted hostility". Hierarchical multiple regressions analyses were performed. We showed that, in patients with disease duration less than one year, narcissistic rage had a minor impact on psychosocial variables studied, indicating that the rage was rather part of a "normal" mourning process. On the contrary, in patients with longer disease duration, increased rates of narcissistic rage had a great impact on all outcome variables, and the opposite was true for patients with low rates of narcissistic rage, indicating that narcissistic rage constitutes actually an "Achilles' Heel" for patients with long-term physical illness. These findings may have important clinical implications. PMID:19936167

  19. Narcissistic rage: The Achilles’ heel of the patient with chronic physical illness

    PubMed Central

    Hyphantis, Thomas; Almyroudi, Augustina; Paika, Vassiliki; Goulia, Panagiota; Arvanitakis, Konstantinos

    2009-01-01

    Based on the psychoanalytic reading of Homer’s Iliad whose principal theme is “Achilles’ rage” (the semi-mortal hero invulnerable in all of his body except for his heel, hence “Achilles’ heel” has come to mean a person’s principal weakness), we aimed to assess whether “narcissistic rage” has an impact on several psychosocial variables in patients with severe physical illness across time. In 878 patients with cancer, rheumatological diseases, multiple sclerosis, inflammatory bowel disease, and glaucoma, we assessed psychological distress (SCL-90 and GHQ-28), quality of life (WHOQOL-BREF), interpersonal difficulties (IIP-40), hostility (HDHQ), and defense styles (DSQ). Narcissistic rage comprised DSQ “omnipotence” and HDHQ “extraverted hostility”. Hierarchical multiple regressions analyses were performed. We showed that, in patients with disease duration less than one year, narcissistic rage had a minor impact on psychosocial variables studied, indicating that the rage was rather part of a “normal” mourning process. On the contrary, in patients with longer disease duration, increased rates of narcissistic rage had a great impact on all outcome variables, and the opposite was true for patients with low rates of narcissistic rage, indicating that narcissistic rage constitutes actually an “Achilles’ Heel” for patients with long-term physical illness. These findings may have important clinical implications. PMID:19936167

  20. Flucytosine Pharmacokinetics in a Critically Ill Patient Receiving Continuous Renal Replacement Therapy

    PubMed Central

    Kunka, Megan E.; Cady, Elizabeth A.; Woo, Heejung C.; Thompson Bastin, Melissa L.

    2015-01-01

    Purpose. A case report evaluating flucytosine dosing in a critically ill patient receiving continuous renal replacement therapy. Summary. This case report outlines an 81-year-old male who was receiving continuous venovenous hemofiltration (CVVH) for acute renal failure and was being treated with flucytosine for the treatment of disseminated Cryptococcus neoformans infection. Due to patient specific factors, flucytosine was empirically dose adjusted approximately 50% lower than intermittent hemodialysis (iHD) recommendations and approximately 33% lower than CRRT recommendations. Peak and trough levels were obtained, which were supratherapeutic, and pharmacokinetic parameters were calculated. The patient experienced thrombocytopenia, likely due to elevated flucytosine levels, and flucytosine was ultimately discontinued. Conclusion. Despite conservative flucytosine dosing for a patient receiving CVVH, peak and trough serum flucytosine levels were supratherapeutic (120 μg/mL at 2 hours and 81 μg/mL at 11.5 hours), which increased drug-related adverse effects. The results indicate that this conservative dosing regimen utilizing the patient's actual body weight was too aggressive. This case report provides insight into flucytosine dosing in CVVH, a topic that has not been investigated previously. Further pharmacokinetic studies of flucytosine dosing in critically ill patients receiving CVVH are needed in order to optimize pharmacokinetic and pharmacodynamic parameters while avoiding toxic flucytosine exposure. PMID:26246919

  1. Host factors and clinical outcomes of Candida colonization in critically ill patients.

    PubMed

    Jacobs, David M; Beyda, Nicholas D; Asuphon, Orarik; Alam, M Jahangir; Garey, Kevin W

    2015-02-01

    This study aimed to describe factors and outcomes associated with Candida colonization of critically ill patients. This was a cross-sectional study conducted over 2 weeks in the intensive care unit (ICU) of a tertiary care hospital at the Texas Medical Center, Houston, TX. All Candida samples were prospectively collected with demographic and clinical data collected retrospectively. We examined 48 patients, 32 (67%) were colonized with Candida spp; 25 (52.1%) patients were isolated with Candida albicans and 18 (37.5%) were isolated with a non-albicans species, mostly commonly Candida glabrata. A multivariate analysis identified proton pump inhibitor administration at admission to ICU [odds ratio 5.66; 95% confidence interval 1.12-28.5] as associated with colonization. Patients colonized with Candida had a significantly longer length of ICU and hospital stays (7.6 ± 6.6 vs. 4.2 ± 2.6 days, P = 0.01 and 14.9 ± 12.9 vs. 7.5 ± 6.7 days, P = 0.02, respectively). Clonality testing between C. albicans and C. glabrata strains identified indistinguishable strains among the patient cohort. These data provide additional information on Candida colonization in critically ill patients. PMID:25173925

  2. Management of acutely ill patients in the hospital setting: focus on quetiapine.

    PubMed

    Peuskens, Joseph; Kasper, Siegfried; Arango, Celso; Luca Bandinelli, Pier; Gastpar, Markus; Keks, Nicholas; Mitchell, Sheena; Oral, Timuin; Timdahl, Kristina; Vieta, Eduard

    2007-01-01

    We have considered published work and clinical experience focusing on the atypical antipsychotic quetiapine in order to form a consensus on the most appropriate treatment strategies for hospitalised patients with acute schizophrenia or bipolar disorder. It is important to consider the specific treatment needs of these patients and these are discussed in the context of current treatment guidelines. We will review the efficacy and tolerability of atypical antipsychotics versus conventional antipsychotics and/or benzodiazepines as a first-line treatment, and examine the suitability of oral versus intramuscular formulations in the acute setting. The potentially beneficial properties of specific atypical agents are also considered. Appropriate dosing is particularly important in acutely ill patients as it can help achieve rapid improvement. We will discuss emerging data which show that rapid initiation of quetiapine in patients with acute psychosis or mania is not only as effective as standard initiation, but is also well tolerated. This may be important for treatment in the long term as a positive initial treatment experience can determine patient compliance and treatment adherence. In conclusion, this review recommends that oral atypical antipsychotics should be a first-choice medication for acutely ill cooperative patients in the hospital setting. PMID:24941277

  3. Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study

    PubMed Central

    2010-01-01

    Introduction Higher lactate concentrations within the normal reference range (relative hyperlactatemia) are not considered clinically significant. We tested the hypothesis that relative hyperlactatemia is independently associated with an increased risk of hospital death. Methods This observational study examined a prospectively obtained intensive care database of 7,155 consecutive critically ill patients admitted to the Intensive Care Units (ICUs) of four Australian university hospitals. We assessed the relationship between ICU admission lactate, maximal lactate and time-weighted lactate levels and hospital outcome in all patients and also in those patients whose lactate concentrations (admission n = 3,964, maximal n = 2,511, and time-weighted n = 4,584) were under 2 mmol.L-1 (i.e. relative hyperlactatemia). Results We obtained 172,723 lactate measurements. Higher admission and time-weightedlactate concentration within the reference range was independently associated with increased hospital mortality (admission odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3 to 3.5, P = 0.01; time-weighted OR 3.7, 95% CI 1.9 to 7.00, P < 0.0001). This significant association was first detectable at lactate concentrations > 0.75 mmol.L-1. Furthermore, in patients whose lactate ever exceeded 2 mmol.L-1, higher time-weighted lactate remained strongly associated with higher hospital mortality (OR 4.8, 95% CI 1.8 to 12.4, P < 0.001). Conclusions In critically ill patients, relative hyperlactataemia is independently associated with increased hospital mortality. Blood lactate concentrations > 0.75 mmol.L-1 can be used by clinicians to identify patients at higher risk of death. The current reference range for lactate in the critically ill may need to be re-assessed. PMID:20181242

  4. Prognostic impact of fecal pH in critically ill patients

    PubMed Central

    2012-01-01

    Introduction We have reported that altered gut flora is associated with septic complications and eventual death in critically ill patients with systemic inflammatory response syndrome. It is unclear how fecal pH affects these patients. We sought to determine whether fecal pH can be used as an assessment tool for the clinical course of critically ill patients. Methods Four hundred ninety-one fecal samples were collected from 138 patients who were admitted to the Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Japan. These patients were treated in the intensive care unit for more than 2 days. Fecal pH, fecal organic acids, and fecal bacteria counts were measured and compared by survived group and nonsurvived group, or nonbacteremia group and bacteremia group. Logistic regression was used to estimate relations between fecal pH, age, sex, or APACHE II score and mortality, and incidence of bacteremia. Differences in fecal organic acids or fecal bacteria counts among acidic, neutral, and alkaline feces were analyzed. Results The increase of fecal pH 6.6 was significantly associated with the increased mortality (odds ratio, 2.46; 95% confidence interval, 1.25 to 4.82) or incidence of bacteremia (3.25; 1.67 to 6.30). Total organic acid was increased in acidic feces and decreased in alkaline feces. Lactic acid, succinic acid, and formic acid were the main contributors to acidity in acidic feces. In alkaline feces, acetic acid was significantly decreased. Propionic acid was markedly decreased in both acidic and alkaline feces compared with neutral feces. No differences were noted among the groups in bacterial counts. Conclusions The data presented here demonstrate that the fecal pH range that extended beyond the normal range was associated with the clinical course and prognosis of critically ill patients. PMID:22776285

  5. Factors affecting mental fitness for work in a sample of mentally ill patients

    PubMed Central

    2009-01-01

    Background Mental fitness for work is the ability of workers to perform their work without risks for themselves or others. Mental fitness was a neglected area of practice and research. Mental ill health at work seems to be rising as a cause of disablement. Psychiatrists who may have had no experience in relating mental health to working conditions are increasingly being asked to undertake these examinations. This research was done to explore the relationship of mental ill health and fitness to work and to recognize the differences between fit and unfit mentally ill patients. Methods This study was cross sectional one. All cases referred to Al-Amal complex for assessment of mental fitness during a period of 12 months were included. Data collected included demographic and clinical characteristics, characteristics of the work environment and data about performance at work. All data was subjected to statistical analysis. Results Total number of cases was 116, the mean age was 34.5 1.4. Females were 35.3% of cases. The highly educated patients constitute 50.8% of cases. The decision of the committee was fit for regular work for 52.5%, unfit for 19.8% and modified work for 27.7%. The decision was appreciated only by 29.3% of cases. There were significant differences between fit, unfit and modified work groups. The fit group had higher level of education, less duration of illness, and better performance at work. Patients of the modified work group had more physical hazards in work environment and had more work shift and more frequent diagnosis of substance abuse. The unfit group had more duration of illness, more frequent hospitalizations, less productivity, and more diagnosis of schizophrenia. Conclusion There are many factors affecting the mental fitness the most important are the characteristics of work environment and the most serious is the overall safety of patient to self and others. A lot of ethical and legal issues should be kept in mind during such assessment as patient's rights, society's rights, and the laws applied to unfit people. PMID:19925677

  6. Perfectionism, Type D personality, and illness-related coping styles in cardiac rehabilitation patients.

    PubMed

    Shanmugasegaram, Shamila; Flett, Gordon L; Madan, Mina; Oh, Paul; Marzolini, Susan; Reitav, Jaan; Hewitt, Paul L; Sturman, Edward D

    2014-03-01

    This study investigated the associations among trait perfectionism, perfectionistic self-presentation, Type D personality, and illness-specific coping styles in 100 cardiac rehabilitation patients. Participants completed the Multidimensional Perfectionism Scale, the Perfectionistic Self-Presentation Scale, the Type D Scale-14, and the Coping with Health Injuries and Problems Scale. Correlational analyses established that emotional preoccupation coping was associated with trait perfectionism, perfectionistic self-presentation, and Type D personality. Perfectionism was linked with both facets of the Type D construct (negative emotionality and social inhibition). Our results suggest that perfectionistic Type D patients have maladaptive coping with potential negative implications for their cardiac rehabilitation outcomes. PMID:23493864

  7. Course of illness in comorbid bipolar disorder and obsessive-compulsive disorder patients.

    PubMed

    Amerio, A; Tonna, M; Odone, A; Stubbs, B; Ghaemi, S N

    2016-04-01

    Psychiatric comorbidity is extremely common. One of the most common and difficult to manage comorbid conditions is the co-occurrence of bipolar disorder (BD) and obsessive compulsive disorder (OCD). We updated our recent systematic review searching the electronic databases MEDLINE, Embase, and PsycINFO to investigate course of illness in BD-OCD patients. We identified a total of 13 relevant papers which found that the majority of comorbid OCD cases appeared to be related to mood episodes. OC symptoms in comorbid patients appeared more often during depressive episodes, and comorbid BD and OCD cycled together, with OC symptoms often remitting during manic/hypomanic episodes. PMID:27025465

  8. Diagnosis and treatment of intra-abdominal abscess in critically ill patients

    SciTech Connect

    Snyder, S.K.; Hahn, H.H.

    1982-04-01

    Intra-abdominal abscess remains a challenging clinical problem. Patients are frequently critically ill with major organ system failure. An aggressive diagnostic and therapeutic approach is mandated. Application of newer imaging techniques should allow a better than 90 per cent accuracy of abscess localization. Clearer definition of the abscess cavity by ultrasound or computerized tomography facilitates planning of surgical drainage route preoperatively. Ultrasound and computerized tomography have also allowed directed percutaneous aspiration of intra-abdominal fluid collections for diagnosis. In selected patients, percutaneous drainage has the proven capability to completely resolve a large percentage of intra-abdominal abscesses. Final application of this technique awaits further study.

  9. Stress ulcer prophylaxis in critically ill patients: review of the evidence.

    PubMed

    Alhazzani, Waleed; Alshahrani, Mohammed; Moayyedi, Paul; Jaeschke, Roman

    2012-01-01

    Critically ill patients are at risk of developing stress ulcers in the upper digestive tract. Multiple risk factors have been associated with the development of this condition, with variable risk of association. Decades of research have suggested the benefit of using pharmacologic prophylaxis to reduce the incidence of clinically important upper gastrointestinal bleeding, with no reduction in overall mortality. It has been the standard of care to provide prophylaxis to patients at risk. Options for prophylaxis include: proton?pump inhibitors, histamine(2)?receptor antagonists, or sucralfate. The choice of prophylaxis depends on multiple factors including the presence of risk factors, risk for nosocomial pneumonia, and possibly cost. PMID:22354363

  10. Prevention and diagnosis of venous thromboembolism in critically ill patients: a Canadian survey

    PubMed Central

    Cook, Deborah; McMullin, Joseph; Hodder, Richard; Heule, Mark; Pinilla, Jaime; Dodek, Peter; Stewart, Thomas

    2001-01-01

    Background Venous thromboembolism (VTE) confers considerable morbidity and mortality in hospitalized patients, although few studies have focused on the critically ill population. The objective of this study was to understand current approaches to the prevention and diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE) among patients in the intensive care unit (ICU). Design Mailed self-administered survey of ICU Directors in Canadian university affiliated hospitals. Results Of 29 ICU Directors approached, 29 (100%) participated, representing 44 ICUs and 681 ICU beds across Canada. VTE prophylaxis is primarily determined by individual ICU clinicians (20/29, 69.0%) or with a hematology consultation for challenging patients (9/29, 31.0%). Decisions are usually made on a case-by-case basis (18/29, 62.1%) rather than by preprinted orders (5/29, 17.2%), institutional policies (6/29, 20.7%) or formal practice guidelines (2/29, 6.9%). Unfractionated heparin is the predominant VTE prophylactic strategy (29/29, 100.0%) whereas low molecular weight heparin is used less often, primarily for trauma and orthopedic patients. Use of pneumatic compression devices and thromboembolic stockings is variable. Systematic screening for DVT with lower limb ultrasound once or twice weekly was reported by some ICU Directors (7/29, 24.1%) for specific populations. Ultrasound is the most common diagnostic test for DVT; the reference standard of venography is rarely used. Spiral computed tomography chest scans and ventilationperfusion scans are used more often than pulmonary angiograms for the diagnosis of PE. ICU Directors recommend further studies in the critically ill population to determine the test properties and risk:benefit ratio of VTE investigations, and the most cost-effective methods of prophylaxis in medicalsurgical ICU patients. Interpretation Unfractionated subcutaneous heparin is the predominant VTE prophylaxis strategy for critically ill patients, although low molecular weight heparin is prescribed for trauma and orthopedic patients. DVT is most often diagnosed by lower limb ultrasound; however, several different tests are used to diagnose PE. Fundamental research in critically ill patients is needed to help make practice evidence-based. PMID:11737922

  11. The Impact of Pain Assessment on Critically Ill Patients' Outcomes: A Systematic Review

    PubMed Central

    Georgiou, Evanthia; Hadjibalassi, Maria; Lambrinou, Ekaterini; Andreou, Panayiota; Papathanassoglou, Elizabeth D. E.

    2015-01-01

    In critically ill patients, pain is a major problem. Efficient pain management depends on a systematic, comprehensive assessment of pain. We aimed to review and synthesize current evidence on the impact of a systematic approach to pain assessment on critically ill patients' outcomes. A systematic review of published studies (CINAHL, PUBMED, SCOPUS, EMBASE, and COCHRANE databases) with predetermined eligibility criteria was undertaken. Methodological quality was assessed by the EPHPP quality assessment tool. A total of 10 eligible studies were identified. Due to big heterogeneity, quantitative synthesis was not feasible. Most studies indicated the frequency, duration of pain assessment, and types of pain assessment tools. Methodological quality assessment yielded strong ratings for 5/10 and weak ratings for 3/10 studies. Implementation of systematic approaches to pain assessment appears to associate with more frequent documented reports of pain and more efficient decisions for pain management. There was evidence of favorable effects on pain intensity, duration of mechanical ventilation, length of ICU stay, mortality, adverse events, and complications. This systematic review demonstrates a link between systematic pain assessment and outcome in critical illness. However, the current level of evidence is insufficient to draw firm conclusions. More high quality randomized clinical studies are needed. PMID:26558273

  12. Internalized stigma and its psychosocial correlates in Korean patients with serious mental illness.

    PubMed

    Kim, Woo Jung; Song, Youn Joo; Ryu, Hyun-Sook; Ryu, Vin; Kim, Jae Min; Ha, Ra Yeon; Lee, Su Jin; Namkoong, Kee; Ha, Kyooseob; Cho, Hyun-Sang

    2015-02-28

    We aimed to examine internalized stigma of patients with mental illness in Korea and identify the contributing factors to internalized stigma among socio-demographic, clinical, and psychosocial variables using a cross-sectional study design. A total of 160 patients were recruited from a university mental hospital. We collected socio-demographic data, clinical variables and administered self-report scales to measure internalized stigma and levels of self-esteem, hopelessness, social support, and social conflict. Internalized stigma was identified in 8.1% of patients in our sample. High internalized stigma was independently predicted by low self-esteem, high hopelessness, and high social conflict among the psychosocial variables. Our finding suggests that simple psychoeducation only for insight gaining cannot improve internalized stigma. To manage internalized stigma in mentally ill patients, it is needed to promote hope and self-esteem. We also suggest that a relevant psychosocial intervention, such as developing coping skills for social conflict with family, can help patients overcome their internalized stigma. PMID:25554354

  13. Medical explanations and lay conceptions of disease and illness in doctor-patient interaction.

    PubMed

    Nordby, Halvor

    2008-01-01

    Hilary Putnam's influential analysis of the 'division of linguistic labour' has a striking application in the area of doctor-patient interaction: patients typically think of themselves as consumers of technical medical terms in the sense that they normally defer to health professionals' explanations of meaning. It is at the same time well documented that patients tend to think they are entitled to understand lay health terms like 'sickness' and 'illness' in ways that do not necessarily correspond to health professionals' understanding. Drawing on recent philosophical theories of concept possession, the article argues that this disparity between medical and lay vocabulary implies that it is, in an important range of cases, easier for doctors to create a communicative platform of shared concepts by using and explaining special medical expressions than by using common lay expressions. This conclusion is contrasted with the view that doctors and patients typically understand each other when they use lay vocabulary. Obviously, use of expressions like 'sickness' or 'illness' does not necessarily lead to poor communication, but it is important that doctors have an awareness of how patients interpret such terms. PMID:19043803

  14. Preventive and therapeutic strategies in critically ill patients with highly resistant bacteria.

    PubMed

    Bassetti, Matteo; De Waele, Jan J; Eggimann, Philippe; Garnacho-Montero, Jos; Kahlmeter, Gunnar; Menichetti, Francesco; Nicolau, David P; Paiva, Jose Arturo; Tumbarello, Mario; Welte, Tobias; Wilcox, Mark; Zahar, Jean Ralph; Poulakou, Garyphallia

    2015-05-01

    The antibiotic pipeline continues to diminish and the majority of the public remains unaware of this critical situation. The cause of the decline of antibiotic development is multifactorial and currently most ICUs are confronted with the challenge of multidrug-resistant organisms. Antimicrobial multidrug resistance is expanding all over the world, with extreme and pandrug resistance being increasingly encountered, especially in healthcare-associated infections in large highly specialized hospitals. Antibiotic stewardship for critically ill patients translated into the implementation of specific guidelines, largely promoted by the Surviving Sepsis Campaign, targeted at education to optimize choice, dosage, and duration of antibiotics in order to improve outcomes and reduce the development of resistance. Inappropriate antimicrobial therapy, meaning the selection of an antibiotic to which the causative pathogen is resistant, is a consistent predictor of poor outcomes in septic patients. Therefore, pharmacokinetically/pharmacodynamically optimized dosing regimens should be given to all patients empirically and, once the pathogen and susceptibility are known, local stewardship practices may be employed on the basis of clinical response to redefine an appropriate regimen for the patient. This review will focus on the most severely ill patients, for whom substantial progress in organ support along with diagnostic and therapeutic strategies markedly increased the risk of nosocomial infections. PMID:25792203

  15. Gastric exocrine failure in critically ill patients: incidence and associated features

    PubMed Central

    Stannard, V A; Hutchinson, A; Morris, D L; Byrne, A

    1988-01-01

    Following the observation that many critically ill patients cannot maintain their gastric juice pH below 4 without treatment a study was performed to measure the gastric juice pH in such patients and relate it to other clinical data. The case notes of 64 patients who had been admitted to the intensive care unit and taken part in two trials of ranitidine treatment were reviewed. During those trials gastric juice was aspirated hourly and the pH and volume measured. In this study the values recorded during a six hour untreated control phase were used. Data on age, diagnosis, treatment, outcome, episodes of hypoxia, episodes of hypotension, and use of inotropic drugs were also reviewed. Full data were available for 61 patients: 27 had a mean baseline pH of >5 during the control phase and 34 a mean baseline pH of <5. Significantly more of those with a high pH suffered hypotension (21/27 v 13/34) and received inotropic drugs (16/27 v 8/34). These findings suggest that hypotension in critically ill patients adversely affects gastric exocrine function; prophylaxis with drugs that can improve gastric mucosal blood flow may be more effective than with antacids. PMID:3122979

  16. Sedation and analgesia for critically ill pediatric burn patients: the current state of practice.

    PubMed

    Singleton, Andrew; Preston, Robert J; Cochran, Amalia

    2015-01-01

    The objective of this study was to assess current practice patterns and attitudes toward pediatric sedation and analgesia in United States (US) burn centers for critically ill patients. Survey-based questionnaire was sent to 119 Directors at US burn centers that care for pediatric patients. Forty-one surveys (34%) were analyzed. 48.8% of responding centers mandate pediatric consultation for pediatric burn patients based on factors such as age and burn size. The most common sedation and analgesic agents used were midazolam, fentanyl, morphine, ketamine, and diphenhydramine. Written sedation policies exist at 63.4% of centers. 90.2% of centers employ scoring systems to guide agent titration. 60.9% of respondents practice sedation holidays "always" or "usually." 90.2% of centers perceive the medications they routinely use are "always" or "often" efficacious in pediatric sedation and analgesia. 53.7% of respondents reported the presence of withdrawal signs and symptoms in their patient population. The lack of consensus guidelines for sedation and analgesia delivery to pediatric intensive care unit patients results in practice variation. The majority of centers perceive their sedation and analgesia strategies to be efficacious despite the heavy reliance on propofol and midazolam, both of which have questionable safety profiles in critically ill children. PMID:25933050

  17. Whole body protein kinetics during hypocaloric and normocaloric feeding in critically ill patients

    PubMed Central

    2013-01-01

    Introduction Optimal feeding of critically ill patients in the ICU is controversial. Existing guidelines rest on rather weak evidence. Whole body protein kinetics may be an attractive technique for assessing optimal protein intake. In this study, critically ill patients were investigated during hypocaloric and normocaloric IV nutrition. Methods Neurosurgical patients on mechanical ventilation (n?=?16) were studied during a 48-hour period. In random order 50% and 100% of measured energy expenditure was given as IV nutrition during 24hours, corresponding to hypocaloric and normocaloric nutrition, respectively. At the end of each period, whole body protein turnover was measured using d5-phenylalanine and 13C-leucine tracers. Results The phenylalanine tracer indicated that whole-body protein synthesis was lower during hypocaloric feeding, while whole-body protein degradation and amino acid oxidation were unaltered, which resulted in a more negative protein balance, namely ?1.9??2.1 versus ?0.7??1.3mg phenylalanine/kg/h (P?=?0.014). The leucine tracer indicated that whole body protein synthesis and degradation and amino acid oxidation were unaltered, but the protein balance was negative during hypocaloric feeding, namely ?0.3??0.5 versus 0.6??0.5mg leucine/kg/h (P?patient group studied, hypocaloric feeding was associated with a more negative protein balance, but the amino acid oxidation was not different. The protein kinetics measurements and the studys investigational protocol were useful for assessing the efficacy of nutrition support on protein metabolism in critically ill patients. PMID:23883571

  18. Levosimendan versus dobutamine in critically ill patients: a meta-analysis of randomized controlled trials

    PubMed Central

    Huang, Xuan; Lei, Shu; Zhu, Mei-fei; Jiang, Rong-lin; Huang, Li-quan; Xia, Guo-lian; Zhi, Yi-hui

    2013-01-01

    Objective: To evaluate the clinical efficacy of levosimendan versus dobutamine in critically ill patients requiring inotropic support. Methods: Clinical trials were searched in PubMed, EMBASE, and the Cochrane Central Registry of Clinical Trials, as well as Web of Science. Studies were included if they compared levosimendan with dobutamine in critically ill patients requiring inotropic support, and provided at least one outcome of interest. Outcomes of interest included mortality, incidence of hypotension, supraventricular arrhythmias, and ventricular arrhythmias. Results: Data from a total of 3 052 patients from 22 randomized controlled trials (RCTs) were included in the analysis. Overall analysis showed that the use of levosimendan was associated with a significant reduction in mortality (269 of 1 373 [19.6%] in the levosimendan group, versus 328 of 1 278 [25.7%] in the dobutamine group, risk ratio (RR)=0.81, 95% confidence interval (CI) 0.700.92, P for effect=0.002). Subgroup analysis indicated that the benefit from levosimendan could be found in the subpopulations of cardiac surgery, ischemic heart failure, and concomitant ?-blocker therapy in comparison with dobutamine. There was no significant difference in the incidence of hypotension, supraventricular arrhythmias, or ventricular arrhythmias between the two drugs. Conclusions: In contrast with dobutamine, levosimendan is associated with a significant improvement in mortality in critically ill patients requiring inotropic support. Patients having cardiac surgery, with ischemic heart failure, and receiving concomitant ?-blocker therapy may benefit from levosimendan. More RCTs are required to address the questions about no positive outcomes in the subpopulation in a cardiology setting, and to confirm the advantages in long-term prognosis. PMID:23645177

  19. Endogenous glutamine production in critically ill patients: the effect of exogenous glutamine supplementation

    PubMed Central

    2014-01-01

    Introduction Glutamine rate of appearance (Ra) may be used as an estimate of endogenous glutamine production. Recently a technique employing a bolus injection of isotopically labeled glutamine was introduced, with the potential to allow for multiple assessments of the glutamine Ra over time in critically ill patients, who may not be as metabolically stable as healthy individuals. Here the technique was used to evaluate the endogenous glutamine production in critically ill patients in the fed state with and without exogenous glutamine supplementation intravenously. Methods Mechanically ventilated patients (n?=?11) in the intensive care unit (ICU) were studied on two consecutive days during continuous parenteral feeding. To allow the patients to be used as their own controls, they were randomized for the reference measurement during basal feeding without supplementation, before or after the supplementation period. Glutamine Ra was determined by a bolus injection of 13C-glutamine followed by a period of frequent sampling to establish the decay-curve for the glutamine tracer. Exogenous glutamine supplementation was given by intravenous infusion of a glutamine containing dipeptide, L-alanyl-L-glutamine, 0.28 g/kg during 20 hours. Results A 14% increase of endogenous glutamine Ra was seen at the end of the intravenous supplementation period as compared to the basal measurements (P?=?0.009). Conclusions The bolus injection technique to measure glutamine Ra to estimate the endogenous production of glutamine in critically ill patients was demonstrated to be useful for repetitive measurements. The hypothesized attenuation of endogenous glutamine production during L-alanyl-L-glutamine infusion given as a part of full nutrition was not seen. PMID:24731231

  20. Usefulness of Glycemic Gap to Predict ICU Mortality in Critically Ill Patients With Diabetes

    PubMed Central

    Liao, Wen-I.; Wang, Jen-Chun; Chang, Wei-Chou; Hsu, Chin-Wang; Chu, Chi-Ming; Tsai, Shih-Hung

    2015-01-01

    Abstract Stress-induced hyperglycemia (SIH) has been independently associated with an increased risk of mortality in critically ill patients without diabetes. However, it is also necessary to consider preexisting hyperglycemia when investigating the relationship between SIH and mortality in patients with diabetes. We therefore assessed whether the gap between admission glucose and A1C-derived average glucose (ADAG) levels could be a predictor of mortality in critically ill patients with diabetes. We retrospectively reviewed the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores and clinical outcomes of patients with diabetes admitted to our medical intensive care unit (ICU) between 2011 and 2014. The glycosylated hemoglobin (HbA1c) levels were converted to the ADAG by the equation, ADAG?=?[(28.7??HbA1c)???46.7]. We also used receiver operating characteristic (ROC) curves to determine the optimal cut-off value for the glycemic gap when predicting ICU mortality and used the net reclassification improvement (NRI) to measure the improvement in prediction performance gained by adding the glycemic gap to the APACHE-II score. We enrolled 518 patients, of which 87 (17.0%) died during their ICU stay. Nonsurvivors had significantly higher APACHE-II scores and glycemic gaps than survivors (P?ill patients with diabetes and a glycemic gap ?80?mg/dL had significantly higher ICU mortality and adverse outcomes than those with a glycemic gap <80?mg/dL (P?ill patients with diabetes. The addition of the glycemic gap to the APACHE-II score significantly improved its ability to predict ICU mortality. PMID:26356728

  1. [Ill due to amalgam? 10 rules for managing the symptomatic patient].

