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This study investigated the effectiveness of a psychotherapeutic technique, logotherapy, with terminallyillpatients. Twenty male Veterans Administration volunteers were randomly assigned to one of two possible treatment conditions: (a) treatment group or (b) delayed-treatment, control group. Patients participating in the original treatment group received eight forty-five-minute sessions of psychotherapy over a two-week interval. Pre- and post-treatment measures were taken
Terminallyillpatients are very susceptible to infections, which are the result of disease-related processes and\\/or therapy-induced mechanisms. These patients are already subject to multiple severe symptoms and associated comorbid conditions, with much resultant distress. Infection increases this symptom burden and further reduces quality of life. We have retrospectively investigated the prevalence of infection and clinical course in 102 consecutive
The need to treat dehydration in terminallyillpatients has become a very controversial topic. Numerous reports in the literature\\u000a illustrate opposing viewpoints from both clinical and ethical perspectives. Arguments for the maintenance of hydration in\\u000a terminallyillpatients have tended to come from \\
PurposeThe purpose of this study is to review a multidisciplinary strategy used to identify patients with terminalillnesses and initiate withdrawal of implantable cardioverter defibrillator (ICD) shock therapy as part of a comprehensive comfort care approach. With indications for ICDs increasing, more patients are receiving devices. Once protected from an arrhythmic death, these patients may develop other terminal diseases such
William R. Lewis; Donna L. Luebke; Nancy J. Johnson; Michael D. Harrington; Ottorino Costantini; Mark P. Aulisio
The need to treat dehydration in terminallyillpatients has become a very controversial topic. Numerous reports in the literature illustrate opposing view-points from both clinical and ethical perspectives. Arguments for the maintenance of hydration in terminallyillpatients have tended to come from "the traditional medical model". Many health care professionals looking after terminallyillpatients have reacted to the generalized use of intravenous fluids in dying patients and the perceived negative effects of this management. Our palliative care group has argued that the viewpoint that dehydration in dying patients is not a cause of symptom distress overlooks commonly reported problems, such as agitated delirium, that can be prevented or reversed by the management of dehydration. This review presents a summary of the traditional arguments, a different perspective on the controversy, biochemical parameters reported in terminallyill cancer patients, recent dehydration research, and the use of hypodermoclysis and rectal hydration. We conclude that the data reported to date are insufficient to allow a final conclusion on the benefit or harm of dehydration in terminallyillpatients. Nevertheless, it is worth considering that while some dying patients may not suffer any ill effects from dehydration, there may be others who do manifest symptoms, such as confusion or opioid toxicity, that might be alleviated or prevented by parenteral hydration. PMID:9176966
This article briefly describes the Living With Death Program (a counseling service that helps terminallyillpatients adjust), highlights some of the research findings of the program, and suggests an approach to counseling the terminallyill. (Author/HMV)
We report about an emergency case of a female patient with terminal carcinoma of the ovary. On the basis of this case it becomes evident that palliative care questions are also important in emergency medicine. In this situation cooperation of the medical disciplines involved appears urgently necessary. This may allow the possibility for terminallyillpatients to stay at home in the last days of life. PMID:16816974
Wiese, C H R; Bartels, U; Seidel, N; Vossen-Wellmann, A; Graf, B M; Hanekop, G G
Goals In order to improve the support for family of terminallyillpatients who cared for a dying relative at home, a project with a group programme was started. This article is an evaluation of the programme. The aims of this study were to describe the opinions of participants in a support group programme about the programme and how they
Proposals have been developed to clarify physician responsibility in withholding treatment to terminallyillpatients. These proposals seek to provide a legal shield against malpractice proceedings and to reduce confusion over how to resolve high medical costs through standardizing procedures for withholding treatment. When first published,…
Most terminallyillpatients will express a wish to die at home. To achieve this, patients must rely on the support of family carers, who may experience emotional and health difficulties in providing such care, both before and after the death. Healthcare professionals can help to relieve the burden on family carers, and there is guidance available to direct GPs and other community healthcare professionals on providing good anticipatory palliative care for patients, and support for carers. This will increase the likelihood that patients at the end of life will achieve a 'good death', and family members will have a positive experience of care giving. PMID:24044859
Background Although alleviation of existential distress is important for terminallyill cancer patients, the concept of existential distress has not been fully understood. The aim of this study was to categorize existential concerns of Japanese terminallyill cancer patients and explore care strategies based on the categorizations. Methods A multicenter cross-sectional study in 88 terminallyill cancer patients receiving specialized
In a prospective, open study, 78 patients with terminal cancer received proctoclysis (rectal hydration) in four different centers. In all cases, a #22 French nasogastric catheter was inserted approximately 40 cm into the rectum and an infusion of normal saline (2 cases) or tap water (76 cases) was administered at a rate of 250 +/- 63 cc/hr. Hydration was maintained for 15 +/- 8 days. The main reason for discontinuation of hydration was death (60 cases). The mean visual analogue score for discomfort after infusion (0 = no discomfort, 100 = worst possible discomfort) was 19 +/- 14. The costs of proctoclysis was estimated at Can$0.08 compared with Can$4.56 per day for hypodermoclysis, and Can$2.78 per day for intravenous hydration. Our results suggest that proctoclysis is a safe, effective, and low-cost technique for the delivery of hydration in terminallyill cancer patients. PMID:9601155
Bruera, E; Pruvost, M; Schoeller, T; Montejo, G; Watanabe, S
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 terminalillness. This article describes a series of studies focused on the exploration, development, and analysis of a measure of hopelessness specifically intended for use with terminallyill cancer patients. The 1st stage of measure development involved interviews with 13 palliative care experts and 30 terminallyillpatients. 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.
|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 terminalillness. This article describes a series of studies focused on the exploration, development, and analysis of a measure of hopelessness specifically intended…
The purpose of this concept analysis of good death was to examine the attributes of a good death and explore the changes of the concept over time and its impact on terminallyillpatients. The method used for this analysis was the Rodgers' evolutionary method. A literature search was completed using Medline Ovid and Journal Storage (JSTOR).The findings describe the evolution of the good death concept over time from the prehistoric era followed by premodern, modern, and postmodern times. In addition, information is presented about surrogate terms, attributes, antecedents, and consequences associated with good death followed by analysis and discussion of the findings. General attributes of a good death include pain and symptom management, awareness of death, patient's dignity, family presence, family support, and communication among patient, family, and health care providers. PMID:22363039
Background: No evidence-based guidelines or protocols to treat the infection-related symptoms in cancer patients with terminal stages have been established. Materials and Methods: We retrospectively analyzed all the patients with terminal stage cancer who died between April 2009 and March 2010. The patients’ background, the prevalence of infection and clinical outcomes, pathogens isolated, antibiotics used, and whether blood cultures and some of examinations were performed or not were evaluated. Results: A total of 62 (44 males and 18 females) patients were included in this study. The median age was 73 years (35–98 years). The most common cancer was that of the lung (n =59, 95.2%). A total of 32 patients were diagnosed with the following infections: Infection of respiratory tract in 27 (84.4%), of urinary tract in 4 (12.5%), and cholangitis in 1 (3.1%). Two cases (6.3%) had pneumonia complicated with urinary tract infection. Blood cultures and antibiotic therapies were performed in 28 and 30 cases, respectively. Four (14.3%) positive cultures were isolated from the blood obtained from 28 individual patients. As for clinical course, 3 (10%) of them experienced improved symptoms after antibiotic therapy. Twenty-seven (90%) patients were not confirmed as having any symptom improvement. Conclusions: Blood cultures and antibiotic therapy were limited, and might not be effective in terminallyill cancer patients with lung cancer. We suggest that administering an antibiotic therapy without performing a blood culture would be one of choices in those with respiratory tract infections if patients’ life expectancy is short.
BACKGROUND. The risk of suicide is higher in patients with cancer than in the general population, making end-of-life care of suicidal terminalpatients with cancer critical. To identify factors and longitudinal changes associated with sui- cidality among terminallyill Japanese patients with cancer, a prospective cohort study was performed. METHODS. Consecutive outpatients with cancer who registered with a palliative care
BackgroundThe consistency of codes governing disclosure of terminalillness to patients and families in Islamic countries has not been studied until now.ObjectivesTo review available codes on disclosure of terminalillness in Islamic countries.Data source and extractionData were extracted through searches on Google and PubMed. Codes related to disclosure of terminalillness to patients or families were abstracted, and then classified
Hunida E Abdulhameed; Muhammad M Hammami; Elbushra A Hameed Mohamed
Background: To explore the association between hydration volume and symptoms during the last 3 weeks of life in terminallyill cancer patients. Patients and methods: This was a multicenter, prospective, observational study of 226 consecutive terminallyillpatients with abdominal malignancies. Primary responsible physicians and nurses eval- uated the severity of membranous dehydration (dehydration score calculated from three physical findings),
T. Morita; I. Hyodo; T. Yoshimi; M. Ikenaga; Y. Tamura; A. Yoshizawa; A. Shimada; T. Akechi; M. Miyashita; I. Adachi
A major issue in the care of terminallyillpatients is communication and information provision. This paper reports the extent to which physicians in Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland discuss topics relevant to end of life care with terminallyillpatients and their relatives (without first informing the patient), and possible associations between physician-specific characteristics and such discussions. Response rates to the postal survey ranged from 39% to 68% (n =10139). Physicians in most of the countries except Italy ;in principle, always' discuss issues related to terminalillness with their patients but not with patients' relatives without first informing the patient, unless the relatives ask. Cross-national differences remained strong after controlling for physician characteristics. The majority of physicians appeared to support the principle of patient-centred care to terminallyillpatients, consistent with palliative care philosophy and with the law and/or professional guidelines in most of the countries studied. PMID:17656406
The amount and quality of information and awareness in cancer patients' is a topic frequently debated, but few studies have focussed on terminalpatients. 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
Corli, O; Apolone, G; Pizzuto, M; Cesaris, L; Cozzolino, A; Orsi, L; Enterri, L
Although Wernicke encephalopathy has been reported in the oncological literature, only one terminallyill cancer patient with Wernicke encephalopathy has been reported. Wernicke encephalopathy, a potentially reversible condition, may be unrecognized in terminallyill cancer patients. In this communication, we report three terminallyill cancer patients who developed Wernicke encephalopathy. Early recognition and subsequent treatment resulted in successful palliation of
The fact that terminal cancer patients experience considerable psychological distress is now undisputed, but the effectiveness of psychological treatments in relieving this suffering is less clear. The aim of the present research was to evaluate the efficacy of clinical hypnosis in the enhancement of quality of life of patients with far-advanced cancer. Fifty terminallyill cancer patients were randomly assigned
Palliative care, directed at improving the quality of life of terminallyillpatients, is generally not aimed at any form of postponing or hastening death. It is possible that high quality palliative care could prevent requests for euthanasia. However, empirical evidence on this issue is scarce. In a national survey of end-of-life medical decisions in The Netherlands the subject of
J. J. Georges; B. D. Philipsen; der van Wal G; der van Heide A; Maas van der P. J
To explore the association between hydration volume and laboratory findings, and between calculated fluid balance and changes in clinical signs of dehydration and fluid retention in terminallyill cancer patients, a secondary analysis of a large multicenter, prospective, observational study was performed. The study enrolled 125 abdominal cancer patients who received laboratory examinations in the last week before death. Patients
End stage renal disease (ESRD) patients who are diagnosed to have a terminalillness or severe debility have limited options for their continued care. This results in a frequent decision to withdraw dialysis support. Due to their tenuous condition, continued transportation to the dialysis facility further aggravates the emotional, financial and physical burden to the patient and family. We would
Goals: The aims of this study were to describe the symptoms, their treatment during the final months of life of terminallyill cancer patients and to assess characteristics of the dying process. Patients and methods: We used a prospective study design. From a representative sample of physicians who participat- ed in a study of end-of-life decision making, we asked whether
Jean-Jacques Georges; Bregje D. Onwuteaka-Philipsen; Agnes van der Heide; Gerrit van der Wal; Paul J. van der Maas
Objectives. To determine the frequency, modalities of admission and management of terminallyillpatients who died on a stretcher in an emergency department (ED). Design and setting. Retrospective study in an ED of a university hospital. Methods. Current place of residence, modalities of admission in ED, mortality probability scores and type of management were extracted for each patient in the
B. Tardy; C. Venet; F. Zeni; O. Berthet; A. Viallon; F. Lemaire; J. C. Bertrand
Goals of work The goal of this study was to develop a new, objective prognostic score (OPS) for terminallyill cancer patients based on\\u000a an integrated model that includes novel objective prognostic factors.\\u000a \\u000a \\u000a \\u000a Materials and methods A multicenter study of 209 terminallyill cancer patients from six training hospitals in Korea were prospectively followed\\u000a until death. The Cox proportional hazard model was
BACKGROUND: In an environment characterized by cuts to health care, hospital closures, increasing reliance on home care and an aging population, more terminallyillpatients are choosing to die at home. The authors sought to determine the care received by these patients when paramedics were summoned by a 911 call and to document whether do-not-resuscitate (DNR) requests influenced the care given. METHODS: The records of a large urban emergency medical services system were reviewed to identify consecutive patients with cardiac arrest over the 10-month period November 1996 to August 1997. Data were abstracted from paramedics' ambulance call reports according to a standardized template. The proportion of these patients described as having a terminalillness was determined, as was the proportion of terminallyillpatients with a DNR request. The resuscitative efforts of paramedics were compared for patients with and without a DNR request. RESULTS: Of the 1534 cardiac arrests, 144 (9.4%) involved patients described as having a terminalillness. The mean age of the patients was 72.2 (standard deviation 14.8) years. Paramedics encountered a DNR request in 90 (62.5%) of these cases. Current regulations governing paramedic practice were not followed in 34 (23.6%) of the cases. There was no difference in the likelihood that cardiopulmonary resuscitation (CPR) would be initiated between patients with and those without a DNR request (73% v. 83%; p = 0.17). In patients for whom CPR was initiated, paramedics were much more likely to withhold full advanced cardiac life support if there was a DNR request than if there was not (22% v. 68%; p < 0.001). INTERPRETATION: Paramedics are frequently called to attend terminallyillpatients with cardiac arrest. Current regulations are a source of conflict between the paramedic's duty to treat and the patient's right to limit resuscitative efforts at the time of death.
Withholding and withdrawing artificial nutrition and hydration from terminallyillpatients poses many ethical challenges. The literature provides little information about the Islamic beliefs, attitudes, and laws related to these challenges. Artificial nutrition and hydration may be futile and reduce quality of life. They can also harm the terminallyillpatient because of complications such as aspiration pneumonia, dyspnea, nausea, diarrhea, and hypervolemia. From the perspective of Islam, rules governing the care of terminallyillpatients are derived from the principle that injury and harm should be prevented or avoided. The hastening of death by the withdrawal of food and drink is forbidden, but Islamic law permits the withdrawal of futile, death-delaying treatment, including life support. Nutritional support is considered basic care and not medical treatment, and there is an obligation to provide nutrition and hydration for the dying person unless it shortens life, causes more harm than benefit, or is contrary to an advance directive that is consistent with Islamic law. The decision about withholding or withdrawing artificial nutrition and hydration from the terminallyill Muslim patient is made with informed consent, considering the clinical context of minimizing harm to the patient, with input from the patient, family members, health care providers, and religious scholars. PMID:22845721
Supplementary doses of opioids are recommended to relieve dyspnea in terminallyill cancer patients. We conducted a randomized continuous sequential clinical trial to evaluate their efficacy. We recruited 33 terminallyill cancer patients from three palliative care centers, all of whom had persistent dyspnea after rest and treatment with oxygen. Patients formed 15 successive pairs matched on route of administration.
Pierre Allard; Claude Lamontagne; Pascale Bernard; Chantale Tremblay
The aim of this study was to determine the opinions of private medical practitioners in Bloemfontein, South Africa, regarding euthanasia of terminallyillpatients. This descriptive study was performed amongst a simple random sample of 100 of 230 private medical practitioners in Bloemfontein. Information was obtained through anonymous self-administered questionnaires. Written informed consent was obtained. 68 of the doctors selected
L Brits; L Human; L Pieterse; P Sonnekus; G Joubert
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 terminallyillpatients. The
Randy S. Hebert; Richard Schulz; Valire C. Copeland; Robert M. Arnold
Background Cancer patients usually take many medications. The proportion of patients with advanced cancer who are taking futile drugs\\u000a is unknown.\\u000a \\u000a \\u000a \\u000a Materials and methods We retrospectively reviewed the charts of all consecutive ambulatory patients with advanced cancer and who were receiving\\u000a supportive care exclusively at palliative care clinics, Princess Margaret Hospital, to gather information on futile medications\\u000a used by them. Futile medications
Rachel P. Riechelmann; Monika K. Krzyzanowska; Camilla Zimmermann
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
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.
Thaker, Darshit A; Stafford, Bruce C; Gaffney, Luke S
The role of nutritional support on terminallyillpatients with cancer in a palliative care unit has not been clarified. A total of 63 patients were retrospectively investigated; the patients receiving individualized nutritional support (intervention group [n = 22]) were compared to the others (control group [n = 41]). The intervention group received individualized nutritional support. There were no significant differences in the characteristics of patients between the groups. The prevalence of bedsores was significantly lower in the intervention group (14% vs 46%, P = .012). The prevalence of edema and the use of antibiotic therapies tended to be lower in the intervention group than in the control group (36% vs 54%, P = .19; 14% vs 27%, P = .34, respectively). Some terminallyillpatients with cancer in a palliative care unit might benefit from nutritional support. PMID:23242171
This is a study conducted in the palliative care unit of the INCA National Cancer Institute, in an attempt to understand the nature of the work and its effects on the health of the professionals. A qualitative approach is adopted, based on participant observation and semi-structured interviews with professionals from the hospital. Most of the professionals are female and were unaware of the concept of palliative care when they started their careers in the Unit. Teamwork is highly valued by the professionals who involve the families in the care actions and motivate the participation of patients and relatives in decision-making. However, these workers experience high emotional stress due to their involvement in the suffering of patients and families. They are also exposed to considerable physical stress caused by the intense demand of the daily routine and the dependence of the majority of patients. The study revealed that there are many professionals on leave of absence due to musculoskeletal problems and psychiatric disorders. There is a pressing need for health support programs for these professionals and awareness of daily care measures for their own health. However, their suggestions for improvement of working and health conditions are merely passed on to be implemented by the institutions themselves. PMID:23989561
Kappaun, Nádia Roberta Chaves; Gomez, Carlos Minayo
The aim of this prospective cohort study was to determine whether serum uric acid level is useful as a predictor of survival in terminallyill cancer patients. One hundred eighteen terminallyill cancer patients, including 63 (53.4%) males, were categorized into four groups by serum uric acid levels and followed up until death or to the end of the study.
This study assesses caregivers' perceived level of open communication about illness and death with their terminallyill relatives and examines the contribution of caregivers' characteristics and situational variables to the explanation of open communication. A total of 236 primary caregivers of terminal cancer patients participated in the study. Level of open communication was measured by 6 items clustered into 1
Goals The aims of this study were (1) to evaluate the treatment efficacy of life review interviews on the spiritual well-being of\\u000a terminallyill cancer patients, and (2) to explore any differences in the responses of patients who obtained clinical benefits\\u000a and those who did not.\\u000a \\u000a \\u000a \\u000a Materials and methods Structured life review interviews were conducted with 12 patients in a palliative care
Background. There is considerable debate regarding the clinical issues surrounding the wish to hasten death (WTHD) in the terminallyill. The clinical factors contributing to the WTHD need further investigation among the terminallyill in order to enhance understanding of the clinical assessment and treatment needs that underlie this problem. A more detailed understanding may assist with the development of
B. KELLY; P. BURNETT; D. PELUSI; S. BADGER; F. VARGHESE; M. ROBERTSON
ContextTerminallyill cancer patients often experience a self-perceived burden that affects their quality of life; however, no standard care strategy for coping with this form of suffering has ever been established.
In the debate on euthanasia and physician-assisted suicide, we have to exclude terminallyillpatients in whom the desire\\u000a for death is caused by major depression. However, it is still not clear to what degree major depression can be treated by\\u000a psychiatric intervention in this setting. We evaluated the effect of antidepressant treatment in terminallyill cancer patients.\\u000a Six cancer
There is a dearth of information in the literature about the concordance of preferences for end-of-life care between terminallyillpatients and their family surrogates outside the Western countries. The purpose of this study was to examine the extent of concordance in preferences for end-of-life care goals and life-sustaining treatments between Taiwanese terminallyill cancer patients and their primary family
This article discusses issues relating to information arising from a qualitative study of the experiences of informal carers of terminallyill cancer patients. Qualitative data analysis, drawing on methods of literary criticism, revealed that information was a key area in carers' experience. The findings are presented in the context of needing to provide individualized care to every family and deal with information needs relating to the illness and prognosis. The question of who is in possession of what information is raised, and the effect that this can have on couples is discussed, together with the issue of false information which carers may receive. The discussion centres on the complexity of understanding carers' information needs and considers how these are affected by the context within which carers operate. The work of Glaser and Strauss on awareness contexts is discussed in this respect. Finally, the importance of the nurse's role as a sensitive mediator of information is considered. PMID:10214173
In this study, 24 family caregivers of terminallyillpatients participated in in-depth interviews regarding their experiences of giving care. The data were analyzed using grounded theory qualitative method. Commitment emerged as the precondition of the caregiving process. The caregivers did not perceive the work of caring as a burden. Rather, they felt that despite any personal hardships, what they were doing was important to their loved ones and therefore meaningful to them as caregivers. The components of commitment can be described as relational commitment, the act of showing love, and determination. The process of caregiving includes four phases: 1) holding onto hope for a miracle, 2) taking care, 3) preparing for death, and 4) adjusting to another phase of life. A patient-caregiver relationship, Confucian concepts of yi (appropriateness or rightness), and filial duty are reflected in the process of caregiving. Consequences of the process include finding meaning in life and peace of heart and mind. The emotional aspect of the caregiving experience can be described as an intense emotional experience filled with feelings of hope and hopelessness, guilt, fear, and regret. As a result of the caregiving experience, most participants found they have had a change of worldviews and treasure their lives. Findings show a significant need for interventions at each phase of the caregiving process designed to provide effective and culturally sensitive support and affirmation to family members as they care for their loved ones with terminalillnesses. PMID:12886117
Mok, Esther; Chan, Faye; Chan, Vivian; Yeung, Ellen
BackgroundSerum N-terminal-pro brain natriuretic peptide (NT-proBNP) is regarded as a marker of vascular disease and has previously been shown to exhibit an increased frequency of pathological values in elderly patients with mental illness with vascular disease compared to patients without vascular disease. Vascular disease plays an important role in cognitive impairment in elderly patients with mental illness.