    PubMed

    Bailer, J; Staehle, H J; Rist, F

    2003-08-21

    Over the past two decades, mercury released by amalgam fillings has been held responsible for a number of mental and somatic health complaints. However, a systematic relation between increased mercury levels and the severity of the reported symptoms has never been demonstrated in any of the present well-controlled multidisciplinary studies. These studies, however, have found a high prevalence of mental disorders, especially somatization syndromes, among patients with self-diagnosed "amalgam illness". Additionally, our own studies indicate that amalgam anxiety is often merely one aspect of a general environmental anxiety. Overall, the present findings suggest a psychological etiology for amalgam-related complaints. Our psychosomatic model of "amalgam illness" integrates external factors, individual predispositions and specific processes of perception, awareness, evaluation and attribution. Practical management strategies for primary care physicians can be derived from this model. PMID:14526572

  2. Birthdates of patients affected by mental illness and solar activity: A study from Italy

    NASA Astrophysics Data System (ADS)

    Ventriglio, Antonio; Borelli, Albacenzina; Bellomo, Antonello; Lepore, Alberto

    2011-04-01

    PurposeThis epidemiologic study tested an hypothesized association between the year of birth of persons with major mental illnesses and solar activity over the past century. MethodsWe collected data on diagnoses and birthdates of psychiatric patients born between 1926 and 1975 (N = 1954) in south Italy for comparison to yearly solar activity as registered by the International Observatories. ResultsWe found a strong inverse correlation between high solar activity (HSA) and incidence of schizophrenia and bipolar disorder in a 20-year period whereas the incidence of non-affective/non-psychotic disorders was moderately associated with HSA in the same period. ConclusionsInterpretation of the observed correlations between HSA during years of birth and the incidence of mental illnesses remains unclear, but the findings encourage further study.

  3. The Perfidious Experiences of Men as Palliative Caregivers of People Living with HIV/AIDS and other Terminal illnesses in Botswana. Eclectic Data Sources

    PubMed Central

    Kangethe, Simon

    2010-01-01

    Aim: The aim and objective of this scientific research article is to explore the literature with intent to raise attention to the perfidiousness of the experiences of men as palliative caregivers of people living with HIV/AIDS and other terminal illnesses. Methods: The article has utilized eclectic data sources in Botswana and elsewhere. Results: The findings indicate that care giving position of men has been found beset by: retrogressive gender unfriendly cultures; patriarchy; weaker gender empowerment campaigns; and inadequate male involvement in care. Conclusions: The article recommends: (1) a paradigm shift of structural gender dynamics; (2) making AIDS care programmes both gender sensitive and gender neutral; (3) Strengthening gender mainstreaming; (4) diluting cultures and patriarchy; (5) and signing and domesticating SADC gender protocol and other gender friendly international agreements by Botswana government. PMID:21218009

  4. Parenteral polymyxins: Assessing efficacy and safety in critically ill patients with renal dysfunction

    PubMed Central

    Sekhri, Kavita; Nandha, Ruchika; Mandal, Amit; Bhasin, Deepak; Singh, Harpal

    2013-01-01

    Objectives: Studies have established the effectiveness and safety of polymyxins in treating multidrug resistant (MDR) pathogens. However, the challenge is whether these nephrotoxic drugs can be administered in compromised renal states. The present study was undertaken to establish their role in such patients. The effectiveness and nephrotoxicity of polymyxins in critically ill-patients harboring MDR Gram-negative bacteria with already compromised renal functions was compared with those with normal renal functions. Materials and Methods: This retrospective cohort study (March 2008-March 2010) was conducted in the intensive care unit of a tertiary care hospital. A total of 48 eligible critically ill-patients receiving polymyxins were enrolled. A comparison was carried out (length of stay in hospital, mortality, renal function) between patients with acute kidney injury (AKI, n = 18; defined by the RIFLE classification) and patients with normal renal function (non-AKI, n = 30). Results: Patients with baseline AKI had a significantly higher adjusted mortality rate at admission when compared with the non-AKI group. At the end of therapy with polymyxins, 26.66% non-AKI patients developed renal dysfunction while 38.88% of patients in the AKI group had worsening of renal function (P = 0.006). However, there was no significant difference in the length of hospital stay (23.9 13.24 vs. 30.5 22.50; P = 0.406) and overall mortality (44.4% vs. 36.7%; P = 0.76) between two groups. Conclusion: Polymyxins can be administered in AKI patients with favorable results provided used judiciously with strict monitoring of renal functions, dose modification according to creatinine clearance and aggressive fluid management. PMID:24347770

  5. A case series of critically ill patients with anti- N-methyl-D-aspartate receptor encephalitis.

    PubMed

    Young, Paul J; Baker, Stuart; Cavazzoni, Elena; Erickson, Simon J; Krishnan, Anand; Kruger, Peter S; Rashid, Alan H; Wibrow, Brad A

    2013-03-01

    Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis causes autonomic disturbances, behavioural changes and abnormal movements. It is often a paraneoplastic phenomenon that occurs in association with ovarian teratomas and is the most common paraneoplastic encephalitis. We report nine cases of critically ill patients with anti- NMDA receptor encephalitis from Australia and New Zealand. One patient died and one had a poor neurological recovery. The remaining patients made substantial or complete neurological recoveries. This case series highlights that patients with anti-NMDA receptor encephalitis: often require long periods of support in an intensive care unit; may develop tracheostomy complications related to hypersalivation; may develop life-threatening hyperthermia; can have ovarian teratomas despite normal investigations; and often have very abnormal movements that are difficult to control and make ongoing care difficult. PMID:23432495

  6. Hypocaloric, high-protein nutrition therapy for critically ill patients with obesity.

    PubMed

    Dickerson, Roland N

    2014-12-01

    We published the first article that addressed hypocaloric, high-protein enteral nutrition therapy for critically ill patients with obesity more than 10 years ago. This study demonstrated that it was possible to successfully achieve this mode of therapy with a commercially available high-protein enteral formula and concurrent use of protein supplements. This study was also the first to demonstrate improved clinical outcomes with the use of hypocaloric, high-protein nutrition therapy. The results of this study, its unique findings, and shortcomings are discussed. Subsequent studies have added clarity to the effective use of this therapy, including its use in home parenteral nutrition patients, patients with class III obesity, and older patients with obesity. PMID:25049263

  7. Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention

    PubMed Central

    Knight, Patrick H; Maheshwari, Neelabh; Hussain, Jafar; Scholl, Michael; Hughes, Michael; Papadimos, Thomas J; Guo, Weidun Alan; Cipolla, James; Stawicki, Stanislaw P; Latchana, Nicholas

    2015-01-01

    Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies. PMID:26807395

  8. Development of an interfacility transport program for critically ill cardiovascular patients.

    PubMed

    Greco, A

    1990-05-01

    The expanding use of newer coronary artery intervention modalities in the treatment of critically ill cardiac patients has produced a profound change in the manner in which acute care is rendered to these patients. To meet the needs of community hospitals and to improve the safety of interfacility transport to tertiary care centers, a transport program was developed at The Hospital of the Good Samaritan, Los Angeles, California. Rapid transport by helicopter, fixed-wing aircraft or specialized ground ambulance services has been used to improve patient transit time and safety of transfer between the community hospital and tertiary care facility. Experience at The Hospital of the Good Samaritan (1,012 consecutive patients) compares favorably with other programs and proves to be safe and beneficial. PMID:2357443

  9. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation.

    TOXLINE Toxicology Bibliographic Information

    Díaz MC; Ospina-Tascón GA; Salazar C BC

    2014-02-01

    Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation.

  10. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation.

    PubMed

    Díaz, Magda C; Ospina-Tascón, Gustavo A; Salazar C, Blanca C

    2014-02-01

    Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation. PMID:23669061

  11. The development of a partial hospitalization program for mentally ill chemically abusing (MICA) patients.

    PubMed

    Conner, K R; Silverstein, S M; Melnyk, K A; Maxey, J T

    1995-01-01

    The article begins with a review of the high prevalence of concurrent mental illness and chemical abuse (MICA) disorders among clinical populations, highlighting the need for development of appropriate services to treat these persons. This is followed by a description of a partial hospitalization program developed at the University of Rochester Medical Center-Strong Memorial Hospital, established to treat MICA patients. The program description includes information pertaining to the mission of the program, treatment setting, staffing, schedule, and diagnostic and sociodemographic data on 50 consecutive patients admitted to the program. It includes a review of the major goals of the program and the manner in which each of these goals is addressed. This is followed by a discussion of several arguments for the inclusion of patients with personality disorders in MICA treatment when there is concurrent substance abuse. It concludes with a case vignette of a patient treated in the MICA program. PMID:8583513

  12. Patient-Assessed Chronic Illness Care (PACIC) scenario in an Indian homeopathic hospital

    PubMed Central

    Koley, Munmun; Saha, Subhranil; Ghosh, Shubhamoy; Nag, Goutam; Kundu, Monojit; Mondal, Ramkumar; Purkait, Rajib; Patra, Supratim; Ali, Seikh Swaif

    2015-01-01

    Homeopathy research has focused on chronic conditions; however, the extent to which current homeopathic care is compliant with the Chronic Care Model (CCM) has been sparsely shown. As the Bengali Patient-Assessed Chronic Illness Care (PACIC)-20 was not available, the English questionnaire was translated and evaluated in a government homeopathic hospital in West Bengal, India. The translation was done in six steps, and approved by an expert committee. Face validity was tested by 15 people for comprehension. Test/retest reliability (reproducibility) was tested on 30 patients with chronic conditions. Internal consistency was tested in 377 patients suffering from various chronic conditions. The questionnaire showed acceptable test/retest reliability [intraclass correlation coefficient (ICC) 0.57–0.75; positive to strong positive correlations; p < 0.0001] for all domains and the total score, strong internal consistency (Cronbach’s α = 0.86 overall and 0.65–0.82 for individual subscales), and large responsiveness (1.11). The overall mean score percentage seemed to be moderate at 69.5 ± 8.8%. Gender and presence of chronic conditions did not seem to vary significantly with PACIC-20 subscale scores (p > 0.05); however, monthly household income had a significant influence (p < 0.05) on the subscales except for “delivery system or practice design.” Overall, chronic illness care appeared to be quite promising and CCM-compliant. The psychometric properties of the Bengali PACIC-20 were satisfactory, rendering it a valid and reliable instrument for assessing chronic illness care among the patients attending a homeopathic hospital. PMID:26933640

  13. Estradiol is associated with mortality in critically ill trauma and surgical patients

    PubMed Central

    May, Addison K.; Dossett, Lesly A.; Norris, Patrick R.; Hansen, Erik N.; Dorsett, Randalyn C.; Popovsky, Kimberley A.; Sawyer, Robert G.

    2009-01-01

    Objective: Sexual dimorphism (variation in outcome related to sex) after trauma–hemorrhage and sepsis is well documented in animals, with the pro-estrus state being proinflammatory and associated with a survival advantage. Although some observational studies confirm this pattern in humans, others demonstrate no difference in mortality. Estrogens are important modulators of the inflammatory response and insulin resistance in humans and have been linked to increased mortality during sepsis. Our objective was to determine whether sex hormone levels were associated with outcomes in critically ill surgical patients. Design: Prospective cohort. Patients: A total of 301 adult critically ill or injured surgical patients remaining in the intensive care unit for ≥48 hrs at two academic medical centers. Interventions: None. Measurements: Blood was collected 48 hrs after intensive care unit admission and assayed for sex hormones (estradiol, testosterone, prolactin, and progesterone) and cytokines (tumor necrosis factor-α and interleukin-1, -2, -4, -6, -8, and -10). Demographic and outcome data were also collected. Main Results: Estradiol was significantly higher in nonsurvivors (p < .001). Analysis by quartiles of estradiol demonstrated greater than a three-fold increase in the mortality rate for the highest vs. the lowest estradiol quartiles (29% vs. 8%, p < .001). Estradiol was also higher in nonsurvivors. An estradiol level of 100 pg/mL was associated with an odds ratio for death of 4.60 (95% confidence interval, 1.56–13.0) compared with a reference estradiol level of 45 pg/mL. Conclusions: We conclude that serum estradiol correlates with mortality in critically ill and injured surgical patients and discuss potential mechanisms for this observation. PMID:18090358

  14. Patient-Assessed Chronic Illness Care (PACIC) scenario in an Indian homeopathic hospital.

    PubMed

    Koley, Munmun; Saha, Subhranil; Ghosh, Shubhamoy; Nag, Goutam; Kundu, Monojit; Mondal, Ramkumar; Purkait, Rajib; Patra, Supratim; Ali, Seikh Swaif

    2016-01-01

    Homeopathy research has focused on chronic conditions; however, the extent to which current homeopathic care is compliant with the Chronic Care Model (CCM) has been sparsely shown. As the Bengali Patient-Assessed Chronic Illness Care (PACIC)-20 was not available, the English questionnaire was translated and evaluated in a government homeopathic hospital in West Bengal, India. The translation was done in six steps, and approved by an expert committee. Face validity was tested by 15 people for comprehension. Test/retest reliability (reproducibility) was tested on 30 patients with chronic conditions. Internal consistency was tested in 377 patients suffering from various chronic conditions. The questionnaire showed acceptable test/retest reliability [intraclass correlation coefficient (ICC) 0.57-0.75; positive to strong positive correlations; p < 0.0001] for all domains and the total score, strong internal consistency (Cronbach's α = 0.86 overall and 0.65-0.82 for individual subscales), and large responsiveness (1.11). The overall mean score percentage seemed to be moderate at 69.5 ± 8.8%. Gender and presence of chronic conditions did not seem to vary significantly with PACIC-20 subscale scores (p > 0.05); however, monthly household income had a significant influence (p < 0.05) on the subscales except for "delivery system or practice design." Overall, chronic illness care appeared to be quite promising and CCM-compliant. The psychometric properties of the Bengali PACIC-20 were satisfactory, rendering it a valid and reliable instrument for assessing chronic illness care among the patients attending a homeopathic hospital. PMID:26933640

  15. Depression predicts future emergency hospital admissions in primary care patients with chronic physical illness

    PubMed Central

    Guthrie, Elspeth A.; Dickens, Chris; Blakemore, Amy; Watson, Jennifer; Chew-Graham, Carolyn; Lovell, Karina; Afzal, Cara; Kapur, Navneet; Tomenson, Barbara

    2016-01-01

    Objective More than 15 million people currently suffer from a chronic physical illness in England. The objective of this study was to determine whether depression is independently associated with prospective emergency hospital admission in patients with chronic physical illness. Method 1860 primary care patients in socially deprived areas of Manchester with at least one of four exemplar chronic physical conditions completed a questionnaire about physical and mental health, including a measure of depression. Emergency hospital admissions were recorded using GP records for the year before and the year following completion of the questionnaire. Results The numbers of patients who had at least one emergency admission in the year before and the year after completion of the questionnaire were 221/1411 (15.7%) and 234/1398 (16.7%) respectively. The following factors were independently associated with an increased risk of prospective emergency admission to hospital: having no partner (OR 1.49, 95% CI 1.04 to 2.15); having ischaemic heart disease (OR 1.60, 95% CI 1.04 to 2.46); having a threatening experience (OR 1.16, 95% CI 1.04 to 1.29); depression (OR 1.58, 95% CI 1.04 to 2.40); and emergency hospital admission in the year prior to questionnaire completion (OR 3.41, 95% CI 1.98 to 5.86). Conclusion To prevent potentially avoidable emergency hospital admissions, greater efforts should be made to detect and treat co-morbid depression in people with chronic physical illness in primary care, with a particular focus on patients who have no partner, have experienced threatening life events, and have had a recent emergency hospital admission. PMID:26919799

  16. The Pursuit of Preventive Care for Chronic Illness: Turning Healthy People into Chronic Patients

    PubMed Central

    Kreiner, Meta J.; Hunt, Linda M.

    2013-01-01

    Preventive health care has become prominent in clinical medicine in the United States, emphasizing risk assessment and control, rather than addressing the signs and symptoms of pathology. Current clinical guidelines, reinforced by evidence-based decision aids and quality of care assessment, encourage clinicians to focus on maintaining rigid test thresholds which are based on population norms. While achieving these goals may benefit the total population, this may be of no benefit or even harmful to individual patients. In order to explore how this phenomenon is manifest in clinical care, and consider some factors that promote and sustain this trend, we analyze observations of over 100 clinical consultations, and open-ended interviews with 58 primary care clinicians and 70 of their patients. Both clinicians and patients equated at-risk states with illness, and viewed the associated interventions not as prevention, but as treatment. This conflation of risk and disease redefines clinical success such that reducing the threat of anticipated future illness requires acceptance of aggressive treatments and any associated adverse effects in the present. While the expanding emphasis on preventive medicine may improve the health profile of the total population, the implications of these innovations for the well-being of individual patients merits careful reconsideration. PMID:24372285

  17. Coagulation Disorders and Bleedings in Critically Ill Patients With Hemophagocytic Lymphohistiocytosis.

    PubMed

    Valade, Sandrine; Azoulay, Elie; Galicier, Lionel; Boutboul, David; Zafrani, Lara; Stepanian, Alain; Canet, Emmanuel; Lemiale, Virginie; Venot, Marion; Veyradier, Agns; Mariotte, Eric

    2015-10-01

    Reactive hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition related to a cytokine storm leading to multiorgan dysfunction. A better understanding of coagulation disorders, frequently reported in HLH patients, may improve outcomes. Critically ill HLH patients managed in a multidisciplinary national reference center were retrospectively included. Relationships between coagulation disorders, severe bleedings, and outcomes were assessed. One hundred and seventeen patients fulfilled the HLH 2004 criteria. The most common HLH etiology was hematologic conditions (73%), followed by infectious diseases (20%), systemic rheumatic diseases (5%), and undetermined HLH etiology (3%). All patients exerted thrombocytopenia. Coagulation disorders were diagnosed in 79 (68%) patients (61 had hypofibrinogenemia < 1.5 g/L, 51 had prothrombin time [PT]? patients. Coagulation disorders were more frequent in immunocompromised patients, those with histological/cytological feature of hemophagocytosis, those with the highest ferritin concentrations, and in patients with HLH not related to infection. These patients were more prone to receive mechanical ventilation, vasopressors, or renal replacement therapy. Twenty-six (22%) patients presented severe bleeding complications, including 5 patients dying from hemorrhagic shock. Strikingly, the only coagulation parameter significantly associated with severe bleeding was low fibrinogen with a cutoff value of 2 g/L (P = 0.03). Overall, 33 (28%) patients died in the ICU and hospital mortality was 44%. Coagulation disorders were associated with higher mortality, especially fibrinogen < 2 g/L (P = 0.04) and PT value (P = 0.03). The occurrence of bleeding complications was not associated with higher risk of hospital death. Risk factors associated with mortality by multivariate analysis were fibrinogen level < 2 g/L (OR 2.42 [1.08-5.41]), SOFA score > 6 (OR 3.04 [1.32-6.98]), and age > 46 years (OR 2.26 [1.02-5.04]). Up to two-third of critically ill HLH patients present with coagulation disorders. Hypofibrinogenemia or DIC was found in half of the patients and low PT in 40%. These patients require more life support and have a higher mortality rate. Fibrinogen < 2 g/L is associated with the occurrence of severe bleeding and mortality. PMID:26448017

  18. Coagulation Disorders and Bleedings in Critically Ill Patients With Hemophagocytic Lymphohistiocytosis

    PubMed Central

    Valade, Sandrine; Azoulay, Elie; Galicier, Lionel; Boutboul, David; Zafrani, Lara; Stepanian, Alain; Canet, Emmanuel; Lemiale, Virginie; Venot, Marion; Veyradier, Agns; Mariotte, Eric

    2015-01-01

    Abstract Reactive hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition related to a cytokine storm leading to multiorgan dysfunction. A better understanding of coagulation disorders, frequently reported in HLH patients, may improve outcomes. Critically ill HLH patients managed in a multidisciplinary national reference center were retrospectively included. Relationships between coagulation disorders, severe bleedings, and outcomes were assessed. One hundred and seventeen patients fulfilled the HLH 2004 criteria. The most common HLH etiology was hematologic conditions (73%), followed by infectious diseases (20%), systemic rheumatic diseases (5%), and undetermined HLH etiology (3%). All patients exerted thrombocytopenia. Coagulation disorders were diagnosed in 79 (68%) patients (61 had hypofibrinogenemia?patients. Coagulation disorders were more frequent in immunocompromised patients, those with histological/cytological feature of hemophagocytosis, those with the highest ferritin concentrations, and in patients with HLH not related to infection. These patients were more prone to receive mechanical ventilation, vasopressors, or renal replacement therapy. Twenty-six (22%) patients presented severe bleeding complications, including 5 patients dying from hemorrhagic shock. Strikingly, the only coagulation parameter significantly associated with severe bleeding was low fibrinogen with a cutoff value of 2?g/L (P?=?0.03). Overall, 33 (28%) patients died in the ICU and hospital mortality was 44%. Coagulation disorders were associated with higher mortality, especially fibrinogen??6 (OR 3.04 [1.326.98]), and age?>?46 years (OR 2.26 [1.025.04]). Up to two-third of critically ill HLH patients present with coagulation disorders. Hypofibrinogenemia or DIC was found in half of the patients and low PT in 40%. These patients require more life support and have a higher mortality rate. Fibrinogen <2?g/L is associated with the occurrence of severe bleeding and mortality. PMID:26448017

  19. Use of Opiates to Manage Pain in the Seriously and Terminally Ill Patient

    MedlinePLUS

    ... for control of moderate pain) such as: • Codeine/Acetaminophen combinations (e.g., Tylenol #2, 3, or 4) • Hydrocodone/Acetaminophen combinations (e.g., Vicodin) • Hydrocodone/Ibuprofen combinations (e. ...

  20. Factors Related to the Differential Preference for Cardiopulmonary Resuscitation Between Patients With Terminal Cancer and That of Their Respective Family Caregivers.

    PubMed

    Hwang, In Cheol; Keam, Bhumsuk; Kim, Young Ae; Yun, Young Ho

    2016-02-01

    There is little information regarding concordance between preferences for end-of-life care of terminally ill patients with cancer and those of their family caregivers. A cross-sectional exploration of cardiopulmonary resuscitation (CPR) preference in 361 dyads was conducted. Patients or family caregivers who were willing to approve CPR were compared with dyads who did not support CPR. The patient's quality of life was more associated with family caregiver's willingness than patient's willingness. A patient was more likely to prefer CPR than their caregiver in dyads of females and emotionally stable patients. A family caregiver showed stronger support for CPR if the patient had controlled pain or stable health and the family caregiver had not been counseled for CPR. Communications should be focused on these individuals to improve the planning of end-of-life care. PMID:25138648

  1. Beta-lactam dosing in critically ill patients with septic shock and continuous renal replacement therapy

    PubMed Central

    2014-01-01

    Although early and appropriate antibiotic therapy remains the most important intervention for successful treatment of septic shock, data guiding optimization of beta-lactam prescription in critically ill patients prescribed with continuous renal replacement therapy (CRRT) are still limited. Being small hydrophilic molecules, beta-lactams are likely to be cleared by CRRT to a significant extent. As a result, additional variability may be introduced to the per se variable antibiotic concentrations in critically ill patients. This article aims to describe the current clinical scenario for beta-lactam dosing in critically ill patients with septic shock and CRRT, to highlight the sources of variability among the different studies that reduce extrapolation to clinical practice, and to identify the opportunities for future research and improvement in this field. Three frequently prescribed beta-lactams (meropenem, piperacillin and ceftriaxone) were chosen for review. Our findings showed that present dosing recommendations are based on studies with drawbacks limiting their applicability in the clinical setting. In general, current antibiotic dosing regimens for CRRT follow a one-size-fits-all fashion despite emerging clinical data suggesting that drug clearance is partially dependent on CRRT modality and intensity. Moreover, some studies pool data from heterogeneous populations with CRRT that may exhibit different pharmacokinetics (for example, admission diagnoses different to septic shock, such as trauma), which also limit their extrapolation to critically ill patients with septic shock. Finally, there is still no consensus regarding the %T>MIC (percentage of dosing interval when concentration of the antibiotic is above the minimum inhibitory concentration of the pathogen) value that should be chosen as the pharmacodynamic target for antibiotic therapy in patients with septic shock and CRRT. For empirically optimized dosing, during the first day a loading dose is required to compensate the increased volume of distribution, regardless of impaired organ function. An additional loading dose may be required when CRRT is initiated due to steady-state equilibrium breakage driven by clearance variation. From day 2, dosing must be adjusted to CRRT settings and residual renal function. Therapeutic drug monitoring of beta-lactams may be regarded as a useful tool to daily individualize dosing and to ensure optimal antibiotic exposure. PMID:25042938

  2. Furosemide is associated with acute kidney injury in critically ill patients

    PubMed Central

    Levi, T.M.; Rocha, M.S.; Almeida, D.N.; Martins, R.T.C.; Silva, M.G.C.; Santana, N.C.P.; Sanjuan, I.T.; Cruz, C.M.S.

    2012-01-01

    Acute kidney injury (AKI) is common in critically ill patients. Diuretics are used without any evidence demonstrating a beneficial effect on renal function. The objective of the present study is to determine the incidence of AKI in an intensive care unit (ICU) and if there is an association between the use of furosemide and the development of AKI. The study involved a hospital cohort in which 344 patients were consecutively enrolled from January 2010 to January 2011. A total of 132 patients (75 females and 57 males, average age 64 years) remained for analysis. Most exclusions were related to ICU discharge in the first 24?h. Laboratory, sociodemographic and clinical data were collected until the development of AKI, medical discharge or patient death. The incidence of AKI was 55% (95%CI = 46-64). The predictors of AKI found by univariate analysis were septic shock: OR = 3.12, 95%CI = 1.36-7.14; use of furosemide: OR = 3.27, 95%CI = 1.57-6.80, and age: OR = 1.02, 95%CI = 1.00-1.04. Analysis of the subgroup of patients with septic shock showed that the odds ratio of furosemide was 5.5 (95%CI = 1.16-26.02) for development of AKI. Age, use of furosemide, and septic shock were predictors of AKI in critically ill patients. Use of furosemide in the subgroup of patients with sepsis/septic shock increased (68.4%) the chance of development of AKI when compared to the sample as a whole (43.9%) PMID:22641414

  3. Using A Pharmacy-Based Intervention To Improve Antipsychotic Adherence Among Patients With Serious Mental Illness

    PubMed Central

    Valenstein, Marcia; Kavanagh, Janet; Lee, Todd; Reilly, Peter; Dalack, Gregory W.; Grabowski, John; Smelson, David; Ronis, David L.; Ganoczy, Dara; Woltmann, Emily; Metreger, Tabitha; Wolschon, Patricia; Jensen, Agnes; Poddig, Barbara; Blow, Frederic C.

    2011-01-01

    Background: Similar to patients with other chronic disorders, patients with serious mental illness (SMI) are often poorly adherent with prescribed medications. Objective: We conducted a randomized controlled trial examining the effectiveness of a pharmacy-based intervention (Meds-Help) in increasing antipsychotic medication adherence among Department of Veterans Affairs (VA) patients with SMI. We also examined the impact of Meds-Help on psychiatric symptoms, quality of life, and satisfaction with care. Methods: We enrolled 118 patients from 4 VA facilities with schizophrenia, schizoaffective, or bipolar disorder who were on long-term antipsychotics but had antipsychotic medication possession ratios (MPRs) <0.8 in the prior year. Patients were randomized to usual care (UC; n = 60) or the pharmacy-based intervention (Meds-Help; n = 58). We reassessed adherence at 6 and 12 months, at which time patients completed Positive and Negative Symptom Scales (PANSS), Quality of Well-being Scales (QWB), and Client Satisfaction Questionnaires (CSQ-8). Results: Prior to enrollment, Meds-Help and UC patients had mean antipsychotic MPRs of 0.54 and 0.55, respectively. At 6 months, mean MPRs were 0.91 for Meds-Help and 0.64 for UC patients; at 12 months, they were 0.86 for Meds-Help and 0.62 for UC patients. In multivariate analyses adjusting for patient factors, Meds-Help patients had significantly higher MPRs at 6 and 12 months (P < .0001). There were no significant differences between groups in PANSS, QWB, or CSQ-8 scores, but power to detect small effects was limited. Conclusions: Congruent with prior studies of patients with other disorders, a practical pharmacy-based intervention increased antipsychotic adherence among patients with SMI. However, SMI patients may require additional care management components to improve outcomes. PMID:19933540

  4. Presence of electroencephalogram burst suppression in sedated, critically ill patients is associated with increased mortality

    PubMed Central

    Watson, Paula L.; Shintani, Ayumi K.; Tyson, Richard; Pandharipande, Pratik P.; Pun, Brenda T.; Ely, E. Wesley

    2013-01-01

    Objectives This study investigates the possibility of a relationship between oversedation and mortality in mechanically ventilated patients. The presence of burst suppression, a pattern of severely decreased brain wave activity on the electroencephalogram, may be unintentionally induced by heavy doses of sedatives. Burst suppression has never been studied as a potential risk factor for death in patients without a known neurologic disorder or injury. Design: Post hoc analysis of a prospectively observational cohort study. Setting Medical intensive care units of a tertiary care, university-based medical center. Patients A total of 125 mechanically ventilated, adult, critically ill patients. Measurements and Main Results A validated arousal scale (Richmond Agitation-Sedation Scale) was used to measure sedation level, and the bispectral index monitor was used to capture electroencephalogram data. Burst suppression occurred in 49 of 125 patients (39%). For analysis, the patients were divided into those with burst suppression (49 of 125, 39%) and those without burst suppression (76 of 125, 61%). All baseline variables were similar between the two groups, with the overall cohort demonstrating a high severity of illness (Acute Physiology and Chronic Health Evaluation II scores of 27.4 8.2) and 98% receiving sedation. Of those with burst suppression, 29 of 49 (59%) died within 6 months compared with 25 of 76 (33%) who did not demonstrate burst suppression. Using time-dependent Cox regression to adjust for clinically important covariates (age, Charlson comorbidity score, baseline dementia, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, coma, and delirium), patients who experienced burst suppression were found to have a statistically significant higher 6-month mortality [Hazards ratio = 2.04, 95% confidence interval, 1.123.70, p = 0.02]. Conclusion The presence of burst suppression, which was unexpectedly high in this medical intensive care unit population, was an independent predictor of increased risk of death at 6 months. This association should be studied prospectively on a larger scale in mechanically ventilated, critically ill patients. PMID:19020432

  5. New colistin population pharmacokinetic data in critically ill patients suggesting an alternative loading dose rationale.

    PubMed

    Grgoire, N; Mimoz, O; Mgarbane, B; Comets, E; Chatelier, D; Lasocki, S; Gauzit, R; Balayn, D; Gobin, P; Marchand, S; Couet, W

    2014-12-01

    Colistin is an old antibiotic that has recently gained a considerable renewal of interest as the last-line defense therapy against multidrug-resistant Gram-negative bacteria. It is administered as colistin methanesulfonate (CMS), an inactive prodrug, and it was shown that due to slow CMS conversion, colistin plasma concentrations increase very slowly after treatment initiation, which constitutes the rationale for a loading dose in critically ill patients. However, faster CMS conversion was observed in healthy volunteers but using a different CMS brand, which may also have a major impact on colistin pharmacokinetics. Seventy-three critically ill patients not undergoing dialysis received multiple doses of CMS. The CMS concentrations were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and a pharmacokinetic analysis was conducted using a population approach. We confirmed that CMS renal clearance and colistin concentrations at steady state are mostly governed by creatinine clearance, but we predict a typical maximum concentration of drug in serum (Cmax) of colistin close to 2 mg/liter, occurring 3 h after an initial dose of 2 million international units (MIU) of CMS. Accordingly, the estimated colistin half-life (t1/2) was relatively short (3.1 h), with rapid attainment of steady state. Our results are only partially consistent with other recently published results. We confirm that the CMS maintenance dose should be adjusted according to renal function in critically ill patients. However, much higher than expected colistin concentrations were observed after the initial CMS dose, with rapid steady-state achievement. These discrepancies challenge the pharmacokinetic rationale for a loading dose, which may still be appropriate for rapid bacterial eradication and an improved clinical cure rate. PMID:25267662

  6. New Colistin Population Pharmacokinetic Data in Critically Ill Patients Suggesting an Alternative Loading Dose Rationale

    PubMed Central

    Grgoire, N.; Mimoz, O.; Mgarbane, B.; Comets, E.; Chatelier, D.; Lasocki, S.; Gauzit, R.; Balayn, D.; Gobin, P.; Marchand, S.

    2014-01-01

    Colistin is an old antibiotic that has recently gained a considerable renewal of interest as the last-line defense therapy against multidrug-resistant Gram-negative bacteria. It is administered as colistin methanesulfonate (CMS), an inactive prodrug, and it was shown that due to slow CMS conversion, colistin plasma concentrations increase very slowly after treatment initiation, which constitutes the rationale for a loading dose in critically ill patients. However, faster CMS conversion was observed in healthy volunteers but using a different CMS brand, which may also have a major impact on colistin pharmacokinetics. Seventy-three critically ill patients not undergoing dialysis received multiple doses of CMS. The CMS concentrations were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and a pharmacokinetic analysis was conducted using a population approach. We confirmed that CMS renal clearance and colistin concentrations at steady state are mostly governed by creatinine clearance, but we predict a typical maximum concentration of drug in serum (Cmax) of colistin close to 2 mg/liter, occurring 3 h after an initial dose of 2 million international units (MIU) of CMS. Accordingly, the estimated colistin half-life (t1/2) was relatively short (3.1 h), with rapid attainment of steady state. Our results are only partially consistent with other recently published results. We confirm that the CMS maintenance dose should be adjusted according to renal function in critically ill patients. However, much higher than expected colistin concentrations were observed after the initial CMS dose, with rapid steady-state achievement. These discrepancies challenge the pharmacokinetic rationale for a loading dose, which may still be appropriate for rapid bacterial eradication and an improved clinical cure rate. PMID:25267662

  7. Utility of flexible fiberoptic bronchoscopy for critically ill pediatric patients: A systematic review

    PubMed Central

    Field-Ridley, Aida; Sethi, Viyeka; Murthi, Shweta; Nandalike, Kiran; Li, Su-Ting T

    2015-01-01

    AIM: To investigate the diagnostic yield, therapeutic efficacy, and rate of adverse events related to flexible fiberoptic bronchoscopy (FFB) in critically ill children. METHODS: We searched PubMed, SCOPUS, OVID, and EMBASE databases through July 2014 for English language publications studying FFB performed in the intensive care unit in children < 18 years old. We identified 666 studies, of which 89 full-text studies were screened for further review. Two reviewers independently determined that 27 of these studies met inclusion criteria and extracted data. We examined the diagnostic yield of FFB among upper and lower airway evaluations, as well as the utility of bronchoalveolar lavage (BAL). RESULTS: We found that FFB led to a change in medical management in 28.9% (range 21.9%-69.2%) of critically ill children. The diagnostic yield of FFB was 82% (range 45.2%-100%). Infectious organisms were identified in 25.7% (17.6%-75%) of BALs performed, resulting in a change of antimicrobial management in 19.1% (range: 12.2%-75%). FFB successfully re-expanded atelectasis or removed mucus plugs in 60.3% (range: 23.8%-100%) of patients with atelectasis. Adverse events were reported in 12.9% (range: 0.5%-71.4%) of patients. The most common adverse effects of FFB were transient hypotension, hypoxia and/or bradycardia that resolved with minimal intervention, such as oxygen supplementation or removal of the bronchoscope. Serious adverse events were uncommon; 2.1% of adverse events required intervention such as bag-mask ventilation or intubation and atropine for hypoxia and bradycardia, normal saline boluses for hypotension, or lavage and suctioning for hemorrhage. CONCLUSION: FFB is safe and effective for diagnostic and therapeutic use in critically ill pediatric patients. PMID:25685726

  8. Acute appendicitis in acute leukemia and the potential role of decitabine in the critically ill patient

    PubMed Central

    Warad, Deepti; Kohorst, Mira A.; Altaf, Sadaf; Ishitani, Michael B.; Khan, Shakila; Rodriguez, Vilmarie; Nageswara Rao, Amulya A.

    2015-01-01

    Acute appendicitis in children with acute leukemia is uncommon and often recognized late. Immunocompromised host state coupled with the importance of avoiding treatment delays makes management additionally challenging. Leukemic infiltration of the appendix though rare must also be considered. Although successful conservative management has been reported, surgical intervention is required in most cases. We present our experience with acute appendicitis in children with acute leukemia and a case of complete remission of acute myeloid leukemia with a short course of decitabine. Decitabine may serve as bridging therapy in critically ill patients who are unable to undergo intensive chemotherapy. PMID:25870788

  9. Right-Sided Pleural Effusion in a Critically Ill Stroke Patient

    PubMed Central

    Heine, Michael; van Berkel, Victor; Kelly-Frasher, Lydia; Remmel, Kerri; Akca, Ozan

    2014-01-01

    Pleural fluid collections are common in those critically ill. We report the case of a left middle cerebral artery stroke patient who developed respiratory distress and required intubation and mechanical ventilation. Although the patient’s clinical status and oxygenation improved, there was persistence of right-sided opacity in the chest radiograph. Further workup proved a right-sided pleural effusion, which was drained and managed. Following extubation, a swallow study was ordered, which led to a fluoroscopic examination that demonstrated esophageal perforation. Thoracic surgery was consulted and did a primary repair of perforation and noted non–small cell carcinoma on the perforated site. PMID:26425594

  10. A psychotherapeutic approach to task-oriented groups of severely ill patients.

    PubMed

    Wilson, W H; Diamond, R J; Factor, R M

    1985-01-01

    This paper presents a conceptual approach for leading various types of groups of chronically mentally ill patients. Although these groups may have a concrete, task-oriented purpose, with skillful leadership they also function as psychotherapy groups. The developmental deficits in ego functions, object relations, and social skills that severely impair such groups can be compensated by non-interpretative actions of the therapists. The group leader must actively work to provide for the structure, stability, and safety of the group when group members are unable to provide these for themselves. PMID:4049917

  11. "Shotgunning" in a population of patients with severe mental illness and comorbid substance use disorders.

    PubMed

    Welsh, Christopher; Goldberg, Richard; Tapscott, Stephanie; Medoff, Deborah; Rosenberg, Stanley; Dixon, Lisa

    2012-01-01

    "Shotgunning" refers to the practice of one individual forcibly exhaling smoke into the mouth of another, and may increase the risk of transmission of respiratory pathogens. The extent of shotgunning among individuals with co-occurring serious mental illness and substance use is unknown. We included questions about shotgunning in an interview of 236 participants of a study testing a model to prevent and treat HIV and hepatitis. Shotgunning was common (61% [145/236]) and correlated with increased substance use severity and several high-risk behaviors. Only 8% (11/145) understood that shotgunning could transmit disease. Further research and patient education on shotgunning is warranted. PMID:22332854

  12. Tainted water on tap: what to tell patients about preventing illness from drinking water.

    PubMed

    Chalupka, Stephanie

    2005-11-01

    Annual cases of waterborne illness in the United States are estimated to number about 900,000, but most experts believe the incidence to be much higher. The U.S. Environmental Protection Agency regulates the nation's drinking water supply, setting maximum allowable levels for 87 known natural and synthetic contaminants; but thousands more go unregulated. This article describes selected contaminants and their known health effects, which range from acute gastroenteritis to cancer and reproductive and developmental effects. It discusses which populations are more vulnerable, outlines assessment, and elucidates nurses' roles in patient education and as community advocates for safer drinking water. PMID:16264302

  13. Pharmacokinetics of sufentanil during long-term infusion in critically ill pediatric patients.

    PubMed

    Bartkowska-Śniatkowska, Alicja; Bienert, Agnieszka; Wiczling, Paweł; Rosada-Kurasińska, Jowita; Zielińska, Marzena; Warzybok, Justyna; Borsuk, Agnieszka; Tibboel, Dick; Kaliszan, Roman; Grześkowiak, Edmund

    2016-01-01

    The aim of this study was to develop a population pharmacokinetic model of sufentanil and to assess the influence of covariates in critically ill children admitted to a pediatric intensive care unit. After institutional approval, 41 children were enrolled in the study. Blood samples for pharmacokinetic (PK) assessment were collected from routinely placed arterial catheters during and after discontinuation of infusion. Population nonlinear mixed-effects modeling was performed using NONMEM. A 2-compartment model described sufentanil PK sufficiently. Typical values of the central and peripheral volume of distribution and the metabolic and intercompartmental clearance for a theoretical patient weighing 70 kg were VC  = 7.90 l, VT  = 481 L, Cl = 45.3 L/h, and Q = 38.3 L/h, respectively. High interindividual variability of all PK parameters was noted. Allometric/isometric principles to scale sufentanil PK revealed that to achieve the same steady-state sufentanil concentrations in plasma for pediatric patients of different body weights, the infusion rate should follow the formula (infusion rate for a 70-kg adult patient, μg/h) × (body weight/70 kg)(0.75) . Severity of illness described by PRISM score, the monitored physiological and laboratory parameters, and coadministered drugs such as vasopressors were not found to be significant covariates. PMID:26105145

  14. Cost of Care: A Study of Patients Hospitalized for Treatment of Psychotic Illness

    PubMed Central

    Rejani, P. P.; Sumesh, T. P.; Shaji, K. S.

    2015-01-01

    Background: Combination of ill health and poverty poses special challenges to health care providers. Mental illness and costs are linked in terms of long-term treatment and lost productivity, and it affects social development. The purpose of the present study is to assess the economic burden of poor families when a family member needs hospitalization due to psychosis. Materials and Methods: The information was gathered from caregivers of 100 psychotic inpatients of Medical College Hospital of Kerala during a period of 6 months. Data regarding components of expenses such as cost of medicine, laboratory investigations, food, travel, and other miscellaneous expenses during their inpatient period were collected by direct personal interview using specially designed proforma. The data were analyzed using Epi-info software. The patients below the poverty line (BPL) were compared with those above poverty line (APL). Results: There was no significant difference between patients from BPL and APL in respect of amounts spent on the studied variables except for laboratory investigations during the hospital stay. Conclusions: The results showed that the studied subjects are facing financial difficulties not only due to hospitalization, but also due to the recurrent expense of their ongoing medication. The study recommends the need of financial support from the government for the treatment of psychotic patients. PMID:25722516

  15. Proton pump inhibitor use is not associated with cardiac arrhythmia in critically ill patients.

    PubMed

    Chen, Kenneth P; Lee, Joon; Mark, Roger G; Feng, Mengling; Celi, Leo A; Malley, Brian E; Danziger, John

    2015-07-01

    Hypomagnesemia can lead to cardiac arrythmias. Recently, observational data have linked chronic proton pump inhibitor (PPI) exposure to hypomagnesemia. Whether PPI exposure increases the risk for arrhythmias has not been well studied. Using a large, single-center inception cohort of critically ill patients, we examined whether PPI exposure was associated with admission electrocardiogram readings of a cardiac arrhythmia in more than 8000 patients. There were 25.4% PPI users, whereas 6% were taking a histamine 2 antagonist. In all, 14.0% had a cardiac arrhythmia. PPI use was associated with an unadjusted risk of arrhythmia of 1.15 (95% CI,1.00-1.32; P =.04) and an adjusted risk of arrhythmia of 0.91 (95% CI, 0.77-1.06; P =.22). Among diuretic users (n = 2476), PPI use was similarly not associated with an increased risk of cardiac arrhythmia. In summary, in a large cohort of critically ill patients, PPI exposure is not associated with an increased risk of cardiac arrhythmia. PMID:25655574

  16. Prognostic value of circulating DNA levels in critically ill and trauma patients.

    PubMed

    Rodrigues Filho, Edison Moraes; Ikuta, Nilo; Simon, Daniel; Regner, Andrea Pereira

    2014-01-01

    The number of studies investigating circulating nucleic acids as potential biomarkers has increased in recent years. The detection of such biomarkers is a minimally invasive alternative for the diagnosis and prognosis of various clinical conditions. The value of circulating DNA levels as a predictive biomarker has been demonstrated in patients suffering from numerous acute pathologies that have a high risk of intensive care needs and in-hospital deaths. The mechanism by which circulating DNA levels increase in patients with these conditions remains unclear. In this review, we focused on the potential use of this biomarker for prognosis prediction in critically ill and trauma patients. The literature review was performed by searching MedLine using PubMed in the English language. PMID:25295826

  17. Long-term glucose control among type 2 diabetes patients with and without serious mental illness.

    PubMed

    Brown, Clayton H; Medoff, Deborah; Dickerson, Faith B; Kreyenbuhl, Julie A; Goldberg, Richard W; Fang, Lijuan; Dixon, Lisa B

    2011-11-01

    Although studies suggest that patients with diabetes with a serious mental illness (SMI) have poor diabetes outcomes, reports conflict regarding the quality of their diabetes care and level of glucose control. In an observational follow-up to our initial cross-sectional study, we compared glucose control (glycosylated hemoglobin [HbA1c]) between patients with diabetes with SMI versus those without SMI at two postbaseline assessments during an approximately 5-year period. Both groups continued to have glucose levels higher than what is considered good control and neither group demonstrated a significant change in mean HbA1c at the two follow-up time points. Those with SMI continued to have lower HbA1c levels than those without SMI even after adjusting for potential confounders. More effective strategies are needed to assist patients with diabetes to improve the management of their glucose levels. PMID:22048145

  18. Pharmacokinetics of antifungal agent micafungin in critically ill patients receiving continuous hemodialysis filtration.

    PubMed

    Hirata, Kiyotaka; Aoyama, Takahiko; Matsumoto, Yoshiaki; Ogawa, Futosi; Yamazaki, Hiroshi; Kikuti, Arimichi; Yamamoto, Yasuhiro

    2007-05-01

    Currently in Japan, the preferred method for blood purification in patients with acute renal failure is continuous hemodiafiltration (CHDF). However, CHDF filters out various antifungal drugs such as fluconazole through large pores in the membrane used. Systemic fungal infection is still one of the main causes of death and complications in critically ill patients in intensive care units (ICUs). Therefore it is important to determine the appropriate use of antifungal agents. This study was designed to evaluate the influence of CHDF on the pharmacokinetics of the antifungal agent micafungin in ICU patients. The pharmacokinetics of micafungin were studied in four ICU patients receiving CHDF and in nine ICU patients not receiving CHDF. To evaluate the pharmacokinetics, the ratio of serum micafungin concentration to dose per body weight (C/D) was used in this study. There was no progressive accumulation or exclusion of micafungin in patients receiving CHDF. The mean (+/-S.D.) extraction rate (%) for micafungin during CHDF was 3.6+/-3.9. There was no significant difference in the serum micafungin C/D-time profiles between the patients receiving and not receiving CHDF. These results show that CHDF does not affect the pharmacokinetics of micafungin. Therefore it is not necessary to adjust the micafungin dose in patients receiving CHDF. PMID:17473532

  19. Innate immunity gene expression changes in critically ill patients with sepsis and disease-related malnutrition

    PubMed Central

    Sarnecka, Agnieszka; Dąbrowska, Aleksandra; Kosałka, Katarzyna; Wachowska, Ewelina; Bałan, Barbara J.; Jankowska, Marta; Korta, Teresa; Niewiński, Grzegorz; Kański, Andrzej; Mikaszewska-Sokolewicz, Małgorzata; Omidi, Mohammad; Majewska, Krystyna; Słotwińska, Sylwia M.

    2015-01-01

    The aim of this study was an attempt to determine whether the expression of genes involved in innate antibacterial response (TL R2, NOD 1, TRAF6, HMGB 1 and Hsp70) in peripheral blood leukocytes in critically ill patients, may undergo significant changes depending on the severity of the infection and the degree of malnutrition. The study was performed in a group of 128 patients with infections treated in the intensive care and surgical ward. In 103/80.5% of patients, infections had a severe course (sepsis, severe sepsis, septic shock, mechanical ventilation of the lungs). Clinical monitoring included diagnosis of severe infection (according to the criteria of the ACC P/SCC M), assessment of severity of the patient condition and risk of death (APACHE II and SAPS II), nutritional assessment (NRS 2002 and SGA scales) and the observation of the early results of treatment. Gene expression at the mRNA level was analyzed by real-time PCR. The results of the present study indicate that in critically ill patients treated in the IC U there are significant disturbances in the expression of genes associated with innate antimicrobial immunity, which may have a significant impact on the clinical outcome. The expression of these genes varies depending on the severity of the patient condition, severity of infection and nutritional status. Expression disorders of genes belonging to innate antimicrobial immunity should be diagnosed as early as possible, monitored during the treatment and taken into account during early therapeutic treatment (including early nutrition to support the functions of immune cells). PMID:26648775

  20. The effects of motivation feedback in patients with severe mental illness: a cluster randomized controlled trial

    PubMed Central

    Jochems, Eline C; van der Feltz-Cornelis, Christina M; van Dam, Arno; Duivenvoorden, Hugo J; Mulder, Cornelis L

    2015-01-01

    Objective To evaluate the effectiveness of providing clinicians with regular feedback on the patient’s motivation for treatment in increasing treatment engagement in patients with severe mental illness. Methods Design: cluster randomized controlled trial (Dutch Trials Registry NTR2968). Participants: adult outpatients with a primary diagnosis of a psychotic disorder or a personality disorder and their clinicians, treated in 12 community mental health teams (the clusters) of two mental health institutions in the Netherlands. Interventions: monthly motivation feedback (MF) generated by clinicians additional to treatment as usual (TAU) and TAU by the community mental health teams. Primary outcome: treatment engagement at patient level, assessed at 12 months by clinicians. Randomization: teams were allocated to MF or TAU by a computerized randomization program that randomized each team to a single treatment by blocks of varying size. All participants within these teams received similar treatment. Clinicians and patients were not blind to treatment allocation at the 12-month assessment. Results The 294 randomized patients (148 MF, 146 TAU) and 57 clinicians (29 MF, 28 TAU) of 12 teams (6 MF, 6 TAU) were analyzed according to the intention-to-treat principle. No statistically significant differences between treatment groups on treatment engagement were found (adjusted mean difference =0.1, 95% confidence interval =−2.2 to 2.3, P=0.96, d=0). Preplanned ancillary analyses showed statistically significant interaction effects between treatment group and primary diagnosis on treatment motivation and quality of life (secondary outcomes), which were beneficial for patients with a primary diagnosis of a personality disorder but not for those with a psychotic disorder. There were no reports of adverse events. Conclusion The current findings imply that monitoring and discussing the patient’s motivation is insufficient to improve motivation and treatment engagement, and suggests that more elaborate interventions for severe mental illness patients are needed. PMID:26715847

  1. Psychiatric illness and psychosocial concerns of patients with newly diagnosed lung cancer.

    PubMed Central

    Ginsburg, M L; Quirt, C; Ginsburg, A D; MacKillop, W J

    1995-01-01

    OBJECTIVE: To determine the nature and incidence of psychiatric illness, symptoms of potential psychiatric significance, substance abuse and psychosocial concerns among patients with newly diagnosed lung cancer. DESIGN: Case series. SETTING: Kingston Regional Cancer Centre, a tertiary care facility for ambulatory cancer patients. PATIENTS: Seventy-one consecutive English-speaking patients with recently diagnosed lung cancer undergoing radiotherapy or chemotherapy were asked to participate; 52 of the 57 patients who agreed were available for evaluation. OUTCOME MEASURES: Current and previous psychiatric diagnoses of affective, anxiety and adjustment disorders, and alcohol and tobacco abuse; symptoms of sadness, fear, shock, anger, denial, acceptance, guilt, suicidal ideation, thoughts of death, insomnia, loss of libido, impaired concentration and reduced level of work or interest; psychosocial concerns about family, work and finances; and an impression of coping. RESULTS: At the time of the interview two (4%) of the patients were found to have an affective disorder, none had an anxiety disorder, and six (12%) had an adjustment disorder. Previously, 16 patients (31%) had had an affective or anxiety disorder or both. Two (4%) had had an adjustment disorder following the diagnosis of their lung cancer that had resolved before the interview. At some point in their lives 24 patients (46%) had abused alcohol, and 7 (13%) were currently abusing alcohol. All had smoked, 33 (63%) having been tobacco dependent. Feelings of sadness were expressed by 23 (44%), fear by 15 (29%), anger by 2 (4%), shock by 9 (17%) and guilt by 4 (8%). Seven (13%) had considered suicide, and thoughts of death were reported by 16 (31%). Twenty (38%) were accepting of their diagnosis, and 5 (10%) expressed optimism. Twenty-seven (52%) had insomnia, which was reported to be severe by 15 (29%). Loss of libido was reported by 25 (48%) and was severe in 14 (27%). Difficulty concentrating was reported by 10 (19%) and a reduced ability to work or loss of interest by 17 (33%). Fifteen patients (29%) were concerned about their families and 4 (8%) about work or finances. Most (41 [79%]) had good family support, and 23 (44%) found support in religion. Seven patients (13%) seemed to be coping poorly. CONCLUSIONS: Although psychiatric illness was infrequent, symptoms of potential psychiatric significance and psychosocial concerns were common in this patient population. Attention to these symptoms and concerns should be addressed in a systematic and effective way by all health care professionals and agencies planning the care of patients with lung cancer. PMID:7882232

  2. Outcome of Critically ill Patients with Acute Kidney Injury using the AKIN Criteria

    PubMed Central

    Mandelbaum, Tal; Scott, Daniel J; Lee, Joon; Mark, Roger G.; Malhotra, Atul; Waikar, Sushrut S.; Howell, Michael D.; Talmor, Daniel

    2011-01-01

    Objective Acute kidney injury (AKI) affects 57% of all hospitalized patients with a much higher incidence in the critically ill. The Acute Kidney Injury Network proposed a definition in which serum creatinine rises (>0.3mg/dl) and/or oliguria (<0.5/ml/kg/h) for a period of 6 hours are used to detect AKI. Accurate urine output measurements as well as serum creatinine values from our database were used to detect patients with AKI and calculate their corresponding mortality risk and length of stay. Design Retrospective cohort study. Setting 7 intensive care units at, a large, academic, tertiary medical center. Patients Adult patients without evidence of end stage renal disease, with more than 2 creatinine measurements and at least a 6 hours urine output recording, who were admitted to the ICU between 2001 and 2007. Interventions Medical records of all the patients were reviewed. Demographic information, lab results, charted data, discharge diagnoses, physiological data and patient outcomes were extracted from the MIMIC-II database using a SQL query. Measurements and main results From 19,677 adult patient records, 14,524 patients met the inclusion criteria. 57% developed AKI during their ICU stay. In-hospital mortality rates were: 13.9%, 16.4%, 33.8% for AKI 1, 2 and 3 respectively compared to only 6.2% in patients without AKI (p<0.0001). After adjusting for multiple covariates AKI was associated with increased hospital mortality (OR 1.4 and 1.3 for AKI1 and AKI2 and 2.5 for AKI3; p<0.0001). Using multivariate logistic regression, we found that in patients who developed AKI, urine output alone was a better mortality predictor than creatinine alone or the combination of both. Conclusions More than 50% of our critically ill patients developed some stage of AKI resulting in stage-wise increased mortality risk. However, the mortality risk associated with AKI stages 1 and 2 does not differ significantly. In light of these findings reevaluation of the AKIN staging criteria should be considered. PMID:21765352

  3. Fluid therapy and perfusional considerations during resuscitation in critically ill patients with intra-abdominal hypertension.