Although the dehydration-rehydration problem in end-of-life care is one of the most important issues, clinical indications of hydration therapy have not been clarified because the pathophysiology is poorly understood. To explore the physiological changes of fluid status in terminallyill cancer patients, a prospective observational study was performed. We obtained 9 pairs of blood samplings from hospice inpatients with irreversible bowel obstruction who underwent two or more laboratory examinations during the admission periods. The plasma renin activity (PRA) and brain natriuretic peptide (BNP) were measured, in addition to basic laboratory tests performed as clinically required. A chart review evaluated the degree of fluid retention symptoms. In 7 patients receiving intravenous rehydration of 700-2200 ml/day, the mean PRA level significantly increased from 3.5+/-2.5 ng ml(-1) h(-1) to 11+/-8.2 ng ml(-1) x h(-1) ( P=0.047), and the mean BNP level significantly decreased from 52+/-34 pg/ml to 22+/-14 pg/ml ( P=0.047). Edema, ascites, and pleural effusion/pulmonary edema deteriorated in 5, 3, and 5 patients, respectively. In 2 patients without rehydration therapy, peripheral edema deteriorated with increased PRA levels (0.5 to 20 ng ml(-1) x h(-1), 0.4 to 8.7 ng ml(-1) x h(-1), respectively). In conclusion, intravenous volume depletion with fluid retention symptoms was observed in terminallyill cancer patients with intestinal obstruction both receiving and not receiving intravenous hydration. The pathological mechanism hypothesized is the fluid shift from the intravascular compartment to the interstitial spaces. PMID:12353126
Pain and dyspnea are the most prevalent and distressing symptoms in patients with terminallyill cancer. Evidences have accumulated for the effects of morphine on dyspnea, whereas little is known about the effects of oxycodone on dyspnea. We investigated the effectiveness of oxycodone for dyspnea in patients with terminallyill cancer. The injectable form of compound oxycodone (iOC) containing hydrocotarnine was administered continuously via subcutaneous route. We administered iOC to 136 patients. The effect on dyspnea was less conspicuous than pain, yet iOC was effective for dyspnea with varying degrees. None of the adverse effects observed were serious. These results suggest that continuous subcutaneous administration of oxycodone could be one of the reasonable alternatives in the management of dyspnea in patients with terminallyill cancer. PMID:22669937
By following the guidelines of the World Health Organization, cancer pain can be well controlled in 80-90% of patients. However, 10-20% will required more intensive measures to control pain. In terminallyill cancer patients with refractory pain, intrathecal opioid therapy may provide an option. We use the type of totally implanted, programmable pump system as the choice of treatment. It
Background: The way that health care systems in developing countries like India care for dying patients, has an impact on the expectations of such care for those who migrate to other countries faces. At the end of life, cultural issues may impact on the quality of life remaining and for that reason, it is important that particular cultural practices are understood. This paper describes a study that investigated the cultural issues of access to palliative care services for Indian migrants in Australia. Purpose of the Study: To investigate the experiences of the family members of terminallyill Indian migrants in Victoria, Australia. Objective of the Study: To explore the issues related to accessing palliative care services for Indian migrants; to identify the effectiveness of palliative care in supporting the patient and family and to recommend strategies for improving this care. Materials and Methods: A qualitative descriptive design was utilized. Up to 6 family members were selected for in-depth interviews in understanding cultural issues related to the palliative care services for a family member. Results: Analysis of the interviews revealed that families of Indian patients experience difficulties whilst receiving palliative care services, which fell into three main categories: Indian support systems, cultural issues, and caring experiences. Although each of these issues had a direct influence on the experience of terminal care that their family member received, cultural issues and support systems also influenced the caring experiences. Conclusion: Despite the successful implementation of palliative care services across Australia, there are still problems in accessing and receiving the services among minority and disadvantaged groups like various cultural groups.
A panoramic survey is outlined regarding the care system of terminallyill oncologic patients with particular regard to the elderly. National and international experiences are considered offering a caregiving service out of hospital, in small dwelling centers being able to relieve the sufferings of the last days of life. The caregiving sanitary residences and hospices are inserted in a network of services for the elderly oncological patients, representing an adequate answer for the problems. In those structures there is a need of proper professional sanitary figures and standardized lodgings, which may be of importance in the maintenance of a good quality of life. In addition, this study emphasizes the caregiving activity of the family and the needs of the caregivers, as well as the proper instruction of them through courses of specialization. New figures should be inserted in the hospices, like the volunteers, the animators and spiritual assistants; their help is inevitably necessary to assure a better care during the last days of life. PMID:10989167
Di Mauro S; Scalia; Leotta; Giuffrida; Di Stefano A; Malaguarnera
Anemia is often associated with neoplastic disorders. Blood transfusions are used to alleviate the discomfort of anemic cancer patients. Of 246 terminallyill cancer patients admitted to our palliative care unit from October 1991 to December 1993 (128 women and 118 men), 31 patients (12.6%) (17 men and 14 women; age, 69.5 ± 12 years) received on average 2.8 units
Our research on the texts of the Byzantine historians and chroniclers revealed an apparently curious phenomenon, namely, the abandonment of terminallyill 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 terminallyill 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
... be reprinted for personal, noncommercial use only. Hospice care: Comforting the terminallyill By Mayo Clinic staff ... com/health/hospice-care/HQ00860 End-of-life care (5) Hospice care: Comforting the terminallyillTerminal ...
INTRODUCTION: The purpose of this study was to assess the accuracy of N-terminal-pro-B-type natriuretic peptide (NT-proBNP) as a diagnostic tool to recognize acute respiratory failure of cardiac origin in an unselected cohort of critically illpatients. METHODS: We conducted a prospective observational study of medical ICU patients. NT-proBNP was measured at ICU admission, and diagnosis of cardiac dysfunction relied on
Isaline Coquet; Michael Darmon; Jean-Marc Doise; Michel Degrès; Bernard Blettery; Benoît Schlemmer; Philippe Gambert; Jean-Pierre Quenot
Loneliness is a universal phenomenon, and its pain is intensified by a diagnosis of a terminalillness. 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…
|Loneliness is a universal phenomenon, and its pain is intensified by a diagnosis of a terminalillness. 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…
The purpose of this article is to explore the attitudes of lay people and physicians regarding euthanasia and physician-assisted suicide in terminallyill cancer patients in Greece. The sample consisted of 141 physicians and 173 lay people. A survey questionnaire was used concerning issues such as euthanasia, physician-assisted suicide, and so forth. Many physicians (42.6%) and lay people (25.4%, P
INTRODUCTION: C-type natriuretic peptide (CNP) is a paracrine molecule which is mainly synthesized in the vasculature. High levels have been reported in sepsis, and CNP has been proposed as a biomarker predicting sepsis in traumatized patients. We aimed at evaluating the diagnostic and prognostic value of N-terminal pro-CNP (NT-proCNP) for predicting sepsis, disease severity and mortality in critically ill medical
Alexander Koch; Sebastian Voigt; Edouard Sanson; Hanna Dückers; Andreas Horn; Henning W Zimmermann; Christian Trautwein; Frank Tacke
|Analyzed attitudes of 614 Protestant and Catholic Cleveland clergy toward terminalillness and euthanasia. Clergy responses revealed that, although eager to prolong life, terminallyillpatients feared prolonged illness more than death. The controversial nature of euthanasia became more apparent with clergy who had more training in death…
BACKGROUND:: Studies document that caregivers face severe difficulties in communicating with their loved ones about both illness and death. To date, a paucity of studies has examined caregiver-patient communication at the end of life within the context of ethnic origin. OBJECTIVE:: This study compares the level of open communication between caregivers from 2 ethnic groups and examines the contribution of different caregiver characteristics and situational variables to the explanation of open communication. METHODS:: A total of 77 spouse caregivers of terminallyill cancer patients (comprising 41 Jews of Sephardi origin and 36 Jews of Ashkenazi origin) participated in the study. The questionnaire included measures of caregiver communication, caregiver characteristics (ie, age, gender, education level, optimism, self-efficacy), and situational variables (ie, duration and intensity of care). RESULTS:: Spouses of Ashkenazi origin communicated more with their loved ones about illness and death compared with their Sephardi counterparts. Ethnic origin accounted for 16.6% of the explained variance, caregiver characteristics added 20.3%, and situation variables lent a modest contribution of 3.5%. Four variables emerged as significant predictors of caregivers' level of open communication: self-efficacy (? = .33, P < .05), gender (? = .32, P < .01), ethnic origin (? = .25, P <.05), and duration of care (? = .20, P < .05). CONCLUSIONS:: These findings demonstrate the importance of ethnic origin to caregivers' open communication with terminal cancer patients about illness and death. Moreover, communication level with patients is mostly explained by the caregiver characteristics. IMPLICATIONS FOR PRACTICE:: Caregiver characteristics should be considered by nurses when developing intervention programs for increasing caregivers' level of open communication with dying patients. PMID:23348664
Abstract Background and Objective: Given the important role caregivers play in palliative care planning and decision making, anxiety and depression in caregivers of terminallyill cancer patients and their impact on the caregivers' evaluation of the patients' physical and psychological symptom burden were analyzed. Design and subjects: Thirty-three patients and their caregivers were recruited through the University Medical Center palliative care inpatient ward <24h after admission. Measurements: Patients completed the Memorial Symptom Assessment Scale (MSAS). Caregivers were instructed to evaluate the symptom burden of the patient. Anxiety and depression were measured in caregivers using the PHQ-9 and the GAD-7. Results: Fifty-five percent of male caregivers and 36% of female caregivers showed moderate or severe anxiety; 36% of male caregivers compared to 14% of female caregivers had moderate or severe depression. Caregivers' anxiety was associated with a discrepancy in the patients' symptom evaluation for shortness of breath (p<0.05); nausea (p<0.05); and frequency, intensity, and distress due to anxiety (p<0.01). Depression was associated with a discrepancy in the patients' evaluation of distress due to constipation (p<0.05), as well as intensity and distress due to anxiety (p<0.05). Both the caregivers' anxiety and depression were not significantly associated with an underestimation of symptoms. There was a trend towards a higher risk of overestimation in caregivers with higher levels of anxiety (r=0.32) (p=0.07) and depression (r=0.33) (p=0.06). Conclusion: Integrative palliative care should offer psychooncological care for the caregivers on a routine basis to avoid misleading perspectives possibly influencing end-of-life treatment decisions. PMID:23909373
Objective: To determine patient characteristics associated with the desire for life-sustaining treatments in the event of terminalillness.\\u000a \\u000a \\u000a Design: In-person survey from October 1986 to June 1988.\\u000a \\u000a \\u000a \\u000a \\u000a Setting: 13 internal medicine and family practices in North Carolina.\\u000a \\u000a \\u000a \\u000a \\u000a Patients: 2,536 patients (46% of those eligible) aged 65 years and older who were continuing care patients of participating practices,\\u000a enrolled in Medicare.
Joanne Mills Garrett; Russell P. Harris; Jean K. Norburn; Donald L. Patrick; Marion Danis
Objectives To determine the relative influence of different factors on place of death in patients with cancer. Data sources Four electronic databases—Medline (1966-2004), PsycINFO (1972-2004), CINAHL (1982-2004), and ASSIA (1987-2004); previous contacts with key experts; hand search of six relevant journals. Review methods We generated a conceptual model, against which studies were analysed. Included studies had original data on risk factors for place of death among patients, > 80% of whom had cancer. Strength of evidence was assigned according to the quantity and quality of studies and consistency of findings. Odds ratios for home death were plotted for factors with high strength evidence. Results 58 studies were included, with over 1.5 million patients from 13 countries. There was high strength evidence for the effect of 17 factors on place of death, of which six were strongly associated with home death: patients' low functional status (odds ratios range 2.29-11.1), their preferences (2.19-8.38), home care (1.37-5.1) and its intensity (1.06-8.65), living with relatives (1.78-7.85), and extended family support (2.28-5.47). The risk factors covered all groups of the model: related to illness, the individual, and the environment (healthcare input and social support), the latter found to be the most important. Conclusions The ne of factors that influence where patients with cancer die is complicated. Future policies and clinical practice should focus on ways of empowering families and public education, as well as intensifying home care, risk assessment, and training practitioners in end of life care.
Although many cancer patients receiving palliative care experience distressing levels of fatigue, no well-designed studies have investigated contributing factors in Korean patients. We conducted a cross-sectional study using the Brief Fatigue Inventory-K (BFI-K) to measure fatigue while assessing a variety of possible correlates. Ninety patients with incurable cancer in the terminal stage (median survival: 27 days) participated in a structured interview and questionnaire related to their medical conditions and underwent blood sampling for laboratory data and cytokines, including interleukin (IL)-6 and tumor necrosis factor (TNF)-?. Body mass index, dyspnea, the Eastern Cooperative Oncology Group performance status, and levels of albumin, blood urea nitrogen (BUN), total bilirubin, and C-reactive protein were significantly associated with fatigue. However, levels of the two proinflammatory cytokines, IL-6 and TNF-?, were not significantly correlated with the BFI-K score. In stepwise multiple linear regression, fatigue was related to elevated BUN (? = 0.376, p = 0.002), severe pain intensity (? = 0.349, p = 0.004), and impaired performance status (? = 0.268, p = 0.027), but not related to levels of inflammatory cytokines. In conclusion, the diagnostic work-up and therapeutic plan for patients with cancer-related fatigue should include an evaluation of laboratory parameters, pain severity, and physical performance. PMID:21807751
Kwak, Sang Mi; Choi, Youn Seon; Yoon, Ho Min; Kim, Dae Gyun; Song, Seung Hun; Lee, Young Jae; Yeom, Chang Hwan; Koh, Su Jin; Park, Jeanno; Lee, Myung Ah; Suh, Sang-Yeon
Purpose. An existing and validated palliative prognostic (PaP) score predicts survival in terminallyill cancer patients based on dyspnea, anorexia, Karnofsky performance status score, clinical prediction of survival, total WBC, and lymphocyte percentage. The PaP score assigns patients to three different risk groups according to a 30-day survival probability—group A, >70%; group B, 30%–70%; group C, <30%. The impact of delirium is known but was not incorporated into the PaP score. Materials and Methods. Our aim was to incorporate information on delirium into the PaP score based on a retrospective series of 361 terminallyill cancer patients. We followed the approach of “validation by calibration,” proposed by van Houwelingen and later adapted by Miceli for achieving score revision with inclusion of a new variable. The discriminating performance of the scores was estimated using the K statistic. Results. The prognostic contribution of delirium was confirmed as statistically significant (p < .001) and the variable was accordingly incorporated into the PaP score (D-PaP score). Following this revision, 30-day survival estimates in groups A, B, and C were 83%, 50%, and 9% for the D-PaP score and 87%, 51%, and 16% for the PaP score, respectively. The overall performance of the D-PaP score was better than that of the PaP score. Conclusion. The revision of the PaP score was carried out by modifying the cutoff values used for prognostic grouping without, however, affecting the partial scores of the original tool. The performance of the D-PaP score was better than that of the PaP score and its key feature of simplicity was maintained.
As part of a larger study, four decisions related to a vignette scenario of the elective death of a terminallyillpatient suffering intractable pain are examined (doctor supplying information and drugs, assisting patient to take the drugs, or administering a lethal injection). Judgments on justifiability and legality of actions were obtained from laypersons and general practitioners (GPs) in Auckland,
Terminallyill cancer patients who have an early talk with their physician about care at the end-of-life are less likely to receive aggressive therapy â€“ and more likely to enter hospice care â€“ than patients who delay such discussions until the days and weeks before death, a new study by Dana-Farber Cancer Institute researchers suggests.
OBJECTIVES: To study the opinions of nationals (Emiratis) and doctors practising in the United Arab Emirates (UAE) with regard to informing terminallyillpatients. 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.
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
Background: In jurisdictions that permit euthanasia or physician-assisted suicide, patients with cancer com- prise the largest group to die by these methods. We in- vestigated the personal attitudes toward these practices of patients receiving palliative care for advanced cancer. Methods: Seventy patients (32 men and 38 women; median survival, 44.5 days) took part in a survey using in-depth semistructured interviews.
Keith G. Wilson; John F. Scott; Ian D. Graham; Jean F. Kozak; Susan Chater; Raymond A. Viola; Barbara J. de Faye; Lynda A. Weaver; Dorothyann Curran
The United States is considering allowing experimental drugs to be given to people at the end of life. Emil J Freireich believes patients should be able to judge the risks for themselves, and Dean Gesme counters that use of such drugs outside trials will damage both individuals and science
Objectives To determine the relative influence of different factors on place of death in patients with cancer. Data sources Four electronic databases—Medline (1966-2004), PsycINFO (1972-2004), CINAHL (1982-2004), and ASSIA (1987-2004); previous contacts with key experts; hand search of six relevant journals. Review methods We generated a conceptual model, against which studies were analysed. Included studies had original data on risk
The vast majority of patients with incurable lung or colorectal cancer talk with a physician about their options for care at the end of life, but often not until late in the course of their illness, according to a new study by Dana-Farber Cancer Institute investigators published in the Feb. 7 issue of the Annals of Internal Medicine.
Goals of work C-reactive protein (CRP) has been investigated as a predictor of life expectancy in terminal cancer in one previous study.\\u000a However, the other variables such as patient’s symptom or physical examination findings were not considered. The aim of this\\u000a study is to prove serum CRP level as a predictor of survival time, considering patient’s symptoms, physical examination findings,\\u000a and
Objective: This study examined the impact of spirituality and religiosity on depressive symptom severity in a sample of terminallyillpatients with cancer and AIDS. Methods: One hundred sixty-two patients were recruited from palliative-care facilities (hospi- tals and specialized nursing facilities), all of whom had a life expectancy,6 months. The pri- mary variables used in this study were the FACIT
CHRISTIAN J. NELSON; BARRY ROSENFELD; WILLIAM BREITBART; MICHELE GALIETTA
When a terminalillness is diagnosed, it is appropriate for the family physician to take a primary role in future management. Care goals change from being disease-focused and cure-directed to being person-focused and comfort-targeted. The patient and family comprise the unit of care. Care of the terminallyill in the home requires good planning, teamwork, excellent symptom management, and a commitment by the family physician to be available or provide alternate coverage. Death in the home should be an option for the patient and family whenever feasible. Caring for patients until death and supporting their families and friends are rewarding and positive parts of family practice.
This article discusses general principles of managing both elderly and terminallyillpatients. The decision to care for the chronically sick in their homes is necessarily a joint one, made by the patient and supported by his or her family and physician. The physician must understand the patient's medical problems, and determine that the home environment is conducive to care and that one family member is available as a fulltime caregiver. The physician can call upon other professionals, including physiotherapists, pharmacists, dietitians, social workers, and clergymen, to help him care for the patient at home.
Objectives We describe modern and alternative health services use in terminalillness of adults, and assess whether utilization patterns of TB/AIDS patients are distinct from those of patients suffering from other illnesses. Methods Data are from post-mortem interviews with close relatives or caretakers of the deceased. We provide descriptive statistics of health care utilization in adults and discuss their covariates in multivariate analyses. Results Over 85% of terminally sick patients visited a modern medical facility, but less than 40% spent more than 24 hours in a medical facility and only 25% died in one. Traditional healer (11%) and holy water (46%) visits offer a common treatment and healing alternative, but these visits do not co-vary in any consistent manner with the utilization of modern medical services. In terms of the cause of death, we find a higher contact rate with both modern and alternative medical service providers among TB/AIDS patients compared with those suffering from other medical conditions. The duration of illness seems to account for a good share of that variability. Other covariates of health services utilization are socio-economic status, education and age. Conclusions The contact rate of adults with modern medical facilities in terminalillness is almost universal, but their usage intensity is rather low. Alternative curative options are less commonly used, and do not exclude modern health services use. This suggests that both types of services are considered complements rather than alternatives for each other. Because the contact rate with health service providers is greatest for TB/AIDS patients, it is unlikely that HIV/AIDS-related stigma is an impediment to seeking care. We cannot exclude, however, that it delays health-seeking behaviour.
Objective: In patients with advanced cancer, malignant bowel obstruction (MBO) causes gastrointestinal symptoms such as nausea and vomiting leading to severely impaired oral food intake. Thus, MBO markedly diminishes the quality of life (QOL) of these patients because placement of a nasogastric tube becomes necessary. Many studies have shown that octreotide (SMS201-995; SMS), a synthetic analog of somatostatin, is effective
Objective. We examined whether health care workers would wake an intubated patient whose preferences are not known, and whether attitudes are influenced by how health care workers themselves would like to be treated if they were in the patient's place. Design, setting, and subjects. Convenience sample of 90 participants at a postgraduate lecture to anesthesiologists and related professions. Participants filled
Background Family caregiving is common and important in Taiwanese culture. However, the combination of anticipated loss, prolonged psychological\\u000a distress, and the physical demands of caregiving can seriously compromise the quality of life (QOL) of a family caregiver\\u000a (FC). The effect of caring for a dying cancer patient on a FC’s QOL has been explored in western countries—primarily with\\u000a small sample sizes
The law stipulates that death is irreversible. Patients treated in accord with the Pittsburgh protocol have death pronounced when their condition might well be reversed by intervention that is intentionally withheld. Nevertheless, the protocol is in accord with the medical "Guidelines for the Determination of Death." However, the Guidelines fail to capture the intent of the law, which turns out to be a good thing, for the law embodies a faulty definition of death. The inclusion of "irreversible" in the legal definition makes that definition excessively demanding and out of step with the ordinary concept of death. On this basis the protocol is absolved of the moral but not the legal charge that it involves vivisection. PMID:10126527
Palliative care patients who live alone report greater psychological distress, and are less likely to die at home than those living with a family carer. However, there is a lack of research on the value of models of care that specifically address this disadvantage. This article describes the experiences of terminallyill 'home alone' people using one of two models of care aimed at maintaining participants' need for independent living, focusing on the effect of these two models of care on their physical, social and emotional needs. Twenty six palliative care patients of Silver Chain Hospice Care, in Western Australia, were randomly assigned to either having a personal alarm or additional care-aide hours in their home. An in-depth qualitative study was conducted in two phases in 2010 using face-to-face interviews. The care-aide model of care resulted in benefits such as easing the burden of everyday living; supporting well-being; enhancing quality of life and preserving a sense of dignity; and reducing loneliness and isolation. The personal alarm model of care imparted a sense of security; provided peace of mind; and helped to deal with feelings of isolation. Participants in both groups felt that they could remain at home longer. By providing a safer, more secure environment through the use of a personal alarm or additional care-aide hours, patients were able to continue their activities of daily living, could build a sense of 'normality' into their lives, and they could live independently through support and dignity. PMID:22804820
Alzheimer's disease is a common illness of the elderly population, with an estimated prevalence of 4.5 million people in the United States and 24.3 million worldwide. Despite current pharmaceutic advances in delaying disease progression, there is no cure. This article reviews the evidence for conceptualizing Alzheimer's disease as a terminal medical illness. Discussed are principles of palliative care as applied
Gisele Wolf-Klein; Renee Pekmezaris; Lisa Chin; Joseph Weiner
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
A random sample of Cleveland clergy was asked to assess 1) the terminalpatient's views on death, 2) the desires of some terminallyillpatients to find an easy and dignified death, and 3) the role the physician ought to play in treating terminalpatients. Protestant clergy more than their Catholic counterparts are substantially in favor of 1) disclosure of
Mostafa H. Nagi; Neil G. Lazerine; Meredith D. Pugh
This quasiexperimental study examined the effect of an educational program on attitudes toward caring for terminallyill persons and their families. Participants were 115 undergraduate students: intervention group, N = 49; control group, N = 66. Preand post-intervention measurements were done with the Frommelt Attitude Toward Care of the Dying Scale (FATCOD, Form B). Students in the intervention group participated
The effectiveness of docusate for constipation has not been studied in the terminallyill. Controversy also exists concerning its effectiveness in the chronically ill. Because chronically illpatients and terminallyillpatients have several risk factors for constipation in common, we undertook a systematic review of prospective controlled trials of oral docusate in the chronically ill to clarify the utility
Interviews with 22 randomly selected general practitioners (GPs) investigated their communication with terminallyillpatients. In interview analysis a conceptual distinction was drawn between objectives, strategies and tactics. When treating terminalpatients, GPs expressed the objectives of keeping the patient comfortable, painfree, happy and maintaining dignity. A strategy is a plan and mode of approaching patients existing over an extended time period. Three strategies were described by GPs for use when interacting with terminallyillpatients. These are characterized as 'try to disclose', 'let the patient decide' and 'avoid disclosing'. Tactics refer to behaviours used within a single consultation, as part of a strategy. Six tactics are described: evasion, denial, uncertainty, hints and prompts, euphemism and reassurance. Different strategies imply quite different forms of consultation. Thus to understand a consultation we must place it into the context of the series. PMID:7506681
This article explores the role of psychodynamics as it applies to the understanding and treatment of medically illpatients in the consultation-liaison psychiatry setting. It provides historical background that spans the eras from Antiquity (Hippocrates and Galen) to nineteenth-century studies of hysteria (Charcot, Janet, and Freud) and into the twentieth century (Flanders Dunbar, Alexander, Engle, and the DSM). The article then discusses the effects of personality on medical illness, treatment, and patients' ability to cope by reviewing the works of Bibring, Kahana, and others. The important contribution of attachment theory is reviewed as it pertains the patient-physician relationship and the health behavior of physically illpatients. A discussion of conversion disorder is offered as an example of psychodynamics in action. This article highlights the important impact of countertransference, especially in terms of how it relates to patients who are extremely difficult and "hateful," and explores the dynamics surrounding the topic of physician-assisted suicide, as it pertains to the understanding of a patient's request to die. Some attention is also given to the challenges surrounding the unique experience of residents learning how to treat medically illpatients on the consultation-liaison service. Ultimately, this article concludes that the use and understanding of psychodynamics and psychodynamic theory allows consultation-liaison psychiatrists the opportunity to interpret the life narratives of medically illpatients in a meaningful way that contributes importantly to treatment. PMID:19968453
Children discharged in the terminal phase of illness were offered the possibility of having central venous line infections treated with teicoplanin at home by their parents after suitable instruction. The decision to begin antibiotic treatment was subjective, based on a history of rigors and/or raised temperature in an otherwise "well" child. No difficulties were encountered in instructing the chosen parents. In all, five treatment periods of 7 days were required in the five children selected. The review time was 31 weeks (mean duration, 6.2 weeks/patient; range, 4-12 weeks), ended in all cases by death. Infection occurred a mean of 3.2 weeks after discharge (range, 1-8 weeks), and all episodes were successfully treated at home without hospital admission or ward-based support. No deaths occurred as a result of antibiotic therapy failure, and there were no clinically relevant side-effects. Autopsy confirmed the absence of central venous line infection in one patient, but blood culture was positive for Staphylococcus aureus in another. This study shows that home treatment of line infections with teicoplanin is effective and well tolerated, and offers advantages in terms of quality of life and parent-child relationships. PMID:8365460
Objectives Dignity Therapy is a unique, individualized, brief psychotherapy, developed for patients (and their families) living with life threatening or life limiting illness. The purpose of this study was to determine if Dignity Therapy could mitigate distress and/or bolster end-of-life experience for patients nearing death. Trial Design Multi-site randomized controlled trial, with patients assigned to Dignity Therapy, Client Centred Care or Standard Palliative Care. Study arm assignment was based on a computer-generated table of random numbers. Blinding was achieved using opaque sealed envelopes, containing allocations that were only opened once consent had been obtained. Participants Patients receiving hospital or community (hospice or home) based palliative care, in Winnipeg, New York, or Perth, randomly assigned to, Dignity Therapy [n=108], Client Centered Care [n=107] and Standard Palliative Care (n=111). Main Outcome Measures The primary outcome measures included the FACIT Spiritual Well-Being Scale, the Patient Dignity Inventory, the Hospital Anxiety and Depression Scale; items from the Structured Interview for Symptoms and Concerns, the Quality of Life Scale and a modified Edmonton Symptom Assessment Scale. Mean changes between baseline and end of intervention ratings were determined. Secondary outcomes, examining self-report end-of-life experience, consisted of a post-study survey administered across all study arms. Intervention Dignity Therapy, a novel, brief psychotherapy, provides patients with life threatening and life limiting illnesses an opportunity to speak about things that matter most to them. These recorded conversations form the basis of a generativity document, which patients can bequeath to individuals of their choosing. Client Centred Care is a supportive psychotherapeutic approach, in which research nurse/therapists guide patients through discussions focusing on here and now issues. Findings No significant differences across study arms, between the primary study outcome measures of pre and post distress, were found. However, on the secondary outcomes, comprised of the post study survey, patients reported that Dignity Therapy was significantly more likely to be experienced as helpful (?2=35.501; p<0.001), improve quality of life (?2 =14.520; p<0.001), sense of dignity (?2 =12.655; p=0.002); change how their family sees and appreciates them (?2 =33.811; p<0.001) and be helpful to their family (?2=33.864; p<0.001). Interpretation Despite the beneficial effects of Dignity Therapy, its ability to mitigate outright distress, such as depression, desire for death or suicidality, has yet to be proven. However, there is currently ample evidence supporting its clinical application for patients nearing death, as a means of enhancing their end-of-life experience.
Chochinov, Harvey Max; Kristjanson, Linda J.; Breitbart, William; McClement, Susan; Hack, Thomas F; Hassard, Tom; Harlos, Mike
A hospice-care program offers an opportunity to provide effective palliative care for patientsterminallyill with malignant disease and to develop improved methods for coping with the problems of the dying patient. All patients for whom antitumor therapy does not offer a reasonable possibility of cure are eligible for Church Hospital's multidisciplinary program, the focus of which is on both the patient and his family. Acceptance by medical staff, patients and families has been enthusiastic. Both conventional and unconventional methods can be helpful in making terminallyillpatients more comfortable. Much has been learned about the control of pain in such patients. Intestinal obstruction can often be managed non-operatively without the use of nasogastric tube. Other common symptoms such as weakness, anorexia, depression, dyspnea, etc. can be relieved with varying degrees of success. An objective of the program is to allow the patient to be at home for most of his terminalillness and to die there if possible. By utilizing patient and family instruction, visiting nurses and home health aides, approximately two-thirds of the patients in the program at any given time are at home. Basing the program in an acute care hospital has allowed coordination with the curative treatment of malignant disease and effective use of radiation and chemotherapy for palliative purposes. The organizational structure, financing, facilities and clinical experience with 100 consecutive patients of the Church Hospital hospice-care program are described.
The purpose of the present research was to determine (a) the level and (b) the change over time in terminal cancer patients in terms of denial, death anxiety, anxiety, depression, hostility, love, being, and self-esteem. The subjects were 30 cancer patients, 27 arthritic patients who constituted a chronically ill, but not terminal, control group, and 30 healthy control subjects. Psychometric
Kimberly Dougherty; Donald I. Templer; Richard Brown
Abstract Rationale This study was designed to identify nurses' perspectives on nursing skills that are important yet under-utilized in end-of-life care. Methods A 45-item survey was administered to nurses (n?=?717) in four U.S. states with a response rate of 79%. We identified skills that were endorsed by more than 60% of nurses as extremely important and also endorsed as not currently practiced by more than 25% of nurses. We used Chi square statistics to examine professional characteristics associated with ratings of end-of-life care skills including practice settings, years of experience, and end-of-life care education. Content analysis was used to examine nurses' responses to open-ended questions. Results Nineteen items were endorsed as extremely important and also ranked as under-utilized. These end-of-life care skills included communication skills, symptom management competencies especially those concerning anxiety and depression, and issues related to patient-centered care systems. Four complementary themes emerged from qualitative analysis of nurses' comments, which supported the quantitative findings. Conclusions This study provides a summary of skills nurses feel are important and under-utilized in their care of patients with life-limiting illnesses. The findings support the need to target both nursing education and healthcare system interventions to improve the use of practical end-of-life care skills by nurses with a focus on communication and symptom management skills.
Shannon, Sarah E.; Engelberg, Ruth; Dotolo, Danae; Silvestri, Gerard A.; Curtis, J. Randall
Background: Whereas most studies have focused on euthanasia and physician-assisted suicide, few have dealt comprehensively with other critical interventions administered at the end of life. We surveyed cancer patients, family caregivers, oncologists and members of the general public to determine their attitudes toward such interventions. Methods: We administered a questionnaire to four groups about their attitudes toward five end-of-life interventions — withdrawal of futile life-sustaining treatment, active pain control, withholding of life-sustaining measures, active euthanasia and physician-assisted suicide. We performed multivariable analyses to compare attitudes and to identify sociodemographic characteristics associated with the attitudes. Results: A total of 3840 individuals — 1242 cancer patients, 1289 family caregivers and 303 oncologists from 17 hospitals, as well as 1006 members of the general Korean population — participated in the survey. A large majority in each of the groups supported withdrawal of futile life-sustaining treatment (87.1%–94.0%) and use of active pain control (89.0%–98.4%). A smaller majority (60.8%–76.0%) supported withholding of life-sustaining treatment. About 50% of those in the patient and general population groups supported active euthanasia or physician-assisted suicide, as compared with less than 40% of the family caregivers and less than 10% of the oncologists. Higher income was significantly associated with approval of the withdrawal of futile life-sustaining treatment and the practice of active pain control. Older age, male sex and having no religion were significantly associated with approval of withholding of life-sustaining measures. Older age, male sex, having no religion and lower education level were significantly associated with approval of active euthanasia and physician-assisted suicide. Interpretation: Although the various participant groups shared the same attitude toward futile and ameliorative end-of-life care (the withdrawal of futile life-sustaining treatment and the use of active pain control), oncologists had a more negative attitude than those in the other groups toward the active ending of life (euthanasia and physician-assisted suicide).
Yun, Young Ho; Han, Kyung Hee; Park, Sohee; Park, Byeong Woo; Cho, Chi-Heum; Kim, Sung; Lee, Dae Ho; Lee, Soon Nam; Lee, Eun Sook; Kang, Jung Hun; Kim, Si-Young; Lee, Jung Lim; Heo, Dae Seog; Lee, Chang Geol; Lim, Yeun Keun; Kim, Sam Yong; Choi, Jong Soo; Jeong, Hyun Sik; Chun, Mison
Background Serum levels of N–terminal proB–type natriuretic peptide (NT–proBNP) are elevated in patients acute respiratory distress syndrome (ARDS). Recent studies showed a lower incidence of acute cor pulmonale in ARDS patients ventilated with lower tidal volumes. Consequently, serum levels of NT–proBNP may be lower in these patients. We investigated the relation between serum levels of NT–proBNP and tidal volumes in critically illpatients without ARDS at the onset of mechanical ventilation. Methods Secondary analysis of a randomized controlled trial of lower versus conventional tidal volumes in patients without ARDS. NT–pro BNP were measured in stored serum samples. Serial serum levels of NT–pro BNP were analyzed controlling for acute kidney injury, cumulative fluid balance and presence of brain injury. The primary outcome was the effect of tidal volume size on serum levels of NT–proBNP. Secondary outcome was the association with development of ARDS. Results Samples from 150 patients were analyzed. No relation was found between serum levels of NT–pro BNP and tidal volume size. However, NT-proBNP levels were increasing in patients who developed ARDS. In addition, higher levels were observed in patients with acute kidney injury, and in patients with a more positive cumulative fluid balance. Conclusion Serum levels of NT–proBNP are independent of tidal volume size, but are increasing in patients who develop ARDS.
End-of-Life Care for Children With TerminalIllness KidsHealth > Parents > Doctors & Hospitals > Caring for a Seriously or Chronically Ill Child > End-of- ... families cope with terminalillness. What Is Hospice Care? Hospice care, sometimes called end-of-life palliative ...
Research continues to confirm that sharing one's life story through the process of life review enhances psychological well-being and increases life satisfaction. Although researchers have outlined techniques and activities that may be used in life review with older adults, little work has focused on the use of life review methods with terminallyillpatients. Additionally, researchers have suggested that life review can take on the form of a spiritual assessment; and that such spiritually oriented life reviews may enhance a sense of meaning and foster reconciliation as one approaches dying. In this article, the authors provide a brief review of the research on and the practice of life review. Further, by merging concepts of life review with systematic theology, they offer a sample instrument--using the example of one faith framework--with which pastoral caregivers can better approach the spiritual needs of patients and facilitate a less traumatic death in the terminallyill. PMID:14579630
This quasiexperimental study examined the effect of an educational program on attitudes toward caring for terminallyill persons and their families. Participants were 115 undergraduate students: intervention group, N = 49; control group, N = 66. Pre- and post-intervention measurements were done with the Frommelt Attitude Toward Care of the Dying Scale (FATCOD, Form B). Students in the intervention group participated in a semester-long (15-week, 45-hour) educational program. Demographic variables, including age, gender, religion, major area of study, influence of religious beliefs, profession, previous education, and past or present experience with loss were evaluated. Statistical analyses (t-test, ANOVA, ANCOVA, and APVs) indicated a significant positive change in the attitude scores of the intervention group and no significant change in the attitude scores of the control group. PMID:12568433
The study reported here explored the factors associated with the implementation of Martinson's model of home care and treatment for children in the terminal stages of illness with cancer. The model is described as an example of a health care strategy that was dramatically different from the prevalent model of care and may have conflicted with existing values. Data for the study were gathered from the hospital records of the children and from a survey of their oncologists. The findings suggest that physicians viewed the model of care as desirable and made their referral decisions on the basis of their judgment about whether the family in question was technically and emotionally capable of providing the care.
Data from interviews with 100 social workers who treat the terminallyill in hospitals, skilled nursing facilities, and hospices were analyzed. A number of concepts which-may be related to an optimal model of care were found, including open communication between the patient, family, and hospital staff; the control of symptoms to ease the patients' pain; and the patient\\/family as a
In medically illpatients, given the many entities the phenotype of depression may represent, clinicians must be prepared to cast their diagnostic nets widely, not settling for the obvious but frequently incorrect choice of major depressive episode and throwing antidepressants at it willy nilly. Having chosen the correct diagnosis from among a broad differential of depression “look-alikes,” clinicians can draw upon a broad swath of treatment modalities including medications, psychotherapy, social supports, and spiritual interventions. Working as a psychiatrist in the medical arena requires the curiosity and analytic skills of a detective and the breadth of knowledge of a polymath adapting therapeutic tools from across the biopsychosociospiritual spectrum to the specific needs of the patient. PMID:22370500
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 patients (79%) had spoken about their wishes
Jean-Jacques Georges; Bregje D. Onwuteaka-Philipsen; Martien T. Muller; Gerrit van der Wal; Agnes van der Heide; Paul J. van der Maas
Severe sepsis with associated multisystem organ dysfunction is a leading cause of death in patients hospitalized in intensive care units. The gastrointestinal system plays a key role in the pathogenesis of multisystem organ dysfunction owing to a breakdown of intestinal barrier function and increased translocation of bacteria and bacterial components into the systemic circulation. During critical illness, alterations occur in gut microflora owing to several factors, including changes in circulating stress hormones, gut ischemia, immunosuppression, the use of antibiotics, and lack of nutrients. The importance of endogenous strains of probiotic bacteria such as Bifidobacterium and Lactobacillus in maintaining intestinal barrier function and also in modulating mucosal and systemic immune responses is becoming evident from numerous studies. Bacteria in synbiotic (prebiotic and probiotic combinations) and probiotic (mutistrain combinations) preparations are being used experimentally in the treatment of acute pancreatitis, liver transplantation, and in trauma patients. Recent studies have shown treatment of patients with multiple trauma or acute pancreatitis with synbiotic preparations resulted in reduced rates of infection, sepsis, and mortality in patients. Enterally fed patients in the intensive care unit treated with a probiotic compound demonstrated enhanced immune function and decreased incidence of diarrhea. Results from these clinical trials are encouraging, and warrant further investigation to clarify which probiotic bacterial strains are of most benefit to this population. PMID:18806700
AIMS AND OBJECTIVES: To describe the process that nurses experienced in engaging with families in Malaysian palliative care settings and the challenges they faced. BACKGROUND: In palliative care settings, nurses and the terminallyill person's family members interact very closely with each other. It is important for nurses to work with families to ensure that the care of the terminallyill person is optimised. RESEARCH DESIGN: A qualitative design using grounded theory methods was used to describe how nurses engaged with families and the challenges they faced. METHODS: Twenty-two nurses from home care and inpatient palliative care settings across Malaysia participated in this study. Data were collected through seven interviews and eight focus group discussions conducted between 2007-2009. RESULTS: The main problem identified by nurses was the different expectations to patient care with families. The participants used the core process of Engaging with families to resolve these differences and implemented strategies described as Preparing families for palliative care, Modifying care and Staying engaged to promote greater consistency and quality of care. When participants were able to resolve their different expectations with families, these resulted in positive outcomes, described as Harmony. However, negative outcomes of participants not being able to resolve their different expectations with families were Disharmony. CONCLUSIONS: This study highlights the importance of engaging and supporting families of the terminallyill as well as providing a guide that may be used by nurses and carers to better respond to families' needs and concerns. RELEVANCE TO CLINICAL PRACTICE: The study draws attention to the need for formal palliative care education, inclusive of family care, to enable nurses to provide the terminallyill person and their family effective and appropriate care. PMID:23651099
Namasivayam, Pathma; Lee, Susan; O'Connor, Margaret; Barnett, Tony
|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…
Georges, Jean-Jacques; Onwuteaka-Philipsen, Bregje D.; Muller, Martien T.; van der Wal, Gerrit; van der Heide, Agnes; van der Maas, Paul J.
|The number of terminallyill 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 terminallyill inmate, using a client-centered approach. Drawing…
|Caregivers experience multiple losses during the downhill trajectory of a loved one's terminalillness. Using mixed methods, this two-stage study explored caregiver grief during a terminalillness and after the care recipient's death. Caregiver grief was a state of heightened responsiveness during end-stage care: anxiety, hostility, depression,…
Caregivers experience multiple losses during the downhill trajectory of a loved one's terminalillness. Using mixed methods, this two-stage study explored caregiver grief during a terminalillness and after the care recipient's death. Caregiver grief was a state of heightened responsiveness during end-stage care: anxiety, hostility, depression,…
This multicenter trial examined the efficacy and safety of dextromethorphan (DM) as an enhancer of analgesia and modulator of opioid tolerance in cancer patients with pain. Eligible patients were randomized to slow-release morphine plus DM or slow-release morphine plus placebo. The initial DM dose was 60mg four times daily for seven days, with an increase to 120mg four times daily,
Deborah J. Dudgeon; Eduardo Bruera; Bruno Gagnon; Sharon M. Watanabe; Sharon J. Allan; David G. Warr; Susan M. MacDonald; Colleen Savage; Dongsheng Tu; Joseph L. Pater
The use of family caregivers to report patients’ dying experiences has been suggested as a way of resolving the problem of\\u000a non-response bias and missing data in end-of-life research. There is a dearth of information in the literature about the predictors\\u000a of the extent of agreement for quality of life (QOL) assessments between patients and family informants outside of Western
Klopotowska and colleagues underscore the value of the hospital pharmacists’ expertise in reducing medication errors and improving patient safety in critical care . Th e authors emphasise that drug inaccuracies are frequent and that the limited physiological reserve of critically ill individuals increases the potential harm of adverse prescribing. Critically illpatients represent a unique population with altered pharmacokinetics, and
Andrew Carson-Stevens; Christopher D Hingston; Matt P Wise
Whether a terminallyill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients.Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what
Federico Bozzetti; Nazionale Tumori; EDUARDO BRUERA; LUCA COZZAGLIO; Zstituto Nazionale Tumori; OSCAR CORLI; Ospedale Buzzi; ANTONIO FILIBERTI; CHARLES-HENRI RAPIN; HANS NEUENSCHWANDER; MICHEL AOUN; SANTE BASSO RICCI; ROBERTO DOCI; MARIUCCIA GARRONE; Zstituto Neurologico; C. Besta; MARA GENTILINI; NICOLE LERY; MARK MANTELL; RAE SHELDON-COLLINS; GIUSEPPE TROMPINO
End-of-life care is continuously becoming an issue of paramount importance given an increase in medical advances, the aging of the population, and the movement toward contributing toward a quality of life among terminallyillpatients. However, there is a dearth in literature related to this topic specifically in terms of preparing counselors to…
|End-of-life care is continuously becoming an issue of paramount importance given an increase in medical advances, the aging of the population, and the movement toward contributing toward a quality of life among terminallyillpatients. However, there is a dearth in literature related to this topic specifically in terms of preparing counselors to…
We developed a Spirituality Transcendence Measure (STM) and studied whether awareness of terminalillness affects spiritual well-being in terminal cancer patients. Three sources of spiritual transcendence--the situational, the moral and biographical, and the religious aspect--were assessed in the STM. Cronbach's alpha of the STM was 0.95, and the principle axis factor analysis extracted only one factor. Thirty-seven terminal cancer patients with male predominance (59.5%) were studied. Awareness of terminalillness was associated with a higher total STM score (Z = -2.21, P = 0.027), along with the individual scores for each of the three transcendences (Z = -2.39, P = 0.017; Z = -2.71, P = 0.007; and Z = -1.96, P = 0.050). Acceptance of death was associated with a higher situational score (Z = 2.01, P = 0.046) and a higher religious score (Z = -2.27, P = 0.023). Announcement of testament was associated with a higher situational score (Z = -2.30, P = 0.021). We conclude that awareness of terminalillness is associated with spiritual well-being. Telling the complete truth is necessary even when dealing with terminal conditions. PMID:16716875
Critical care medicine has evolved as a field of science and clinical care. Despite important contributions to our understanding of the molecular basis of critical illness, we still remain troubled by our lack of insight into why some patients have favorable outcomes from critical illness and others do not. This article explores the hypothesis that at least five important variables may alter the outcome of patients suffering from a variety of critical illnesses. These variables include the premorbid immune or genetic status of the patient, the patient's gender, the circulating cholesterol concentration, the patient's age, and various iatrogenic and nosocomial events. Insights into the importance of these five variables may provide opportunities for physicians and scientists to improve outcome in patients suffering from critical illness. Clearly, altering iatrogenic and nosocomial events is already within the realm of opportunity. PMID:10331337
For persons with psychiatric disabilities, maintaining a job is often more difficult than acquiring a job. A large proportion of jobs end unsatisfactorily. This study explored job terminations among 63 persons with severe mental illness who participated in competitive jobs through supported employment programs. More than half of the job terminations were unsatisfactory, defined as the client quitting without having
Deborah R. Becker; Robert E. Drake; Gary R. Bond; Haiyi Xie; Bradley J. Dain; Katherine Harrison
Critically illpatients 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 illpatients within hospital is needed. Thorough preparation for the move and adequate maintenance of treatment during movement requires the skill of experienced medical staff.