    PubMed

    Regli, Adrian; De Keulenaer, Bart; De Laet, Inneke; Roberts, Derek; Dabrowski, Wojciech; Malbrain, Manu L N G

    2015-01-01

    Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are consistently associated with morbidity and mortality among the critically ill or injured. Thus, avoiding or potentially treating these conditions may improve patient outcomes. With the aim of improving the outcomes for patients with IAH/ACS, the World Society of the Abdominal Compartment Syndrome recently updated its clinical practice guidelines. In this article, we review the association between a positive fluid balance and outcomes among patients with IAH/ACS and how optimisation of fluid administration and systemic/regional perfusion may potentially lead to improved outcomes among this patient population.Evidence consistently associates secondary IAH with a positive fluid balance. However, despite increased research in the area of non-surgical management of patients with IAH and ACS, evidence supporting this approach is limited. Some evidence exists to support implementing goal-directed resuscitation protocols and restrictive fluid therapy protocols in shocked and recovering critically ill patients with IAH. Data from animal experiments and clinical trials has shown that the early use of vasopressors and inotropic agents is likely to be safe and may help reduce excessive fluid administration, especially in patients with IAH. Studies using furosemide and/or renal replacement therapy to achieve a negative fluid balance in patients with IAH are encouraging. The type of fluid to be administered in patients with IAH remains far from resolved. There is currently insufficient evidence to recommend the use of abdominal perfusion pressure as a resuscitation endpoint in patients with IAH. However, it is important to recognise that IAH either abolishes or increases threshold values for pulse pressure variation and stroke volume variation to predict fluid responsiveness, while the presence of IAH may also result in a false negative passive leg raising test.Correct fluid therapy and perfusional support during resuscitation form the cornerstone of medical management in patients with abdominal hypertension. Controlled studies determining whether the above medical interventions may improve outcomes among those with IAH/ACS are urgently required. PMID:25421925

  4. Co-enrollment of critically ill patients into multiple studies: patterns, predictors and consequences

    PubMed Central

    2013-01-01

    Introduction Research on co-enrollment practices and their impact are limited in the ICU setting. The objectives of this study were: 1) to describe patterns and predictors of co-enrollment of patients in a thromboprophylaxis trial, and 2) to examine the consequences of co-enrollment on clinical and trial outcomes. Methods In an observational analysis of an international thromboprophylaxis trial in 67 ICUs, we examined the co-enrollment of critically ill medical-surgical patients into more than one study, and examined the clinical and trial outcomes among co-enrolled and non-co-enrolled patients. Results Among 3,746 patients enrolled in PROTECT (Prophylaxis for ThromboEmbolism in Critical Care Trial), 713 (19.0%) were co-enrolled in at least one other study (53.6% in a randomized trial, 37.0% in an observational study and 9.4% in both). Six factors independently associated with co-enrollment (all P < 0.001) were illness severity (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.19 to 1.53 for each 10-point Acute Physiology and Chronic Health Evaluation (APACHE) II score increase), substitute decision-makers providing consent, rather than patients (OR 3.31, 2.03 to 5.41), experience of persons inviting consent (OR 2.67, 1.74 to 4.11 for persons with > 10 years' experience compared to persons with none), center size (all ORs > 10 for ICUs with > 15 beds), affiliation with trials groups (OR 5.59, 3.49 to 8.95), and main trial rather than pilot phase (all ORs > 8 for recruitment year beyond the pilot). Co-enrollment did not influence clinical or trial outcomes or risk of adverse events. Conclusions Co-enrollment was strongly associated with features of the patients, research personnel, setting and study. Co-enrollment had no impact on trial results, and appeared safe, acceptable and feasible. Transparent reporting, scholarly discourse, ethical analysis and further research are needed on the complex topic of co-enrollment during critical illness. PMID:23298553

  5. Clinical review: practical approach to hyponatraemia and hypernatraemia in critically ill patients.

    PubMed

    Overgaard-Steensen, Christian; Ring, Troels

    2013-01-01

    Disturbances in sodium concentration are common in the critically ill patient and associated with increased mortality. The key principle in treatment and prevention is that plasma [Na+] (P-[Na+]) is determined by external water and cation balances. P-[Na+] determines plasma tonicity. An important exception is hyperglycaemia, where P-[Na+] may be reduced despite plasma hypertonicity. The patient is first treated to secure airway, breathing and circulation to diminish secondary organ damage. Symptoms are critical when handling a patient with hyponatraemia. Severe symptoms are treated with 2 ml/kg 3% NaCl bolus infusions irrespective of the supposed duration of hyponatraemia. The goal is to reduce cerebral symptoms. The bolus therapy ensures an immediate and controllable rise in P-[Na+]. A maximum of three boluses are given (increases P-[Na+] about 6 mmol/l). In all patients with hyponatraemia, correction above 10 mmol/l/day must be avoided to reduce the risk of osmotic demyelination. Practical measures for handling a rapid rise in P-[Na+] are discussed. The risk of overcorrection is associated with the mechanisms that cause hyponatraemia. Traditional classifications according to volume status are notoriously difficult to handle in clinical practice. Moreover, multiple combined mechanisms are common. More than one mechanism must therefore be considered for safe and lasting correction. Hypernatraemia is less common than hyponatraemia, but implies that the patient is more ill and has a worse prognosis. A practical approach includes treatment of the underlying diseases and restoration of the distorted water and salt balances. Multiple combined mechanisms are common and must be searched for. Importantly, hypernatraemia is not only a matter of water deficit, and treatment of the critically ill patient with an accumulated fluid balance of 20 litres and corresponding weight gain should not comprise more water, but measures to invoke a negative cation balance. Reduction of hypernatraemia/hypertonicity is critical, but should not exceed 12 mmol/l/day in order to reduce the risk of rebounding brain oedema. PMID:23672688

  6. Critically ill patients with H1N1 influenza A undergoing extracorporeal membrane oxygenation.

    PubMed

    Bibro, Christopher; Lasich, Christine; Rickman, Frank; Foley, Nichole E; Kunugiyama, Sujen K; Moore, Ember; O'Brien, Amy; Sherman, Natalie; Schulman, Christine S

    2011-10-01

    The most common cause of death due to the H1N1 subtype of influenza A virus (swine flu) in the 2009 to 2010 epidemic was severe acute respiratory failure that persisted despite advanced mechanical ventilation strategies. Extracorporeal membrane oxygenation (ECMO) was used as a salvage therapy for patients refractory to traditional treatment. At Legacy Emanuel Hospital, Portland, Oregon, the epidemic resulted in a critical care staffing crisis. Among the 15 patients with H1N1 influenza A treated with ECMO, 4 patients received the therapy simultaneously. The role of ECMO in supporting patients with severe respiratory failure due to H1N1 influenza is described, followed by discussions of the nursing care challenges for each body system. Variations from standards of care, operational considerations regarding staff workload, institutional burden, and emotional wear and tear of the therapy on patients, patients' family members, and the entire health care team are also addressed. Areas for improvement for providing care of the critically ill patient requiring ECMO are highlighted in the conclusion. PMID:21965390

  7. Protein-Sparing Effect in Skeletal Muscle of Growth Hormone Treatment in Critically Ill Patients

    PubMed Central

    Gamrin, Lena; Essn, Pia; Hultman, Eric; McNurlan, Margaret A.; Garlick, Peter J.; Wernerman, Jan

    2000-01-01

    Objective To investigate the effect of growth hormone (GH) treatment on skeletal muscle protein catabolism in patients with multiple organ failure in the intensive care unit (ICU). Summary Background Data Skeletal muscle depletion affects the incidence of complications and the length of hospital stay. A protein-sparing effect of GH treatment in skeletal muscle of long-term ICU patients was hypothesized. Methods Twenty critically ill ICU patients were randomized to treatment with GH (0.3 U/kg/day) or as controls. Percutaneous muscle biopsy samples were taken before and after a 5-day treatment period starting on day 3 to 42 of the patients ICU stay. Protein content, protein synthesis, water, nucleic acids, and free amino acids in muscle were analyzed. Results The protein content decreased by 8% 11% in the control patients, with no significant change in the GH group. The fractional synthesis rate of muscle proteins increased in the GH group by 33% 48%, and muscle free glutamine increased by 207% 327% in the GH group. Total intramuscular water increased by 12% 14% in the control group as a result of an increase in extracellular water of 67% 86%; these increases were not seen in the GH group. In contrast, the intracellular water increased by 6% 8% in the GH group. Conclusion Treatment with GH for 5 days in patients with multiple organ failure stimulated muscle protein synthesis, increased muscle free glutamine, and increased intracellular muscle water. PMID:10749620

  8. A well-being support program for patients with severe mental illness: a service evaluation

    PubMed Central

    2011-01-01

    Background The risk of cardiovascular disease is increased in patients with severe mental illness (SMI) dramatically reducing life expectancy. Method A real world pragmatic service evaluation of a Well-Being Support Program (WSP) was conducted. This was a four-session package delivered over a one-year period by mental health practitioners that had received additional training in providing physical health assessment and intervention. Patients' physical health was screened and appropriate one-to-one and group intervention was offered. Results 212 mental health practitioners were trained in the WSP and 782 patients were enrolled on the program. The majority of our sample was overweight or obese; 66% had a Body Mass Index (BMI) >25. Lifestyle risk factors for cardiovascular disease (CVD) were common and the patients had low self esteem. The average number of formally recorded well-being sessions attended was 2.10. Just under a quarter of those patients enrolled in the program completed. The only cardiovascular risk factor that significantly altered in patients that completed the program was BMI. The qualitative feedback about the program was largely positive. Conclusions The need to intervene to enhance the physical health of people with SMI is beyond doubt. Maintaining patient engagement in a physical health improvement program is challenging. Regular comprehensive physical health monitoring is necessary to establish the benefit of intervention and increase life expectancy and well-being in this population. PMID:21418627

  9. Duration of antibiotic therapy for critically ill patients with bloodstream infections: A retrospective cohort study

    PubMed Central

    Havey, Thomas C; Fowler, Robert A; Pinto, Ruxandra; Elligsen, Marion; Daneman, Nick

    2013-01-01

    BACKGROUND: The optimal duration of antibiotic treatment for bloodstream infections is unknown and understudied. METHODS: A retrospective cohort study of critically ill patients with bloodstream infections diagnosed in a tertiary care hospital between March 1, 2010 and March 31, 2011 was undertaken. The impact of patient, pathogen and infectious syndrome characteristics on selection of shorter (?10 days) or longer (>10 days) treatment duration, and on the number of antibiotic-free days, was examined. The time profile of clinical response was evaluated over the first 14 days of treatment. Relapse, secondary infection and mortality rates were compared between those receiving shorter or longer treatment. RESULTS: Among 100 critically ill patients with bloodstream infection, the median duration of antibiotic treatment was 11 days, but was highly variable (interquartile range 4.5 to 17 days). Predictors of longer treatment (fewer antibiotic-free days) included foci with established requirements for prolonged treatment, underlying respiratory tract focus, and infection with Staphylococcus aureus or Pseudomonas species. Predictors of shorter treatment (more antibiotic-free days) included vascular catheter source and bacteremia with coagulase-negative staphylococci. Temperature improvements plateaued after the first week; white blood cell counts, multiple organ dysfunction scores and vasopressor dependence continued to decline into the second week. Among 72 patients who survived to 10 days, clinical outcomes were similar between those receiving shorter and longer treatment. CONCLUSION: Antibiotic treatment durations for patients with bloodstream infection are highly variable and often prolonged. A randomized trial is needed to determine the duration of treatment that will maximize cure while minimizing adverse consequences of antibiotics. PMID:24421823

  10. How to communicate with patients about future illness progression and end of life: a systematic review

    PubMed Central

    Parry, Ruth; Land, Victoria; Seymour, Jane

    2014-01-01

    Background Conversation and discourse analytic research has yielded important evidence about skills needed for effective, sensitive communication with patients about illness progression and end of life. Objectives To: ??Locate and synthesise observational evidence about how people communicate about sensitive future matters; ??Inform practice and policy on how to provide opportunities for talk about these matters; ??Identify evidence gaps. Design Systematic review of conversation/discourse analytic studies of recorded interactions in English, using a bespoke appraisal approach and aggregative synthesis. Results 19 publications met the inclusion criteria. We summarised findings in terms of eight practices: fishing questionsopen questions seeking patients perspectives (5/19); indirect references to difficult topics (6/19); linking to what a patient has already saidor noticeably not said (7/19); hypothetical questions (12/19); framing difficult matters as universal or general (4/19); conveying sensitivity via means other than words, for example, hesitancy, touch (4/19); encouraging further talk using means other than words, for example, long silences (2/19); and steering talk from difficult/negative to more optimistic aspects (3/19). Conclusions Practices vary in how strongly they encourage patients to engage in talk about matters such as illness progression and dying. Fishing questions and indirect talk make it particularly easy to avoid engagingthis may be appropriate in some circumstances. Hypothetical questions are more effective in encouraging on-topic talk, as is linking questions to patients cues. Shifting towards more optimistic aspects helps maintain hope but closes off further talk about difficulties: practitioners may want to delay doing so. There are substantial gaps in evidence. PMID:25344494

  11. Are the Dysnatremias a Permanent Threat to the Critically Ill Patients?

    PubMed Central

    Basile-Filho, Anibal; Menegueti, Mayra Goncalves; Nicolini, Edson Antonio; Lago, Alessandra Fabiane; Martinez, Edson Zangiacomi; Auxiliadora-Martins, Maria

    2016-01-01

    Backgroud The dysnatremias (hyponatremia and hypernatremia) are relatively common findings on admission of intensive care unit (ICU) patients and may represent a major risk. The aim of the study was to assess the ability of serum sodium levels and the Acute Physiology and Chronic Health Evaluation II (APACHE II) to predict mortality of surgical critically ill patients. Methods One hundred and ninety-five surgical patients (62% males and 38% females; mean age of 51.8 ± 17.3 years) admitted to the ICU in the postoperative phase were retrospectively studied. The patients were divided into survivors (n = 152) and non-survivors (n = 43). APACHE II, and serum sodium levels at admission, 48 h and discharge were analyzed by generation of receiver operating characteristic (ROC) curves. Results The mean APACHE II was 16.3 ± 8.3 (13.6 ± 6.1 for survivors and 25.5 ± 8.5 for non-survivors). The area under the ROC curve for APACHE II was 0.841 (0.782 - 0.889) and 0.721 (0.653 - 0.783), 0.754 (0.653 - 0.783) and 0.720 (0.687 - 0.812) for serum sodium level at admission, 48 h and discharge, respectively. Conclusion Even though APACHE II scoring system was the most effective index to predict mortality in the surgical critically ill patients, the serum sodium levels on admission may also be used as an independent predictor of outcome. PMID:26767083

  12. Bioelectrical impedance spectroscopy to estimate fluid balance in critically ill patients.

    PubMed

    Dewitte, Antoine; Carles, Pauline; Joannès-Boyau, Olivier; Fleureau, Catherine; Roze, Hadrien; Combe, Christian; Ouattara, Alexandre

    2016-04-01

    Fluid management is a crucial issue in intensive-care medicine. This study evaluated the feasibility and reproducibility of bioimpedance spectroscopy to measure body-water composition in critically ill patients, and compared fluid balance and daily changes in total body water (TBW) measured by bioimpedance. This observational study included 25 patients under mechanical ventilation. Fluid balance and bioimpedance measurements were recorded on 3 consecutive days. Whole-body bioimpedance spectroscopy was performed with exact or ideal body weights entered into the device, and with or without ICU monitoring. Reproducibility of bioimpedance spectroscopy was very good in all conditions despite ICU monitoring and mechanical ventilation. Bioimpedance measurements using an ideal body weight varied significantly, making the weighing procedure necessary. Comparison of fluid balance and daily changes in body weight provided the best correlation (ρ = 0.74; P < 0.0001). Daily changes in TBW were correlated with fluid balance (Spearman coefficient ρ = 0.31; P = 0.003) and this correlation was improved after exclusion of patients with a SOFA score >10 (ρ = 0.36; P = 0.05) and with extracorporeal circulation (ρ = 0.50; P = 0.005). Regardless of the technique used to estimate volume status, important limits of agreement were observed. Non-invasive determination of body-water composition using bioimpedance spectroscopy is feasible in critically ill patients but requires knowledge of the patient's weight. The best method to assess volume status after fluid resuscitation and the value gained from information about body composition provided by bioimpedance techniques needs further evaluation. PMID:26018457

  13. Variations in Patients' Assessment of Chronic Illness Care across Organizational Models of Primary Health Care: A Multilevel Cohort Analysis

    PubMed Central

    Lévesque, Jean-Frédéric; Feldman, Debbie Ehrmann; Lemieux, Valérie; Tourigny, André; Lavoie, Jean-Pierre; Tousignant, Pierre

    2012-01-01

    Purpose: To measure patients' assessment of chronic illness care and its variation across primary healthcare (PHC) models. Methods: We recruited 776 patients with diabetes, heart failure, arthritis or chronic obstructive pulmonary disease from 33 PHC clinics. Face-to-face interviews, followed by a telephone interview at 12 months, were conducted using the Patient Assessment of Chronic Illness Care (PACIC). Multilevel regression was used in the analysis. Results: The mean PACIC score was low at 2.5 on a scale of 1 to 5. PACIC scores were highest among patients affiliated with family medicine groups (mean, 2.78) and lowest for contact models (mean, 2.35). Patients with arthritis and older persons generally reported a lower assessment of chronic care. Conclusion: Family medicine groups represent an integrated model of PHC associated with higher levels of achievement in chronic care. Variations across PHC organizations suggest that some models are more appropriate for improving management of chronic illness. PMID:23968619

  14. Rethinking autonomy: decision making between patient and surgeon in advanced illnesses

    PubMed Central

    Hinshaw, Daniel B.

    2016-01-01

    Patients with advanced illness such as advanced stage cancer presenting with the need for possible surgical intervention can be some of the most challenging cases for a surgeon. Often there are multiple factors influencing the decisions made. For patients they are facing not just the effects of the disease on their body, but the stark realization that the disease will also limit their life. Not only are these factors a consideration when patients are making decisions, but also the desire to make the decision that is best for themselves, the autonomous decision. Also included in this process for the patient facing the possible need for an intervention is the surgeon. While patient autonomy remains one of the main principles within medicine, guiding treatment decisions, there is also the surgeon’s autonomy to be considered. Surgeons determine if there is even a possible intervention to be offered to patients, a decision making process that respects surgeons’ autonomous choices and includes elements of paternalism as surgeons utilize their expertise to make decisions. Included in the treatment decisions that are made and the care of the patient is the impact patients’ outcomes have on the surgeon, the inherent drive to be the best for the patient and desire for good outcomes for the patient. While both the patient’s and surgeon’s autonomy are a dynamic interface influencing decision making, the main goal for the patient facing a palliative procedure is that of making treatment decisions based on the concept of shared decision making, always giving primary consideration to the patient’s goals and values. Lastly, regardless of the decision made, it is the responsibility of surgeons to their patients to be a source of support through this challenging time. PMID:27004224

  15. Identification and Treatment of Symptoms Associated with Inflammation in Medically Ill Patients

    PubMed Central

    Dantzer, Robert; Capuron, Lucile; Irwin, Michael R.; Miller, Andrew H.; Ollat, Helene; Perry, Victor Hugh; Rousey, Sarah; Yirmiya, Raz

    2008-01-01

    Medically ill patients present with a high prevalence of non-specific comorbid symptoms including pain, sleep disorders, fatigue and cognitive and mood alterations that is a leading cause of disability. However, despite major advances in the understanding of the immune-to-brain communication pathways that underlie the pathophysiology of these symptoms in inflammatory conditions, little has been done to translate this newly acquired knowledge to the clinics and to identify appropriate therapies. In a multidisciplinary effort to address this problem, clinicians and basic scientists with expertise in areas of inflammation, psychiatry, neurosciences and psychoneuroimmunology were brought together in a specialized meeting organized in Bordeaux, France, on May 2829, 2007. These experts considered key questions in the field, in particular those related to identification and quantification of the predominant symptoms associated with inflammation, definition of systemic and central markers of inflammation, possible domains of intervention for controlling inflammation associated symptoms, and relevance of animal models of inflammation associated symptoms. This resulted in a number of recommendations that should improve the recognition and management of inflammation-associated symptoms in medically ill patients. PMID:18061362

  16. Invasive candidiasis as a cause of sepsis in the critically ill patient

    PubMed Central

    Delaloye, Julie; Calandra, Thierry

    2014-01-01

    Invasive fungal infections are an increasingly frequent etiology of sepsis in critically ill patients causing substantial morbidity and mortality. Candida species are by far the predominant agent of fungal sepsis accounting for 10% to 15% of health-care associated infections, about 5% of all cases of severe sepsis and septic shock and are the fourth most common bloodstream isolates in the United States. One-third of all episodes of candidemia occur in the intensive care setting. Early diagnosis of invasive candidiasis is critical in order to initiate antifungal agents promptly. Delay in the administration of appropriate therapy increases mortality. Unfortunately, risk factors, clinical and radiological manifestations are quite unspecific and conventional culture methods are suboptimal. Non-culture based methods (such as mannan, anti-mannan, β-d-glucan, and polymerase chain reaction) have emerged but remain investigational or require additional testing in the ICU setting. Few prophylactic or pre-emptive studies have been performed in critically ill patients. They tended to be underpowered and their clinical usefulness remains to be established under most circumstances. The antifungal armamentarium has expanded considerably with the advent of lipid formulations of amphotericin B, the newest triazoles and the echinocandins. Clinical trials have shown that the triazoles and echinocandins are efficacious and well tolerated antifungal therapies. Clinical practice guidelines for the management of invasive candidiasis have been published by the European Society for Clinical Microbiology and Infectious Diseases and the Infectious Diseases Society of North America. PMID:24157707

  17. Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI

    PubMed Central

    Pistolesi, Valentina; Tritapepe, Luigi; Fiaccadori, Enrico

    2014-01-01

    Hemorrhagic complications have been reported in up to 30% of critically ill patients with AKI undergoing RRT with systemic anticoagulation. Because bleeding is associated with significantly increased mortality risk, strategies aimed at reducing hemorrhagic complications while maintaining extracorporeal circulation should be implemented. Among the alternatives to systemic anticoagulation, regional citrate anticoagulation has been shown to prolong circuit life while reducing the incidence of hemorrhagic complications and lowering transfusion needs. For these reasons, the recently published Kidney Disease Improving Global Outcomes Clinical Practice Guidelines for Acute Kidney Injury have recommended regional citrate anticoagulation as the preferred anticoagulation modality for continuous RRT in critically ill patients in whom it is not contraindicated. However, the use of regional citrate anticoagulation is still limited because of concerns related to the risk of metabolic complications, the complexity of the proposed protocols, and the need for customized solutions. The introduction of simplified anticoagulation protocols based on citrate and the development of dialysis monitors with integrated infusion systems and dedicated software could lead to the wider use of regional citrate anticoagulation in upcoming years. PMID:24993448

  18. Meta-Analysis of Patient Education Interventions to Increase Physical Activity among Chronically Ill Adults

    PubMed Central

    Conn, Vicki S.; Hafdahl, Adam R.; Brown, Sharon A.; Brown, Lori M.

    2008-01-01

    Objective This meta-analysis integrates primary research testing the effect of patient education to increase physical activity (PA) on behavior outcomes among adults with diverse chronic illnesses. Methods Extensive literature searching strategies located published and unpublished intervention studies that measured PA behavior outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses. Results Data were synthesized across 22,527 subjects from 213 samples in 163 reports. The overall mean weighted effect size for two-group comparisons was 0.45 (higher mean for treatment than control). This effect size is consistent with a difference of 48 minutes of PA per week or 945 steps per day. Preliminary moderator analyses suggest interventions were most effective when they targeted only PA behavior, used behavioral strategies (vs. cognitive strategies), and encouraged PA self-monitoring. Differences among chronic illnesses were documented. Individual strategies unrelated to PA outcomes included supervised exercise sessions, exercise prescription, fitness testing, goal setting, contracting, problem solving, barriers management, and stimulus/cues. PA outcomes were unrelated to gender, age, ethnicity, or socioeconomic distribution among samples. Conclusion These findings suggest that some patient education interventions to increase PA are effective, despite considerable heterogeneity in the magnitude of intervention effect. Practice Implications Moderator analyses are preliminary and provide suggestive evidence for further testing of interventions to inform practice. PMID:18023128

  19. Crowdsourcing Diagnosis for Patients With Undiagnosed Illnesses: An Evaluation of CrowdMed

    PubMed Central

    Meyer, Ashley N.D; Longhurst, Christopher A

    2016-01-01

    Background Despite visits to multiple physicians, many patients remain undiagnosed. A new online program, CrowdMed, aims to leverage the “wisdom of the crowd” by giving patients an opportunity to submit their cases and interact with case solvers to obtain diagnostic possibilities. Objective To describe CrowdMed and provide an independent assessment of its impact. Methods Patients submit their cases online to CrowdMed and case solvers sign up to help diagnose patients. Case solvers attempt to solve patients’ diagnostic dilemmas and often have an interactive online discussion with patients, including an exchange of additional diagnostic details. At the end, patients receive detailed reports containing diagnostic suggestions to discuss with their physicians and fill out surveys about their outcomes. We independently analyzed data collected from cases between May 2013 and April 2015 to determine patient and case solver characteristics and case outcomes. Results During the study period, 397 cases were completed. These patients previously visited a median of 5 physicians, incurred a median of US $10,000 in medical expenses, spent a median of 50 hours researching their illnesses online, and had symptoms for a median of 2.6 years. During this period, 357 active case solvers participated, of which 37.9% (132/348) were male and 58.3% (208/357) worked or studied in the medical industry. About half (50.9%, 202/397) of patients were likely to recommend CrowdMed to a friend, 59.6% (233/391) reported that the process gave insights that led them closer to the correct diagnoses, 57% (52/92) reported estimated decreases in medical expenses, and 38% (29/77) reported estimated improvement in school or work productivity. Conclusions Some patients with undiagnosed illnesses reported receiving helpful guidance from crowdsourcing their diagnoses during their difficult diagnostic journeys. However, further development and use of crowdsourcing methods to facilitate diagnosis requires long-term evaluation as well as validation to account for patients’ ultimate correct diagnoses. PMID:26769236

  20. A program of nurse algorithm-guided care for adult patients with acute minor illnesses in primary care

    PubMed Central

    2013-01-01

    Background Attention to patients with acute minor-illnesses requesting same-day consultation represents a major burden in primary care. The workload is assumed by general practitioners in many countries. A number of reports suggest that care to these patients may be provided, at in least in part, by nurses. However, there is scarce information with respect to the applicability of a program of nurse management for adult patients with acute minor-illnesses in large areas. The aim of this study is to assess the effectiveness of a program of nurse algorithm-guided care for adult patients with acute minor illnesses requesting same-day consultation in primary care in a largely populated area. Methods A cross-sectional study of all adult patients seeking same day consultation for 16 common acute minor illnesses in a large geographical area with 284 primary care practices. Patients were included in a program of nurse case management using management algorithms. The main outcome measure was case resolution, defined as completion of the algorithm by the nurse without need of referral of the patient to the general practitioner. The secondary outcome measure was return to consultation, defined as requirement of new consultation for the same reason as the first one, in primary care within a 7-day period. Results During a two year period (April 2009-April 2011), a total of 1,209,669 consultations were performed in the program. Case resolution was achieved by nurses in 62.5% of consultations. The remaining cases were referred to a general practitioner. Resolution rates ranged from 94.2% in patients with burns to 42% in patients with upper respiratory symptoms. None of the 16 minor illnesses had a resolution rate below 40%. Return to consultation during a 7-day period was low, only 4.6%. Conclusions A program of algorithms-guided care is effective for nurse case management of patients requesting same day consultation for minor illnesses in primary care. PMID:23679821

  1. Sources of Stress in Nursing Terminal Patients in a Hospice.

    ERIC Educational Resources Information Center

    Gray-Toft, Pamela; Anderson, James G.

    1987-01-01

    Investigated sources of stress experienced by hospice nurses. Stress sources included: physical characteristics of the unit as well as staffing policies designed to improve the quality of care; procedures followed in admitting patients; policies related to the preparation of meals and open visitation; and greater involvement with the patient and…

  2. Sources of Stress in Nursing Terminal Patients in a Hospice.

    ERIC Educational Resources Information Center

    Gray-Toft, Pamela; Anderson, James G.

    1987-01-01

    Investigated sources of stress experienced by hospice nurses. Stress sources included: physical characteristics of the unit as well as staffing policies designed to improve the quality of care; procedures followed in admitting patients; policies related to the preparation of meals and open visitation; and greater involvement with the patient and

  3. Baseline acetylcholinesterase activity and serotonin plasma levels are not associated with delirium in critically ill patients

    PubMed Central

    Tomasi, Cristiane Damiani; Salluh, Jorge; Soares, Mrcio; Vuolo, Francieli; Zanatta, Francieli; Constantino, Larissa de Souza; Zugno, Alexandra Ioppi; Ritter, Cristiane; Dal-Pizzol, Felipe

    2015-01-01

    Objective The aim of this study was to investigate whether plasma serotonin levels or acetylcholinesterase activities determined upon intensive care unit admission could predict the occurrence of acute brain dysfunction in intensive care unit patients. Methods A prospective cohort study was conducted with a sample of 77 non-consecutive patients observed between May 2009 and September 2010. Delirium was determined using the Confusion Assessment Method for the Intensive Care Unit tool, and the acetylcholinesterase and serotonin measurements were determined from blood samples collected up to a maximum of 24 h after the admission of the patient to the intensive care unit. Results In the present study, 38 (49.6%) patients developed delirium during their intensive care unit stays. Neither serum acetylcholinesterase activity nor serotonin level was independently associated with delirium. No significant correlations of acetylcholinesterase activity or serotonin level with delirium/coma-free days were observed, but in the patients who developed delirium, there was a strong negative correlation between the acetylcholinesterase level and the number of delirium/coma-free days, indicating that higher acetylcholinesterase levels are associated with fewer days alive without delirium or coma. No associations were found between the biomarkers and mortality. Conclusions Neither serum acetylcholinesterase activity nor serotonin level was associated with delirium or acute brain dysfunction in critically ill patients. Sepsis did not modify these relationships. PMID:26340158

  4. A critical appraisal of point-of-care coagulation testing in critically ill patients.

    PubMed

    Levi, M; Hunt, B J

    2015-11-01

    Derangement of the coagulation system is a common phenomenon in critically ill patients, who may present with severe bleeding and/or conditions associated with a prothrombotic state. Monitoring of this coagulopathy can be performed with conventional coagulation assays; however, point-of-care tests have become increasingly attractive, because not only do they yield a more rapid result than clinical laboratory testing, but they may also provide a more complete picture of the condition of the hemostatic system. There are many potential areas of study and applications of point-of-care hemostatic testing in critical care, including patients who present with massive blood loss, patients with a hypercoagulable state (such as in disseminated intravascular coagulation), and monitoring of antiplatelet treatment for acute arterial thrombosis, mostly acute coronary syndromes. However, the limitations of near-patient hemostatic testing has not been fully appreciated, and are discussed here. The currently available evidence indicates that point-of-care tests may be applied to guide appropriate blood product transfusion and the use of hemostatic agents to correct the hemostatic defect or to ameliorate antithrombotic treatment. Disappointingly, however, only in cardiac surgery is there adequate evidence to show that application of near-patient thromboelastography leads to an improvement in clinically relevant outcomes, such as reductions in bleeding-related morbidity and mortality, and cost-effectiveness. More research is required to validate the utility and cost-effectiveness of near-patient hemostatic testing in other areas, especially in traumatic bleeding and postpartum hemorrhage. PMID:26333113

  5. The pharmacokinetics and pharmacodynamics of cisatracurium in critically ill patients with severe sepsis

    PubMed Central

    Liu, Xin; Kruger, Peter S; Weiss, Michael; Roberts, Michael S

    2012-01-01

    AIM To characterize the pharmacokinetics (PK) and pharmacodynamics (PD) of cisatracurium in critically ill patients with severe sepsis. METHODS Blood samples were collected before and over 8 h after a single bolus dose of cisatracurium 0.1 mg kg?1. Neuromuscular block was assessed by accelerometric peripheral nerve stimulation (TOF Watch). Plasma concentration and neuromuscular block data were fitted using population analysis. RESULTS Steady-state volume of distribution was determined to be 111 71 ml kg?1 and plasma clearance was 5.2 1.8 ml min?1 kg?1 in these patients with greater inter-patient variability compared with other populations. The time to maximum block (8.3 2.9 min) and delay time of transferring from central to effect compartment (17.2 min) was much longer, while the maximum block (95.0 6.3%) was less compared with those in other patient populations. The effect compartment concentration resulting in 50% of maximum effect (128 58 ng ml?1) was larger than previously described. CONCLUSIONS This study suggests that standard dosing of cisatracurium in patients with severe sepsis results in a slower patient response with a reduced effect. Use of a larger dose may overcome this reduced delayed response. PMID:22114771

  6. Benefits of Teaching Medical Students How to Communicate with Patients Having Serious Illness

    PubMed Central

    Ellman, Matthew S.; Fortin, Auguste H.

    2012-01-01

    Innovative approaches are needed to teach medical students effective and compassionate communication with seriously ill patients. We describe two such educational experiences in the Yale Medical School curriculum for third-year medical students: 1) Communicating Difficult News Workshop and 2) Ward-Based End-of-Life Care Assignment. These two programs address educational needs to teach important clinical communication and assessment skills to medical students that previously were not consistently or explicitly addressed in the curriculum. The two learning programs share a number of educational approaches driven by the learning objectives, the students development, and clinical realities. Common educational features include: experiential learning, the Biopsychosocial Model, patient-centered communication, integration into clinical clerkships, structured skill-based learning, self-reflection, and self-care. These shared features ? as well as some differences ? are explored in this paper in order to illustrate key issues in designing and implementing medical student education in these areas. PMID:22737055

  7. Disturbances of sodium in critically ill adult neurologic patients: a clinical review

    PubMed Central

    Tisdall, Martin; Crocker, Matthew; Watkiss, Jonathan; Smith, Martin

    2006-01-01

    Disorders of sodium and water balance are common in critically ill adult neurologic patients. Normal aspects of sodium and water regulation are reviewed. The etiology of possible causes of sodium disturbance is discussed in both the general inpatient and neurologic populations. Areas of importance are highlighted with regard to the differential diagnosis of sodium disturbance in neurologic patients and management strategies are discussed. Specific discussions of the etiology, diagnosis and management of cerebral salt wasting syndrome, the syndrome of inappropriate antidiuretic hormone secretion and central diabetes insipidus are presented, as well as the problems of over-treatment. The importance of diagnosis at an early stage of these diseases is stressed, with a recommendation for conservative management of milder cases. PMID:16369141

  8. Non-invasive monitoring of oxygen delivery in acutely ill patients: new frontiers.

    PubMed

    Perel, Azriel

    2015-12-01

    Hypovolemia, anemia and hypoxemia may cause critical deterioration in the oxygen delivery (DO2). Their early detection followed by a prompt and appropriate intervention is a cornerstone in the care of critically ill patients. And yet, the remedies for these life-threatening conditions, namely fluids, blood and oxygen, have to be carefully titrated as they are all associated with severe side-effects when administered in excess. New technological developments enable us to monitor the components of DO2 in a continuous non-invasive manner via the sensor of the traditional pulse oximeter. The ability to better assess oxygenation, hemoglobin levels and fluid responsiveness continuously and simultaneously may be of great help in managing the DO2. The non-invasive nature of this technology may also extend the benefits of advanced monitoring to wider patient populations. PMID:26380992

  9. Assessment of accuracy of Cockcroft-Gault and MDRD formulae in critically ill Indian patients

    PubMed Central

    Kharbanda, Mohit; Majumdar, Arghya; Basu, S.; Todi, Subhash

    2013-01-01

    Background: Cockroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) formulae have not been validated in critically ill Indian patients. We sought to quantify the discrepancy, if any, in Glomerular Filteration Rate (GFR) estimated by CG and MDRD formulae with 24 hrs urine Creatinine Clearance (Cr Cl). Materials and Methods: Prospective cohort study in 50 adult patients in a mixed medical-surgical intensive care unit. Inclusion criteria: Intensive Therapy Unit (ITU) stay >48 hrs and indwelling urinary catheter. Exclusion criteria: Age <18 years, pregnancy, dialysis, urine output <400 ml/day and patients receiving ranitidine, cefoxitin, trimethoprim or diuretics. We estimated Creatinine Clearance by CG and MDRD formula and measured GFR by 24 hrs urine creatinine clearance. Bland Altman plot was used to find the difference between the paired observations. The association between the methods was measured by the product moment correlation coefficient. Result: The mean GFR as calculated by Creatinine Clearance was 79.76 ml/min/1.73 m2 [95% Confidence Interval (CI) 65.79 to 93.72], that by CG formula was 90.05 ml/min/1.73 m2 [95% CI: 74.50 to 105.60], by MDRD was 85.92 ml/min/1.73 m2 [95% CI: 71.25 to 100.59]. The Bias and Precision between CG and Cr Cl were ?4.5 and 140.24 respectively, between MDRD and Cr Cl was ?6.1 and 122.52. The Correlation coefficient of CG formula as a measure of GFR was 0.65 (P < 0.0001), that of MDRD was 0.70 (P < 0.0001). Conclusion: We conclude that CG and MDRD formulae have a strong correlation with measured GFR but are not a reliable measure and overestimate GFR in critically ill Indian patients. PMID:23983410

  10. Identifying critically ill patients with acute kidney injury for whom renal replacement therapy is inappropriate: an exercise in futility?

    PubMed Central

    Gabbay, Ezra; Meyer, Klemens B.

    2009-01-01

    Clinicians treating critically ill patients must consider the possibility that painful and expensive aggressive treatments might confer negligible benefit. Such treatments are often described as futile or inappropriate. We discuss the problem of deciding whether to initiate renal replacement therapy (RRT) for critically ill patients with acute kidney injury (AKI) in the context of the debate surrounding medical futility. The main problems in deciding when such treatment would be futile are that the concept itself is controversial and eludes quantitative definition, that available outcome data do not allow confident identification of patients who will not benefit from treatment and that the decision on RRT in a critically ill patient with AKI is qualitatively different from decisions on other modalities of intensive care and resuscitation, as well as from decisions on dialysis for chronic kidney disease. Despite these difficulties, nephrologists need to identify circumstances in which continued aggressive care would be futile before proceeding to initiate RRT. PMID:25949304

  11. Nephrology Referral and Outcomes in Critically Ill Acute Kidney Injury Patients

    PubMed Central

    Costa e Silva, Vernica Torres; Liao, Fernando; Muriel, Alfonso; Dez, Rafael; de Castro, Isac; Yu, Luis

    2013-01-01

    Background Delayed nephrology consultation (NC) seems to be associated with worse prognosis in critically ill acute kidney injury (AKI) patients. Design, Setting, Participants, & Measurements The aims of this study were to analyze factors related with timing of NC and its relation with AKI patients' outcome in intensive care units of a tertiary hospital. AKI was defined as an increase ?50% in baseline serum creatinine (SCr). Early NC and delayed NC were defined as NC performed before and two days after AKI diagnosis day. Multivariable logistic regression and propensity scores (PS) were used to adjust for confounding and selection biases. Hospital mortality and dialysis dependence on hospital discharge were the primary outcomes. Results A total of 366 AKI patients were analyzed and NCs were carried out in 53.6% of the patients. Hospital mortality was 67.8% and dialysis required in 31.4% patients (115/366). Delayed NCs (34%) occurred two days after AKI diagnosis day. This group presented higher mortality (OR: 4.04/CI: 1.6010.17) and increased dialysis dependence (OR: 3.00/CI: 1.436.29) on hospital discharge. Four variables were retained in the PS model for delayed NC: diuresis (1000 ml/24 h - OR: 1.92/CI: 1.272.90), SCr (OR: 0.49/CI: 0.320.75), surgical AKI (OR: 3.67/CI: 1.658.15), and mechanical ventilation (OR: 2.82/CI: 1.067.44). After correction by PS, delayed NC was still associated with higher mortality (OR: 3.39/CI: 1.249.29) and increased dialysis dependence (OR: 3.25/CI: 1.417.51). Delayed NC was associated with increased mortality either in dialyzed patients (OR: 1.54/CI: 1.351.78) or non-dialyzed patients (OR: 2.89/CI: 1.008.35). Conclusion Delayed NC was associated with higher mortality and increased dialysis dependence rates in critically ill AKI patients at hospital discharge. Further studies are necessary to ascertain whether this effect is due to delayed nephrology intervention or residual confounding factors. PMID:23936440

  12. Termination of Twin Pregnancies with Hydatidiform Moles: a Case Series of Four Patients

    PubMed Central

    PENG, Mei; LI, Li; ZHENG, Jingjie; DING, Yiling; YU, Ling; HUANG, Jian

    2014-01-01

    Abstract P A twin pregnancy with a complete hydatidiform mole with a coexistent foetus (CHMF) is a rare condition that typically results in poor pregnancy outcomes. For patients with refractory vaginal bleeding, termination of pregnancy is more appropriate. However, unified methods for termination remain to be explored. In the present study, we reviewed the termination measures in four cases of twin pregnancy with CHMF. Additional understanding of this condition will aid in the treatment of women with this condition and improve their pregnancy outcomes. PMID:25909068

  13. Health Care Providers and Dying Patients: Critical Issues in Terminal Care.

    ERIC Educational Resources Information Center

    Benoliel, Jeanne Quint

    1988-01-01

    Identifies three major areas of concern in relationship between health care providers and dying patients: (1) nature of difficulties and stresses associated with terminal care; (2) education of providers for work; and (3) influence of organizational structure and institutionalized values on services for dying patients and families. Reviews

  14. Health Care Providers and Dying Patients: Critical Issues in Terminal Care.

    ERIC Educational Resources Information Center

    Benoliel, Jeanne Quint

    1988-01-01

    Identifies three major areas of concern in relationship between health care providers and dying patients: (1) nature of difficulties and stresses associated with terminal care; (2) education of providers for work; and (3) influence of organizational structure and institutionalized values on services for dying patients and families. Reviews…

  15. Alignment of patient and primary care practice member perspectives of chronic illness care: a cross-sectional analysis

    PubMed Central

    2014-01-01

    Background Little is known as to whether primary care teams perceptions of how well they have implemented the Chronic Care Model (CCM) corresponds with their patients own experience of chronic illness care. We examined the extent to which practice members perceptions of how well they organized to deliver care consistent with the CCM were associated with their patients perceptions of the chronic illness care they have received. Methods Analysis of baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM in small, community-based primary care practices. All practice members (i.e., physician providers, non-physician providers, and staff) completed the Assessment of Chronic Illness Care (ACIC) survey and adult patients with 1 or more chronic illnesses completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire. Results Two sets of hierarchical linear regression models accounting for nesting of practice members (N?=?283) and patients (N?=?1,769) within 39 practices assessed the association between practice member perspectives of CCM implementation (ACIC scores) and patients perspectives of CCM (PACIC). ACIC summary score was not significantly associated with PACIC summary score or most of PACIC subscale scores, but four of the ACIC subscales [Self-management Support (p?patient characteristics. The magnitude of the coefficients, however, indicates that the level of association is weak. Conclusions The ACIC and PACIC scales appear to provide complementary and relatively unique assessments of how well clinical services are aligned with the CCM. Our findings underscore the importance of assessing both patient and practice member perspectives when evaluating quality of chronic illness care. Trial registration NCT00482768 PMID:24678983

  16. Would you terminate a pregnancy affected by sickle cell disease? Analysis of views of patients in Cameroon.

    PubMed

    Wonkam, Ambroise; de Vries, Jantina; Royal, Charmaine D; Ramesar, Raj; Angwafo, Fru F

    2014-09-01

    Sickle cell disease (SCD) is a debilitating illness that affects quality of life and life expectancy for patients. In Cameroon, it is now possible to opt for termination of an affected pregnancy (TAP) where the fetus is found to be affected by SCD. Our earlier studies found that, contrary to the views of Cameroonian physicians, a majority of parents with their children suffering from SCD would choose to abort if the fetuses were found to be affected. What have not yet been investigated are the views of people suffering from/living with SCD. We used a quantitative sociological method, with administered structured questionnaires, to study the attitudes of adult patients suffering from SCD on prenatal genetic diagnosis (PND) and possible TAP. The majority of the 89 participants were urban dwellers (84.3%), women (57.3%), Christian (95.5%) and single (90.9%), with a secondary/tertiary education (79.5%). The majority (89.2%) would consider PND for SCD; almost half (48.5%) would reject TAP while 40.9% would consider it. Respondents who rejected TAP claimed mostly ethical reasons (78.1%) while those who found TAP acceptable cited fear of having an affected child (88.9%) and the poor quality of the affected child's health (81.5%). Cameroonian patients with SCD are generally supportive of PND and a remarkably high number of patients living with SCD reported that they would consider terminating a pregnancy based on their assessment of the future well-being of the child. Research is required to investigate the burden of SCD on families and their quality of life. PMID:23918815

  17. Accuracy of a Novel Noninvasive Transdermal Continuous Glucose Monitor in Critically Ill Patients

    PubMed Central

    Saur, Nicole M.; England, Michael R.; Menzie, Wayne; Melanson, Ann Marie; Trieu, My-Quyen; Berlin, Jason; Hurley, James; Krystyniak, Keith; Kongable, Gail L.

    2014-01-01

    Stress hyperglycemia and hypoglycemia are associated with increased morbidity and mortality in the critically ill. Intermittent, random blood glucose (BG) measurements can miss episodes of hyper- and hypoglycemia. The purpose of this study was to determine the accuracy of the Symphony® continuous glucose monitor (CGM) in critically ill cardiac surgery patients. Fifteen adult cardiac surgery patients were evaluated immediately postoperatively in the intensive care unit. Prelude® SkinPrep prepared the skin and a sensor was applied to 2 test sites on each subject to monitor interstitial fluid glucose. Reference BG was sampled at 30- to 60-minute intervals. The skin at the test sites was inspected for adverse effects. Accuracy of the retrospectively analyzed CGM data relative to reference BG values was determined using continuous glucose-error grid analysis (CG-EGA) and mean absolute relative difference (MARD). Using 570 Symphony CGM glucose readings paired with reference BG measurements, CG-EGA showed that 99.6% of the readings were within zones A and B. BG measurements ranged from 73 to 251 mg/dL. The MARD was 12.3%. No adverse device effects were reported. The Symphony CGM system is able to safely, continuously, and noninvasively monitor glucose in the transdermal interstitial fluid of cardiac surgery intensive care unit patients with accuracy similar to that reported with other CGM systems. Future versions of the system will need real-time data analysis, fast warm-up, and less frequent calibrations to be used in the clinical setting. PMID:24876448

  18. Neuromuscular electrical stimulation prevents muscle wasting in critically ill comatose patients.

    PubMed

    Dirks, Marlou L; Hansen, Dominique; Van Assche, Aim; Dendale, Paul; Van Loon, Luc J C

    2015-03-01

    Fully sedated patients, being treated in the intensive care unit (ICU), experience substantial skeletal muscle loss. Consequently, survival rate is reduced and full recovery after awakening is compromised. Neuromuscular electrical stimulation (NMES) represents an effective method to stimulate muscle protein synthesis and alleviate muscle disuse atrophy in healthy subjects. We investigated the efficacy of twice-daily NMES to alleviate muscle loss in six fully sedated ICU patients admitted for acute critical illness [n=3 males, n=3 females; age 63 6 y; APACHE II (Acute Physiology and Chronic Health Evaluation II) disease-severity-score: 29 2]. One leg was subjected to twice-daily NMES of the quadriceps muscle for a period of 7 1 day whereas the other leg acted as a non-stimulated control (CON). Directly before the first and on the morning after the final NMES session, quadriceps muscle biopsies were collected from both legs to assess muscle fibre-type-specific cross-sectional area (CSA). Furthermore, phosphorylation status of the key proteins involved in the regulation of muscle protein synthesis was assessed and mRNA expression of selected genes was measured. In the CON leg, type 1 and type 2 muscle-fibre-CSA decreased by 16 9% and 24 7% respectively (P<0.05). No muscle atrophy was observed in the stimulated leg. NMES increased mammalian target of rapamycin (mTOR) phosphorylation by 19 5% when compared with baseline (P<0.05), with no changes in the CON leg. Furthermore, mRNA expression of key genes involved in muscle protein breakdown either declined [forkhead box protein O1 (FOXO1); P<0.05] or remained unchanged [muscle atrophy F-box (MAFBx) and muscle RING-finger protein-1 (MuRF1)], with no differences between the legs. In conclusion, NMES represents an effective and feasible interventional strategy to prevent skeletal muscle atrophy in critically ill comatose patients. PMID:25296344

  19. Timing of (supplemental) parenteral nutrition in critically ill patients: a systematic review

    PubMed Central

    2014-01-01

    Supplemental parenteral nutrition (SPN) is used in a step-up approach when full enteral support is contraindicated or fails to reach caloric targets. Recent nutrition guidelines present divergent advices regarding timing of SPN in critically ill patients ranging from early SPN (<48 h after admission; EPN) to postponing initiation of SPN until day 8 after Intensive Care Unit (ICU) admission (LPN). This systematic review summarizes results of prospective studies among adult ICU patients addressing the best timing of (supplemental) parenteral nutrition (S)PN. A structured PubMed search was conducted to identify eligible articles. Articles were screened and selected using predetermined criteria and appraised for relevance and validity. After critical appraisal, four randomized controlled trials (RCTs) and two prospective observational studies remained. One RCT found a higher percentage of alive discharge from the ICU at day 8 in the LPN group compared to EPN group (p = 0.007) but no differences in ICU and in-hospital mortality. None of the other RCTs found differences in ICU or in-hospital mortality rates. Contradicting or divergent results on other secondary outcomes were found for ICU length of stay, hospital length of stay, infection rates, nutrition targets, duration of mechanical ventilation, glucose control, duration of renal replacement therapy, muscle wasting and fat loss. Although the heterogeneity in quality and design of relevant studies precludes firm conclusions, it is reasonable to assume that in adult critically ill patients, there are no clinically relevant benefits of EPN compared with LPN with respect to morbidity or mortality end points, when full enteral support is contraindicated or fails to reach caloric targets. However, considering that infectious morbidity and resolution of organ failure may be negatively affected through mechanisms not yet clearly understood and acquisition costs of parenteral nutrition are higher, the early administration of parenteral nutrition cannot be recommended. PMID:25593747

  20. How aminoglycosides are used in critically ill patients in a teaching hospital in North of Iran

    PubMed Central

    Salehifar, Ebrahim; Eslami, Gohar; Ahangar, Nematollah; Rafati, Mohammad Reza; Eslami, Shafagh

    2015-01-01

    Background: Resistance to antimicrobial agents including aminoglycosides (AGs) is a great concern that is mainly related to inappropriate use. Since there were not adequate data regarding how rationally AGs are being prescribed in our critically ill patients, this study was conducted to determine the main issues in the area of appropriate use of this antibiotic class. Methods: One hundred patients who were in the intensive care units (ICUs) of Imam Khomeini Teaching Hospital from February 2012 to August 2012 were included. A data gathering form was prepared based upon the recommendations provided by Up-to-date (20.1) 2012 and Medscape 2013. All demographic characteristics and other information about time of beginning and duration of dosage, interval of administration of AGs and creatinine (Cr) level were collected. In statistical analysis, SPSS Version 16 software was used. Independent samples t-test was used to compare the quantitative and chi-square for qualitative variables. Results: Sixty six (66%) of patients received gentamicin and 38% received amikacin. In 27% of patients, serum creatinine (Cr) had been checked before and after AGs administration and 4 patients had no renal function monitoring. Monitoring of serum concentration and Cr clearance estimation was not carried out for any patients. Culture and laboratory sensitivity tests were done on 17 patients and E-coli (57%) was the most common isolated organism. Conclusion: The results of this study revealed that majority of the hospitalized patients in the ICU and the dosage of AGs had not been adjusted to renal function. PMID:26644900

  1. Functional evolution of critically ill patients undergoing an early rehabilitation protocol

    PubMed Central

    Murakami, Fernanda Murata; Yamaguti, Wellington Pereira; Onoue, Mirian Akemi; Mendes, Juliana Mesti; Pedrosa, Renata Santos; Maida, Ana Lígia Vasconcellos; Kondo, Cláudia Seiko; de Salles, Isabel Chateaubriand Diniz; de Brito, Christina May Moran; Rodrigues, Miguel Koite

    2015-01-01

    Objective Evaluation of the functional outcomes of patients undergoing an early rehabilitation protocol for critically ill patients from admission to discharge from the intensive care unit. Methods A retrospective cross-sectional study was conducted that included 463 adult patients with clinical and/or surgical diagnosis undergoing an early rehabilitation protocol. The overall muscle strength was evaluated at admission to the intensive care unit using the Medical Research Council scale. Patients were allocated to one of four intervention plans according to the Medical Research Council score, the suitability of the plan’s parameters, and the increasing scale of the plan expressing improved functional status. Uncooperative patients were allocated to intervention plans based on their functional status. The overall muscle strength and/or functional status were reevaluated upon discharge from the intensive care unit by comparison between the Intervention Plans upon admission (Planinitial) and discharge (Planfinal). Patients were classified into three groups according to the improvement of their functional status or not: responsive 1 (Planfinal > Planinitial), responsive 2 (Planfinal = Planinitial) and unresponsive (Planfinal < Planinitial). Results In total, 432 (93.3%) of 463 patients undergoing the protocol responded positively to the intervention strategy, showing maintenance and/or improvement of the initial functional status. Clinical patients classified as unresponsive were older (74.3 ± 15.1 years of age; p = 0.03) and had longer lengths of intensive care unit (11.6 ± 14.2 days; p = 0.047) and hospital (34.5 ± 34.1 days; p = 0.002) stays. Conclusion The maintenance and/or improvement of the admission functional status were associated with shorter lengths of intensive care unit and hospital stays. The results suggest that the type of diagnosis, clinical or surgical, fails to define the positive response to an early rehabilitation protocol. PMID:26340157

  2. Clinical Relevance of Multiple Respiratory Virus Detection in Adult Patients with Acute Respiratory Illness

    PubMed Central

    Choi, Seong-Ho; Kim, Hye Ryoun

    2015-01-01

    Because increasing numbers of nasopharyngeal swab specimens from adult patients with acute respiratory illness (ARI) are being tested by respiratory virus (RV) multiplex reverse transcriptase PCR (RVM-RT-PCR), multiple RV detection (MRVD) is being encountered more frequently. However, the clinical relevance of MRVD in adult patients has rarely been evaluated. The clinical characteristics of hospitalized adult patients with ARI and MRVD by RVM-RT-PCR tests were compared to those of patients with single RV detection (SRVD) during a single year at a tertiary care center. MRVD was observed in 26 of the 190 adult patients (13.7%). The patients with MRVD had a higher incidence of chronic lung disease than the patients with SRVD (34.6% versus 15.9%, crude odds ratio [OR] = 2.81, 95% confidence interval [CI] = 1.13 to 6.98, P = 0.03). Although the former were more likely than the latter to receive mechanical ventilation (19.2% versus 6.7%, crude OR = 3.31, 95% CI = 1.05 to 10.47, P = 0.049), the length of hospital stay (median, 7 versus 6.5 days; P = 0.66), and the in-hospital mortality rate (7.7% versus 4.3%, crude OR = 1.87, 95% CI = 0.37 to 9.53, P = 0.35) were not different between the two groups. In multivariate analysis, chronic lung disease was associated with MRVD (adjusted OR = 3.08, 95% CI = 1.12 to 8.46, P = 0.03). In summary, it was not uncommon to encounter adult patients with ARI and MRVD by RVM-RT-PCR tests of nasopharyngeal swab specimens. MRVD was associated with chronic lung disease rather than the severity of the ARI. PMID:25631799

  3. A specially tailored vancomycin continuous infusion regimen for renally impaired critically ill patients

    PubMed Central

    Sabry, Nirmeen A; Abbassi, Maggie M; Abdel Shafy, Sanaa S; Mokhtar, Mohamed S; Abdel Bary, Ahmed

    2013-01-01

    Background: Vancomycin remains the gold standard for treatment of methicillin-resistant Staphylococcus aureus. Specially designed continuous infusion of vancomycin leads to better therapy. Methodology: A total of 40 critically ill patients who suffered from pneumonia susceptible to vancomycin, had serum creatinine >1.4 mg%, and oliguria <0.5 mL/kg/h for 6 h were included in the study with respiratory culture sensitivity to vancomycin ?2 mg/L. Patients clinical, microbiological, and biological data were obtained by retrospective analysis of the corresponding medical files before and after vancomycin treatment. Patients with serum creatinine level ?4 mg% and patients who received renal replacement therapy during the treatment period were excluded. The patients were divided into two groupsgroup 1 (intermittent dosing) and group 2 (continuous infusion) based on the following formula: rate of vancomycin continuous infusion (g/day) = [0.0205 creatinine clearance (mL/min) + 3.47] [target vancomycin concentration at steady state (g/mL)] (24/1000). Trough vancomycin serum levels were also assessed using high-performance liquid chromatographic technique. Patients outcomes such as clinical improvement, adverse events, and 15-day mortality were reported. Results: Group 2 showed significant reduction in blood urea nitrogen, creatinine serum levels, white blood cells, partial carbon dioxide pressure, body temperature, and Sequential Organ Failure Assessment score, while significant increase in partial oxygen pressure and saturated oxygen was also observed. A significantly shorter duration of treatment with a comparable vancomycin serum levels was also reported with group 2. Conclusion: After treatment, comparison in patients criteria supports the superiority of using continuous infusion of vancomycin according to this equation in renally impaired patients.