Examined differences on 9 psychological measures among groups of 25 critically ill hospitalized patients, 25 noncritically ill hospitalized patients, and 25 normal well controls. The instruments used were the Purpose in Life Test, the Fundamental Interpersonal Relations Orientation-Behavior test, and 2 listening measures on which eye-blink rates were recorded. 4 multivariate discriminate function analyses were performed to determine those variables
Discusses the philosophy of the rehabilitation services department at McLean Hospital on patient education for the mentally ill, noting patient library collection and recommended resources on marital problems, sex education, drug manuals, and diagnostic and research findings. A list of magazines subscribed to, color code classification, and 23…
The rapidly changing physiology of critically illpatients causes variations in the absorption, distribution, metabolism, excretion, and pharmacodynamic effect of drugs used to treat these patients. Alterations in fluid status, cardiac, renal and hepatic function, and circulating serum proteins necessitate increased attention to drug selection and dosage modification. Cardiac failure results in decreased absorption, metabolism, and excretion of drugs while
Patients with adrenal insufficiency in the critical care setting may present with a spectrum of disease severity ranging from life-threatening adrenal crisis to mild organ dysfunction. The recognition of adrenal insufficiency is made more difficult in the critically illpatient because of the unavailability of a reli- able history, delay in reporting of diagnostic laboratory results, and the comorbidities that
Pleural effusions (PEs) are common in critically illpatients mainly as a consequence of severe cardiopulmonary disorders frequently encountered in these patients. Their impact on the pathophysiology of acute respiratory failure remains unknown. They are usually small and uncomplicated transudates that are easily overlooked on a supine portable chest X-ray and do not require drainage or infectious exudates that always
Critical illness dramatically increases muscle proteolysis and more than doubles the dietary protein requirement. Yet surprisingly, most critically illpatients receive less than half the recommended amount of protein during their stay in a modern intensive care unit. What could explain the wide gap between the recommendations in clinical care guidelines and actual clinical practice? We suggest that an important aspect of the problem is the failure of guidelines to explain the pathophysiology of protein-energy malnutrition and the ways critical illness modifies protein metabolism. The difficulty created by the lack of a framework for reasoning about appropriate protein provision in critical illness is compounded by the many ambiguous and often contradictory ways the word malnutrition is used in the critical care literature. Failing to elucidate these matters, the recommendations for protein provision in the guidelines are incoherent, unconvincing, and easy to ignore. PMID:23459750
Fever, commonly defined by a temperature of >or=38.3 degrees C (101 degrees F), occurs in approximately one half of patients admitted to intensive care units. Fever may be attributed to both infectious and noninfectious causes, and its development in critically ill adult medical patients is associated with an increased risk for death. Although it is widespread and clinically accepted practice to therapeutically lower temperature in patients with hyperthermic syndromes, patients with marked hyperpyrexia, and selected populations such as those with neurologic impairment, it is controversial whether most medical patients with moderate degrees of fever should be treated with antipyretic or direct cooling therapies. Although treatment of fever may improve patient comfort and reduce metabolic demand, fever is a normal adaptive response to infection and its suppression is potentially harmful. Clinical trials specifically comparing fever management strategies in neurologically intact critically ill medical patients are needed. PMID:19535958
Critically illpatients in intensive care units are subject to many complications associated with therapy. Many of these complications are health care-associated infections and are related to indwelling devices, including ventilator-associated pneumonia, central line-associated bloodstream infection, catheter-associated urinary tract infection; surgical site infection, venous thromboembolism, deep venous thrombosis, and pulmonary embolus are other common complications. All efforts should be undertaken to prevent these complications in surgical critical care, and national efforts are under way for each of these complications. In this article, epidemiology, risk factors, diagnosis, treatment, and prevention of these complications in critically illpatients are discussed. PMID:23153883
This study, which explored job terminations among 60 individuals with severe mental illness participating in a supported employment program in Hong Kong, used the Chinese Job Termination Interview that was validated and translated from the Job Termination Interview (JTI; Becker, Drake, Bond et al., 1988). More than half of the job terminations (53%) were unsatisfactory which included dissatisfaction with job (44%) and lack of interest (22%). Modification of work schedules and provision of adequate supervision and coaching at the workplace were identified as necessary job accommodations. Similarities and differences of findings were compared with overseas studies. Possible improvement of current supported employment program was discussed. PMID:17040175
Mak, Donald C S; Tsang, Hector W H; Cheung, Leo C C
Terminal changes in frogs infected with the amphibian fungal pathogen Batrachochytrium dendrobatidis (Bd) include epidermal degeneration leading to inhibited epidermal electrolyte transport, systemic electrolyte disturbances, and asystolic cardiac arrest. There are few reports of successful treatment of chytridiomycosis and none that include curing amphibians with severe disease. Three terminallyill green tree frogs (Litoria caerulea) with heavy Bd infections were cured using a combination of continuous shallow immersion in 20 mg/L chloramphenicol solution for 14 days, parenteral isotonic electrolyte fluid therapy for 6 days, and increased ambient temperature to 28 degrees C for 14 days. All terminallyill frogs recovered rapidly to normal activity levels and appetite within 5 days of commencing treatment. In contrast, five untreated terminallyill L. caerulea with heavy Bd infections died within 24-48 hr of becoming moribund. Subclinical infections in 15 experimentally infected L. caerulea were cured within 28 days by continuous shallow immersion in 20 mg/L chloramphenicol solution without adverse effects. This is the first known report of a clinical treatment protocol for curing terminallyill Bd-infected frogs. PMID:22779237
Young, Sam; Speare, Rick; Berger, Lee; Skerratt, Lee F
Perception of illness has been described as an important predictor in the medical health psychology literature, but has been given little attention in the domain of mental disorders. The patient's Perception of Depression Questionnaire (PDIQ) is a newly developed measure whose factor structure and psychometric properties were evaluated on a sample of 174 outpatients meeting criteria for major depressive disorder.
Rachel Manber; Andrea S Chambers; Sabrina K Hitt; Cynthia McGahuey; Pedro Delgado; John J. B Allen
The perormance of two groups of hospitalized mentally illpatients (schizophrenia and major depression) and two groups of non-mentally-illpatients (patients hospitalized for ischemic heart disease and non-ill primary care patients) was compared on a standardized, objective instrument for assessing patients' understanding of information relevant for patient decision making (consent) about treatment with medication. Generally, hospitalized schizophrenic patients manifested significantly
Malnutrition in the critically illpatient is associated with adverse outcomes such as increased morbidity, infectious processes, and length of stay. Alterations to the gastrointestinal system during critical illness can be devastating. Current evidence suggests that, in the presence of a functioning gut, initiating early enteral nutrition therapy (within 24-48 hours of intensive care unit admission) results in enhanced tissue repair, preservation of immune competence, and conservation of the integrity of gut flora. Recommendations for practice include development of a national nutrition support protocol for widespread use in the intensive care unit. PMID:22874539
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
Whether defined as chronically critically ill, long-term mechanical ventilator dependent (or otherwise chronically medically supported), or medically fragile, a population of infants and children with chronic illness clearly exists. Infants and children with chronic healthcare needs are at an increased risk for physical, developmental, behavioral, and/or emotional conditions and generally require healthcare services of a type or amount beyond that of a general pediatric or adult population. This review will focus on the specific management and psychosocial needs associated with the healthcare of this subgroup of infants and children with chronic illness. Attention will be paid to defining the population, describing trends over time, reviewing their special needs, and discussing outcomes. Increased focus and an increasing quantity of resources for this subgroup of infants and children are needed, as the number of such pediatric patients continues to grow. PMID:22663972
For many neurologists, seizures in critically illpatients represent a difficult problem. Etiology can be elusive because\\u000a of the complexity of the environment, and treatment decisions can be compromised by the paucity of evidence-based guidelines.\\u000a Emerging data support a higher than previously thought incidence of nonconvulsive epileptic activity in this patient population,\\u000a which is another important consideration. Although a seizure
Intoxications present in many forms including: known drug overdose or toxic exposure, illicit drug use, suicide attempt, accidental exposure, and chemical or biological terrorism. A high index of suspicion and familiarity with toxidromes can lead to early diagnosis and intervention in critically ill, poisoned patients. Despite a paucity of evidence-based information on the management of intoxicated patients, a rational and systematic approach can be life saving. PMID:14710698
One of the most perplexing problems in the medicolegal field concerns the criteria on which decisions not to treat terminallyill incompetent patients should be made. These decisions traditionally have been made by physicians in hospitals--sometimes with the assistance of the patient's family--on the basis of their perceptions of the patient's "best interests." Recently, two state supreme courts have ruled on this question. The New Jersey Supreme Court, in the Quinlan case, developed a medical prognosis criterion, and permitted the patient's guardian, family, and physicians to apply it with the concurrence of a hospital "ethics committee." The Massachusetts Supreme Judicial Court, in the Saikewicz case, adopted, on different facts, the test of "substituted judgment" to be applied by a probate court after an adjudicatory hearing. The two cases have been interpreted by many in the medical profession as representing conflicting viewpoints--one supportive of traditional medical decision making and the other distrustful of it. It is the thesis of this Article that Quinlan and Saikewicz are in fundamental agreement and can be reconciled by the next state supreme court that rules on this question. Both courts enunciate a constitutional right to refuse life-sustaining treatment, based on the right to privacy. They agree that incompetents should be afforded the opportunity to exercise this right, and that certain state interests can overcome it. They agree also that physicians should be permitted to make medical judgments, and that societal judgments belong in the courts. The differences in how the opinions are perceived result from the interplay of several factors: the differences in the facts of the cases; the inarticulate use of the term "ethics committee" by the Quinlan court; the literal interpretation of the role of such a committee by the Saikewicz court; a desire for 100 percent immunity on the part of physicians and hospital administrators in Massachusetts; and advice from their counsel on how such immunity can be guaranteed. It is the author's hope that this Article will help to dispel much of the misinformation surrounding these two cases, and to refocus the debate on how decisions should be made for the terminallyill incompetent patient on the real issues regarding criteria and the decision-making process that remain to be resolved. PMID:507056
|The political and social development of the Medicare Hospice Benefit combines humanitarian and cost-saving strategies. Although it mainstreamed care of the terminallyill and provided multiple services, four major constraints of the benefit package are identified and explored. It is important that we analyze this policy before we devise new ways…
Do terminallyill individuals have the right to decide the timing of their death and to have assistance in a hastened death? This article is based on an American Psychological Association briefing paper prepared for the media regarding the June 1997 Supreme Court decision on physician-assisted suicide. The Court's decision clarified the role medical doctors can play in caring for
|In 2005, the American Counseling Association (ACA) introduced a new ethical standard for counselors working with clients with terminalillness 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).|
The political and social development of the Medicare Hospice Benefit combines humanitarian and cost-saving strategies. Although it mainstreamed care of the terminallyill and provided multiple services, four major constraints of the benefit package are identified and explored. It is important that we analyze this policy before we devise new ways…
This study explored terminallyill elders' anticipation of future support, which may be particularly important due to their vulnerable state and resulting support needs. Qualitative data was gathered from face-to-face interviews with 100 elders receiving hospice care; 85 of whom discussed anticipating future support. Content analysis revealed that anticipating support was based on current experiences of received support and that
Infection is common in the critically ill and often results due to the severity of the patient's illness. Recent data suggest 51% of intensive care unit (ICU) patients are infected, and 71% receive antimicrobial therapy. Bacterial infection is the primary concern, although some fungal infections are opportunistic. Infection more than doubles the ICU mortality rate, and the costs associated with infection may be as high as 40% of total ICU expenditures. There are many contemporary antimicrobial resistance concerns that the critical care clinician must consider in managing the pharmacotherapy of infection. Methicillin resistance in Staphylococcus aureus, vancomycin resistance in Enterococci, beta-lactamase resistance in Enterobacteriaceae, multidrug resistance in Pseudomonas aeruginosa and Acinetobacter species, fluoroquinolone resistance in Escherichia coli, and fungal resistance are among the most common issues ICU clinician's must face in managing infection. Critical illness causes changes in pharmacokinetics that influence drug and dosing considerations. Absorption, distribution, metabolism, and excretion may all be affected by the various disease states that define critical illness. Several specific diseases are discussed, including ventilator-associated pneumonia, various fungal infections, gastrointestinal infections due to Clostridium difficile, urinary tract infections, and bloodstream infections. Within each disease section, discussion includes causes and prevention strategies, microbiology, evidence-based guidelines, and important caveats. PMID:21507873
To answer some of the questions surrounding the medicinal use of narcotic analgesics in advanced cancer, a group of 500 patients admitted to St Christopher's Hospice was reviewed. To achieve and maintain pain relief many of the patients received diamorphine (heroin) regularly every four hours. Almost all the patients received a phenothiazine concurrently; other drugs were prescribed when indicated. It was concluded that: 1) Although most patients receive parenteral diamorphine during the last 12 to 24 hours, the majority can be maintained on oral medication until this time. 2) There is no single optimal dose of diamorphine. 3) Psychological dependence does not occur. 4) Physical dependence may develop but does not prevent the downward adjustment of the dose of diamorphine when considered clinically feasible. 5) Tolerance is not a practical problem. 6) The prescription of diamorphine does not, by itself, lead to impairment of mental faculties. Also discussed are: 1) the psychobiological nature of pain; 2) the rational use of analgesics; 3) the need for further research; 4) the importance of the doctor's attitude.
BACKGROUND: Previous qualitative research proved that relatives of elderly terminallyill Turkish and Moroccan immigrants experience several barriers to the use of Dutch professional home care. The aim of this study was to explore how general practitioners and home care nurses perceive the home care for terminallyill Turkish and Moroccan migrants and their families in the Netherlands. METHODS: Questionnaires
Background: Depressive symptoms, fatigue, and apathy are common symptoms among medically ill older adults and patients with advanced disease, and have been associated with morbidity and mortality. Methylphenidate has been used to treat these symptoms because of its rapid effect. Despite the long history of methylphenidate use for the treatment of depressive symptoms, fatigue, and apathy, there is little definitive
OBJECTIVE--To assess the preference of terminallyillpatients with cancer for their place of final care. DESIGN--Prospective study of randomly selected patients with cancer from hospital and the community who were expected to die within a year. Patients expected to live less than two months were interviewed at two week intervals; otherwise patients were interviewed monthly. Their main carer was
J Townsend; A O Frank; D Fermont; S Dyer; O Karran; A Walgrove; M Piper
ABSTRACT: INTRODUCTION: The precise role of cytomegalovirus (CMV) infection in contributing to outcomes in critically ill immunocompetent patients has not been fully defined. METHODS: Studies in which critically ill immunocompetent adults were monitored for CMV infection in the intensive care unit (ICU) were reviewed. RESULTS: CMV infection occurs in 0 to 36% of critically illpatients, mostly between 4 and
Purpose of review In this article we summarize recent investigations into the influence of illness perceptions on outcomes in patients with medical conditions. Recent findings Developments in assessment include the publishing of a new brief scale to assess illness perceptions and the examination of the relationship between patient drawings of their illness and outcomes. Recent studies in primary care highlight
Background: In a general hospital, few clinical settings match the intensity of the intensive care unit (ICU) experience. Clinical rotations in ICUs elicit and emphasize the struggles house officers face on a daily basis throughout their training. Method: These struggles were recorded by hundreds of residents in a journal maintained in the Massachusetts General Hospital's Medical ICU for the past 20 years. We systematically reviewed these unsolicited entries to define and to illustrate how house officers respond to caring for terminallyillpatients. The 3 overarching topics that surfaced repeatedly were assessment of terminallyillpatients, reaction to their prognosis, and management of their disease or their eventual demise. Results: House officers record affective reactions and cognitive assessments to cope with the stress and dysfunction associated with the care of the critically ill and to facilitate their management of these patients. Journal entries by residents reveal a deep concern for the welfare of their patients, conflict about the technological advances and limitations of the system, and reflection on how involved physicians should become with their patients. Conclusion: House officer journal entries reflect a combination of newly gained medical knowledge and coping strategies in managing terminallyillpatients. House officers also demonstrate a deep concern for the welfare of their patients. Insight from years of reflection from past house officers can help prepare trainees and residency programs for the breadth and intensity of the ICU experience and for work in clinical practice settings that follow completion of training.
The objective of this study was to determine the pharmacokinetics and dosing recommendations of vancomycin in critically illpatients receiving continuous venovenous haemofiltration (CVVH). A prospective study was conducted in the Intensive Care Unit of a university hospital. Seven patients receiving CVVH with a triacetate hollow-fibre dialyser were enrolled. CVVH was performed in pre-dilution mode with a blood flow rate of 200-250 mL/min and an ultrafiltrate flow rate of 800-1200 mL/h. To determine vancomycin pharmacokinetics, serum and ultrafiltrate were collected over 12 h after a 2-h infusion of 1000 mg vancomycin. The mean (± standard deviation) sieving coefficient of vancomycin was 0.71±0.13, which is consistent with previously reported values. Clearance of vancomycin by CVVH (0.73±0.21 L/h or 12.11±3.50 mL/min) constituted 49.4±20.8% of total vancomycin clearance (1.59±0.47 L/h) and was consistent with previously reported clearances. Approximately one-fifth of the vancomycin dose was removed during the 12-h CVVH (213.9±104.0 mg). The volume of distribution was 24.69±11.00 L, which is smaller than previously reported. The elimination rate constant and terminal half-life were 0.08±0.05 h(-1) and 12.02±7.00 h, respectively. In conclusion, elimination of vancomycin by CVVH contributed to ca. 50% of the total elimination in critically illpatients. The maintenance dose of vancomycin, calculated from parameters from patients in this study, would be 500-750 mg every 12 h to provide a steady-state trough concentration of 15-20 mg/L. Owing to alterations in clinical conditions, serum vancomycin concentrations must be closely monitored in critically illpatients. PMID:21636256
The purpose of this retrospective study was to determine the prevalence of alcoholism among terminallyill cancer patients when assessed by multidisciplinary interviews and by the CAGE Questionnaire. We reviewed the charts of 100 consecutive patients assessed by a multidisciplinary team for the presence of alcoholism during 1989, and 100 consecutive patients assessed by the CAGE Questionnaire during 1992. Alcoholism
Eduardo Bruera; Jairo Moyano; Linda Seifert; Robin L. Fainsinger; John Hanson; Maria Suarez-Almazor
Previous research suggests that caregivers and terminallyillpatients 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 psychological distress (i.e., depressive symptomatology, emotional exhaustion) among secular and religiously observant family
|Previous research suggests that caregivers and terminallyillpatients 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…
Summary This investigation was specifically concerned with testing the hypothesis that social class differences exist among hospitalized mental patients in their perceptions of the etiology of their illness. Previous studies have reported that higher class patients usually visualize their illness int terms of subjective and interpersonal factors while patients in lower social classes primarily see objective and external causes. These
A common cause of acute kidney injury (AKI) is sepsis, which makes appropriate dosing of antibiotics in these patients essential. Drug dosing in critically illpatients with AKI, however, can be complicated. Critical illness and AKI can both substantially alter pharmacokinetic parameters as compared with healthy individuals or patients with end-stage renal disease. Furthermore, drug pharmacokinetic parameters are highly variable
Intensive care is increasingly being used in the management of cancer patients. It is important that a disproportionate share\\u000a of special care resources is not expended on futile care of terminallyillpatients. A requirement for mechanical ventilation\\u000a has been stated to affect survival in cancer patients. The objectives of this study were to determine our hospital utilisation\\u000a of ICU
Anemia is common in critically illpatients. As a consequence packed red blood cell (PRBC) transfusions are frequent in the critically ill. Over the past two decades a growing body of literature has emerged, linking PRBC transfusion to infections, immunosuppression, organ dysfunction, and a higher mortality rate. However, despite growing evidence that risk of PRBC transfusion outweighs its benefit, significant numbers of critically illpatients still receive PRBC transfusion during their intensive care unit (ICU) stay. In this paper, we summarize the current literature concerning the impact of anemia on outcomes in critically illpatients and the potential complications of PRBC transfusions.
Objective To determine if fat-free mass and fat mass in acutely ill and chronically illpatients differed from healthy controls at hospital admission and if prevalence of malnutrition differed by body mass index (BMI) or fat-free mass percentile.Subjects\\/Setting 995 consecutive patients 15 to 100 years of age admitted to the hospital were measured in the hospital admission center and compared
URSULA G. KYLE; PIERRE UNGER; YVES M. DUPERTUIS; VERONIQUE L. KARSEGARD; LAURENCE GENTON; CLAUDE PICHARD
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.
The nonthyroidal illness syndrome (NTIS) is a clinical condition of abnormal thyroid function tests observed in patients with acute or chronic systemic illnesses. The laboratory parameters of NTIS usually include low serum levels of triiodothyronine, with normal or low levels of thyroxine and normal or low levels of thyroid-stimulating hormone. It is still a matter of controversy whether the NTIS represents a protective adaptation of the organism to a stressful event or a maladaptive response to illness that needs correction. Multiple studies have investigated the effect of thyroid hormone replacement therapy in certain clinical situations, such as caloric restriction, cardiac disease, acute renal failure, brain-dead potential donors, and burn patients. Treating patients with NTIS seems not to be harmful, but there is no persuasive evidence that it is beneficial. The administration of hypothalamic releasing factors in patients with NTIS appears to be safe and effective in improving metabolism and restoring the anterior pituitary pulsatile secretion in the chronic phase of critical illness. However, also this promising strategy needs to be explored further. Anyhow, an extremely prudent approach is needed if treatment is given. Much of the data appearing in the literature on the treatment of NTIS encourage further randomized controlled trials on large number of patients. At present, however, we believe that there is no indication for treating thyroid hormone abnormalities in critically illpatients until convincing proof of efficacy and safety is provided. PMID:19702524
Bello, G; Paliani, G; Annetta, M G; Pontecorvi, A; Antonelli, M
BACKGROUND: Menopause is a significant biological event in the life of every woman, including women with men- tal disorders. This brief report describes the results of a survey of 39 patients with mental illness and their family mem- bers regarding perceived effects of menopause on mental illness. METHODS: The survey was distributed to participants attending a National Alliance for the
Martha Sajatovic; Miriam B. Rosenthal; Miriam Solomon Plax; Mindy L. Meyer; C. Raymond Bingham
From a gastroenterological point of view, for chronic critically illpatients a differentiation has to be made between general gastroenterological problems, which are important in many or all chronic critically illpatients and patients with gastroenterological diseases which are the reason for the chronic critically ill status. General gastroenterological problems are, for example the nutrition of these patients and also considerations about ulcer prophylaxis or gastroenterological complications, such as antibiotic-associated colitis. Gastroenterological diseases as the reason for a chronic critically ill status are more in the minority. Diseases which should be taken into consideration are advanced liver cirrhosis and short bowel syndrome. This manuscript is intended to discuss gastroenterological problems in this selected group of patients and to show possible solutions and treatment options. PMID:23423578
This book contains papers addressing the pharmacologic approach to the critically illpatient. Chapter topics include: Radiation injury; Red cell substitutes: a current appraisal; and Psychopharmacology in the ICU.
Chernow, B. (Harvard Medical School, Massachusetts General Hospital, Boston, MA (US))
Acute hyperglycaemia has been associated with complications, prolonged intensive care unit and hospital stay, and increased\\u000a mortality. We made an inventory of the prevalence and prognostic value of hyperglycaemia, and of the effects of glucose control\\u000a in different groups of critically illpatients. The prevalence of hyperglycaemia in critically illpatients, using stringent\\u000a criteria, approaches 100%. An unambiguous negative correlation
Anouk M Corstjens; Iwan CC van der Horst; Jan G Zijlstra; AB Johan Groeneveld; Felix Zijlstra; Jaap E Tulleken; Jack JM Ligtenberg
In 1986, the European Organization for Research and Treatment (EORTC) initiated a research program to develop an integrated, modular approach for evaluating the quality of life of patients participating in international clinical trials. The questionnaire was designed to measure cancer patients' physical, psychological and social functions. The questionnaire is composed of 5 multiitem scales (physical, role, social, emotional and cognitive functioning) and 9 single items (pain, fatigue, financial impact, appetite loss, nausea/vomiting, diarrhea, constipation, sleep disturbance and quality of life). It was administered to the patients before the initiation of palliative treatment and then once again during the treatment. The validation of the questionnaire took place at Areteion Hospital, while the translation was conducted by the EORTC bureau. The final validation sample consisted of 120 cancer patients. The clinical variable assessed was the performance status. The aim of our study was to assess the applicability of this quality of life measurement on a Hellenic sample of cancer patients receiving palliative care. The results showed that the questionnaire was well accepted in the present patient population. In addition, the questionnaire was found to be useful in detecting the effectiveness of palliative treatment over time. The scale reliability was very good (pretreatment from 0.57-0.79, ontreatment from 0.56-0.75), especially for the functioning scale. In addition, very good validity was found in all the approaches used. Moreover, the factor analysis results in a 6-factor solution that satisfies the criteria of reproducibility, interpretability and confirmatory setting. Performance status showed an improvement (p < 0.0025) during the studied period. These results support that the QLQ-C30 (version 3.0) has proven to be a reliable and valid measure of the quality of life in Greek cancer patients receiving palliative care treatment. PMID:11668488
Kyriaki, M; Eleni, T; Efi, P; Ourania, K; Vassilios, S; Lambros, V
Critically illpatients 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
This study sought to determine the cffectiveness of an education program on nurses' attitudes toward caring for terminallyill persons and their family members. The program, based on the hospice concept of care, included a didactic section based on Kubler-Ross' stages of death and dying, and a roleplay model designed by the researcher. Data were collected from 34 licensed nurses,
The Supreme Court will hear the case of Gonzales v. Oregon in the fall of2005 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 terminalillness, primarily because of
The aim of the study was to investigate the course of psychiatric illness in primary care patients. A 12-month follow-up study was conducted using a subsample of 93 patients, assessed by interviewing with the aid of the Present State Examination (PSE), from an original cohort of 388 primary care patients in a Swedish health district. The relationships of the course
L. Hansson; L. Borgquist; P. Nettelbladt; G. Nordström
Summary Endoscopic studies have shown that all critically illpatients are liable to a degree of stress ulceration. Diffuse erosions appear first in the fundus and then spread to the corpus and antrum within 48 h. Duodenal disease is particuarly common in burns patients. Discrete ulceration occurs in most severely injured patients. Mucosal damage is probably initiated by ischaemia but
Acute hyperglycaemia has been associated with complications, prolonged intensive care unit and hospital stay, and increased mortality. We made an inventory of the prevalence and prognostic value of hyperglycaemia, and of the effects of glucose control in different groups of critically illpatients. The prevalence of hyperglycaemia in critically illpatients, using stringent criteria, approaches 100%. An unambiguous negative correlation between hyperglycaemia and mortality has been described in various groups of critically illpatients. Although the available evidence remains inconsistent, there appears to be a favourable effect of glucose regulation. This effect on morbidity and mortality depends on patient characteristics. To be able to compare results of future studies involving glucose regulation, better definitions of hyperglycaemia (and consequently of normoglycaemia) and patient populations are needed.