  4. Adaptation and validation of the patient assessment of chronic illness care in the French context

    PubMed Central

    2014-01-01

    Background Chronic diseases are major causes of disability worldwide with rising prevalence. Most patients suffering from chronic conditions do not always receive optimal care. The Chronic Care Model (CCM) has been developed to help general practitioners making quality improvements. The Patient Assessment of Chronic Illness Care (PACIC) questionnaire was increasingly used in several countries to appraise the implementation of the CCM from the patients perspective. The objective of this study was to adapt the PACIC questionnaire in the French context and to test the validity of this adaptation in a sample of patients with multiple chronic conditions. Methods The PACIC was translated into French language using a forward/backward procedure. The French version was validated using a sample of 150 patients treated for obstructive sleep apnea syndrome (OSAS) and having multiple chronic co-morbidities. Several forms of validity were analysed: content; face; construct; and internal consistency. The construct validity was investigated with an exploratory factorial analysis. Results The French-version of the PACIC consisted in 18 items, after merging two pairs of items due to redundancy. The high number of items exhibiting floor/ceiling effects and the non-normality of the ratings suggested that a 5-points rating scale was somewhat inappropriate to assess the patients experience of care. The construct validity of the French-PACIC was verified and resulted in a bi-dimensional structure. Overall this structure showed a high level of internal consistency. The PACIC score appeared to be significantly related to the age and self-reported health of the patients. Conclusions A French-version of the PACIC questionnaire is now available to evaluate the patients experience of care and to monitor the quality improvements realised by the medical structures. This study also pointed out some methodological issues about the PACIC questionnaire, related to the format of the rating scale and to the structure of the questionnaire. PMID:24947538

  5. Opioid rotation for toxicity reduction in terminal cancer patients.

    PubMed

    de Stoutz, N D; Bruera, E; Suarez-Almazor, M

    1995-07-01

    Accumulation of active (toxic) metabolites of opioids might explain cases of opioid toxicity when high doses are used for long periods of time. Other mechanisms of late toxicity of opioids may be found at the receptor level. Whatever the cause, a change of opioids using equianalgesic doses can be expected to improve symptoms of toxicity in some patients, while maintaining pain control. We reviewed the experience with this technique in patients admitted to the Palliative Care Unit of the Edmonton General Hospital. Of 191 patients, 80 underwent opioid rotation (OR) for cognitive failure, hallucinations, myoclonus, nausea and vomiting, local toxicity, and persistent pain. These leading symptoms improved in 58/80 patients (73%, P < 0.01). Pain control, as measured on a 10-cm visual analogue scale (VAS), improved from 4.4 +/- 2.3 to 3.6 +/- 2.0 (P < 0.004) at a dose significantly lower than that predicted to be equianalgesic (577 +/- 1535 mg before OR versus 336 +/- 593 mg after OR, P < 0.04). We conclude that symptoms of opioid toxicity can be relieved by OR, and that a choice of two or three different opioids is necessary to obtain satisfactory long-term pain control. PMID:7673770

  6. Association of physicians' illness perception of fibromyalgia with frustration and resistance to accepting patients: a cross-sectional study.

    PubMed

    Homma, Mieko; Ishikawa, Hirono; Kiuchi, Takahiro

    2014-08-01

    The aim of this study was to elucidate whether physicians' illness perceptions correlate with their frustration or resistance to accepting patients with fibromyalgia (FM). In this cross-sectional postal survey, questionnaires were sent to member physicians of the Japan College of Rheumatology and Japan Rheumatism Foundation. Measures collected included the Brief Illness Perception Questionnaire with Causal Attribution, the Illness Invalidation Inventory, and the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10). Multiple logistic regression was performed to examine associations between the DDPRQ-10 and resistance to accepting patients with FM for treatment. We analyzed data from 233 physicians who had experience in consulting with patients with FM. Only 44.2% answered that they wanted to accept additional patients with FM. Physicians' frustration was associated with difficulty controlling symptoms, patients' emotional responses, and causal attribution of FM to patient internal factors. Conversely, lower levels of frustration were associated with causal attributions to biological factors and uncontrollable external factors. However, the "difficult patient" perception did not correlate with resistance to accepting patients with FM. Difficulty controlling symptoms with treatment was the one factor common to both physicians' frustration and resistance to accepting patients with FM. Physicians may hesitate to accept patients with FM not because of the stigmatic image of the "difficult patient," but instead because of the difficulty in controlling the symptoms of FM. Thus, to improve the quality of consultation, physicians must continuously receive new information about the treatments and causes of FM. PMID:25085273

  7. Psychological process from hospitalization to death among uninformed terminal liver cancer patients in Japan

    PubMed Central

    Maeda, Yuko; Hagihara, Akihito; Kobori, Eiko; Nakayama, Takeo

    2006-01-01

    Background Although the attitude among doctors toward disclosing a cancer diagnosis is becoming more positive, informing patients of their disease has not yet become a common practice in Japan. We examined the psychological process, from hospitalization until death, among uninformed terminal cancer patients in Japan, and developed a psychological model. Methods Terminal cancer patients hospitalized during the recruiting period voluntarily participated in in-depth interviews. The data were analyzed by grounded theory. Results Of the 87 uninformed participants at the time of hospitalization, 67% (N = 59) died without being informed of their diagnosis. All were male, 5166 years of age, and all experienced five psychological stages: anxiety and puzzlement, suspicion and denial, certainty, preparation, and acceptance. At the end of each stage, obvious and severe feelings were observed, which were called "gates." During the final acceptance stage, patients spent a peaceful time with family, even talking about their dreams with family members. Conclusion Unlike in other studies, the uninformed patients in this study accepted death peacefully, with no exceptional cases. Despite several limitations, this study showed that almost 70% of the uninformed terminal cancer patients at hospitalization died without being informed, suggesting an urgent need for culturally specific and effective terminal care services for cancer patients in Japan. PMID:16948863

  8. Relationship of Plasma Gelsolin Levels to Outcomes in Critically Ill Surgical Patients

    PubMed Central

    Lee, Po-Shun; Drager, Leslie R.; Stossel, Thomas P.; Moore, Francis D.; Rogers, Selwyn O.

    2006-01-01

    Objective: To examine the relationship between plasma gelsolin levels and mortality following surgery or trauma. Background: Few simple predictive diagnostic tests are available to predict mortality following surgery or trauma. We hypothesize that plasma concentrations of gelsolin, a protein that responds to injured tissue, might be a predictor of patient outcomes. Methods: We conducted a prospective, observational study in the surgical intensive units (ICU) at a tertiary care teaching hospital. A total of 31 patients were enrolled in the study. Chart abstraction was used to gather data about patient demographics, clinical characteristics, and clinical outcomes. Plasma gelsolin concentrations were assessed serially on day 0 through day 5. Results: Low plasma gelsolin levels were associated with increased risk of death occurring in the ICU. Plasma gelsolin levels lower than 61 mg/L predicted longer ICU stay, prolonged ventilator dependence, and increased overall in-hospital mortality. Conclusion: Plasma gelsolin is a potential prognostic biomarker for critically ill surgical patients. Plasma gelsolin replacement may have therapeutic application. PMID:16495706

  9. Environment of care: vertical evacuation concerns for acutely ill patients and others with restricted mobility.

    PubMed

    Tzeng, Huey-Ming; Yin, Chang-Yi

    2014-01-01

    This perspective paper was intended to raise awareness and the urgency of needing additional evacuation-related, hospital building design policies. We addressed the challenges to maintain the integrity of exits and inadequate hospital design considerations for individuals with restricted mobility. Hospitals are occupied by people who may have restricted mobility and visitors who are likely unfamiliar with their surroundings. A hospital fire threatens all people in the building, but especially patients in the intensive care unit who are frail and have limited mobility. Evacuating immobile patients is complex, involving horizontal and vertical evacuation approaches. Hospital design must consider the needs of individuals with restricted mobility, who are the most vulnerable in case of a hospital fire. Consequently, we urge that acutely ill patients and others with restricted mobility should occupy units located on the ground floor or Level 2. In addition, when configuring the physical environment of hospitals, providing step-free ground floor access (indoor or outdoor ramps) and evacuation aids for vertical evacuation is crucial. Step-free ground floor access between Level 2 and the ground floor should be wide enough to allow transporting patients on their beds. A standard revision to include these recommendations is desperately needed. PMID:24404945

  10. [Illness-specific knowledge, coping with illness and metabolic control in insulin-injecting diabetic patients in a random city population].

    PubMed

    Mller, U A; Berlet, G; Ross, I S; Klinger, H

    1993-08-01

    A knowledge test about diabetes using a standardized interview was assessed in 186 (81%) of 229 insulin treated patients below the age of 60 who are registered and treated in the diabetes care unit Jena. 90% of these patients were on conventional insulin therapy. The frequency of errors was positive correlated to glycosylated haemoglobin, age and body-mass-index, it was lower in type 1 than in type 2 diabetic patients and decreased with a better education level. Deficiencies of knowledge were detected in the following areas: hyperglycaemic coma, consequence of acetone and obesitas. Knowledge regarding late complications was on a high level. 20% of type 1 and 43% of type 2 diabetic patients did not know their daily carbohydrate units. But the metabolic control in these patients was not different from the patients who know their carbohydrates exactly. Most frequent missed subjects in the patient information were reported: modern therapy strategies, insulin pumps and nutrition. 77% of all patients did not feel ill because of their diabetes and 91% reported an unchanged relationship to their family after diabetes was diagnosed. PMID:8379218

  11. Palliative Medicine and Decision Science: The Critical Need for a Shared Agenda To Foster Informed Patient Choice in Serious Illness

    PubMed Central

    Kryworuchko, Jennifer; Matlock, Dan D.; Volandes, Angelo E.

    2011-01-01

    Abstract Assisting patients and their families in complex decision making is a foundational skill in palliative care; however, palliative care clinicians and scientists have just begun to establish an evidence base for best practice in assisting patients and families in complex decision making. Decision scientists aim to understand and clarify the concepts and techniques of shared decision making (SDM), decision support, and informed patient choice in order to ensure that patient and family perspectives shape their health care experience. Patients with serious illness and their families are faced with myriad complex decisions over the course of illness and as death approaches. If patients lose capacity, then surrogate decision makers are cast into the decision-making role. The fields of palliative care and decision science have grown in parallel. There is much to be gained in advancing the practices of complex decision making in serious illness through increased collaboration. The purpose of this article is to use a case study to highlight the broad range of difficult decisions, issues, and opportunities imposed by a life-limiting illness in order to illustrate how collaboration and a joint research agenda between palliative care and decision science researchers, theorists, and clinicians might guide best practices for patients and their families. PMID:21895453

  12. Evaluation of a Model for Glycemic Prediction in Critically Ill Surgical Patients

    PubMed Central

    Pappada, Scott M.; Cameron, Brent D.; Tulman, David B.; Bourey, Raymond E.; Borst, Marilyn J.; Olorunto, William; Bergese, Sergio D.; Evans, David C.; Stawicki, Stanislaw P. A.; Papadimos, Thomas J.

    2013-01-01

    We evaluated a neural network model for prediction of glucose in critically ill trauma and post-operative cardiothoracic surgical patients. A prospective, feasibility trial evaluating a continuous glucose-monitoring device was performed. After institutional review board approval, clinical data from all consenting surgical intensive care unit patients were converted to an electronic format using novel software. This data was utilized to develop and train a neural network model for real-time prediction of serum glucose concentration implementing a prediction horizon of 75 minutes. Glycemic data from 19 patients were used to train the neural network model. Subsequent real-time simulated testing was performed in 5 patients to whom the neural network model was naive. Performance of the model was evaluated by calculating the mean absolute difference percent (MAD%), Clarke Error Grid Analysis, and calculation of the percent of hypoglycemic (?70 mg/dL), normoglycemic (>70 and <150 mg/dL), and hyperglycemic (?150 mg/dL) values accurately predicted by the model; 9,405 data points were analyzed. The models successfully predicted trends in glucose in the 5 test patients. Clark Error Grid Analysis indicated that 100.0% of predictions were clinically acceptable with 87.3% and 12.7% of predicted values falling within regions A and B of the error grid respectively. Overall model error (MAD%) was 9.0% with respect to actual continuous glucose modeling data. Our model successfully predicted 96.7% and 53.6% of the normo- and hyperglycemic values respectively. No hypoglycemic events occurred in these patients. Use of neural network models for real-time prediction of glucose in the surgical intensive care unit setting offers healthcare providers potentially useful information which could facilitate optimization of glycemic control, patient safety, and improved care. Similar models can be implemented across a wider scale of biomedical variables to offer real-time optimization, training, and adaptation that increase predictive accuracy and performance of therapies. PMID:23894489

  13. Evaluation of a model for glycemic prediction in critically ill surgical patients.

    PubMed

    Pappada, Scott M; Cameron, Brent D; Tulman, David B; Bourey, Raymond E; Borst, Marilyn J; Olorunto, William; Bergese, Sergio D; Evans, David C; Stawicki, Stanislaw P A; Papadimos, Thomas J

    2013-01-01

    We evaluated a neural network model for prediction of glucose in critically ill trauma and post-operative cardiothoracic surgical patients. A prospective, feasibility trial evaluating a continuous glucose-monitoring device was performed. After institutional review board approval, clinical data from all consenting surgical intensive care unit patients were converted to an electronic format using novel software. This data was utilized to develop and train a neural network model for real-time prediction of serum glucose concentration implementing a prediction horizon of 75 minutes. Glycemic data from 19 patients were used to "train" the neural network model. Subsequent real-time simulated testing was performed in 5 patients to whom the neural network model was naive. Performance of the model was evaluated by calculating the mean absolute difference percent (MAD%), Clarke Error Grid Analysis, and calculation of the percent of hypoglycemic (?70 mg/dL), normoglycemic (>70 and <150 mg/dL), and hyperglycemic (?150 mg/dL) values accurately predicted by the model; 9,405 data points were analyzed. The models successfully predicted trends in glucose in the 5 test patients. Clark Error Grid Analysis indicated that 100.0% of predictions were clinically acceptable with 87.3% and 12.7% of predicted values falling within regions A and B of the error grid respectively. Overall model error (MAD%) was 9.0% with respect to actual continuous glucose modeling data. Our model successfully predicted 96.7% and 53.6% of the normo- and hyperglycemic values respectively. No hypoglycemic events occurred in these patients. Use of neural network models for real-time prediction of glucose in the surgical intensive care unit setting offers healthcare providers potentially useful information which could facilitate optimization of glycemic control, patient safety, and improved care. Similar models can be implemented across a wider scale of biomedical variables to offer real-time optimization, training, and adaptation that increase predictive accuracy and performance of therapies. PMID:23894489

  14. Intensive insulin treatment in critically ill trauma patients normalizes glucose by reducing endogenous glucose production.

    PubMed

    Thorell, Anders; Rooyackers, Olav; Myrenfors, Peter; Soop, Mattias; Nygren, Jonas; Ljungqvist, Olle H

    2004-11-01

    Critical illness is associated with insulin resistance and hyperglycemia. Intensive insulin treatment to normalize blood glucose during feeding has been shown to improve morbidity and mortality in patients in intensive care. The mechanisms behind the glucose-controlling effects of insulin in stress are not well understood. Six previously healthy, severely traumatized patients (injury severity score > 15) were studied early (24-48 h) after trauma. Endogenous glucose production (EGP) and whole-body glucose disposal (WGD) were measured (6,6-(2)H(2)-glucose) at basal, during total parenteral nutrition (TPN), and during TPN plus insulin to normalize blood glucose (TPN+I). Six matched volunteers served as controls. At basal and TPN, concentrations of glucose and insulin were higher in patients (P < 0.05). During TPN+I, insulin concentrations were 30-fold higher in patients. At basal, WGD and EGP were 30% higher in patients (P < 0.05). During TPN, EGP decreased in both groups but less in patients, resulting in 110% higher EGP than controls (P < 0.05). Normoglycemia coincided with reduced EGP, resulting in similar rates in both groups. WGD did not change during TPN or TPN+I and was not different between the groups. In conclusion, in healthy subjects, euglycemia is maintained during TPN at physiological insulin concentrations by a reduction of EGP, whereas WGD is maintained at basal levels. In traumatized patients, hyperglycemia is due to increased EGP. In contrast to controls, normalization of glucose concentration during TPN needs high insulin infusion rates and is accounted for by a reduction in EGP, whereas WGD is not increased. PMID:15531485

  15. Understanding family responses to life-limiting illness: In-depth interviews with hospice patients and their family members.

    PubMed

    Waldrop, Deborah P; Milch, Robert A; Skretny, Judith A

    2005-01-01

    Understanding family dynamics is a key component in providing comprehensive care for persons with progressive illnesses and their caregivers. The purpose of this study was to investigate what families experience during an advancing illness and to describe their pattems of response. In-depth interviews (n=108) were conducted with families two weeks after hospice admission. Interviews were tape recorded, transcribed, and analyzed using qualitative methods. Six modes were distilled: reactive (illness generates intense responses), advocacy (vulnerability ignites assertive actions), fused (illness and decline are shared experiences), dissonant (diametrically opposed viewpoints cause struggle), resigned (decline and death are anticipated), and closed (outward responses are impassive). Three events triggered movement from one mode to another: (1) functional changes, (2) crisis events, and (3) provider communication. Providers who understand varied family reactions can ease the patient's suffering, assist relatives in providing effective care, and prepare them for the approaching death. PMID:16114807

  16. The Effects of Group Psychoeducational Programme on Attitude toward Mental Illness in Families of Patients with Schizophrenia, 2014

    PubMed Central

    Rahmani, Farnaz; Ranjbar, Fatemeh; Ebrahimi, Hossein; Hosseinzadeh, Mina

    2015-01-01

    Introduction: Family members often play a vital role as caregivers in the lives of individuals with schizophrenia. Results of the studies showed that family invironment is the most important determinint of patients outcomes like as quality of life, relapse, adherence. This study aimed to determine the effect of group psychoeducational programme on attitude towards mental illness in families of patients with schizophrenia. Methods: In this quasi-experimental study, 74 families who have schizophrenic patients hospitalized in psychiatric wards during sampling were selected by convenience sampling method. Then the sample was randomly assigned to experimental and control groups. The families of experimental group received 8 continuous 90-minute 3 times a week psychoeducational sessions. Family attitude towards mental illness was measured using the questionnaire of Opinion about Mental Illnesses (OMI) before and after intervention. Data analysis was conducted using χ2 test, independent t-test, and paired t-test on SPSS software version 13. Results: The results showed that majority of the families had negative attitude towards mental illness (88.90%). In addition, the results showed that there was significant difference between different dimensions of attitude towards mental illness before and after psychoeducation in the experimental group. The mean score of families' post-test in the experimental group increased compared to control group 108.86 (14.9), vs. 88.86 (7.5). Conclusion: The results of this study indicate that psychoeducation improves family attitude towards mental illness. Training methods like group psych education for the families of mental patients can be effective on their attitudes towards mental illness. PMID:26464841

  17. Thromboprophylaxis patterns and determinants in critically ill patients: a multicenter audit

    PubMed Central

    2014-01-01

    Introduction Heparin is safe and prevents venous thromboembolism in critical illness. We aimed to determine the guideline concordance for thromboprophylaxis in critically ill patients and its predictors, and to analyze factors associated with the use of low molecular weight heparin (LMWH), as it may be associated with a lower risk of pulmonary embolism and heparin-induced thrombocytopenia without increasing the bleeding risk. Methods We performed a retrospective audit in 28 North American intensive care units (ICUs), including all consecutive medical-surgical patients admitted in November 2011. We documented ICU thromboprophylaxis and reasons for omission. Guideline concordance was determined by adding days in which patients without contraindications received thromboprophylaxis to days in which patients with contraindications did not receive it, divided by the total number of patient-days. We used multilevel logistic regression including time-varying, center and patient-level covariates to determine the predictors of guideline concordance and use of LMWH. Results We enrolled 1,935 patients (62.3??16.7 years, Acute Physiology and Chronic Health Evaluation [APACHE] II score 19.1??8.3). Patients received thromboprophylaxis with unfractionated heparin (UFH) (54.0%) or LMWH (27.6%). Guideline concordance occurred for 95.5% patient-days and was more likely in patients who were sicker (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.17, 1.75 per 10-point increase in APACHE II), heavier (OR 1.32, 95% CI 1.05, 1.65 per 10-m/kg2 increase in body mass index), had cancer (OR 3.22, 95% CI 1.81, 5.72), previous venous thromboembolism (OR 3.94, 95% CI 1.46,10.66), and received mechanical ventilation (OR 1.83, 95% CI 1.32,2.52). Reasons for not receiving thromboprophylaxis were high risk of bleeding (44.5%), current bleeding (16.3%), no reason (12.9%), recent or upcoming invasive procedure (10.2%), nighttime admission or discharge (9.7%), and life-support limitation (6.9%). LMWH was less often administered to sicker patients (OR 0.65, 95% CI 0.48, 0.89 per 10-point increase in APACHE II), surgical patients (OR 0.41, 95% CI 0.24, 0.72), those receiving vasoactive drugs (OR 0.47, 95% CI 0.35, 0.64) or renal replacement therapy (OR 0.10, 95% CI 0.05, 0.23). Conclusions Guideline concordance for thromboprophylaxis was high, but LMWH was less commonly used, especially in patients who were sicker, had surgery, or received vasopressors or renal replacement therapy, representing a potential quality improvement target. PMID:24766968

  18. Influence of the central venous site on the transpulmonary thermodilution parameters in critically ill burn patients.

    PubMed

    Soussi, Sabri; Sisso, Fiona; Maurel, Vronique; Oueslati, Haikel; Legrand, Matthieu

    2015-11-01

    The aim of this study was to verify the measurement concordance of cardiac index (CI), extra-vascular lung water index (EVLWI) and global end diastolic volume index (GEDVI) with transpulmonary thermodilution (TPTD) between the jugular and femoral access with catheters inserted ipsilaterally in critically ill burn patients. Correlations were excellent and the concordance was good for the CI, EVLW and GEDVI (mean bias -0.11 L/min/m, -0.3 mL/kg and -20 mL/m for CI, EVLW and GEDVI, respectively). We conclude that ipsilateral arterial and venous femoral and jugular measurement of TPTD parameters can be used interchangeably if catheters with different lengths on the femoral site are used. PMID:26771037

  19. Metabolic and nutritional support of critically ill patients: consensus and controversies.

    PubMed

    Preiser, Jean-Charles; van Zanten, Arthur R H; Berger, Mette M; Biolo, Gianni; Casaer, Michael P; Doig, Gordon S; Griffiths, Richard D; Heyland, Daren K; Hiesmayr, Michael; Iapichino, Gaetano; Laviano, Alessandro; Pichard, Claude; Singer, Pierre; Van den Berghe, Greet; Wernerman, Jan; Wischmeyer, Paul; Vincent, Jean-Louis

    2015-01-01

    The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients. PMID:25886997

  20. Evaluation of the pressure ulcers risk scales with critically ill patients: a prospective cohort study 1

    PubMed Central

    Borghardt, Andressa Tomazini; do Prado, Thiago Nascimento; de Arajo, Thiago Moura; Rogenski, Noemi Marisa Brunet; Bringuente, Maria Edla de Oliveira

    2015-01-01

    AIMS: to evaluate the accuracy of the Braden and Waterlow risk assessment scales in critically ill inpatients. METHOD: this prospective cohort study, with 55 patients in intensive care units, was performed through evaluation of sociodemographic and clinical variables, through the application of the scales (Braden and Waterlow) upon admission and every 48 hours; and through the evaluation and classification of the ulcers into categories. RESULTS: the pressure ulcer incidence was 30.9%, with the Braden and Waterlow scales presenting high sensitivity (41% and 71%) and low specificity (21% and 47%) respectively in the three evaluations. The cut off scores found in the first, second and third evaluations were 12, 12 and 11 in the Braden scale, and 16, 15 and 14 in the Waterlow scale. CONCLUSION: the Braden scale was shown to be a good screening instrument, and the Waterlow scale proved to have better predictive power. PMID:25806628

  1. Update on point of care ultrasound in the care of the critically ill patient

    PubMed Central

    Blaivas, Michael

    2012-01-01

    One of the most exciting developments to come to the aid of the critically ill patient in recent years is not new at all, but rather has been repackaged and evolved to a level where point-of-care use by critical care physicians has been made possible. Critical care or point-of-care ultrasound dates back more than twenty years, but has come to prominence in the last 5 years and is spreading quickly. Multiple critical care societies have taken up ultrasound policy and training and one organization has been formed that concentrates only on point-of-care ultrasound in critical settings and interventions. The amount of literature generated on the topic is increasing rapidly and hardly a major clinical journal exists that has not published ultrasound related topics. PMID:24701407

  2. Stratification of the severity of critically ill patients with classification trees

    PubMed Central

    2009-01-01

    Background Development of three classification trees (CT) based on the CART (Classification and Regression Trees), CHAID (Chi-Square Automatic Interaction Detection) and C4.5 methodologies for the calculation of probability of hospital mortality; the comparison of the results with the APACHE II, SAPS II and MPM II-24 scores, and with a model based on multiple logistic regression (LR). Methods Retrospective study of 2864 patients. Random partition (70:30) into a Development Set (DS) n = 1808 and Validation Set (VS) n = 808. Their properties of discrimination are compared with the ROC curve (AUC CI 95%), Percent of correct classification (PCC CI 95%); and the calibration with the Calibration Curve and the Standardized Mortality Ratio (SMR CI 95%). Results CTs are produced with a different selection of variables and decision rules: CART (5 variables and 8 decision rules), CHAID (7 variables and 15 rules) and C4.5 (6 variables and 10 rules). The common variables were: inotropic therapy, Glasgow, age, (A-a)O2 gradient and antecedent of chronic illness. In VS: all the models achieved acceptable discrimination with AUC above 0.7. CT: CART (0.75(0.71-0.81)), CHAID (0.76(0.72-0.79)) and C4.5 (0.76(0.73-0.80)). PCC: CART (72(69-75)), CHAID (72(69-75)) and C4.5 (76(73-79)). Calibration (SMR) better in the CT: CART (1.04(0.95-1.31)), CHAID (1.06(0.97-1.15) and C4.5 (1.08(0.98-1.16)). Conclusion With different methodologies of CTs, trees are generated with different selection of variables and decision rules. The CTs are easy to interpret, and they stratify the risk of hospital mortality. The CTs should be taken into account for the classification of the prognosis of critically ill patients. PMID:20003229