Corstjens, Anouk M; van der Horst, Iwan CC; Zijlstra, Jan G; Groeneveld, AB Johan; Zijlstra, Felix; Tulleken, Jaap E; Ligtenberg, Jack JM
Acute hyperglycaemia has been associated with complications, prolonged intensive care unit and hospital stay, and increased mortality. We made an inventory of the prevalence and prognostic value of hyperglycaemia, and of the effects of glucose control in different groups of critically illpatients. The prevalence of hyperglycaemia in critically illpatients, using stringent criteria, approaches 100%. An unambiguous negative correlation between hyperglycaemia and mortality has been described in various groups of critically illpatients. Although the available evidence remains inconsistent, there appears to be a favourable effect of glucose regulation. This effect on morbidity and mortality depends on patient characteristics. To be able to compare results of future studies involving glucose regulation, better definitions of hyperglycaemia (and consequently of normoglycaemia) and patient populations are needed. PMID:16834760
Corstjens, Anouk M; van der Horst, Iwan C C; Zijlstra, Jan G; Groeneveld, A B Johan; Zijlstra, Felix; Tulleken, Jaap E; Ligtenberg, Jack J M
Support of patient self-management is a key component of effective chronic illness care and improved patient outcomes. Self-management support goes beyond traditional knowledge-based patient education to include processes that develop patient problem-solving skills, improve self-efficacy, and support application of knowledge in real-life situa- tions that matter to patients. This approach also encompasses system- focused changes in the primary care environment.
Probiotic bacteria are live microorganisms which confer to health benefits of the host. They help to maintain the integrity of the intestinal barrier function by modulating the mucosal and systemic immune response of the host. These bacteria have proven their beneficial effect in several conditions of ulcerative colitis. More recently probiotics/synbiotics have been included in the treatment of critically illpatients. However to date it remains uncertain whether probiotics/synbiotics are beneficial or even dangerous to the clinical outcome of this patient group. This article reviews the current evidence of the use of bacteria in critically illpatients in intensive care settings. PMID:21352578
Jacobi, Christoph A; Schulz, Christian; Malfertheiner, Peter
Background Many studies have been carried out that focus on mental patients' access to care for their mental illness, but very few pay attention on these same patients' access to care for their physical diseases. Acute appendicitis is a common surgical emergency. Our population-based study was to test for any possible association between mental illness and perforated appendicitis. We hypothesized that there are significant disparities in access to timely surgical care between appendicitis patients with and without mental illness, and more specifically, between patients with schizophrenia and those with another major mental illness. Methods Using the National Health Insurance (NHI) hospital-discharge data, we compared the likelihood of perforated appendix among 97,589 adults aged 15 and over who were hospitalized for acute appendicitis in Taiwan between the years 1997 to 2001. Among all the patients admitted for appendicitis, the outcome measure was the odds of appendiceal rupture vs. appendicitis that did not result in a ruptured appendix. Results After adjusting for age, gender, ethnicity, socioeconomic status (SES) and hospital characteristics, the presence of schizophrenia was associated with a 2.83 times higher risk of having a ruptured appendix (odds ratio [OR], 2.83; 95% confidence interval [CI], 2.20–3.64). However, the presence of affective psychoses (OR, 1.15; 95% CI: 0.77–1.73) or other mental disorders (OR, 1.58; 95% CI: 0.89–2.81) was not a significant predictor for a ruptured appendix. Conclusion These findings suggest that given the fact that the NHI program reduces financial barriers to care for mentally illpatients, they are still at a disadvantage for obtaining timely treatment for their physical diseases. Of patients with a major mental illness, schizophrenic patients may be the most vulnerable ones for obtaining timely surgical care.
ABSTRACT: INTRODUCTION: Smoking is highly addictive, and nicotine abstinence is associated with withdrawal syndrome in hospitalized patients. In this study, we aimed to evaluate the impact of sudden nicotine abstinence on the development of agitation and delirium, and on morbidities and outcomes in critically illpatients who required respiratory support, either noninvasive ventilation or intubation, and mechanical ventilation. METHODS: We
Olivier Lucidarme; Amélie Seguin; Cédric Daubin; Michel Ramakers; Nicolas Terzi; Patrice Beck; Pierre Charbonneau; Damien du Cheyron
There is a crisis in both health care spending and health care quality in the United States, regardless of our ability to\\u000a ignore it. Even with projections of a budget surplus by the year 2003, the plan is still to cut Medicare by 115 billion over the next five years. Cancer care costs have risen from115 billion over\\u000a the next
Introduction The precise role of cytomegalovirus (CMV) infection in contributing to outcomes in critically ill immunocompetent patients has not been fully defined. Methods Studies in which critically ill immunocompetent adults were monitored for CMV infection in the intensive care unit (ICU) were reviewed. Results CMV infection occurs in 0 to 36% of critically illpatients, mostly between 4 and 12 days after ICU admission. Potential risk factors for CMV infection include sepsis, requirement of mechanical ventilation, and transfusions. Prolonged mechanical ventilation (21 to 39 days vs. 13 to 24 days) and duration of ICU stay (33 to 69 days vs. 22 to 48 days) correlated significantly with a higher risk of CMV infection. Mortality rates in patients with CMV infection were higher in some but not all studies. Whether CMV produces febrile syndrome or end-organ disease directly in these patients is not known. Conclusions CMV infection frequently occurs in critically ill immunocompetent patients and may be associated with poor outcomes. Further studies are warranted to identify subsets of patients who are likely to develop CMV infection and to determine the impact of antiviral agents on clinically meaningful outcomes in these patients.
Although moving and handling is an important aspect of nurse training, the emphasis is often more on the health and safety of the nurse than on the importance of the correct therapeutic positioning of patients. This article outlines optimum patient positioning in different critical care settings and for different medical conditions. PMID:16013206
Introduction Liver dysfunction associated with artificial nutrition in critically illpatients is a complication that seems to be frequent,\\u000a but it has not been assessed previously in a large cohort of critically illpatients.\\u000a \\u000a \\u000a \\u000a \\u000a Methods We conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were\\u000a defined: (a) cholestasis: alkaline phosphatase of more than 280
Teodoro Grau; Alfonso Bonet; Mercedes Rubio; Dolores Mateo; Mercé Farré; José Antonio Acosta; Antonio Blesa; Juan Carlos Montejo; Abelardo García de Lorenzo; Alfonso Mesejo
The development of cancer therapies is a long and arduous process. Because it can take several years for a cancer agent to pass clinical testing and be approved for use, terminal cancer patients rarely have the time to see these experimental therapies become widely available. For most terminal cancer patients the only opportunity they have to access an experimental drug
Cardiology professional societies have recommended that patients with cardiovascular implantable electronic devices complete advance directives (ADs). However, physicians rarely discuss end of life handling of implantable cardioverter defibrillators (ICDs), and standard AD forms do not address the presence of ICDs. We conducted a telephone survey of 278 patients with an ICD from a large, academic hospital. The average period since implantation was 5.15 years. More than 1/3 (38%) had been shocked, with a mean of 4.69 shocks. More than 1/2 had executed an AD, but only 3 had included a plan for their ICD. Most subjects (86%) had never considered what to do with their ICD if they had a serious illness and were unlikely to survive. When asked about ICD deactivation in an end of life situation, 42% said it would depend, 28% favored deactivation, and 11% would not deactivate. One quarter (26%) thought ICD deactivation was a form of assisted suicide, 22% thought a do not resuscitate order did not mean that the ICD should be deactivated, and 46% responded that the ICD should not be automatically deactivated in hospice. The answers did not correlate with any demographic factors. Almost all (95%) agreed that patients should have the opportunity to execute an AD that directs handing of an ICD. When asked who should be responsible for discussing this device for an AD, 31% said electrophysiologists, 45% said general cardiologists, and 14% said primary care physicians. In conclusion, the results of the present study highlight the lack of consensus among patients with an ICD on the issue of deactivation at the end of a patient's life. These findings suggest cardiologists should discuss end of life care and device deactivation with their patients with an ICD. PMID:21943937
Kirkpatrick, James N; Gottlieb, Maia; Sehgal, Priya; Patel, Rutuke; Verdino, Ralph J
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.
Bluman, Rabbi Olga F.; Klein, Linda; Thomas, Jay; Ferrell, Betty
Despite converging evidence that major depressive illness is associated with both memory impairment and hippocam- pal pathology, findings vary widely across studies and it is not known whether these changes are regionally specific. In the present study we acquired brain MRIs (magnetic resonance images) from 31 unmedicated patients with MDD (major depressive disorder; mean age 39.2¡11.9 years; 77% female) and
Carrie E Bearden; Paul M Thompson; Christina Avedissian; Andrea D Klunder; Mark Nicoletti; Nicole Dierschke; Paolo BrambillaI; Jair C Soares
Unreliable delivery of best practice care is a major component of medical error. Critically illpatients are particularly susceptible to error and unreliable care. Human factors analysis, widely used in industry, provides insights into how interactions between organizations, tasks, and the individual worker impact on human behaviour and affect systems reliability. We adopt a human factors approach to examine determinants of clinical reliability in the management of critically illpatients. We conducted a narrative review based on a Medline search (1950-March 2010) combining intensive/critical care (units) with medical errors, patient safety, or delivery of healthcare; keyword and Internet search 'human factors' or 'ergonomics'. Critical illness represents a high-risk, complex system spanning speciality and geographical boundaries. Substantial opportunities exist for improving the safety and reliability of care of critically illpatients at the level of the task, the individual healthcare provider, and the organization or system. Task standardization (best practice guidelines) and simplification (bundling or checklists) should be implemented where scientific evidence is strong, or adopted subject to further research ('dynamic standardization'). Technical interventions should be embedded in everyday practice by the adjunctive use of non-technical (behavioural) interventions. These include executive 'adoption' of clinical areas, systematic methods for identifying hazards and reflective learning from error, and a range of techniques for improving teamworking and communication. Human factors analysis provides a useful framework for understanding and rectifying the causes of error and unreliability, particularly in complex systems such as critical care. PMID:20511333
Both liver and kidney dysfunction are associated with adverse outcomes in critical illness. Advanced liver disease can be complicated by the hepatorenal syndrome (HRS) with liver transplantation offering the best long-term outcome. However, until recently, HRS was associated with such a poor prognosis that this group of patients rarely survived long enough for transplantation to be considered. The use of
Fungal infections are common in critically illpatients and are associated with increased morbidity and mortality. Candida spp are the most commonly isolated fungal pathogens. The last 2 decades have seen an increased incidence of fungal infections in critical illness and the emergence of new pathogenic fungal species and also the development of more effective (better bioavailability) and safer (less toxicity, fewer drug interactions) drugs. The distinction between colonization and infection can be difficult, and problems diagnosing infection may delay initiation of antifungal treatment. A number of factors have been identified that can help to distinguish patients at high risk for fungal infection. The antifungal agents that are most frequently used in the intensive care unit are the first- and second-generation azoles and the echinocandins; amphotericin B derivatives (mainly the liposomal agents) are less widely used because of adverse effects. The choice of antifungal agent in critically illpatients will depend on the aim of therapy (prophylaxis, pre-emptive, empiric, definitive), as well as on local epidemiology and specific properties of the drug (antifungal spectrum, efficacy, toxicity, pharmacokinetic/pharmacodynamic properties, cost). In this article we will review all these aspects and propose an algorithm to guide selection of antifungal agents in critically illpatients. PMID:24018296
Hyperglycemia and insulin resistance develop in the majority of severe acute illness and/or injury. One of the main causes of hyperglycemia in critically illpatients is the release of counterregulatory stress hormones and proinflammatory cytokines, in addition to increased production of glucose along with its decreased utilization. Hyperglycemia plays an important role not only in influencing the cascade of inflammatory cytokines, but it also increases oxidative stress. In the past, stress hyperglycemia was thought to be an evolutionary protective, natural adaptive response of the body to current threat, which allows increased entry of glucose into the cells of non-insulin-tissues, thus improving chances for survival. At present, however, this state of insulin resistance, glucose intolerance and hyperglycemia is called "stress diabetes" or "diabetes of injury". Ever since the time of the breakthrough "Leuven" study, which brought significant reduction in morbidity and mortality in surgical critically illpatients with tight glycemic control, hospitals, particularly their intensive care units, have focused on the treatment of hyperglycemia. Although extensive observational data have shown a consistent, almost linear relationship between blood glucose concentrations seen in hospitalized patients and the incidence of adverse clinical results, there have been particular doubts concerning the universality of control, its safety, and pitfalls resulting from hypoglycemia. This controversial debate is currently enriched by the recent international trial - the NICE-SUGAR, whose post-hoc analyses are currently underway. Despite the controversy there is no doubt that the deliberate control of blood glucose control in critically illpatients is justified. It is the insulin application regimen--the insulin protocol per se--that remains the biggest problem in the implementation of glycemic control. Regarding targets, it is necessary to take into account that the best positive effects on outcomes can be anticipated in certain subgroups of critically illpatients, which is currently the subject of further study. Continued streamlining, achieving optimal blood glucose ranges in critically illpatients will allow us to develop and apply computer algorithms that greatly simplify and improve continuous monitoring of blood glucose. Procedures seeking optimal intensive control in critically illpatients are accepted in intensive care units. However, it is undoubtedly necessary to improve monitoring techniques and the quality of biosensors in order to ensure the safety and effectiveness of interventions aimed at reducing blood glucose levels while using advanced protocols. Automatic closed systems are a promise for the future. PMID:21137171
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 illpatient with AUDs. AUDs are underdiagnosed, and a first step to improving patient outcomes may lie in systematically and accurately identifying AUDs.
Jones, Drew G.; Sessler, Curtis N.; Zilberberg, Marya D.; Weaver, Michael F.
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.
Issues of the meaning of life and spirituality are particularly important subjects given the threat of a serious illness and the confrontation with the finiteness of one's own life. Thus, addressing questions of meaning and spiritual domains of supportive care has been identified as essential by patients as well as by health care professionals. In recent years more research has focussed on theoretical conceptualization, empirical examination as well as on the development of meaning-centred interventions in somatically illpatients. Theoretical models for the understanding, development and adaptation of concepts and interventions addressing meaning and spirituality in the chronically ill are offered by the philosophical tradition of existentialism, logotherapy as well as by cognitive and developmental psychology, in particular studies on autobiographical memory and life story. However, the current state of empirical research focussing on the association between meaning, spirituality and physical as well as mental health and underlying mechanisms is not sufficient to draw reliable conclusions. With regard to psychosocial care, meaning-centred interventions have been developed in recent years primarily within the context of palliative care. These interventions are intended to support patients to find meaning in life in the face of a serious illness and to experience their life as fulfilled. PMID:16865631
The U.S. health care system is struggling to improve the quality of health care while containing costs. The rapidly expanding population of older adults with serious illness presents both the greatest challenge and potentially the greatest opportunity to achieving this goal. In order to capitalize on this opportunity, we must first examine the epidemiology of the care of older adults with serious illness, that is, a full description of the characteristics and quality of care from the time of diagnosis through the full course of illness, including measurement of all factors that may influence or impact that care. Several methodological challenges exist in this area of study, including but not limited to, defining the onset of serious illness, avoiding bias in sample selection, and measuring the full breadth of personal, social, local, regional and provider factors that may influence care. Yet, this work is possible through a combination of targeted primary research and efficient leveraging of ongoing studies and existing data sources. Through these studies, we may identify those factors and services associated with high value health care, and learn to develop and refine policies and health care delivery models that yield the greatest improvements in care for seriously ill older patients and their families. PMID:23718871
It has been shown repeatedly that, contrary to earlier beliefs, blacks may well demonstrate similar prevalence rates for manic depressive illness when compared with whites. Yet the authors believe that black manic depressive patients are frequently misdiagnosed as being chronic undifferentiated schizophrenics and treated with major tranquilizers when lithium is the drug of choice. This contention is supported by three case histories and some institutional dynamics that cause this form of iatrogenic morbidity to continue to prey upon black psychiatric patients.
Objective: Candidemia is increasingly encountered in critically illpatients with a high fatality rate. The available data in the critically ill suggest that patients with prior sur- gery are at a higher risk than others. However, little is known about can- didemia in medical settings. The main goal of this study was to com- pare features of candidemia in criti-
Pierre Emmanuel Charles; Jean Marc Doise; Jean Pierre Quenot; Hervé Aube; Frédéric Dalle; Pascal Chavanet; Nadine Milesi; Ludwig Serge Aho; Henri Portier; Bernard Blettery
Critically illpatients 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 illpatients. Further clinical research is needed to elucidate the multiple inhibitory and excitatory neurohormonal stimuli that motivate patients’ intense desire for water.
Increased blood lactate levels (hyperlactataemia) are common in critically illpatients. Although frequently used to diagnose inadequate tissue oxygenation, other processes not related to tissue oxygenation may increase lactate levels. Especially in critically illpatients, increased glycolysis may be an important cause of hyperlactataemia. Nevertheless, the presence of increased lactate levels has important implications for the morbidity and mortality of the hyperlactataemic patients. Although the term lactic acidosis is frequently used, a significant relationship between lactate and pH only exists at higher lactate levels. The term lactate associated acidosis is therefore more appropriate. Two recent studies have underscored the importance of monitoring lactate levels and adjust treatment to the change in lactate levels in early resuscitation. As lactate levels can be measured rapidly at the bedside from various sources, structured lactate measurements should be incorporated in resuscitation protocols.
Background Despite the well documented advantages of hospice care, most terminallyillpatients do not reap the maximum benefit from hospice services, with the majority of them receiving hospice care either prematurely or delayed. Decision systems to improve the hospice referral process are sorely needed. Methods We present a novel theoretical framework that is based on well-established methodologies of prognostication and decision analysis to assist with the hospice referral process for terminallyillpatients. We linked the SUPPORT statistical model, widely regarded as one of the most accurate models for prognostication of terminallyillpatients, with the recently developed regret based decision curve analysis (regret DCA). We extend the regret DCA methodology to consider harms associated with the prognostication test as well as harms and effects of the management strategies. In order to enable patients and physicians in making these complex decisions in real-time, we developed an easily accessible web-based decision support system available at the point of care. Results The web-based decision support system facilitates the hospice referral process in three steps. First, the patient or surrogate is interviewed to elicit his/her personal preferences regarding the continuation of life-sustaining treatment vs. palliative care. Then, regret DCA is employed to identify the best strategy for the particular patient in terms of threshold probability at which he/she is indifferent between continuation of treatment and of hospice referral. Finally, if necessary, the probabilities of survival and death for the particular patient are computed based on the SUPPORT prognostication model and contrasted with the patient's threshold probability. The web-based design of the CDSS enables patients, physicians, and family members to participate in the decision process from anywhere internet access is available. Conclusions We present a theoretical framework to facilitate the hospice referral process. Further rigorous clinical evaluation including testing in a prospective randomized controlled trial is required and planned.
Assisted suicide has been an issue for terminallyillpatients for many years. This is because patients who suffer from terminalillnesses are forced to make difficult choices at the end of their lives. Currently, a terminallyillpatient has three option...
This case report offers a different perspective on a patient with a long-term non-psychotic psychiatric disorder that was difficult to specify. The patient, a man in his 50s, was unable to profit from outpatient treatment and became increasingly dependent on mental healthcare – which could not be understood based on his history and psychiatric symptoms alone. By separating symptoms from illness behaviour, the negative course of this patient's treatment is analysed. Focusing on ineffective chronic illness behaviour by the patient, and mutual ineffective treatment behaviour by the clinicians, it becomes clear that basic requirements of effective treatment were unmet. By making a proper diagnosis, clarifying expectations and offering a suitable therapy, ineffective illness behaviour was diminished and this ‘difficult’ case became much easier for both patient and clinicians. The illness behaviour framework offers a useful, systematic tool to analyse difficulties between patients and clinicians beyond psychiatric symptoms or explanations.
Most research on illness representations explores how patients view single conditions, but many patients report more than one long-term condition (known as multimorbidity). It is not known how multimorbidity impacts on patientillness representations. This exploratory qualitative study examined patients’ representations of multimorbid long-term conditions and sought to assess how models of illness representation might need modification in the presence
Peter Bower; Elaine Harkness; Wendy Macdonald; Peter Coventry; Christine Bundy; Rona Moss-Morris
The current view in intensive care medicine is that very sick patients need very intensive treatment. However, in this group of highly vulnerable patients, more intensive treatment may promote the chances of unwanted adverse effects and hence, iatrogenic damage. Therefore, we state that critically illpatients probably benefit from a more cautious approach. Using data from large clinical trials of previous years, we exemplify that less intensive treatment is associated with a better outcome in intensive care patients and suggest that we reappraise patient management as well as trial design in intensive care medicine while bearing in mind the "less is more" paradigm. We illustrate our case by describing the intensity of the most relevant treatment options for patients with septic shock, including mechanical ventilation, fluid management, blood pressure-targeted therapy, corticosteroids, patient monitoring, sedation, and nutrition. We conclude that treatment of critically illpatients while keeping in mind the "less is more" paradigm might not only benefit the patient but could also have a notable impact on the ever-increasing intensive care-related health care costs. PMID:23752755
Disturbances in fluid and electrolytes are among the most common clinical problems encountered in the intensive care unit (ICU). Recent studies have reported that fluid and electrolyte imbalances are associated with increased morbidity and mortality among critically illpatients. To provide optimal care, health care providers should be familiar with the principles and practice of fluid and electrolyte physiology and pathophysiology. Fluid resuscitation should be aimed at restoration of normal hemodynamics and tissue perfusion. Early goal-directed therapy has been shown to be effective in patients with severe sepsis or septic shock. On the other hand, liberal fluid administration is associated with adverse outcomes such as prolonged stay in the ICU, higher cost of care, and increased mortality. Development of hyponatremia in critically illpatients is associated with disturbances in the renal mechanism of urinary dilution. Removal of nonosmotic stimuli for vasopressin secretion, judicious use of hypertonic saline, and close monitoring of plasma and urine electrolytes are essential components of therapy. Hypernatremia is associated with cellular dehydration and central nervous system damage. Water deficit should be corrected with hypotonic fluid, and ongoing water loss should be taken into account. Cardiac manifestations should be identified and treated before initiating stepwise diagnostic evaluation of dyskalemias. Divalent ion deficiencies such as hypocalcemia, hypomagnesemia and hypophosphatemia should be identified and corrected, since they are associated with increased adverse events among critically illpatients.
Fluid challenges are considered the cornerstone of resuscitation in critically illpatients. However, clinical studies have demonstrated that only about 50% of hemodynamically unstable patients are volume responsive. Furthermore, increasing evidence suggests that excess fluid resuscitation is associated with increased mortality. It therefore becomes vital to assess a patient's fluid responsiveness prior to embarking on fluid loading. Static pressure (CVP, PAOP) and echocardiographic (IVC diameter, LVEDA) parameters fails to predict volume responsiveness. However, a number of dynamic echocardiographic parameters which are based on changes in vena-caval dimensions or cardiac function induce by positive pressure ventilation or passive leg raising appear to be highly predictive of volume responsiveness.
The incidence of obesity has acquired an epidemic proportion throughout the globe. As a result, increasing number of obese patients is being presented to critical care units for various indications. The attending intensivist has to face numerous challenges during management of such patients. Almost all the organ systems are affected by the impact of obesity either directly or indirectly. The degree of obesity and its prolong duration are the main factors which determine the harmful effect of obesity on human body. The present article reviews few of the important clinical and critical care concerns in critically ill obese patients.
This study explored the coping strategies of families of critically illpatients in a rural Southern Appalachian setting. A convenience sample of 30 family members of 22 critically illpatients in two rural hospitals completed the Jaloweic Coping Scale. The five most frequently used coping methods were helping, thinking positively, worrying about the problem, trying to find out more about the problem and trying to handle things one step at a time. The five most effective coping strategies were talking the problem over with friends, praying, thinking about the good things in life, trying to handle things one step at a time and trying to see the good side of the situation. Findings contradicted many of the more "negative" descriptions of Appalachian people in the literature. Similarities outweighed differences when comparing the coping styles of rural and urban populations. Findings suggest that coping strategies must be considered for positive outcomes in the delivery of care to such a rural population. PMID:11930416
Electrolyte and metabolic disturbances are common in the critically illpatient. Hyponatraemia is most frequently caused by the syndrome of inappropriate antidiuretic hormone secretion. Over-rapid correction of hyponatraemia is associated with osmotic demyelinating syndromes, and sodium rise should usually be restricted to less than 10 mmol\\/day. Hypernatraemia is caused by a loss (e.g. diabetes insipidus after head injury) or inadequate
Context: Determination of arginine vasopressin (AVP) concentra- tions may be helpful to guide therapy in critically illpatients. A new assay analyzing copeptin, a stable peptide derived from the AVP precursor, has been introduced. Objective: Our objective was to determine plasma copeptin concentrations. Design:Weconductedaposthocanalysisofplasmasamplesanddata from a prospective study. Setting:The setting was a 12-bed general and surgical intensive care unit (ICU)
Stefan Jochberger; Nils G. Morgenthaler; Viktoria D. Mayr; Gunter Luckner; Volker Wenzel; Hanno Ulmer; Siegfried Schwarz; Walter R. Hasibeder; Barbara E. Friesenecker; Martin W. Dunser
More and more evidence argues against the concept that the characteristic dysregulation of glucose homeostasis in critical\\u000a illness or “diabetes of injury” is an adaptive, benefical response in the modern intensive care era. Stress hyperglycemia\\u000a has been linked to poor outcome of the patients in several studies. Proof of a causal relationship has been provided by a\\u000a large, prospective, randomized,
Background Anemia, which is common in the critically ill, is often treated with red-cell transfu- sions, which are associated with poor clinical outcomes. We hypothesized that ther- apy with recombinant human erythropoietin (epoetin alfa) might reduce the need for red-cell transfusions. Methods In this prospective, randomized, placebo-controlled trial, we enrolled 1460 medical, surgical, or trauma patients between 48 and 96
Howard L. Corwin; Andrew Gettinger; Timothy C. Fabian; Addison May; Ronald G. Pearl; Stephen Heard; Robert An; Peter J. Bowers; Paul Burton; Mark A. Klausner; Michael J. Corwin
Introduction: Pharmacokinetic variability in critically illpatients is the result of the overlapping of multiple pathophysiological and clinical factors. Unpredictable exposure from standard dosage regimens may influence the outcome of treatment. Therefore, strategies for dosage individualisation are recommended in this setting. Areas covered: The authors focus on several approaches for dosage individualisation that have been developed, ranging from the well-established therapeutic drug monitoring (TDM) up to the innovative application of pharmacogenomics criteria. Furthermore, the authors summarise the specific population pharmacokinetic models for different drugs developed for critically illpatients to improve the initial dosage selection and the Bayesian forecasting of serum concentrations. The authors also consider the use of Monte Carlo simulation for the selection of dosage strategies. Expert opinion: Pharmacokinetic/pharmacodynamics (PK/PD) modelling and dosage individualisation methods based on mathematical and statistical criteria will contribute in improving pharmacologic treatment in critically illpatients. Moreover, substantial effort will be necessary to integrate pharmacogenomics criteria into critical care practice. The lack of availability of target biomarkers for dosage adjustment emphasizes the value of TDM which allows a large part of treatment outcome variability to be controlled. PMID:23898816
Fernández de Gatta, Ma Del Mar; Martin-Suarez, Ana; Lanao, Jose M
The present study examined the relationship between the discrepancy in chronically illpatients' perceptions of the importance and attainability of illness-related goals and their quality of life and psychological well-being. Whether self-efficacy beliefs moderated or mediated the relationship between goal discrepancy and quality of life and well-being was also examined. The sample included patients with asthma, diabetes and heart failure.
Tooth brushing in critically illpatients has been advocated by many as a standard of care despite the limited evidence to support this practice. Attention has been focused on oral care as the evidence accumulates to support an association between the bacteria in the oral microbiome and those respiratory pathogens that cause pneumonia. It is plausible to assume that respiratory pathogens originating in the oral cavity are aspirated into the lungs, causing infection. A recent study of the effects of a powered toothbrush on the incidence of ventilator-associated pneumonia was stopped early because of a lack of effect in the treatment group. This review summarizes the evidence that supports the effectiveness of tooth brushing in critically ill adults and children receiving mechanical ventilation. Possible reasons for the lack of benefit of tooth brushing demonstrated in clinical trials are discussed. Recommendations for future trials in critically illpatients are suggested. With increased emphasis being placed on oral care, the evidence that supports this intervention must be evaluated carefully. PMID:21532045
Tooth brushing in critically illpatients has been advocated by many as a standard of care despite the limited evidence to support this practice. Attention has been focused on oral care as the evidence accumulates to support an association between the bacteria in the oral microbiome and those respiratory pathogens that cause pneumonia. It is plausible to assume that respiratory pathogens originating in the oral cavity are aspirated into the lungs, causing infection. A recent study of the effects of a powered toothbrush on the incidence of ventilator-associated pneumonia was stopped early because of a lack of effect in the treatment group. This review summarizes the evidence that supports the effectiveness of tooth brushing in critically ill adults and children receiving mechanical ventilation. Possible reasons for the lack of benefit of tooth brushing demonstrated in clinical trials are discussed. Recommendations for future trials in critically illpatients are suggested. With increased emphasis being placed on oral care, the evidence that supports this intervention must be evaluated carefully.
Purpose There is little research on determinants and the grief that caregivers experience after their relatives die of cancer. This\\u000a study evaluated factors which influence complicated grief among caregivers who cared for patients who died of cancer in Taiwan.\\u000a \\u000a \\u000a \\u000a \\u000a Methods This prospective study recruited 668 caregivers who cared for terminallyill cancer patients in the hospice ward or who received\\u000a shared-care consultation.
Glomerular filtration rate (GFR) is an accepted measure for assessment of kidney function. For the critically illpatient, creatinine clearance is the method of reference for the estimation of the GFR, although this is often not measured but estimated by equations (i.e., Cockroft-Gault or MDRD) not well suited for the critically illpatient. Functional evaluation of the kidney rests in serum creatinine (Crs) that is subjected to multiple external factors, especially relevant overhydration and loss of muscle mass. The laboratory method used introduces variations in Crs, an important fact considering that small increases in Crs have serious repercussion on the prognosis of patients. Efforts directed to stratify the risk of acute kidney injury (AKI) have crystallized in the RIFLE or AKIN systems, based in sequential changes in Crs or urine flow. These systems have provided a common definition of AKI and, due to their sensitivity, have meant a considerable advantage for the clinical practice but, on the other side, have introduced an uncertainty in clinical research because of potentially overestimating AKI incidence. Another significant drawback is the unavoidable period of time needed before a patient is classified, and this is perhaps the problem to be overcome in the near future.
Seller-Perez, Gemma; Herrera-Gutierrez, Manuel E.; Maynar-Moliner, Javier; Sanchez-Izquierdo-Riera, Jose A.; do Pico, Jose Luis
Although providing spiritual support to patients has received growing attention in the nursing and medical literature, little has been written about how to screen new patients to determine whether a more in-depth spiritual assessment is in order. In many hospitals, newly admitted patients are simply asked whether they are affiliated with a specific religious denomination. This question alone provides little insight into potential spiritual needs that may require attention. Questions that inquire about patients' religious practices and the importance of religion in their lives may be more useful as screening questions to identify the need for a more detailed spiritual assessment. As a part of a longitudinal study on decision control preferences in terminalillness, data were collected on enrollment about religious practices and the importance of religion in a group of subjects recently diagnosed with a life-threatening illness. This study examines cross-sectionally the relationship between religious practices, importance of religion, and demographic variables. Recommendations are presented on how health professionals can use the responses to these questions to determine the need for further spiritual assessment and intervention. PMID:12931334
Kub, Joan E; Nolan, Marie T; Hughes, Mark T; Terry, Peter B; Sulmasy, Daniel P; Astrow, Alan; Forman, Jane H
Maintaining adequate oxygenation to promote vital organ functions represents a common challenge for the critical care nurse. Critically illpatients with impaired cardiac function may be particularly vulnerable to tissue oxygen deprivation because they have limited ability to increase oxygen delivery when oxygen demands increase. Consequently, routine nursing procedures that increase oxygen requirements may have adverse effects on tissue oxygenation. Interventions that enhance patient tolerance to nursing procedures by supporting the balance between oxygen supply and demand promote physiologic adaptation and may prevent complications associated with hypoxia such as cardiac dysrhythmias, hypotension, and cardiac arrest. This discussion will focus on the principles of tissue oxygenation, the effects of nursing interventions on oxygen demand, and interventions that may enhance patient tolerance to routine nursing interventions. PMID:9200016
We reviewed the charts of 25 patients who underwent powered intraosseous line insertion between July 1, 2008 and August 31, 2010 to determine its users, indications, procedural details, success rates, and complications. Intraosseous (IO) line was inserted in the anteromedial aspect of the proximal tibia in all patients. The first attempt was successful in 80%, and the median duration for insertion of the IO line was 4 hours. Extravasation was the most common complication. Ninety-six percent of the physicians had undergone prior training in IO insertion. Because of its high success and short procedure time, IO access should be the first alternative to failed vascular access in critically ill children. Training in IO should be extended to all who care for pediatric patients in inpatient as well as in prehospital and emergency department settings. PMID:23502657
Echocardiography has shown to be an essential diagnostic tool in the critically illpatient'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.
Romero-Bermejo, Francisco J; Ruiz-Bailen, Manuel; Guerrero-De-Mier, Manuel; Lopez-Alvaro, Julian
Blood glucose control aiming at normoglycemia, frequently referred to as "strict glycemic control", decreases mortality and morbidity of critically illpatients. We searched the medical literature for export opinions, surveys, and clinical reports on blood glucose control in intensive care medicine. While strict glycemic control has been recommended standard of care for critically illpatients, the risk of severe hypoglycemia with strict glycemic control is frequently mentioned by experts. Some rationalize this risk, though others strongly point out the high incidence of hypoglycemia to be (one) reason not to perform strict glycemic control. Implementation of strict glycemic control is far from complete in intensive care units across the world. Frequently local guidelines accept higher blood glucose levels than those with strict glycemic control. Only a minority of retrieved manuscripts are on blood glucose regimens with the lower targets as with strict glycemic control. Hypoglycemia certainly is encountered with blood glucose control, in particular with strict glycemic control. Reports show intensive care-nurses can adequately and safely perform strict glycemic control. Implementation of strict glycemic control is far from complete, at least in part because of the feared risks of hypoglycemia. The preference for hyperglycemia over intermittent hypoglycemia is irrational, however, because there is causal evidence of harm for the former but only associative evidence of harm for the latter. For several reasons it is wise to have strict glycemic control being a nurse-based strategy. PMID:18971884
Schultz, Marcus J; de Graaff, Mart J; Royakkers, Annic A N M; van Braam Houckgeest, Floris; van der Sluijs, Johannes P; Kieft, Hans; Spronk, Peter E
Critical illness is characterised by catabolism of the skeletal muscle that releases amino acids for protein synthesis to support tissue repair, immune defence and inflammatory and acute-phase responses. Protein requirements for these patients have generally been based on levels that result in the lowest catabolic rates or most favourable nitrogen balance. The definition of these levels, in particular, in relation to indexing to a measure of patient weight or lean body mass, is controversial. Furthermore, optimal nitrogen balance may not necessarily equate to best clinical outcome. There is some evidence that administration of specific amino acids may be advantageous at least during the early or most catabolic phases of illness, in order to support the specific amino acid requirements of the metabolic pathways activated by the injury or infection. Current widely used guidelines differ in the protein prescription they recommend and in the timing of administration in relation to intensive care admission. A pressing need exists for well-designed randomised trials that compare differing levels of protein or amino acid provision, and the timing of this provision, for their effects on clinical endpoints. PMID:23403870
Despite converging evidence that major depressive illness is associated with both memory impairment and hippocampal pathology, findings vary widely across studies and it is not known whether these changes are regionally specific. In the present study we acquired brain MRIs (magnetic resonance images) from 31 unmedicated patients with MDD (major depressive disorder; mean age 39.2±11.9 years; 77% female) and 31 demographically comparable controls. Three-dimensional parametric mesh models were created to examine localized alterations of hippocampal morphology. Although global volumes did not differ between groups, statistical mapping results revealed that in MDD patients, more severe depressive symptoms were associated with greater left hippocampal atrophy, particularly in CA1 (cornu ammonis 1) subfields and the subiculum. However, previous treatment with atypical antipsychotics was associated with a trend towards larger left hippocampal volume. Our findings suggest effects of illness severity on hippocampal size, as well as a possible effect of past history of atypical antipsychotic treatment, which may reflect prolonged neuroprotective effects. This possibility awaits confirmation in longitudinal studies.
Bearden, Carrie E; Thompson, Paul M; Avedissian, Christina; Klunder, Andrea D; Nicoletti, Mark; Dierschke, Nicole; Brambilla, Paolo; Soares, Jair C
Growing evidence suggests that glycaemic variability increases diabetic complications. However, the significance of glycaemic variability in critically illpatients remains unclear. We evaluated the predictors of glycaemic fluctuation and its association with critical care outcomes. This is a nested-cohort study within a clinical trial in which 523 patients at a medical surgical intensive care unit were randomised to either intensive insulin therapy (target glycaemic control: 4.4 to 6.1 mmol/l) or conventional insulin therapy (target control: 10.0 to 11.1 mmol/l). Glycaemic fluctuation was defined as the mean difference between the highest and lowest daily blood glucose. Patients were divided into wide and narrow fluctuation groups according to the median glycaemic fluctuation (6.0 mmol/l). The association between glycaemic fluctuation and different intensive care unit outcomes was studied. Predictors of glycaemic fluctuation were age (odds ratio for each year increment 1.03, 95% confidence interval 1.02 to 1.05), diabetes mellitus (odds ratio 3.00, 95% confidence interval 1.74 to 5.17), and daily insulin dose (odds ratio for each unit increment 1.04, 95% confidence interval 1.03 to 1.05). Similar levels of glucose fluctuation were observed in intensive insulin therapy and conventional insulin therapy patients. Wide glycaemic fluctuation was associated with higher mortality (22.2 vs. 8.4%, P < 0.001). Glycaemic fluctuation was identified as an independent predictor of intensive care unit mortality (odds ratio per mmol 1.08, 95% confidence interval 1.00 to 1.18) and hospital mortality (odds ratio per mmol 1.09, 95% confidence interval 1.02 to 1.17) using multivariate logistic regression analysis. In conclusion, wide glycaemic fluctuation is an independent predictor of mortality in critically illpatients. Whether reducing glycaemic fluctuation would lead to better outcomes needs further evaluation. PMID:20715734
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.
Acutely illpatients received tube feeding for an average of 15.8 days and, on average, 35% of those days were spent in the intensive care unit (ICU). Patients were prospectively assigned either a fiber-free formula (FFF-OSMOLITE HN, Ross; n = 50) or a fiber-supplemented (soy polysaccharide 14.4 g/L) formula (FSF = JEVITY, Ross; n = 50). Diarrhea was defined as three or more loose or watery stools per day and occurred in 30% of all patients. Diarrhea developed in 29 (41%) of the 71 patients who received antibiotics during, or within 2 weeks prior to, the feeding period, whereas only 1 (3%) of the 29 patients not receiving antibiotics developed diarrhea (p less than 0.005); and this patient developed diarrhea on the day of death. Among the 30 patients with diarrhea, stool Clostridium difficile (CD) toxin was positive in 15 (50%), negative in 11 (37%), and was not measured in four. The mean serum albumin was significantly lower in patients with diarrhea (2.43) than in those without diarrhea (2.75) (p = 0.043). There were no significant differences in age, sex, diagnoses, number of feeding days, and percent ICU days between patients with and without diarrhea. While not statistically significant, patients who received FSF were observed to have a lower incidence of diarrhea, a lower percentage of diarrhea days per total feeding days, and a lower frequency of positive CD toxin assays than patients who received FFF. In this patient population, antibiotic usage was the factor most strongly associated with diarrhea during tube feedings. PMID:1650854
Guenter, P A; Settle, R G; Perlmutter, S; Marino, P L; DeSimone, G A; Rolandelli, R H
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 ICU’s at two separate hospitals at a large tertiary care academic medical center between 2004–2006. 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 3–57) and 26 days (range 9–56), respectively. By logistic regression, CMV infection at any level (adjusted OR: 4.3 [1.6–11.9], p = 0.005), >1,000 copies/ml (adjusted OR 13.9 [3.2–60], p < 0.001), or average CMV area under the curve [AUC] (adjusted OR 2.1 [1.3–3.2], 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 (2.9–9.1) p < 0.0001) and CMV AUC (OR 3.2 (2.1–4.7), 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.
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
This study sought to determine the effectiveness of an education program on nurses' attitudes toward caring for terminallyill persons and their family members. The program, based on the hospice concept of care, included a didactic section based on Kubler-Ross' stages of death and dying, and a role-play model designed by the researcher. Data were collected from 34 licensed nurses, aged 18 to 65, practicing in the midwestern United States. The Frommelt Attitude Toward Care of the Dying Scale (FATCOD) was designed by the researcher to assess nurses' attitudes. The FATCOD was found to be a valid and reliable tool. All nurses completed the tool before and after the education program (pre-test, post-test). Compared by a t-test, the scores for the nurses were significantly higher after participation in the educational program. The t-value was found to be 2.97, significant at the less than 0.01 level, 2-tailed probability = 0.006. These findings support the hypothesis that nurses have a more positive attitude toward caring for terminallyill persons and their family members after participation in the program, than the same nurses had before participating in the program. Demographic information including age, years of experience in nursing, highest degree held, basic type of nursing preparation and previous education on death and dying were analyzed to determine their relationship to the nurses' attitudes. The only information which demonstrated any significant relationship to the nurses' attitudes was that of previous education on death and dying. These were computed by an analysis of variance (ANOVA) F = 3.22, F prob = 0.04, significant at less than 0.05 level.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:1742142
Background: In earlier work, it was shown that patients with septic shock who also have adrenal insufficiency experience a benefit in terms of lower mortality rates with hydrocortisone supplementation. As such, the adrenocorticotropic hormone (ACTH) stimulation test has been used frequently to identify these patients. However, recent evidence has suggested that the identification and treatment of adrenal insufficiency in patients with septic shock does not reduce mortality. These results call into question the utility of the ACTH stimulation test in this patient population. Objectives: To determine the indications for ordering the ACTH stimulation test for critically illpatients at a tertiary care hospital and to classify the indications as either appropriate (e.g., primary adrenal insufficiency or medication-induced suppression of the hypothalamus–pituitary–adrenal axis) or inappropriate (e.g., patients with septic shock, prior etomidate exposure, or absence of steroid use). Methods: A retrospective analysis of health care records was conducted for all patients who had been admitted to the intensive care unit and who had undergone an ACTH stimulation test during 2007. For each patient, the indication for the test was identified and classified as appropriate or inappropriate. Results: A total of 35 ACTH stimulation tests were performed during the study period, of which 8 (23%) were classified as having an appropriate indication and 27 (77%) as having an inappropriate indication. Of the tests with an inappropriate indication, 15 (56%) were ordered for patients with septic shock. However, the number of ACTH tests ordered for this indication declined as the year progressed. Conclusions: The ACTH stimulation test was often used inappropriately for patients with septic shock. Over time, there appeared to be a trend away from use of this test in this patient population, perhaps reflecting increasing awareness of the lack of benefit.
If the employment has terminated and the performance capacity of the employee is no longer up to demands made by his last job, the second consideration in respect of his disablement concerns the following points: similar work to be performed within the narrow framework of his former in case of compensation payment because of unemployment: activities within the framework of jobs he can be judged to perform, as laid down by German labour legislation in respect of compensation payments to the unemployed. The compulsory sickness body will have to clarify by expertising which activities can be considered as yardsticks from a medical point of view. PMID:8268702
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 (VO2) and carbon dioxide production (VCO2) (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, VO2, or VCO2 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 VO2 and VCO2, 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 (VO2, VCO2) or glucose response.
Briassoulis, George; Venkataraman, Shekhar; Thompson, Ann
The caloric requirement of the critically ill septic patient was determined by measuring body composition, by multiple isotope dilution, before and at 2-wk intervals while receiving total parenteral nutrition (TPN) in 86 septic and 57 nonseptic malnourished patients. All patients received a TPN solution containing 25% dextrose and 2.75% crystalline amino acids. The body composition of the nonseptic patients, who received 51.9 +/- 1.5 kcal/kg.day, improved significantly, while that of the septic patients, receiving 46.8 +/- 1.1 kcal/kg.day was only maintained. The relationship between caloric intake and the restoration of a malnourished body cell mass (BCM) was determined for each group by correlating, using multiple linear regression, the mean daily change in the BCM with the caloric intake and the nutritional state, as determined by body composition. According to the resultant regressions, an intake of 35.1 and 50.7 kcal/kg.day was required to maintain the BCM of the septic and nonseptic patients, respectively. To restore a depleted BCM, caloric intakes in excess of this amount are required.
Objective The organizational structure of health care facilities has been shown to affect outcome in critically illpatients. We evaluated the association between structures, treatments and outcomes in a large cohort of critically illpatients. Design Prospective multicentre cohort study. Patients and setting A total of 26,186 patients consecutively admitted to 31 intensive care units (ICUs) in Austria from January
Philipp G. H. Metnitz; Ana Reiter; Barbara Jordan; Thomas Lang
Air hunger at end-of-life poses challenges to providers who attempt to comfort while not diminishing mental capacities. We examined the presence, methods of assessment, and treatment of air hunger. This observational study prospectively screened 198 consecutive medicine admissions for increased risk of near-term death. These patients in turn were screened for dyspnea. Patients screening positive were assessed on admission and the next day with the Visual Analog Scale (VAS), modified Borg Scale, and the American Thoracic Society (ATS) Shortness of Breath Scale. Additionally, resident physician opinions of patient dyspnea level were assessed using the same tools. Treatments focused on alleviating air hunger were recorded. Thirty-nine percent of patients were at risk for near-term death and of these, 53% (95% CI: 41-65%) reported air hunger. All dyspnea scales improved to a statistically and clinically significant degree (Borg p=0.007, VAS p<0.0005, ATS p=0.008). There was statistically significant agreement between Borg-VAS and between Borg-ATS with a trend toward significance with ATS-VAS. Physician assessment of dyspnea showed poor agreement with patients. A median of three treatments were received by patients but dyspnea improvement did not correlate with the type, number, or specific combination of therapies. Dyspnea is common near end-of-life. Borg or VAS scales appear useful in assessing terminal dyspnea and can be employed in assessing terminal air hunger. No individual treatment or combination of treatments significantly improved patients' dyspnea. However, air hunger significantly improved with hospitalization. PMID:17935962
Shumway, Nathan M; Wilson, Ramey L; Howard, Robin S; Parker, Joseph M; Eliasson, Arn H
Objective To date, there is no systematic analysis of mental health laws and their implementation across the People’s Republic of China. This article aims to describe and analyze current legal frameworks for voluntary and involuntary admissions of mentally illpatients in the five cities of China that currently have municipal mental health regulations. Methods Information on the legislation and practice of involuntary admission in the five cities was gathered and assessed using the “WHO Checklist on Mental Health Legislation.” The checklist was completed for each city by a group of psychiatrists trained in mental health legislation. Results Although the mental health regulations in these five cities cover the basic principles needed to meet international standards of mental health legislation, some defects in the legislation remain. In particular, these regulations lack detail in specifying procedures for dealing with admission and treatment and lack oversight and review mechanisms and procedures for appeal of involuntary admission and treatment. Conclusions A more comprehensive and enforceable national mental health act is needed in order to ensure the rights of persons suffering mental illness in terms of admission and treatment procedures. In addition, more research is needed to understand how the current municipal regulations of mental health services in these cities are implemented in routine practice.
Shao, Yang; Xie, Bin; Good, Mary-Jo DelVecchio; Good, Byron J.