  3. Use of acid suppressive therapy in hospitalized non-critically ill patients

    PubMed Central

    Sheikh-Taha, Marwan; Alaeddine, Sarah; Nassif, Julie

    2012-01-01

    AIM: To assess the appropriateness of prescribing acid suppressive therapy (AST) in a general medicine service in a tertiary care hospital. METHODS: In this retrospective observational study, we reviewed the inpatient records of all patients admitted to the general medical service in a tertiary care hospital in Beirut, Lebanon, from April 1 to May 31, 2011. Treatment with AST was considered appropriate if the patient had a specific indication or appropriate treatment purpose [e.g., gastro-esophageal reflux disease (GERD), peptic ulcer disease, dyspepsia, acute or suspected gastrointestinal (GI) bleeding]. Appropriate administration of stress ulcer prophylaxis (SUP) was derived from an internal guideline that is based on the American Society of Health System Pharmacists guidelines. Prophylaxis was considered appropriate if a patient had 1 absolute indication (coagulopathy or requiring mechanical ventilation), or 2 or more relative indications (sepsis, occult bleeding, use of high dose corticosteroids, recent use of non-steroidal anti-inflammatory drugs for more than 3 mo, renal or liver failure, enteral feeding and anticoagulant use). RESULTS: Of the 153 patient admissions during the study period, 130 patients (85%) were started on AST, out of which 11 (8.5%) had a diagnosis that supports the use of this therapy (GI bleed, gastritis and GERD), 16 (12.3%) had an absolute indication for SUP, 59 (45.4%) had 2 or more relative indications for SUP, and 44 (33.8%) received AST without an appropriate indication. In addition, one patient with an absolute indication for SUP and four with two or more relative indications did not receive AST. Rabeprazole was the most frequently used AST (59.2%), followed by omeprazole (24.6%), esomeprazole (11.6%) and ranitidine (4.6%). The dose of AST was appropriate in 126 patients (96.9%) and the route of administration was appropriate in 123 patients (94.6%). Fifteen of the admitted patients (10%) were discharged on AST, 7 of which (47%) did not have an appropriate indication. CONCLUSION: AST is overused in hospitalized non-critically ill patients and many patients are discharged on unnecessary AST which can increase cost, drug interactions and adverse events. Potential interventions include implementation of institutional protocols and prescriber education. PMID:23494814

  4. Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness

    PubMed Central

    2014-01-01

    Background In this article we outline Burden of Treatment Theory, a new model of the relationship between sick people, their social networks, and healthcare services. Health services face the challenge of growing populations with long-term and life-limiting conditions, they have responded to this by delegating to sick people and their networks routine work aimed at managing symptoms, and at retarding – and sometimes preventing – disease progression. This is the new proactive work of patient-hood for which patients are increasingly accountable: founded on ideas about self-care, self-empowerment, and self-actualization, and on new technologies and treatment modalities which can be shifted from the clinic into the community. These place new demands on sick people, which they may experience as burdens of treatment. Discussion As the burdens accumulate some patients are overwhelmed, and the consequences are likely to be poor healthcare outcomes for individual patients, increasing strain on caregivers, and rising demand and costs of healthcare services. In the face of these challenges we need to better understand the resources that patients draw upon as they respond to the demands of both burdens of illness and burdens of treatment, and the ways that resources interact with healthcare utilization. Summary Burden of Treatment Theory is oriented to understanding how capacity for action interacts with the work that stems from healthcare. Burden of Treatment Theory is a structural model that focuses on the work that patients and their networks do. It thus helps us understand variations in healthcare utilization and adherence in different healthcare settings and clinical contexts. PMID:24969758

  5. Influenza Sentinel Surveillance among Patients with Influenza-Like-Illness and Severe Acute Respiratory Illness within the Framework of the National Reference Laboratory, Niger, 2009-2013

    PubMed Central

    Manassara, Halima Boubacar; Lagare, Adamou; Tempia, Stefano; Sidiki, Ali; Issaka, Bassira; Abdou Sidikou, Bibata; Ouwe Missi Oukem-Boyer, Odile

    2015-01-01

    Background Little is known about the epidemiology of influenza in Africa, including Niger. We documented the epidemiology of seasonal and pandemic influenza among outpatients with influenza-like-illness (ILI) and inpatients with severe acute respiratory illness (SARI) presenting at selected sentinel sites in Niger from April 2009 through April 2013. Methods Patients meeting the ILI or the SARI case definitions and presenting at the outpatient or inpatient departments of selected sentinel sites were enrolled. Epidemiological data and nasopharyngeal swabs were collected. The respiratory samples were tested by real-time reverse transcription polymerase chain reaction. Results From April 2009 to April 2013, laboratory results were obtained from 1176 ILI and 952 SARI cases, of which 146 (12%) and 54 (6%) tested positive for influenza virus, respectively. The influenza positivity rate was highest in the 5-14 year age-group (32/130; 24% among ILI patients and 6/61; 10% among SARI patients) followed by the 1-4 year age-group (69/438; 16% among ILI patients and 32/333; 9% among SARI patients). Of the 200 influenza positive cases 104 (52%) were A(H1N1)pdm09, 62 (31%) were A(H3N2) and 34 (17%) were B. Influenza viruses were detected predominantly from November to April with peak viral activity observed in February. Conclusions The Niger sentinel surveillance system allowed to monitor the circulation of seasonal influenza as well as the introduction and spread of influenza A(H1N1)pdm09 in the country. Continuous influenza surveillance is needed to better understand the epidemiology of seasonal influenza and monitor the emergence of influenza strains with pandemic potential. PMID:26230666

  6. Soft Set-Based Decision Making for Patients Suspected Influenza-Like Illness

    NASA Astrophysics Data System (ADS)

    Herawan, Tutut

    In previous work, we presented an applicability of soft set theory for decision making of patients suspected influenza. The proposed technique is based on maximal supported objects by parameters. At this stage of the research, results are presented and discussed from a qualitative point of view against recent soft decision making techniques through an artificial dataset. In this paper, we present an extended application of our soft set-based decision making through a Boolean valued information system from a dataset of patients suspected ILI (Influenza-Like Illness). Using soft set theory and maximal symptoms co-occurences in patients, we explore how soft set-based decision making technique can be used to reduce the number of dispensable symptoms and further make a correct and fast decision. The result of this work can be used for recommendation of decision making based on the clusters decision captured. Finally, this technique may potentially contribute to lowering the complexity of medical decision making without loss of original information.

  7. [Feeding a terminal patient, sustaining treatment and respecting the right to die].

    PubMed

    Ishay, Ram

    2002-02-01

    Great changes have occurred in the doctor-patient relationship--in medical and social scopes. Lately, there are deliberations regarding whether to withdraw nutrition from a terminal patient. This question raises the basic issues of respecting the patient's wish and his autonomy. Nourishment through the digestive system may prolong life; however, the decision concerning this dilemma differs from country to country. The Jewish religion has its own position on the matter. The patient knows the doctor has no conflict between trying to help or kill and continues to fully trust the physician. Whenever nourishing or treating a terminal patient, the doctor should be assisted by the family's decision or a psychiatric resolution. Actually, there is rarely conflict between the evaluation of the treating physician, the position of the family and the court's decision. PMID:11905098

  8. The Effect of a Patient Portal With Electronic Messaging on Patient Activation Among Chronically Ill Patients: Controlled Before-and-After Study

    PubMed Central

    Linna, Miika; Rnkk, Ilona

    2014-01-01

    Background It has been suggested that providing patients with access to their medical records and secure messaging with health care professionals improves health outcomes in chronic care by encouraging and activating patients to manage their own condition. Objectives The aim was to evaluate the effect of access to a patient portal on patient activation among chronically ill patients. Further, the relationship between temporal proximity of a severe diagnosis and patient activation were assessed. Methods A total of 876 chronically ill patients from public primary care were allocated to either an intervention group receiving immediate access to a patient portal that included their medical records, care plan, and secure messaging with a care team, or to a control group receiving usual care. Patient Activation Measure (PAM) at baseline and at 6-month follow-up was obtained from 80 patients in the intervention group and 57 patients in the control group; thus, a total of 137 patients were included in the final analysis. Results No significant effect of access to patient portal on patient activation was detected in this study (F 1,133=1.87, P=.17, ?2=0.01). Patients starting at a lower level of activation demonstrated greater positive change in activation compared to patients starting at higher levels of activation in both the intervention and control groups. Further, patients diagnosed with a severe diagnosis during the intervention showed greater positive change in patient activation compared to patients whose last severe diagnosis was made more than 2 years ago. The results also suggest that the intervention had greatest effect on patients starting at the highest level of patient activation (difference in change of patient activation=4.82, P=.13), and among patients diagnosed within a year of the intervention (difference in change of patient activation=7.65, P=.12). Conclusions Time since last severe diagnosis and patient activation at baseline may affect changes in patient activation, suggesting that these should be considered in evaluation of activating chronic care interventions and in the specification of possible target groups for these interventions. This may be relevant in designing services for a heterogeneous group of patients with a distinct medical history and level of activation. PMID:25413368

  9. Even Mild Hyperlactatemia Is Associated with Increased Mortality in Critically Ill Patients

    PubMed Central

    2013-01-01

    Introduction The clinical significance of elevation of lactate levels within the reference range is not well studied. The objective of this study was to determine the best cutoff threshold for serum lactate within the reference range (0.01 to 2.00 mM) that best discriminated between survivors and nonsurvivors of critical illness and to examine the association between relative hyperlactatemia (lactate above the identified threshold) and mortality. Methods This was a retrospective cohort study of adult patients admitted to the medical-surgical intensive care unit (ICU) of a tertiary care academic center. Youden index was calculated to identify the best lactate cutoff threshold that discriminated between survivors and nonsurvivors. Patients with lactate above the identified threshold were defined as having relative hyperlactatemia. Multivariate logistic regression, adjusting for baseline variables, was performed to determine the relationship between the above two ranges of lactate levels and mortality. In addition, a test of interaction was performed to assess the effect of selected subgroups on the association between relative hyperlactatemia and hospital mortality. Results During the study period, 2,157 patients were included in the study with mean lactate of 1.3 0.4 mM, age of 55.1 20.3 years, and acute physiology and chronic health evaluation (APACHE) II score of 22.1 8.2. Vasopressors were required in 42.4%. Lactate of 1.35 mM was found to be the best cutoff threshold for the whole cohort. Relative hyperlactatemia was associated with increased hospital mortality (adjusted odds ratio (aOR), 1.60, 95% confidence interval (CI) 1.29 to 1.98), and ICU mortality (aOR, 1.66; 95% CI, 1.26 to 2.17) compared with a lactate level of 0.01 to 1.35 mM. This association was consistent among all examined subgroups. Conclusions Relative hyperlactatemia (lactate of 1.36 to 2.00 mM) within the first 24 hours of ICU admission is an independent predictor of hospital and ICU mortality in critically ill patients. PMID:24025259

  10. Metabolic Syndrome in South African Patients with Severe Mental Illness: Prevalence and Associated Risk Factors

    PubMed Central

    Saloojee, Shamima; Burns, Jonathan K; Motala, Ayesha A

    2016-01-01

    Background There is a surge of cardiovascular disease (CVD) in Africa. CVD is the leading cause of mortality among patients with severe mental illness (SMI) in developed countries, with little evidence from the African context. Objective To determine the prevalence and risk factors for MetS among South African patients with SMI. Method In a cross sectional study, individuals with SMI treated with antipsychotics and a control group without a mental illness, matched for age, gender and ethnicity were evaluated for MetS using the 2009 Joint Interim statement (JIS) criteria. Results Of the 276 study group subjects, 65.9% were male, 84.1% black African, 9.1% white, 5.4% of Indian descent and 1.5% coloured (mixed race) with a mean age of 34.7 years (±12.5). Schizophrenia was the most common diagnosis (73.2%) and 40% were taking first generation antipsychotics. The prevalence of MetS was 23.2% (M: 15.4%, F: 38.3%) in the study group and 19.9% (M: 11.9%, F: 36.3%) in the control group (p = 0.4). MetS prevalence was significantly higher in study subjects over 55 years compared to controls (p = 0.03). Increased waist circumference (p< 0.001) and low high density lipoprotein (HDL) cholesterol (p = 0.003) were significantly more prevalent in study subjects compared to controls. In study subjects, risk factors associated with MetS included age (OR: 1.09, 95% CI 1.06–1.12, p < 0.001), female gender (OR: 2.19, 95% CI 1.06–4.55, p = 0.035) and Indian descent (OR: 5.84, 95% CI 1.66–20.52, p = 0.006) but not class of antipsychotic (p = 0.26). Conclusion The overall MetS prevalence was not increased in patients with SMI compared to controls; however, the higher prevalence of the individual components (HDL cholesterol and waist circumference) suggests an increased risk for CVD, especially in patients over 55 years. PMID:26882230

  11. Fluid intake and nutritional risk in non-critically ill patients at hospital referral.

    PubMed

    Cereda, Emanuele; Pedrolli, Carlo; Lucchin, Lucio; D'Amicis, Amleto; Gentile, Maria Gabriella; Battistini, Nino Carlo; Fusco, Maria Antonia; Palmo, Augusta; Muscaritoli, Maurizio

    2010-09-01

    The association between hyporexia/anorexia, reduced food intake and disease-related malnutrition at hospital admission is well established. However, information on fluid intake according to nutritional risk has never been provided. Thus, we assessed the attitude and adequacy of fluid intake among case-mix hospitalised patients according to nutritional risk. A sample of 559 non-critically ill patients randomly taken from medical and surgical wards was evaluated. Nutritional risk was diagnosed by the Nutritional Risk Screening 2002. Usual fluid consumption the week before admission was assessed and categorised as < 5 and > or = 5 cups/d (1 cup = 240 ml), with the acceptable intake being > or = 5 cups/d. Prevalence of nutritional risk was 57.2%, and 46.2% of the patients reported a fluid intake < 5 cups/d. Multiple-adjusted logistic regression revealed that age > or = 65 years (OR: 1.88 (95% CI: 1.03, 3.43); P < 0.04), energy intake (for every 25% increase in food intake compared with estimated requirements, OR: 0.37 (95% CI: 0.25, 0.55); P < 0.001) and the number of drugs taken (every three-drug increase, OR: 0.63 (95 % CI: 0.44, 0.90); P < 0.02) were independently associated with inadequate fluid intake (< 5 cups/d). A significant independent association was also found with nutritional risk (OR: 0.64 (95% CI: 0.43, 0.95); P < 0.03). Nutritional risk appears to be positively associated with greater fluid intake in non-acute hospitalised patients, but both the reasons and the consequences of this relationship, as well as the impact on clinical practice, need to be explored. However, water replacement by oral nutritional support should take advantage of the patients' attitude to assuming a greater fluid intake, limiting at the same time fluid overload during the refeeding phase. PMID:20447327

  12. Prevalence and impact of late defecation in the critically ill, thermally injured adult patient.

    PubMed

    Trexler, Scott T; Lundy, Jonathan B; Chung, Kevin K; Nitzschke, Stephanie L; Burns, Christopher J; Shields, Beth A; Cancio, Leopoldo C

    2014-01-01

    The aim of this study was to determine the prevalence of late defecation (absence of laxation for more than 6 days after admission) as an indicator of lower-gastrointestinal (GI) tract dysfunction in burn patients. In addition, the authors wanted to determine whether the addition of polyethylene glycol 3350 to the standard bowel regimen led to improvement in markers of lower-GI function and outcomes. The authors conducted a retrospective chart review of patients admitted to the burn intensive care unit during a 26-month period. Inclusion criteria were 20% or more TBSA burn, requirement for mechanical ventilation, and age over 18 years. Of 83 patients included, the prevalence of late defecation was 36.1% (n = 30). There was no association between late defecation and mortality. Patients with late defecation had more frequent episodes of constipation after first defecation (P =.03), of feeding intolerance (P =.007), and received total parenteral nutrition more frequently (P =.005). The addition of polyethylene glycol to the standard bowel regimen did not affect markers of lower-GI function. Late defecation occurs in more than one third of critically ill burn patients. Late defecation was associated with ongoing lower-GI dysfunction, feeding intolerance, and the use of total parenteral nutrition. The causal relationship between these problems has not been determined. A prospective study at the authors' institution is currently planned to attempt to validate late defecation as a marker of lower-GI tract dysfunction, determine its relationship to various outcomes, and determine risk factors for its development. PMID:23877139

  13. Study of multiparameter respiratory pattern complexity in surgical critically ill patients during weaning trials

    PubMed Central

    2011-01-01

    Background Separation from mechanical ventilation is a difficult task, whereas conventional predictive indices have not been proven accurate enough, so far. A few studies have explored changes of breathing pattern variability for weaning outcome prediction, with conflicting results. In this study, we tried to assess respiratory complexity during weaning trials, using different non-linear methods derived from theory of complex systems, in a cohort of surgical critically ill patients. Results Thirty two patients were enrolled in the study. There were 22 who passed and 10 who failed a weaning trial. Tidal volume and mean inspiratory flow were analyzed for 10 minutes during two phases: 1. pressure support (PS) ventilation (15-20 cm H2O) and 2. weaning trials with PS: 5 cm H2O. Sample entropy (SampEn), detrended fluctuation analysis (DFA) exponent, fractal dimension (FD) and largest lyapunov exponents (LLE) of the two respiratory parameters were computed in all patients and during the two phases of PS. Weaning failure patients exhibited significantly decreased respiratory pattern complexity, reflected in reduced sample entropy and lyapunov exponents and increased DFA exponents of respiratory flow time series, compared to weaning success subjects (p < 0.001). In addition, their changes were opposite between the two phases of the weaning trials. A new model including rapid shallow breathing index (RSBI), its product with airway occlusion pressure at 0.1 sec (P0.1), SampEn and LLE predicted better weaning outcome compared with RSBI, P0.1 and RSBI* P0.1 (conventional model, R2 = 0.874 vs 0.643, p < 0.001). Areas under the curve were 0.916 vs 0.831, respectively (p < 0.05). Conclusions We suggest that complexity analysis of respiratory signals can assess inherent breathing pattern dynamics and has increased prognostic impact upon weaning outcome in surgical patients. PMID:21255420

  14. Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients

    PubMed Central

    2013-01-01

    Non-invasive mechanical ventilation (NIV) has proved to be an excellent technique in selected critically ill patients with different forms of acute respiratory failure. However, NIV can fail on account of the severity of the disease and technical problems, particularly at the interface. The helmet could be an alternative interface compared to face mask to improve NIV success. We performed a clinical review to investigate the main physiological and clinical studies assessing the efficacy and related issues of NIV delivered with a helmet. A computerized search strategy of MEDLINE/PubMed (January 2000 to May 2012) and EMBASE (January 2000 to May 2012) was conducted limiting the search to retrospective, prospective, nonrandomized and randomized trials. We analyzed 152 studies from which 33 were selected, 12 physiological and 21 clinical (879 patients). The physiological studies showed that NIV with helmet could predispose to CO2 rebreathing and increase the patients' ventilator asynchrony. The main indications for NIV were acute cardiogenic pulmonary edema, hypoxemic acute respiratory failure (community-acquired pneumonia, postoperative and immunocompromised patients) and hypercapnic acute respiratory failure. In 9 of the 21 studies the helmet was compared to a face mask during either continous positive airway pressure or pressure support ventilation. In eight studies oxygenation was similar in the two groups, while the intubation rate was similar in four and lower in three studies for the helmet group compared to face mask group. The outcome was similar in six studies. The tolerance was better with the helmet in six of the studies. Although these data are limited, NIV delivered by helmet could be a safe alternative to the face mask in patients with acute respiratory failure. PMID:23680299

  15. Microbiological Profile of Organisms Causing Bloodstream Infection in Critically Ill Patients

    PubMed Central

    Orsini, Jose; Mainardi, Carlo; Muzylo, Eliza; Karki, Niraj; Cohen, Nina; Sakoulas, George

    2012-01-01

    Background Bloodstream infection (BSI) is the most frequent infection in critically ill patients. As BSI’s among patients in intensive care units (ICU’s) are usually secondary to intravascular catheters, they can be caused by both Gram-positive and Gram-negative microorganisms as well as fungi. Infection with multidrug-resistant (MDR) organisms is becoming more common, making the choice of empirical antimicrobial therapy challenging. The objective of this study is to evaluate the spectrum of microorganisms causing BSI’s in a Medical-Surgical Intensive Care Unit (MSICU) and their antimicrobial resistance patterns. Methods A prospective observational study among all adult patients with clinical signs of sepsis was conducted in a MSICU of an inner-city hospital in New York City between May 1, 2010 and May 30, 2011. Results A total of 722 adult patients with clinical signs of systemic inflammatory response syndrome (SIRS) and/or sepsis were admitted to the MSICU between May 1, 2010 and May 30, 2011. From those patients, 91 (12.6%) had one or more positive blood culture. A 122 isolates were identified: 72 (59%) were Gram-positive bacteria, 38 (31.1%) were Gram-negative organisms, and 12 (9.8%) were fungi. Thirteen (34.2%) Gram-negative organisms and 14 (19.4%) Gram-positive bacteria were classified as MDR. Conclusions Antimicrobial resistance, particularly among Gram-negative organisms, continues to increase at a rapid rate, especially in the ICU’s. Coordinated infection control interventions and antimicrobial stewardship policies are warranted in order to slow the emergence of resistance. PMID:23226169

  16. Depot-medication compliance for patients with psychotic disorders: the importance of illness insight and treatment motivation

    PubMed Central

    Noordraven, Ernst L; Wierdsma, André I; Blanken, Peter; Bloemendaal, Anthony FT; Mulder, Cornelis L

    2016-01-01

    Background Noncompliance is a major problem for patients with a psychotic disorder. Two important risk factors for noncompliance that have a severe negative impact on treatment outcomes are impaired illness insight and lack of motivation. Our cross-sectional study explored how they are related to each other and their compliance with depot medication. Methods Interviews were conducted in 169 outpatients with a psychotic disorder taking depot medication. Four patient groups were defined based on low or high illness insight and on low or high motivation. The associations between depot-medication compliance, motivation, and insight were illustrated using generalized linear models. Results Generalized linear model showed a significant interaction effect between motivation and insight. Patients with poor insight and high motivation for treatment were more compliant (94%) (95% confidence interval [CI]: 1.821, 3.489) with their depot medication than patients with poor insight and low motivation (61%) (95% CI: 0.288, 0.615). Patients with both insight and high motivation for treatment were less compliant (73%) (95% CI: 0.719, 1.315) than those with poor insight and high motivation. Conclusion Motivation for treatment was more strongly associated with depot-medication compliance than with illness insight. Being motivated to take medication, whether to get better or for other reasons, may be a more important factor than having illness insight in terms of improving depot-medication compliance. Possible implications for clinical practice are discussed. PMID:26893565

  17. Influence of Patient Caregivers on Course of Patient Illness. "Expressed Emotion" and Alternative Measures.

    ERIC Educational Resources Information Center

    Gottschalk, Louis A.; Keatinge, Carolyn

    1993-01-01

    Examines historical context, generalizability, methodological strengths and limitations of construct of "expressed emotion" (EE), designed to explore impact of family and social environment on vulnerability to relapse of schizophrenic patients, and Camberwell Family Interview, as well as nature and effects of treatment intervention programs…

  18. Illness perception and fibromyalgia impact on female patients from Spain and the Netherlands: do cultural differences exist?

    PubMed

    Ruiz-Montero, Pedro J; Van Wilgen, C Paul; Segura-Jimnez, Victor; Carbonell-Baeza, Ana; Delgado-Fernndez, Manuel

    2015-12-01

    The purpose of this study was to examine the differences in illness perception and overall impact on fibromyalgia females from Spain and the Netherlands. A total of 325 fibromyalgia females from Spain (54.37.1years) and the Netherlands (51.87.2years) participated in the study. Illness perception and impact of fibromyalgia were assessed by the Revised Illness Perception Questionnaire and the Fibromyalgia Impact Questionnaire, respectively. Spanish fibromyalgia females perceived more symptoms related to their fibromyalgia (identity) such as nausea, breathlessness, wheezing or fatigue (P<0.001) and had greater emotional representation (P<0.01). Dutch fibromyalgia females experienced less timeline (acute/chronic) and consequences (all, P<0.05), had a better cyclical timeline, personal control, treatment control and illness coherence (all, P<0.001). Spanish fibromyalgia females reported higher impact of fibromyalgia than Dutch females (61.2+14.8 vs. 54.9+16.4, respectively; P<0.001), but the effect size was small (Cohen's d=0.41) . Impact of fibromyalgia and negative views of fibromyalgia were higher in Spanish fibromyalgia females, whereas Dutch fibromyalgia females presented higher score of positive beliefs about the controllability of the illness. Psychological interventions which help patients to cope with their illness perception might lead to an improvement of the impact of the disease on fibromyalgia females. PMID:25969339

  19. Person-Centered Psychopathology of Schizophrenia: Building on Karl Jaspers Understanding of Patients Attitude Toward His Illness

    PubMed Central

    Stanghellini, Giovanni

    2013-01-01

    In this article, building on and extending Jaspers concept of the patients attitude toward his illness we draw attention to the active role that the person, as a self-interpreting agent engaged in a world shared with other persons, has in interacting with his/her basic disorder and in the shaping of psychopathological syndromes. This person-centered approach helps us to see patients as meaning-making entities rather than passive individuals and their attempt at self-understanding as not necessarily pathological and potentially adaptive. We describe 3 contemporary resources for a person-centered psychopathology: dialectical psychopathology, contemporary approaches to the meanings-causes debate, and value-based practice. Each of these provides a theoretical framework and practical resources for understanding the diversity of schizophrenic phenotypes, including symptom presentation, course, and outcome as a consequence of the different ways people with schizophrenia seek to make sense of the basic changes in self and world experiences. A person-centered approach, in building on patients individual values and experiences as key aspects of their self-understanding of their psychosis, supports recovery and development of self-management skills. PMID:23314193

  20. Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients

    PubMed Central

    2013-01-01

    Background To successfully implement the recommendations of critical care nutrition guidelines, one potential approach is to identify barriers to providing optimal enteral nutrition (EN) in the intensive care unit (ICU), and then address these barriers systematically. Therefore, the purpose of this study was to develop a questionnaire to assess barriers to enterally feeding critically ill patients and to conduct preliminary validity testing of the new instrument. Methods The content of the questionnaire was guided by a published conceptual framework, literature review, and consultation with experts. The questionnaire was pre-tested on a convenience sample of 32 critical care practitioners, and then field tested with 186 critical care providers working at 5 hospitals in North America. The revised questionnaire was pilot tested at another ICU (n?=?43). Finally, the questionnaire was distributed to a random sample of ICU nurses twice, two weeks apart, to determine test retest reliability (n?=?17). Descriptive statistics, exploratory factor analysis, Cronbach alpha, intraclass correlations (ICC), and kappa coefficients were conducted to assess validity and reliability. Results We developed a questionnaire with 26 potential barriers to delivery of EN asking respondents to rate their importance as barriers in their ICU. Face and content validity of the questionnaire was established through literature review and expert input. The factor analysis indicated a five-factor solution and accounted for 72% of the variance in barriers: guideline recommendations and implementation strategies, delivery of EN to the patient, critical care provider attitudes and behavior, dietitian support, and ICU resources. Overall, the indices of internal reliability for the derived factor subscales and the overall instrument were acceptable (subscale Cronbach alphas range 0.84 0.89). However, the test retest reliability was variable and below acceptable thresholds for the majority of items (ICCs range ?0.13 to 0.70). The within group agreement, an indices reflecting the reliability of aggregating individual responses to the ICU level was also variable (ICCs range 0.0 to 0.82). Conclusions We developed a questionnaire to identify barriers to enteral feeding in critically ill patients. Additional studies are planned to further revise and evaluate the reliability and validity of the instrument. PMID:24305039

  1. Challenges and Potential Solutions Individualised Antibiotic Dosing at the Bedside for Critically Ill Patients: a structured review

    PubMed Central

    Roberts, Jason A.; Aziz, Mohd Hafiz Abdul; Lipman, Jeffrey; Mouton, Johan W.; Vinks, Alexander A.; Felton, Timothy W.; Hope, William W.; Farkas, Andras; Neely, Michael N.; Schentag, Jerome J.; Drusano, George; Frey, Otto R.; Theuretzbacher, Ursula; Kuti, Joseph L.