Although noninvasive ventilation (NIV) use in severe acute exacerbation of COPD has substantially reduced the need for intubation, an important number of COPD patients still are mechanically ventilated through a tracheal tube in the ICU. Intubation is a major risk factor for lower respiratory tract colonization (LRTC) in ICU patients. Other risk factors for LRTC include colonization of the oral cavity, nasopharynx, and gastric content. Aspiration of contaminated oropharyngeal secretions is increased by supine position, underinflation of tracheal cuff, coma, and sedation. Tracheal tube biofilm formation plays an important role as a reservoir for microorganisms. Reduced cough reflex, altered mucocilliary clearance, hypersecretion and retention of mucus are frequent in COPD patients. In addition, malnutrition and corticosteroid use are common in this population resulting in altered cellular, and humoral immunity and higher risk for LRTC. Incidence of LRTC varies from 22-95% of intubated patients. Pseudomonas aeruginosa is the most frequently isolated microorganism at day 3 after intubation in COPD patients. LRTC is a major risk factor for ventilator-associated pneumonia, which is associated with increased mortality and morbidity in ICU patients. Several measures could be suggested to reduce LRTC in critically ill COPD patients. NIV use in severe acute exacerbations reduces the need for intubation. In addition, the early use of NIV averts respiratory failure after extubation and could reduce the duration of invasive mechanical ventilation. Other measures might be efficient in preventing LRTC such as semirecumbent position, avoidance of gastric distension, polyurethane-cuffed tracheal tubes, silver-coated tracheal tubes, subglottic aspiration, and continuous control of cuff pressure. Further studies should determine the impact of preventive measures aiming at preventing LRTC on outcome of COPD patients requiring intubation and mechanical ventilation in the ICU. PMID:21194404
This study examined associations between illness representation dimensions specified by the self-regulation model, coping and mood in recently diagnosed gynaecological cancer patients. Participants were 61 patients recruited from a specialist outpatient gynaecology clinic. Patients completed a survey measuring their cognitive illness representations (IPQ-R), coping strategies (COPE) and mood (POMS-SF). Consistent with research into other illnesses, the study found theoretically congruent
The objective of this study was to assess the utility of bioelectrical impedance analysis (BIA) in determining nutritional status in critically illpatients in the intensive care unit (ICU). Data were collected prospectively in 33 mechanically ventilated medical and surgical ICU patients requiring nutrition as part of their care. BIA, with subsequent calculation of body-composition indexes, was performed every other day for the duration of ICU stay. Body cell mass (BCM) changes correlated with energy and protein intakes (r2 = 0.87, P < 0.001 and r2 = 0.67, P < 0.001, respectively). Maintenance of BCM was achieved by a daily provision of 125.5 kJ.kg-1.d-1 (30 kcal.kg-1.d-1) and 1.5 g protein/kg whereas greater intakes allowed restoration of BCM. The mean ratios of exchangeable sodium to potassium (Nae:Ke) improved only in patients achieving positive nitrogen balance (P = 0.013). Body-composition changes determined by BIA represent a feasible adjunctive method for evaluating and monitoring nutritional status in ICU patients. PMID:8503350
Robert, S; Zarowitz, B J; Hyzy, R; Eichenhorn, M; Peterson, E L; Popovich, J
OBJECTIVE: To determine the relationship between enteral nutrition discontinuation and outcome in general critically illpatients. MATERIALS AND METHODS: All patients admitted to a mixed intensive care unit in a tertiary care hospital from May-August 2009 were screened for an indication for enteral nutrition. Patients were followed up until leaving the intensive care unit or a maximum of 28 days. The gastrointestinal failure score was calculated daily by adding values of 0 if the enteral nutrition received was identical to the nutrition prescribed, 1 if the enteral nutrition received was at least 75% of that prescribed, 2 if the enteral nutrition received was between 50-75% of that prescribed, 3 if the enteral nutrition received was between 50-25% of that prescribed, and 4 if the enteral nutrition received was less than 25% of that prescribed. RESULTS: The mean, worst, and categorical gastrointestinal failure scores were associated with lower survival in these patients. Age, categorical gastrointestinal failure score, type of admission, need for mechanical ventilation, sequential organ failure assessment, and Acute Physiologic and Chronic Health Evaluation II scores were selected for analysis with binary regression. In both models, the categorical gastrointestinal failure score was related to mortality. CONCLUSION: The determination of the difference between prescribed and received enteral nutrition seemed to be a useful prognostic marker and is feasible to be incorporated into a gastrointestinal failure score.
Silva, Marco Antonio; da Graca Freitas dos Santos, Saionara; Tomasi, Cristiane Damiani; da Luz, Gabrielle; da Silva Paula, Marcos Marques; Pizzol, Felipe Dal; Ritter, Cristiane
Objective Intensive insulin therapy is associated with the risk of hypoglycemia and increased costs of material and personnel. We therefore evaluated the safety and efficiency of a computer-assisted glucose control protocol in a large population of critically illpatients. Design and setting Observational cohort study in three intensive care units (32 beds) in a 1,300-bed university teaching hospital. Patients All 2,800 patients admitted to the surgical, neurosurgical, and cardiothoracic units; the study period started at each ICU after implementation of Glucose Regulation for Intensive Care Patients (GRIP), a freely available computer-assisted glucose control protocol. Measurements and results We analysed compliance in relation to recommended insulin pump rates and glucose measurement frequency. Patients were on GRIP-ordered pump rates 97% of time. Median measurement time was 5?min late (IQR 20?min early to 34?min late). Hypoglycemia was uncommon (7% of patients for mild hypoglycemia, 3.5?mmol/l; 0.86% for severe hypoglycemia, 2.2?mmol/l). Our predefined target range (4.0–7.5?mmol/l) was reached after a median of 5.6?h (IQR 0.2–11.8) and maintained for 89% (70–100%) of the remaining stay at the ICU. The number of measurements needed was 5.9 (4.8–7.3) per patient per day. In-hospital mortality was 10.1%. Conclusions Our computer-assisted glucose control protocol provides safe and efficient glucose regulation in routine intensive care practice. A low rate of hypoglycemic episodes was achieved with a considerably lower number of glucose measurements than used in most other schemes. Electronic supplementary material The online version of this article (doi:10.1007/s00134-008-1091-y) contains supplementary material, which is available to authorized users.
Loef, Bert G.; Regtien, Joost G.; van der Horst, Iwan C. C.; van Assen, Hein; Zijlstra, Felix; Nijsten, Maarten W. N.
This study aimed to better understand the meaning of desire for euthanasia. An hermeneutic approach was undertaken using a purposively selected sample of advanced cancer patients who desired euthanasia while receiving palliative care. Unstructured interviews were conducted with six participants, which were audiotaped, transcribed and analysed. This approach allowed in-depth exploration and interpretation of the patients' lived experience. The findings illustrated a timeline from previous wellness to approaching death with five major themes: (1) reality, (2) perception, (3) anticipation, (4) desire and (5) holding environment. The desire for euthanasia is not confined to physical or psychosocial concerns relating to advanced cancer, but incorporates hidden existential yearnings for connectedness, care and respect, understood within the context of the patients' lived experience. Euthanasia requests cannot be taken at face value but require in-depth exploration of their covert meaning, in order to ensure that the patients' needs are being addressed adequately. PMID:15984507
BACKGROUND: This study was designed to evaluate the use of laxative prophylaxis for constipation in intensive care unit (ICU) and the impact of early versus late bowel movement on patient’s outcome. METHODS: The study was a prospective, randomized controlled trial in critically ill ventilated adult patients, who were expected to stay on ventilator for >72 h. Control group did not receive any intervention for bowel movement for the first 72 h, whereas interventional group received prophylactic dose of lactulose 20 cc enterally every 12 h for the first 72 h. The parameters measured during the study were admission diagnosis, age, gender, comorbid conditions, admission Simplified Acute Physiologic Score (SAPS II), sedative and narcotic agents with doses and duration, timing and tolerance of nutrition, daily assessment of bowel movement, total use of prokinetic, doses of suppositories, and enema for first bowel movement, total number of days on ventilator, weaning failures, extubation or tracheostomy, ICU length of stay, and death or discharge. RESULTS: A total of 100 patients were enrolled, 50 patients in each control and interventional group. Mean age was 38.8 years, and both groups had male predominance. Mean SAPS II score for both was 35. Mean dose of Fentanyl (323.8 ± 108.89 mcg/h in control and 345.83 ± 94.43 mcg/h in interventional group) and mean dose of Midazolam (11.1 ± 4.04 mg/h in control and 12.4 ± 3.19 mg/h in interventional group). There were only two (4%) patients in control, while nine (18%) patients in interventional group who had bowel movement in <72 h (P < 0.05). Mean ventilator days were 16.19, and 17.36 days in control and interventional groups, respectively. Subgroup analysis showed that the patients who moved bowel in <5 days in both groups had mean ventilator days of 18.5, whereas it was 15.88 days for the patients who moved bowel after 5 days in both groups (P< 0.05). Mean ICU days for control was 21.15 ± 10.44 and 20.77 ± 8.33 days for interventional group. Forty-eight (96%) patients in each group were discharged from the ICU. Two (4%) patients died in ICU in each group. CONCLUSIONS: Laxative prophylaxis can be used successfully to prevent constipation in ICU patients. Late bowel movement >5 days is associated with less ventilator days, compared to early <5 days bowel movement.
INTRODUCTION: Our goal was to describe the epidemiology, clinical profiles, outcomes, and factors that might predict progression of critically illpatients to chronically critically ill (CCI) patients, a still poorly characterized subgroup. METHODS: We prospectively studied all patients admitted to a university-affiliated hospital intensive care unit (ICU) between 1 July 2002 and 30 June 2005. On admission, we recorded epidemiological
Elisa Estenssoro; Rosa Reina; Héctor S Canales; María Gabriela Saenz; Francisco E Gonzalez; María M Aprea; Enrique Laffaire; Victor Gola; Arnaldo Dubin
In patients receiving long-term therapeutic or replacement corticosteroids, delayed or inappropriate adjustment of steroid dosage during intercurrent illness may be fatal. We used a questionnaire to assess current levels of patient knowledge, awareness of the need for action during intercurrent illness and the frequency with which steroid warning cards and Medic Alert pendants were carried, in 61 patients on long-term
S. R. Peacey; R. M. Pope; K. S. Naik; R. D. Hardern; M. D. Page; P. E. Belchetz
Assessing pain in critically illpatients, particularly in nonverbal patients, is a great challenge. In this study, we validated a behavioral pain scale (BPS) in critically ill, sedated, and mechanically ventilated patients. The BPS score was the sum of 3 subscales that have a range score of 1-4: facial expression, upper limb movements, and compliance with mechanical ventilation. Two as-
Amine Ali Zeggwagh; Khalid Abidi; Redouane Abouqal
Anaemia is a common finding in critically illpatients. There are often multiple causes. Obvious causes include surgical bleeding and gastrointestinal haemorrhage but many patients have no overt bleeding episodes. Phlebotomy can be a significant source of blood loss. In addition, critically illpatients have impaired erythropoiesis as a consequence of blunted erythropoietin production and direct inhibitory effects of inflammatory
BACKGROUND: Pain in critically illpatients in the intensive care unit (ICU) is common. However, pain assessment in critically illpatients often is complicated because these patients are unable to communicate effectively. Therefore, we designed a study (a) to determine the inter-rater reliability of the Numerical Rating Scale (NRS) and the Behavioral Pain Scale (BPS), (b) to compare pain scores
Sabine JGM Ahlers; Laura van Gulik; Aletta M van der Veen; Hendricus PA van Dongen; Peter Bruins; Svetlana V Belitser; Anthonius de Boer; Dick Tibboel; Catherijne AJ Knibbe
Purpose:Reversible myocardial dysfunction or myocardial stunning is frequently described in patients with episodes of acute coronary syndrome and has recently been reported in critically illpatients without ischaemic heart disease. This article presents a study and description of the possible existence of myocardial dysfunction in critically illpatients in our setting who present no acute episode or history of cardiovascular
Manuel Ruiz Bailén; Eduardo Aguayo de Hoyos; Asunción López Mart??nez; Miguel Ángel D??az Castellanos; Silvia Ruiz Navarro; Luis Javier Fierro Rosón; Francisco Javier Gómez Jiménez; Ziad Issa-Masad Khozouz
|These guidelines are intended to assist states and local communities in developing quality respite services that meet the diverse needs of families and children with disabilities, with chronic and terminalillnesses, or at risk of abuse or neglect. The guidelines support the philosophy that all families can benefit from temporary intervals of…
Glucose management in patients with burn injury is often difficult because of their hypermetabolic state with associated hyperglycemia, hyperinsulinemia, and insulin resistance. Recent studies suggest that time to glycemic control is associated with improved outcomes. The authors sought to determine the influence of early glycemic control on the outcomes of critically illpatients with burn injury. A retrospective analysis was performed at the Ohio State University Medical Center. Patients hospitalized with burn injury were enrolled if they were admitted to the intensive care unit between March 1, 2006, and February 28, 2009. Early glycemic control was defined as the achievement of a mean daily blood glucose of ?150 mg/dl for at least two consecutive days by postburn day 3. Forty-six patients made up the study cohort with 26 achieving early glycemic control and 20 who did not. The two groups were similar at baseline with regard to age, pre-existing diabetes, APACHE II score and burn size and depth. There were no differences in number of surgical interventions, infectious complications, or length of stay between patients who achieved or failed early glycemic control. Failure of early glycemic control was, however, associated with significantly higher mortality both by univariate (35.0 vs 7.7%, P = .03) and multivariate analyses (hazard ratio 6.754 [1.16-39.24], P = .03) adjusting for age, TBSA, and inhalation injury. Failure to achieve early glycemic control in patients with burn injury is associated with an increased risk of mortality. However, further prospective controlled trials are needed to establish causality of this association. PMID:21841493
Murphy, Claire V; Coffey, Rebecca; Cook, Charles H; Gerlach, Anthony T; Miller, Sidney F
|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…
Hanson, Mark D.; Johnson, Samantha; Niec, Anne; Pietrantonio, Anna Marie; High, Bradley; MacMillan, Harriet; Eva, Kevin W.
Culturally competent nursing care regarding the ethical dilemma of terminal dehydration (withholding or withdrawing food and fluid) for the Jewish hospice patient involves applying the ethical principles of justice, autonomy, beneficence, and nonmaleficence to nursing interventions by identifying outcomes that focus on the high value Jews place on life; avoiding stereotyping as to what it means to be Jewish; knowledge
The aim of the present study was to investigate the psychobiological personality dimensions in two subgroups of patients with environmental illness (EI). Fifty-nine patients, 34 women and 25 men (aged 32-69 years), were referred for symptoms allegedly caused by abnormal sensitivity to either dental fillings (DF; n=26) or electromagnetic fields (EMF; n=33). For the evaluation of personality, the Swedish 238-item version of the Temperament and Character Inventory (TCI) was used. Compared with a control group, the EMF group scored higher on the temperament dimension Persistence. The DF group scored higher on the TCI subscales Harm Avoidance (fatigability and asthenia) and Self-Directedness (self-acceptance). Women scored higher than men did on the Novelty Seeking and Reward Dependence (RD) dimensions in the DF group and on RD in the control group, indicating an inherited gender difference. No differences were found between men and women in the EMF group. Our results indicate that the high level of persistence found in the EMF group and the high level of fatigability and asthenia in combination with high self-acceptance found in the DF group represent vulnerable personalities. No significant differences were found between the two patient groups, indicating that these groups are quite similar regarding personality. This vulnerability can be expressed as various mental and somatic symptoms, which can be interpreted as EI symptoms by the affected individual. PMID:16215748
BackgroundTotal plasma homocysteine (tHcy) concentration is elevated in elderly patients with mental illness, and patients with vascular disease have higher plasma tHcy concentration than patients without vascular disease.
This is the account of a mother who lived through the 5-year experience of watching her child fight and finally succumb to a genetic disorder. Lessons about caring practices and insights into the needs of patients and families are emphasized. PMID:23399711
Background Various malfunctions involving working memory, semantics, prediction error, and dopamine neuromodulation have been hypothesized to cause disorganized speech and delusions in schizophrenia. Computational models may provide insights into why some mechanisms are unlikely, suggest alternative mechanisms, and tie together explanations of seemingly disparate symptoms and experimental findings. Methods Eight corresponding illness mechanisms were simulated in DISCERN, an artificial neural network model of narrative understanding and recall. For this study, DISCERN learned sets of “autobiographical” and “impersonal” crime stories with associated emotion-coding. In addition, 20 healthy controls and 37 patients with schizophrenia or schizoaffective disorder matched for age, gender and parental education were studied using a delayed story-recall task. A goodness-of-fit analysis was performed to determine the mechanism best reproducing narrative breakdown profiles generated by healthy controls and patients with schizophrenia. Evidence of delusion-like narratives was sought in simulations best matching the narrative breakdown profile of patients. Results All mechanisms were equivalent in matching the narrative breakdown profile of healthy controls. However, exaggerated prediction-error signaling during consolidation of episodic memories, termed hyperlearning, was statistically superior to other mechanisms in matching the narrative breakdown profile of patients. These simulations also systematically confused “autobiographical” agents with “impersonal” crime story agents to model fixed, self-referential delusions. Conclusions Findings suggest that exaggerated prediction-error signaling in schizophrenia intermingles and corrupts narrative memories when incorporated into long-term storage, thereby disrupting narrative language and producing fixed delusional narratives. If further validated by clinical studies, these computational patients could provide a platform for developing and testing novel treatments.
Hoffman, Ralph E.; Grasemann, Uli; Gueorguieva, Ralitza; Quinlan, Donald; Lane, Douglas; Miikkulainen, Risto
Purpose The purpose of this study is to evaluate the prescription of essential or futile medications for terminal cancer patients during their final admission. Materials and Methods We conducted a retrospective review of the medical charts of terminallyill cancer patients admitted to the Hemato-oncology Department of two teaching hospitals from March 1, 2007 to December 31, 2009. Essential medications were based on the drugs listed by the International Association for Hospice and Palliative Care, while futile medications were defined when short-term benefit to patients with respect to survival, quality of life, or symptom control was not anticipated. Results A total of 196 patients were included. Among essential medications, strong opioids were the most frequently prescribed drugs during the last admission (62.2% fentanyl, 44.3% morphine), followed by megestrol (46.0%), and metoclopramide (37.2%); 51% of gastric protectors were prescribed with potential futility. Anti-hypertensive and antiglycemic agents were administered to those who experienced arterial blood pressure below 90 mm Hg (47.3%) or presented with a single measurement of fasting glucose below 50 mg/dL (10.7%), respectively. Statins were prescribed to 6.1% (12/196) of patients, and 75% of those prescriptions were regarded as futile. Conclusion Our data suggest that effective prescription of essential medications and withdrawal from futile medications should be actively reconciled for improvement of a patient's end-of-life care.
We studied changes in cardio-respiratory synchronization and dynamics of cardiovascular system during transition from mechanical ventilation to spontaneous respiration in critically illpatients. 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.
The illness behavior of patients with medically unexplained physical symptoms (MUS) depends largely on what the patient believes to be the cause of the symptoms. Little data are available on the illness attributions of patients with MUS in China. This cross-sectional study investigated the illness attributions of 96 patients with MUS in the outpatient departments of Psychosomatic Medicine, biomedicine (Neurology, Gynecology), and Traditional Chinese Medicine in Shanghai. Patients completed the Illness Perception Questionnaire (IPQ) for illness attribution, the Screening Questionnaire for Somatoform Symptoms, the Hospital Anxiety and Depression Scale for emotional distress, and questionnaires on clinical and sociodemographic data. The physicians also filled out a questionnaire regarding the cause of the illness (IPQ). In contrast to previous research, both physicians and patients from all three areas of medicine most frequently reported "psychological attributions." The concordance between the physicians' and the patients' illness attributions was low. Emotional distress was an important predictor of psychological attributions. Further research should include large-scale studies among patients from different regions of China and qualitative studies to deepen our understanding of cultural influences on illness attribution. PMID:23264572
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 illpatient.