    2014-01-01

    Summary Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in sub-optimal outcomes. In this paper, we review the patient- and pathogen-related challenges that contribute to inadequate antibiotic dosing and discuss how a process for individualised antibiotic therapy, that increases the accuracy of dosing, can be implemented to further optimise care for the critically ill patient. The process for optimised antibiotic dosing firstly requires determination of the physiological derangements in the patient that can alter antibiotic concentrations including altered fluid status, microvascular failure, serum albumin concentrations as well as altered renal and hepatic function. Secondly, knowledge of the susceptibility of the infecting pathogen should be determined through liaison with the microbiology laboratory. The patient and pathogen challenges can then be solved by combining susceptibility data with measured antibiotic concentration data (where possible) into a clinical dosing software. Such software uses pharmacokinetic-pharmacodynamic (PK/PD) models from critically ill patients to accurately predict the dosing requirements for the individual patient with the aim of optimising antibiotic exposure and maximising effectiveness. PMID:24768475

  2. Septic versus non-septic acute kidney injury in critically ill patients: characteristics and clinical outcomes

    PubMed Central

    Cruz, Marlia Galvo; Dantas, Joo Gabriel Athayde de Oliveira; Levi, Talita Machado; Rocha, Mrio de Seixas; de Souza, Srgio Pinto; Boa-Sorte, Ney; de Moura, Carlos Geraldo Guerreiro; Cruz, Constana Margarida Sampaio

    2014-01-01

    Objective This study aimed to describe and compare the characteristics and clinical outcomes of patients with septic and non-septic acute kidney injury. Methods This study evaluated an open cohort of 117 critically ill patients with acute kidney injury who were consecutively admitted to an intensive care unit, excluding patients with a history of advanced-stage chronic kidney disease, kidney transplantation, hospitalization or death in a period shorter than 24 hours. The presence of sepsis and in-hospital death were the exposure and primary variables in this study, respectively. A confounding analysis was performed using logistic regression. Results No significant differences were found between the mean ages of the groups with septic and non-septic acute kidney injury [65.3021.27 years versus 66.3512.82 years, respectively; p=0.75]. In the septic and non-septic acute kidney injury groups, a predominance of females (57.4% versus 52.4%, respectively; p=0.49) and Afro-descendants (81.5% versus 76.2%, respectively; p=0.49) was observed. Compared with the non-septic patients, the patients with sepsis had a higher mean Acute Physiology and Chronic Health Evaluation II score [21.737.26 versus 15.755.98; p<0.001)] and a higher mean water balance (p=0.001). Arterial hypertension (p=0.01) and heart failure (p<0.001) were more common in the non-septic patients. Septic acute kidney injury was associated with a greater number of patients who required dialysis (p=0.001) and a greater number of deaths (p<0.001); however, renal function recovery was more common in this group (p=0.01). Sepsis (OR: 3.88; 95%CI: 1.51-10.00) and an Acute Physiology and Chronic Health Evaluation II score >18.5 (OR: 9.77; 95%CI: 3.73-25.58) were associated with death in the multivariate analysis. Conclusion Sepsis was an independent predictor of death. Significant differences were found between the characteristics and clinical outcomes of patients with septic versus non-septic acute kidney injury. PMID:25607268

  3. What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families

    PubMed Central

    You, John J.; Dodek, Peter; Lamontagne, Francois; Downar, James; Sinuff, Tasnim; Jiang, Xuran; Day, Andrew G.; Heyland, Daren K.

    2014-01-01

    Background: The guideline-recommended elements to include in discussions about goals of care with patients with serious illness are mostly based on expert opinion. We sought to identify which elements are most important to patients and their families. Methods: We used a cross-sectional study design involving patients from 9 Canadian hospitals. We asked older adult patients with serious illness and their family members about the occurrence and importance of 11 guideline-recommended elements of goals-of-care discussions. In addition, we assessed concordance between prescribed goals of care and patient preferences, and we measured patient satisfaction with goals-of-care discussions using the Canadian Health Care Evaluation Project (CANHELP) questionnaire. Results: Our study participants included 233 patients (mean age 81.2 yr) and 205 family members (mean age 60.2 yr). Participants reported that clinical teams had addressed individual elements of goals-of-care discussions infrequently (range 1.4%–31.7%). Patients and family members identified the same 5 elements as being the most important to address: preferences for care in the event of life-threatening illness, values, prognosis, fears or concerns, and questions about goals of care. Addressing more elements was associated with both greater concordance between patients’ preferences and prescribed goals of care, and greater patient satisfaction. Interpretation: We identified elements of goals-of-care discussions that are most important to older adult patients in hospital with serious illness and their family members. We found that guideline-recommended elements of goals-of-care discussions are not often addressed by health care providers. Our results can inform interventions to improve the determination of goals of care in the hospital setting. PMID:25367427

  4. Predicting Premature Termination within a Randomized Controlled Trial for Binge-Eating Patients

    ERIC Educational Resources Information Center

    Fluckiger, Christoph; Meyer, Andrea; Wampold, Bruce E.; Gassmann, Daniel; Messerli-Burgy, Nadine; Munsch, Simone

    2011-01-01

    Understanding the dropout rates of efficacious forms of psychotherapy for patients with binge eating disorder (BED) is an unsolved problem within this increasing population. Up until now the role of psychotherapy process characteristics as predictors of premature termination has not been investigated in the BED literature. Within a randomized

  5. Facility based cross-sectional study of self stigma among people with mental illness: towards patient empowerment approach

    PubMed Central

    2013-01-01

    Background Self stigma among people with mental illness results from multiple cognitive and environmental factors and processes. It can negatively affect adherence to psychiatric services, self esteem, hope, social integration and quality of life of people with mental illness. The purpose of this study was to measure the level of self stigma and its correlates among people with mental illness at Jimma University Specialized Hospital, Psychiatry clinic in southwest Ethiopia. Methods Facility based cross-sectional study was conducted on 422 consecutive samples of people with mental illness using interviewer administered and pretested internalized stigma of mental illness (ISMI) scale. Data was entered using EPI-DATA and analysis was done using STATA software. Bivariate and multivariate linear regressions were done to identify correlates of self stigma. Results On a scale ranging from 1 to 4, the mean self stigma score was 2.32 (SD = 0.30). Females had higher self stigma (std. β = 0.11, P < 0.05) than males. Patients with a history of traditional treatment had higher self stigma (std. β = 0.11, P < 0.05). There was an inverse relationship between level of education and self-stigma (std. β = −0.17, P < 0.01). Perceived signs (std. β = 0.13, P < 0.05) and supernatural causes of mental illness (std. β = 0.16, P < 0.01) were positively correlated with self stigma. Higher number of drug side effects were positively correlated (std. β = 0.15, P < 0.05) while higher self esteem was negatively correlated (std. β = −0.14, P < 0.01) with self stigma. Conclusions High feeling of inferiority (alienation) but less agreement with common stereotypes (stereotype endorsement) was found. Female showed higher self stigma than male. History of traditional treatment and higher perceived supernatural explanation of mental illness were associated with higher self stigma. Drug side effects and perceived signs of mental illness were correlated with increased self stigma while education and self esteem decreased self stigma among people with mental illness. Patient empowerment psychosocial interventions and strategies to reduce drug side effects can be helpful in reducing self stigma among people with mental illnesses. PMID:24004512

  6. Perceptions and practices regarding delirium, sedation and analgesia in critically ill patients: a narrative review.

    PubMed

    Shinotsuka, Cassia Righy; Salluh, Jorge Ibrain Figueira

    2013-01-01

    A significant number of landmark studies have been published in the last decade that increase the current knowledge on sedation for critically ill patients. Therefore, many practices that were considered standard of care are now outdated. Oversedation has been shown to be hazardous, and light sedation and no-sedation protocols are associated with better patient outcomes. Delirium is increasingly recognized as a major form of acute brain dysfunction that is associated with higher mortality, longer duration of mechanical ventilation and longer lengths of stay in the intensive care unit and hospital. Despite all the available evidence, translating research into bedside care is a daunting task. International surveys have shown that practices such as sedation interruption and titration are performed only in the minority of cases. Implementing best practices is a major challenge that must also be addressed in the new guidelines. In this review, we summarize the findings of sedation and delirium research over the last years. We also discuss the gap between evidence and clinical practice and highlight ways to implement best practices at the bedside. PMID:23917981

  7. Highly sensitive detection of dengue virus nucleic acid in samples from clinically ill patients.

    PubMed

    Muñoz-Jordán, Jorge L; Collins, Cynthia S; Vergne, Edgardo; Santiago, Gilberto A; Petersen, Lyle; Sun, Wellington; Linnen, Jeffrey M

    2009-04-01

    Dengue virus (DENV) is a major cause of febrile illness and hemorrhagic fever in tropical and subtropical regions. Typically, patients presenting with acute dengue disease are viremic but may not have yet developed detectable titers of antibody. Therefore, early diagnosis depends mostly on detection of viral components, such as the RNA. To define the potential use of transcription-mediated amplification (TMA) DENV RNA as a diagnostic tool, we first compared its analytic sensitivity using a routine real-time reverse transcription (RT)-PCR and found that TMA is approximately 10 to 100 times more sensitive. In addition, we tested acute-phase serum samples (<5 days post-symptom onset) submitted as part of laboratory-based surveillance in Puerto Rico and determined that among patients with serologically confirmed dengue infection, TMA detected DENV RNA in almost 80% of serum specimens that were negative by the RT-PCR test used for diagnosis and in all specimens with positive RT-PCR results. We conclude that TMA is a highly sensitive method which can detect DENV RNA in approximately 89% of clinical, acute-phase serum specimens. PMID:19225099

  8. Body cell mass evaluation in critically ill patients: killing two birds with one stone.

    PubMed

    Fiaccadori, Enrico; Morabito, Santo; Cabassi, Aderville; Regolisti, Giuseppe

    2014-01-01

    Body cell mass (BCM) is the metabolically active cell mass involved in O? consumption, CO? production and energy expenditure. BCM measurement has been suggested as a tool for the evaluation of nutritional status. Since BCM is closely related to energy expenditure, it could also represent a good reference value for the calculation of nutrient needs. In a recent issue of Critical Care, Ismael and colleagues used bioelectrical impedance analysis parameters and anthropometric variables to evaluate BCM in patients with acute kidney injury, before and after a hemodialysis session. The results of this study suggest that BCM is relatively insensitive to major body fluid shifts, a well known factor interfering with nutritional evaluation/monitoring and energy need calculations in the ICU. Thus, BCM seems to be a more 'stable' nutritional variable, as it is apparently less influenced by non-nutritional factors. The results of this paper emphasize the need to identify biologically sound parameters for nutritional status evaluation and energy need calculation in critically ill patients; in this regard, BCM could fulfill these expectations. PMID:25033220

  9. Mixed group of Rhizobiales microbes in lung and blood of a patient with fatal pulmonary illness

    PubMed Central

    Lo, Shyh-Ching; Hung, Guo-Chiuan; Li, Bingjie; Lei, Haiyan; Li, Tianwei; Nagamine, Kenjiro; Tsai, Shien; Zucker, Mark J; Olesnicky, Ludmilla

    2015-01-01

    We examined the microbial composition in the diseased lung and early-phase microbial cultures from the blood of a patient with a rapidly progressing fatal pulmonary illness. Although no microbes could be isolated from such cultures during the initial study, the HTS-microbiome study revealed the presence of a unique mixture of alphaproteobacteria, composed mainly of different families of Rhizobiales microbes. Microbial 16S rDNA sequences matching closely to Afipia cberi were identified mainly in the patient’s diseased lung tissue, but only rarely in the early-phase blood cultures. Conversely, the high abundance of sequences found in early-phase blood cultures of different broth media matched closely with those of the families Methylobacteriaceae, Phyllobacteriaceae and Sphingomonadaceae. The two species that successfully adapted to grow in a laboratory culture system were A. cberi and Mesorhizobium hominis, which eventually were isolated from a previously cryopreserved blood culture of SP4 broth. Many other species, including members of the Bradyrhizobiaceae and Phyllobacteriaceae families, and all members of the Methylobacteriaceae and Sphingomonadaceae families identified by HTS remained non-cultivated. We developed specific PCR primers and FISH probes, which detected the target Rhizobiales microbes in former blood cultures and autopsy lung tissues. It is unclear what role these Rhizobiales microbes might have played in the patient’s complex disease process. However, the above mentioned assays should help in rapidly detecting and identifying these previously unrecognized Rhizobiales microbes in patients. PMID:26823697

  10. Patient Assessment of Chronic Illness Care (PACIC) in Type 2 Diabetes: A Longitudinal Study.

    PubMed

    Aung, Eindra; Ostini, Remo; Dower, Jo; Donald, Maria; Coll, Joseph R; Williams, Gail M; Doi, Suhail A R

    2014-11-01

    The Patient Assessment of Chronic Illness Care (PACIC) was designed to measure care congruent with several elements of the chronic care model (CCM), including self-management support and delivery system design. However, support for the a priori 5-subscale structure of the PACIC in previous research has been conflicting. Thus, we aim to investigate psychometric characteristics of the PACIC including the content and stability of its construct over time. A population-based prospective cohort study of patients with type 2 diabetes was conducted in Queensland, Australia, from 2008 (N = 3,761) to 2010 (N = 3,040). Participants completed annually the 20-item PACIC as well as measures of providers' adherence to guideline-recommended self-management support activities. We used exploratory factor analysis to determine its factor structure and examined internal consistency as well as agreement between the PACIC at baseline with repeated measurements at follow-up after 1 and 2 years. We also determined a criterion-related validity using multinomial logistic regression to explore PACIC's association with providers' self-management support. A one-factor structure was deemed optimal according to our findings. High internal consistency and moderate agreement within the scales over time were observed. Higher PACIC scores predicted better providers' self-management support. In conclusion, the PACIC is a reliable, valid, and reproducible instrument for assessment of diabetes care, and we recommend its promotion and use as a single scale rather than subscales as originally proposed. PMID:25380699

  11. International recommendations for glucose control in adult non diabetic critically ill patients

    PubMed Central

    2010-01-01

    Introduction The purpose of this research is to provide recommendations for the management of glycemic control in critically ill patients. Methods Twenty-one experts issued recommendations related to one of the five pre-defined categories (glucose target, hypoglycemia, carbohydrate intake, monitoring of glycemia, algorithms and protocols), that were scored on a scale to obtain a strong or weak agreement. The GRADE (Grade of Recommendation, Assessment, Development and Evaluation) system was used, with a strong recommendation indicating a clear advantage for an intervention and a weak recommendation indicating that the balance between desirable and undesirable effects of an intervention is not clearly defined. Results A glucose target of less than 10 mmol/L is strongly suggested, using intravenous insulin following a standard protocol, when spontaneous food intake is not possible. Definition of the severe hypoglycemia threshold of 2.2 mmol/L is recommended, regardless of the clinical signs. A general, unique amount of glucose (enteral/parenteral) to administer for any patient cannot be suggested. Glucose measurements should be performed on arterial rather than venous or capillary samples, using central lab or blood gas analysers rather than point-of-care glucose readers. Conclusions Thirty recommendations were obtained with a strong (21) and a weak (9) agreement. Among them, only 15 were graded with a high level of quality of evidence, underlying the necessity to continue clinical studies in order to improve the risk-to-benefit ratio of glucose control. PMID:20840773

  12. Prediction scores do not correlate with clinically adjudicated categories of pulmonary embolism in critically ill patients

    PubMed Central

    Katsios, CM; Donadini, M; Meade, M; Mehta, S; Hall, R; Granton, J; Kutsiogiannis, J; Dodek, P; Heels-Ansdell, D; McIntyre, L; Vlahakis, N; Muscedere, J; Friedrich, J; Fowler, R; Skrobik, Y; Albert, M; Cox, M; Klinger, J; Nates, J; Bersten, A; Doig, C; Zytaruk, N; Crowther, M; Cook, DJ

    2014-01-01

    BACKGROUND: Prediction scores for pretest probability of pulmonary embolism (PE) validated in outpatient settings are occasionally used in the intensive care unit (ICU). OBJECTIVE: To evaluate the correlation of Geneva and Wells scores with adjudicated categories of PE in ICU patients. METHODS: In a randomized trial of thromboprophylaxis, patients with suspected PE were adjudicated as possible, probable or definite PE. Data were then retrospectively abstracted for the Geneva Diagnostic PE score, Wells, Modified Wells and Simplified Wells Diagnostic scores. The chance-corrected agreement between adjudicated categories and each score was calculated. ANOVA was used to compare values across the three adjudicated PE categories. RESULTS: Among 70 patients with suspected PE, agreement was poor between adjudicated categories and Geneva pretest probabilities (kappa 0.01 [95% CI −0.0643 to 0.0941]) or Wells pretest probabilities (kappa −0.03 [95% CI −0.1462 to 0.0914]). Among four possible, 16 probable and 50 definite PEs, there were no significant differences in Geneva scores (possible = 4.0, probable = 4.7, definite = 4.5; P=0.90), Wells scores (possible = 2.8, probable = 4.9, definite = 4.1; P=0.37), Modified Wells (possible = 2.0, probable = 3.4, definite = 2.9; P=0.34) or Simplified Wells (possible = 1.8, probable = 2.8, definite = 2.4; P=0.30). CONCLUSIONS: Pretest probability scores developed outside the ICU do not correlate with adjudicated PE categories in critically ill patients. Research is needed to develop prediction scores for this population. PMID:24083302

  13. Pharmacological Prophylaxis for Venous Thromboembolism Among Hospitalized Patients With Acute Medical Illness: An Electronic Medical Records Study.

    PubMed

    Rosenman, Marc; Liu, Xianchen; Phatak, Hemant; Qi, Rong; Teal, Evgenia; Nisi, Daniel; Liu, Larry Z; Ramacciotti, Eduardo

    2016-01-01

    Patients hospitalized with acute medical illness have an elevated risk of venous thromboembolism (VTE). American College of Chest Physicians guidelines list various chronic illnesses, sepsis, advanced age, history of VTE, and immobility as risk factors and recommend prophylactic anticoagulation using fondaparinux, low-molecular weight heparin, or low-dose unfractionated heparin. The objectives of this study were to examine pharmacological prophylaxis against VTE among hospitalized medically ill patients and to assess demographic and clinical correlates related to VTE prophylaxis. A retrospective (1999-2010) electronic medical records study included patients aged 40 years and older hospitalized for at least 3 days, with significant medical illness or with a VTE hospitalization 30-365 days before admission. Each patient's first qualifying hospitalization was analyzed. Exclusions were if VTE treatment was started within 1 day of admission, or if warfarin (and not heparin or enoxaparin) was used. Prophylaxis was defined if the first inpatient dose of subcutaneous heparin or enoxaparin was at prophylaxis levels (lower than treatment levels). Multivariable logistic regression was used to examine factors associated with VTE prophylaxis. Among 12,980 patients, 22.1% received prophylaxis (11.8% with enoxaparin, 10.3% with heparin). VTE prophylaxis was positively associated with year of hospitalization, subcutaneous heparin in the month before admission, aspirin, self-pay status, age, and sepsis. VTE prophylaxis was negatively associated with smoking, alcohol, warfarin in the past 30 days, and primary diagnoses of stroke, infectious disease, or inflammatory bowel disease. Pharmacological VTE prophylaxis has increased significantly over the past 12 years but is still largely underused in patients hospitalized with acute medical illness. Multiple demographic, behavioral, and clinical factors are associated with inpatient VTE prophylaxis. PMID:26720163

  14. Physical Activity on Medical Prescription: A Qualitative Study of Factors Influencing Take-Up and Adherence in Chronically Ill Patients

    ERIC Educational Resources Information Center

    Gasparini, William; Knob, Sandrine; Didierjean, Romaine

    2015-01-01

    Objective: This study sought to determine the effects of an innovative public health programme offering physical and sports activities on medical prescription to chronically ill patients. Method: Semi-structured interviews were conducted with programme participants at two time points: at the start of their activity (n?=?33) and 3?months after the

  15. High Seroprevalence of Antibodies against Spotted Fever and Scrub Typhus Bacteria in Patients with Febrile Illness, Kenya

    PubMed Central

    Thiga, Jacqueline W.; Mutai, Beth K.; Eyako, Wurapa K.; Nganga, Zipporah; Jiang, Ju; Richards, Allen L.

    2015-01-01

    Serum samples from patients in Kenya with febrile illnesses were screened for antibodies against bacteria that cause spotted fever, typhus, and scrub typhus. Seroprevalence was 10% for spotted fever group, <1% for typhus group, and 5% for scrub typhus group. Results should help clinicians expand their list of differential diagnoses for undifferentiated fevers. PMID:25811219

  16. Telephone-based health coaching for chronically ill patients: study protocol for a randomized controlled trial

    PubMed Central

    2013-01-01

    Background The rising prevalence of chronic conditions constitutes a major burden for patients and healthcare systems and is predicted to increase in the upcoming decades. Improving the self-management skills of patients is a strategy to steer against this burden. This could lead to better outcomes and lower healthcare costs. Health coaching is one method for enhancing the self-management of patients and can be delivered by phone. The effects of telephone-based health coaching are promising, but still inconclusive. Economic evaluations and studies examining the transferability of effects to different healthcare systems are still rare. Aim of this study is to evaluate telephone-based health coaching for chronically ill patients in Germany. Methods/Design The study is a prospective randomized controlled trial comparing the effects of telephone-based health coaching with usual care during a 4-year time period. Data are collected at baseline and after 12, 24 and 36 months. Patients are selected based on one of the following chronic conditions: diabetes, coronary artery disease, asthma, hypertension, heart failure, COPD, chronic depression or schizophrenia. The health coaching intervention is carried out by trained nurses employed by a German statutory health insurance. The frequency and the topics of the health coaching are manual-based but tailored to the patients needs and medical condition, following the concepts of motivational interviewing, shared decision-making and evidence-based-medicine. Approximately 12,000 insurants will be enrolled and randomized into intervention and control groups. Primary outcome is the time until hospital readmission within two years after enrolling in the health coaching, assessed by routine data. Secondary outcomes are patient-reported outcomes like changes in quality of life, depression and anxiety and clinical values assessed with questionnaires. Additional secondary outcomes are further economic evaluations like health service use as well as costs and hospital readmission rates. The statistical analyses includes intention-to-treat and as-treated principles. The recruitment will be completed in September 2014. Discussion This study will provide evidence regarding economic and clinical effects of telephone-delivered health coaching. Additionally, this study will show whether health coaching is an adequate option for the German healthcare system to address the growing burden of chronic diseases. Trial registration German Clinical Trials Register (Deutsches Register Klinischer Studien; DRKS) DRKS00000584. PMID:24135027

  17. Echinocandin to fluconazole step-down therapy in critically ill patients with invasive, susceptible Candida albicans infections.

    PubMed

    van der Geest, Patrick J; Rijnders, Bart J A; Vonk, Alieke G; Groeneveld, A B Johan

    2016-03-01

    Invasive Candida spp. infections are increasingly diagnosed in critically ill patients. For initial treatment, an echinocandin is recommended with a possible step-down to fluconazole when the patients' condition is improving and the isolate appears susceptible, but there are no data to support such policy. We studied the safety and efficacy of step-down therapy in critically ill patients with culture proven deep seated or bloodstream infections by C. albicans susceptible to fluconazole. All patients admitted into the intensive care unit from January 2010 to December 2014, who had a culture proven invasive C. albicans infection and received initial treatment with an echinocandin for at least 4 days were included. Data on patient characteristics, treatment and vital outcomes were assessed. Of the 56 patients, 32 received step-down fluconazole therapy, at median day 5, whereas the echinocandin was continued in the other 24. No differences where seen in baseline characteristics or risk factors for invasive C. albicans infection between the two groups. Response rates were similar and no difference where seen in 28-day or 90-day mortality between the groups. Step-down therapy to fluconazole may be safe and effective in critically ill patients with invasive infections by C. albicans, susceptible to fluconazole, who have clinically improved as early as 4 days after start of treatment with an echinocandin. PMID:26707572

  18. Promotora assisted depression care among predominately Hispanic patients with concurrent chronic illness: Public care system clinical trial design.

    PubMed

    Ell, Kathleen; Aranda, María P; Wu, Shinyi; Oh, Hyunsung; Lee, Pey-Jiuan; Guterman, Jeffrey

    2016-01-01

    Depression frequently negatively affects patient overall self-care and social stress management within United States safety net care systems. Rates of major depression are significantly high among low-income predominantly Hispanic/Latino with chronic illness, such as diabetes and heart disease. The study design of the A Helping Hand to Activate Patient-Centered Depression Care among Low-income Patients (AHH) randomized clinical trial aims to enhance patient depression care receipt and overall bio-psychosocial self-care management. The AHH trial is conducted in collaboration with three Los Angeles County Department of Health Services (DHS) safety net clinics that provide Patient-Centered Medical Home (PCMH) care. The study compares AHH intervention (AHH) in which community-based bilingual promotoras provide in-person or telephone patient engagement and intervention aimed to reduce the burden and strain on patients, families, and care providers by assessing, enhancing, and facilitating patient depression and co-morbid illness self-care management skill, and activating patient communication with clinic medical providers versus DHS PCMH team usual care (PCMHUC). AHH independent bilingual recruiters screened 1957 and enrolled 348 predominantly Hispanic/Latino patients, of whom 296 (85%) had diabetes, 14 (4%) with heart disease, and 38 (11%) with both diseases. Recruiters identified depressed patients by baseline Patient Health Questionnaire-9 scores of 10 or more, completed baseline assessments, and randomized patients to either AHH or PCMHUC study group. The comprehensive assessments will be repeated at 6 and 12months by an independent bilingual follow-up interviewer. Baseline and outcome data include mental health assessment and treatment receipt, co-morbid illness self-care, social relationships, and environmental stressor assessments. PMID:26600285

  19. Selected pharmacokinetic issues of the use of antiepileptic drugs and parenteral nutrition in critically ill patients

    PubMed Central

    2010-01-01

    Objectives To conduct a systematic review for the evidence supporting or disproving the reality of parenteral nutrition- antiepileptic drugs interaction, especially with respect to the plasma protein-binding of the drug. Methods The articles related to the topic were identified through Medline and PubMed search (1968-Feburary 2010) for English language on the interaction between parenteral nutrition and antiepileptic drugs; the search terms used were anti-epileptic drugs, parenteral nutrition, and/or interaction, and/or in vitro. The search looked for prospective randomized and nonrandomized controlled studies; prospective nonrandomized uncontrolled studies; retrospective studies; case reports; and in vitro studies. Full text of the articles were then traced from the Universiti Sains Malaysia (USM) library subscribed databases, including Wiley-Blackwell Library, Cochrane Library, EBSCOHost, OVID, ScienceDirect, SAGE Premier, Scopus, SpringerLINK, and Wiley InterScience. The articles from journals not listed by USM library were traced through inter library loan. Results There were interactions between parenteral nutrition and drugs, including antiepileptics. Several guidelines were designed for the management of illnesses such as traumatic brain injuries or cancer patients, involving the use of parenteral nutrition and antiepileptics. Moreover, many studies demonstrated the in vitro and in vivo parenteral nutrition -drugs interactions, especially with antiepileptics. Conclusions There was no evidence supporting the existence of parenteral nutrition-antiepileptic drugs interaction. The issue has not been studied in formal researches, but several case reports and anecdotes demonstrate this drug-nutrition interaction. However, alteration in the drug-free fraction result from parenteral nutrition-drug (i.e. antiepileptics) interactions may necessitate scrupulous reassessment of drug dosages in patients receiving these therapies. This reassessment may be particularly imperative in certain clinical situations characterized by hypoalbuminemia (e.g., burn patients). PMID:21194458

  20. High dose tigecycline in critically ill patients with severe infections due to multidrug-resistant bacteria

    PubMed Central

    2014-01-01

    Introduction The high incidence of multidrug-resistant (MDR) bacteria among patients admitted to ICUs has determined an increase of tigecycline (TGC) use for the treatment of severe infections. Many concerns have been raised about the efficacy of this molecule and increased dosages have been proposed. Our purpose is to investigate TGC safety and efficacy at higher than standard doses. Methods We conducted a retrospective study of prospectively collected data in the ICU of a teaching hospital in Rome. Data from all patients treated with TGC for a microbiologically confirmed infection were analyzed. The safety profile and efficacy of high dosing regimen use were investigated. Results Over the study period, 54 patients (pts) received TGC at a standard dose (SD group: 50mg every 12hours) and 46 at a high dose (HD group: 100mg every 12hours). Carbapenem-resistant Acinetobacter.baumannii (blaOXA-58 and blaOXA-23 genes) and Klebsiella pneumoniae (blaKPC-3 gene) were the main isolated pathogens (n?=?79). There were no patients requiring TGC discontinuation or dose reduction because of adverse events. In the ventilation-associated pneumonia population (VAP) subgroup (63 patients: 30 received SD and 33 HD), the only independent predictor of clinical cure was the use of high tigecycline dose (odds ratio (OR) 6.25; 95% confidence interval (CI) 1.59 to 24.57; P?=?0.009) whilst initial inadequate antimicrobial treatment (IIAT) (OR 0.18; 95% CI 0.05 to 0.68; P?=?0.01) and higher Sequential Organ Failure Assessment (SOFA) score (OR 0.66; 95% CI 0.51 to 0.87; P?=?0.003) were independently associated with clinical failure. Conclusions TGC was well tolerated at a higher than standard dose in a cohort of critically ill patients with severe infections. In the VAP subgroup the high-dose regimen was associated with better outcomes than conventional administration due to Gram-negative MDR bacteria. PMID