The aim of monitoring patients is to detect organ dysfunction and guide the restoration and maintenance of tissue oxygen delivery. Monitoring is a crucial part of the care of the critically illpatient in the emergency department as the physiological response to critical illness is linked strongly to outcome. As it is important to appreciate the limitations of monitoring systems
The aim of this study was to examine the effects of illness acceptance on the subjective health of hospitalized chronic medical patients. Participants were 128 patients with a previous diagnosis of chronic coronary artery disease, cancer, or chronic renal disease, who were admitted to a public hospital. Illness acceptance was associated with higher levels of subjective health. It was negatively
Evangelos C. Karademas; Aggeliki Tsagaraki; Nikoleta Lambrou
More than 100 million Americans are currently living with at least one chronic health condition and expenditures on chronic diseases account for more than 75 percent of the $2.3 trillion cost of our healthcare system. To improve chronic illness care, patients must be empowered and engaged in health self-management. However, only half of all patients with chronic illness comply with
Guanling Chen; Bo Yan; Minho Shin; David Kotz; Ethan Berkel
Although trends in health care point to the increasing use of home health services in caring for the chronically ill elderly, little attention has been focused on assessing the specific services that these patients perceive as most needed. Twenty eight elderly patients with chronic illness who had been referred for home health agency service self reported their functional status using
Sleep disturbances in the intensive care unit (ICU) seem to lead to development of delirium, prolonged ICU stay, and increased mortality. That is why sufficient sleep is important for good outcome and recovery in critically illpatients. A variety of small studies reveal pathological sleep patterns in critically illpatients including abnormal circadian rhythm, high arousal and awakening index, reduced Slow Wave Sleep, and Rapid Eye Movement sleep. The purpose of this study is to summarise different aspects of sleep-awake disturbances, causes and handling methods in critically illpatients by reviewing the underlying literature. There are no studies of level 1 evidence proving the positive impact of the tested interventions on the critically illpatients' sleep pattern. Thus, disturbed sleep in critically illpatients with all the severe consequences remains an unresolved problem and needs further investigation. PMID:22404330
Congenital agranulocytosis terminating in acute myelogenous leukemia has been previously reported in only two cases of adolescent males. We describe the clinical and laboratory features of a 13-year-old male with congenital agranulocytosis, treated with G-CSF with initial good neutrophil response, who subsequently developed acute myeloid leukemia. This rare complication may define a preleukemic subset of patients for whom G-CSF therapy is ineffective. The diagnostic challenges of this case are presented. PMID:8342541
Wong, W Y; Williams, D; Slovak, M L; Charak, B; Mazumder, A; Snyder, D; Powars, D R; Brynes, R K
Sustained low-efficiency dialysis for critically illpatients requiring renal replacement therapy.BackgroundThe replacement of renal function for critically illpatients is procedurally complex and expensive, and none of the available techniques have proven superiority in terms of benefit to patient mortality. In hemodynamically unstable or severely catabolic patients, however, the continuous therapies have practical and theoretical advantages when compared with conventional
Mark R Marshall; Thomas A Golper; Mary J Shaver; Muhammad G Alam; Dinesh K Chatoth
The aims of this study were (1) to investigate what are the illness perceptions of hypertensive patients and their relationship with beliefs about specific medicines, and (2) to identify different illness schemata and how they relate to the choice of medication. This was a cross-sectional study in which 191 Portuguese patients (59% females), with a hypertension diagnosis, aged over 18 years old, were recruited from a hospital clinic in the Lisbon Metropolitan area. The questionnaire included measures of choice of medication, beliefs about specific medicines (BMQ-Specific), illness perception (Brief-IPQ), and socio-demographic information. The results indicated that the components of the illness perceptions were associated with patients' beliefs about necessity and concerns about medication. Patients seem to differ in their choice of medication (generic or brand names) according to the three illness schemata identified. Patients with more negative illness schemata were more likely to choose a brand medicine, whereas patients with a more positive perception of hypertension were more likely to choose a generic medicine. Our findings support the argument that illness perceptions and beliefs about medicines play a role in influencing patients' preferences of medicines for the treatment of hypertension. PMID:20204931
Figueiras, Maria; Marcelino, Dalia Silva; Claudino, Adelaide; Cortes, Maria Armanda; Maroco, Joao; Weinman, John
A psychologist with a client who is terminallyill and wishes to discuss end-of-life options, specifically the option of hastening death, is faced with an ethical dilemma as to how to proceed with treatment. Specifically, he or she is bound by the American Psychological Association's potentially-conflicting Principles A and E, which advise a psychologist to “do no harm” as well
African Americans have greater misperceptions about heart failure (HF) than Caucasians. We examined socioeconomic and medical history factors to determine if they explain differences in accuracy of HF illness beliefs by race. 519 patients completed an illness beliefs and socioeconomic status survey. After establishing univariate associations by race, linear regression with backward selection was used to identify factors associated with
Nancy M. Albert; Kathleen Trochelman; Kathryn H. Meyer; Benjamin Nutter
Critically illpatients show a variety of hormonal changes that appear to differ considerably in acute and prolonged critical illness. Whether these endocrine alterations serve as physiological adaptation or contribute to further deterioration remains an intriguing question. We review the recent literature and discuss whether measuring circulating hormone concentrations, performing stimulation tests, and intervening with hormone substitution could contribute to
J. Ligtenberg; A. Girbes; J. Beentjes; J. Tulleken; T. Werf; J. Zijlstra
Purpose To confirm the pharmacodynamics and evaluate the efficacy of high-dose selenium (Se) administered by continuous infusion,\\u000a following an initial loading bolus of selenite, on clinical outcome in critically illpatients with systemic inflammatory\\u000a response syndrome (SIRS).\\u000a \\u000a \\u000a \\u000a \\u000a Methods Prospective, placebo-controlled, randomized, single-blinded phase II study in a multidisciplinary university hospital intensive\\u000a care unit (ICU). Two groups of patients with SIRS, age >18 years, and
William Manzanares; Alberto Biestro; María H. Torre; Federico Galusso; Gianella Facchin; Gil Hardy
Objective: To assess the preventive effect of Saccharomyces boulardii on diarrhea in critically ill tube-fed patients and to evaluate risk factors for diarrhea. Design: Prospective, multicenter, randomized, double-blind placebo-controlled study. Setting: Eleven intensive care units in teaching and general hospitals. Patients: Critically illpatients whose need for enteral nutrition was expected to exceed 6 days. Intervention: S. boulardii 500 mg
G. Bleichner H. Bléhaut; H. Bléhaut; H. Mentec; D. Moyse
OBJECTIVE: To describe the short-term and long-term effects of a hospital-wide pressure ulcer prevention and treatment guideline on both the incidence and the time to the onset of pressure ulcers in critically illpatients. DESIGN: Prospective cohort study. SETTING: Adult intensive care department of a university medical center. PATIENTS: Critically illpatients (n = 399). INTERVENTIONS: A guideline for pressure
Erik H. de Laat; Peter Pickkers; Lisette Schoonhoven; Ton Feuth; Theo van Achterberg
In Switzerland, the highest rates of suicide are observed in persons without religious affiliation and the lowest in Catholics, with Protestants in an intermediate position. We examined whether this association was modified by concomitant psychiatric diagnoses or malignancies, based on 6,909 suicides (ICD-10 codes X60-X84) recorded in 3.69 million adult residents 2001-2008. Suicides were related to mental illness or cancer if codes F or C, respectively, were mentioned on the death certificate. The protective effect of religion was substantially stronger if a diagnosis of cancer was mentioned on the death certificate and weaker if a mental illness was mentioned. PMID:23331329
As part of a study in Danish internship pharmacies, 70 fourth-year pharmacy interns interviewed 123 angina pectoris patients. Information was collected about the patients' medication- and illness-related factual knowledge and perceptions as well as their medication use. The results obtained showed that patients' perceptions and factual knowledge about medications and illness varied greatly, and that they administered their medication in a variety of ways. Patients' factual knowledge on illness, illness prevention and the function of medication was generally low. The patients were grouped in different categories according to their perceptions of illness and medication. A quarter had actively and reflectively self-regulated their medication and the rest of the patients did not do any deliberate self-regulation in terms of their medication. Half of the patients occasionally forgot to take their medication. Health care personnel should incorporate the results of this study in their efforts to improve patient counselling on illness, medication and other health-related matters. PMID:12135819
Haugbølle, Lotte Stig; Sørensen, Ellen Westh; Henriksen, Hanne Herborg
This study is framed in theories of illness uncertainty (Babrow, A. S., 2007, Problematic integration theory. In B. B. Whaley & W. Samter (Eds.), Explaining communication: Contemporary theories and exemplars (pp. 181–200). Mahwah, NJ: Erlbaum; Babrow & Matthias, 2009; Brashers, D. E., 2007, A theory of communication and uncertainty management. In B. B. Whaley & W. Samter (Eds.), Explaining communication:
Maria G. Checton; Kathryn Greene; Kate Magsamen-Conrad; Maria K. Venetis
Summary Deinstitutionalization began with some noble sentiments: to treat and care for the mentally ill in settings that were closer to their homes, families, and neighborhoods; to treat people in more therapeutic and less restrictive settings; and to provide the array of services and settings in the community rather than in far distant institutions. However, few of these intentions have
When transferring critically illpatients, vast distances from rural hospitals to tertiary hospitals means nurses play a key role in facilitating communication between the patient, family and health care providers in both settings. Whether nurses are communicating information that patients and the family of the patients, perceive to have meaning for them is not clear. This study identifies the common
As oversedation is still common and significant variability between and within critically illpatients makes empiric dosing difficult, the population pharmacokinetics and pharmacodynamics of propofol upon long-term use are characterized, particularly focused on the varying disease state as determinant of the effect. Twenty-six critically illpatients were evaluated during 0.7–9.5 days (median 1.9 days) using the Ramsay scale and the
Background\\/Method: Total plasma homocysteine (tHcy) concentration is elevated in elderly patients with mental illness. Plasma tHcy is known to be associated with cardiovascular disease, renal impairment and negative lifestyle factors, and has been shown to predict mortality in human subjects. Epidemiological data on this topic in elderly patients with mental illness are missing. We therefore investigated the association between plasma
The present study explored illness perceptions of end stage renal disease (ESRD) patients on both haemodialysis (HD) and peritoneal dialysis (PD) treatment, and their associations with quality of life. Leventhal's self-regulation model (SRM) was used as a theoretical framework. Illness perceptions and quality of life were assessed with the IPQ-R and the SF-36 in 91 HD and 42 PD patients
Lucie Timmers; Melissa S. Y. Thong; Friedo W. Dekker; Elisabeth W. Boeschoten; Monique Heijmans; Mieke Rijken; John Weinman
OBJECTIVE--To assess general practitioners' involvement with long term mentally illpatients and attitudes towards their care. DESIGN--Postal questionnaire survey. SETTING--General practices in South West Thames region. SUBJECTS--507 general practitioners, 369 (73%) of whom returned the questionnaire. MAIN OUTCOME MEASURES--The number of adult long term mentally illpatients whom general practitioners estimate they have on their lists and general practitioners' willingness
The way individual conceptions and experiences of illnesses are socially constructed is shown through the historical analysis of diseases, particularly epidemics. For centuries, sickness did not clearly correspond to what we now call the patient status. Several factors were necessary for this social status to develop. Sickness had to cease being a mass phenomenon. Medicine had to become capable of providing efficacious treatment and of taking the sick out of the custody of religious institutions. Through social legislation, the notions of illness and of health had to be related to the world of work. Owing to the first two factors, sickness was transformed from a collective into an individual affair, from a way of dying into a way of living. Once related to production processes and medical custody, it became the individual's social condition. PMID:3883507
Introduction: N-terminal prohormone of atrial natriuretic peptide ((proANP(1–98)) has been extensively analyzed in patients with chronic renal failure. It has been found to be closely related to the renal function and to interdialytic hydration status. The clinical relevance of proANP(1–98) and cystatin C, a novel marker of glomerular filtration, has not been investigated in the subgroup of critically ill septic
B. Mazul-Sunko; N. Antoljak; M. Bekavac Bešlin; R. Klinger
"Death rattle" is a term used to describe the noisy sound produced by dying patients caused by the oscillatory movements of secretions in the upper airways. Antimuscarinic drugs, including atropine, scopolamine (hyoscine hydrobromide), hyoscine butylbromide, and glycopyrronium, have been used to diminish the noisy sound by reducing airway secretions. We report on the effectiveness of sublingual atropine eyedrops in alleviating death rattle in a terminal cancer patient. We present a 58-year-old man with pancreatic cancer who was admitted to our hospital because of severe dyspnea, cough, and death rattle with excessive bronchial secretion as a result of multiple lung metastases. We administered 1% atropine eyedrops sublingually to obviate the need for subcutaneous infusions and to prevent somnolence. On the basis of our experience, we conclude that atropine eyedrops, administered sublingually for distressing upper respiratory secretions, may be an effective alternative to the injection of antimuscarinic drugs, or as an option when other antimuscarinic formulations are not available. PMID:22747099
Probiotic bacteria are live microorganisms which confer to health benefits of the host. They help to maintain the integrity\\u000a of the intestinal barrier function by modulating the mucosal and systemic immune response of the host. These bacteria have\\u000a proven their beneficial effect in several conditions of ulcerative colitis. More recently probiotics\\/synbiotics have been\\u000a included in the treatment of critically ill
Christoph A Jacobi; Christian Schulz; Peter Malfertheiner
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
Hueso Montoro, César; Siles González, José; Amezcua, Manuel; Bonill de Las Nieves, Candela; Pastor Montero, Sonia; Celdrán Mañas, Miriam
SUMMARY. Immediate family members of veterans diagnosed with Gulf War Illnesses often complain of fatiguing illnesses, and upon analysis they report similar signs and symptoms as their veteran family members. Since a relatively common finding in Gulf War Illnesspatients is a bacterial infection due to Mycoplasma species, we examined military families (149 patients: 42 veterans, 40 spouses, 32 other
Garth L. Nicolson; Marwan Y. Nasralla; Nancy L. Nicolson; Joerg Haier
This Article explores the oftentimes mistaken notion that we can realistically identify severely ill individuals seeking physician-suicide who do so willingly, knowingly, and voluntarily. Medical science and medical practice support this proposition. To date, there exists no sound clinical basis for distinguishing suicidal patients with terminal conditions from suicidal patients without terminal conditions. Thus, it is a mistake to posit
Background Long-term survival outcome of critically illpatients is important in assessing effectiveness of new treatments and making treatment decisions. We developed a prognostic model for estimation of long-term survival of critically illpatients. Methodology and Principal Findings This was a retrospective linked data cohort study involving 11,930 critically illpatients who survived more than 5 days in a university teaching hospital in Western Australia. Older age, male gender, co-morbidities, severe acute illness as measured by Acute Physiology and Chronic Health Evaluation II predicted mortality, and more days of vasopressor or inotropic support, mechanical ventilation, and hemofiltration within the first 5 days of intensive care unit admission were associated with a worse long-term survival up to 15 years after the onset of critical illness. Among these seven pre-selected predictors, age (explained 50% of the variability of the model, hazard ratio [HR] between 80 and 60 years old?=?1.95) and co-morbidity (explained 27% of the variability, HR between Charlson co-morbidity index 5 and 0?=?2.15) were the most important determinants. A nomogram based on the pre-selected predictors is provided to allow estimation of the median survival time and also the 1-year, 3-year, 5-year, 10-year, and 15-year survival probabilities for a patient. The discrimination (adjusted c-index?=?0.757, 95% confidence interval 0.745–0.769) and calibration of this prognostic model were acceptable. Significance Age, gender, co-morbidities, severity of acute illness, and the intensity and duration of intensive care therapy can be used to estimate long-term survival of critically illpatients. Age and co-morbidity are the most important determinants of long-term prognosis of critically illpatients.
Ho, Kwok M.; Knuiman, Matthew; Finn, Judith; Webb, Steven A.
Fifty consecutive critically illpatients transported between hospitals by a mobile intensive care team were assessed prospectively using a modification of the acute physiology and chronic health evaluation (APACHE II) sickness scoring system. Assessments were made before and after resuscitation, on return to base, and after 24 hours of intensive care. No patient died during transport. Twenty two patients died
J F Bion; S A Edlin; G Ramsay; S McCabe; I M Ledingham
INTRODUCTION: Disturbed gastric emptying (GE) occurs commonly in critically illpatients. Admission diagnoses are believed to influence the incidence of delayed GE and subsequent feed intolerance. Although patients with burns and head injury are considered to be at greater risk, the true incidence has not been determined by examination of patient groups of sufficient number. This study aimed to evaluate
Nam Q Nguyen; Mei P Ng; Marianne Chapman; Robert J Fraser; Richard H Holloway
Measurement of cardiac output using thermodilution technique in mechanically ventilated patients is associated with significant morbidity. The goal of the present study was to assess the validity of car- diac output measurement using transesophageal Doppler in critically illpatients. Forty-six patients from three different intensive care units underwent 136 paired cardiac output measurements using thermodilution (CO TH ) and transesophageal
BRUNO VALTIER; BERNARD P. CHOLLEY; JEAN-PIERRE BELOT; JOAQUIM MATEO; DIDIER M. PAYEN
Background. Our objective was to study the risk factors and mechanisms of hypernatraemia in critically illpatients, a common and potentially serious problem. Methods. In 2005, all patients admitted to the medical, surgical or neurological intensive care unit (ICU) of a university hospital were reviewed. A 1:2 matched case-control study was performed, defining cases as patients who developed a serum
E. J. Hoorn; M. G. H. Betjes; J. Weigel; R. Zietse
|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…
INTRODUCTION: There is little objective comparative information about the postoperative complications of tracheostomy in morbidly obese patients. The aim of this study was to determine the incidence and severity of complications associated with open tracheostomy in critically ill morbidly obese patients during hospitalization. METHODS: During a six year period, all consecutive morbidly obese patients (body mass index [BMI] of greater
The objective of this study was to evaluate the evidence behind specific but common patient care decisions in support of enteral feedings for patients admitted to intensive care units. Six specific questions were developed and refined to address clinical outcomes specific to clinical practice decisions pertinent to enteral feeding of critically illpatients. The data sources consisted of an intensive
Kendra K. Kattelmann; Mary Hise; Mary Russell; Pam Charney; Milton Stokes; Charlene Compher
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…
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.
In deciding Addington vs Texas the US Supreme Court established "clear and convincing evidence" as the standard of proof necessary for civil commitment of the mentally ill rather than the criminal standard, "beyond a reasonable doubt." This decision has major implications for the mentally ill person, the family, and the psychiatrist. The mentally ill person is returned to the role of patient. The family is given aid in their dilemma of coping with their psychotic member. The psychiatrist is seen as helper rather than jailer. PMID:490828
The prevalence and survival rates of critically illpatients with cancer in the intensive care unit have increased considerably in the past 2 decades; yet, the meaning of caring for cancer patients in this setting may fall along a continuum. This article addresses the nurse's experience in caring for the critically illpatient with cancer by presenting a current profile of these patient in the intensive care unit in the context of the historical development and mission of critical care and the evolution of cancer as a chronic disease. The moral distress that can result when these 2 "cultures" or "realities" collide and the meaning of the nurse's work will be examined. Strategies and resources for critical care nurses to incorporate into their practice when caring for the critically illpatient with cancer, and themselves, will be addressed. PMID:22064587
Antibiotic prescription for critically illpatients is a complicated process because of the pharmacokinetic differences of this patient population with non-critically illpatients and the lack of robust informative studies. This article seeks to review the available literature describing dosing requirements for optimized treatment of critically illpatients and to discuss a framework to rationally address complex cases by outlining the suggested processes for optimal achievement of pharmacokinetic/ pharmacodynamic targets. A variety of papers exist describing the effect of pathophysiology on antibiotic kinetics. In the critically illpatient, dysfunction of almost any organ system can result in significant changes to drug volume of distribution and clearance. Dysfunction of the cardiovascular and renal systems in particular is problematic and can lead to potentially sub-therapeutic antibiotic concentrations in blood and in interstitial fluid. In response to altered pharmacokinetics, dose regimens that adhere to the pharmacodynamics of the antibiotic are essential. In the absence of validated dosing algorithms, therapeutic drug monitoring data and susceptibility data of the infecting pathogen should be inputted into a Bayesian software program that include population pharmacokinetic models to calculate dosing regimens that are personalized for the critically illpatient. PMID:21554211
For children, the diagnosis of a serious disease of near relatives is a dramatic experience, particularly when their parents are involved. Such a situation demands great efforts to cope with. Therefore these children have an increased risk of developing mental health problems. To prevent this, children and adolescents need support according to their personal developmental stage. Above all it is necessary to give support to the parents, as their expertise as father and mother provides stability for their children. All interventions aim at one goal, which is maintaining the stability of the family. In the following, results of studies will be discussed with respect to the case report. According to the European research project "COSIP" (Children of Somatically Ill Parents) a recommendation for medical doctors of all specialities, caring for adults with severe diseases, should be lined out. PMID:22328052
In patients receiving long-term therapeutic or replacement corticosteroids, delayed or inappropriate adjustment of steroid dosage during intercurrent illness may be fatal. We used a questionnaire to assess current levels of patient knowledge, awareness of the need for action during intercurrent illness and the frequency with which steroid warning cards and Medic Alert pendants were carried, in 61 patients on long-term replacement corticosteroids and in 40 patients receiving long-term therapeutic corticosteroids. Only 67 of the 101 patients taking corticosteroids were carrying a steroid warning card. Eleven of the 21 Medic Alert owners wore their pendants. Only 18 of the 41 patients in the therapeutic group and 41 of the 60 patients in the replacement group would take appropriate action during an intercurrent illness (P < 0.001). Lack of patient knowledge in this important area emphasizes the need for continuing and effective education of these groups of patients during follow-up. An information sheet detailing the exact changes to be made during intercurrent illness may help reinforce verbal advice.
Peacey, S. R.; Pope, R. M.; Naik, K. S.; Hardern, R. D.; Page, M. D.; Belchetz, P. E.
Introduction Clinicians and specialty societies often emphasize the potential importance of natural light for quality care of critically\\u000a illpatients, but few studies have examined patient outcomes associated with exposure to natural light. We hypothesized that\\u000a receiving care in an intensive care unit (ICU) room with a window might improve outcomes for critically illpatients with\\u000a acute brain injury.\\u000a \\u000a \\u000a \\u000a \\u000a Methods This was
Hannah Wunsch; Hayley Gershengorn; Stephan A Mayer; Jan Claassen
The use of computers to aid care for chronically ill pediatric patients is a relatively new concept. We are currently using Filemaker II software and a Macintosh Plus computer to augment overall patient care in children with chronic diseases, such as spina bifida, cerebral palsy, neuromuscular diseases, head injury, and spinal cord injury. This is a computerized medical record with a clinical database for dissemination of information to multidisciplinary team members, generating letters to private health care providers, displaying telephone messages, and assisting inpatient care. Advances in computer technology will provide future applications to aid health care providers in caring for patients with chronic illnesses. PMID:2773878
A convenience snowball sample of 228 mental health practitioners were surveyed and administered two vignettes of persons with mental illness and a 12-question survey that included occupational background and attitudinal questions about diagnosing mental illness. The gender and race of the patients were randomly altered, while the symptoms and characteristics of mental illness remained constant for each vignette. Each practitioner
Sixty-eight depressed patients were subdivided according to their family’s level of family functioning into functional and dysfunctional groups. Patients from dysfunctional families did not differ from those from functional families on measures of severity of depression, chronicity of depression, depression subtypes, other nonaffective psychiatric diagnoses, history of depression, or neuroendocrine functioning. Patients from dysfunctional families did have significantly higher levels
Ivan W. Miller; Gabor I. Keitner; Mark A. Whisman; Christine E. Ryan; Nathan B. Epstein; Duane S. Bishop
ABSTRACT: INTRODUCTION: Whereas most studies focus on laboratory and clinical research, little is known about the causes of death and risk factors for death in critically illpatients. METHODS: Three thousand seven hundred patients admitted to an adult intensive care unit (ICU) were prospectively evaluated. Study endpoints were to evaluate causes of death and risk factors for death in the
Viktoria D Mayr; Martin W Dünser; Veronika Greil; Stefan Jochberger; Günter Luckner; Hanno Ulmer; Barbara E Friesenecker; Jukka Takala; Walter R Hasibeder
INTRODUCTION: Critically illpatients are characterized by increased loss of muscle mass, partially attributed to sepsis and multiple organ failure, as well as immobilization. Recent studies have shown that electrical muscle stimulation (EMS) may be an alternative to active exercise in chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) patients with myopathy. The aim of our study was
Due to concerns that individuals with severe mental illness (SMI) are too fragile to participate in trauma/PTSD research, we examined reactions to PTSD research participation among these patients. Most patients viewed their participation favorably and were not significantly distressed, suggesting an adequate benefit of trauma/PTSD research participation in this population. PMID:22884217
Grubaugh, Anouk L; Tuerk, Peter W; Egede, Leonard E; Frueh, Bartley Christopher
Studies have shown that early enteral nutrition in critically illpatients reduces the incidence of morbidity and death. Nonetheless, intolerance to gastric enteral nutrition is common in these patients as a result of gastroparesis. The use of prokinetic agents such as metoclopramide, domperidone, cisapride, and erythromycin can improve gastric emptying, but these agents are not without deleterious adverse effects. Tegaserod,
Hoan Linh Banh; Charles MacLean; Trevor Topp; Richard Hall
Critically illpatients often receive sedatives, which may delay libera- tion from mechanical ventilation and intensive care unit discharge. Daily interruption of sedatives alleviates these problems, but the impact of this practice on long-term psychological outcomes is un- known. We compared psychological outcomes of intensive care unit patients undergoing daily sedative interruption (intervention) with those without this protocol (control). Assessments
John P. Kress; Brian Gehlbach; Maureen Lacy; Neil Pliskin; Anne S. Pohlman; Jesse B. Hall
|The patients and staff of a psychiatric hospital were asked about their attitudes toward mental illness and how they conceive the roles of various patient and staff groups in the therapeutic community. The focus was on the bipolar dimension of "Custodial" vs. "Accountability" orientation. (Author)|
Conclusions Decisive action needs to be taken in regard to the housing needs of deinstitutionalized elderly chronically illpatients. Specifically, present housing trends toward random integration of geriatric ex-patients with well old people is at best highly questionable. While it cannot be said with any degree of certainty that residential integration of this kind can never succeed under any circumstances,
The objective of the study presented here was to assess the economic impact of Candida colonization and Candida infection in critically illpatients admitted to intensive care units (ICUs). For this purpose, a prospective, cohort, observational, and multicenter study was designed. A total of 1,765 patients over the age of 18 years who were admitted for at least 7 days
P. M. Olaechea; M. Palomar; C. León-Gil; F. Álvarez-Lerma; R. Jordá; J. Nolla-Salas; M. A. León-Regidor
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)
Background: Patients admitted to intensive care units (ICUs) are at high risk for acquiring nosocomial infections. We examined the association between markers of severity of illness at ICU admission and the development of ICU-attributable nosocomial infections. Methods: Retrospective cohort study of 851 patients admitted to the medical or surgical ICU in an urban teaching hospital from January 1997 to January
Margaret E. McCusker; André R. S. Périssé; Mary-Claire Roghmann
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
Deborah Cook; Joseph McMullin; Richard Hodder; Mark Heule; Jaime Pinilla; Peter Dodek; Thomas Stewart
Background: The ultimate therapy for acute cholecystitis is cholecystectomy. However, in critically ill elderly patients the mortality of emergency cholecystectomy may reach up to 30%. Open cholecystostomy performed under local anesthesia was considered to be the procedure of choice for treatment of acute cholecystitis in high-risk patients. In recent years, ultrasound- or computed tomography (CT)-guided percutaneous transhepatic cholecystostomy (PTHC) replaced
Ram M Spira; Aviran Nissan; Oded Zamir; Tzeela Cohen; Scott I Fields; Herbert R Freund
BACKGROUND: This study evaluated whether commercially available blood volume measurements in critically ill surgical patients altered fluid management. METHODS: Patients admitted to the surgical intensive care unit of a tertiary care teaching hospital were prospectively evaluated. The frequency of changes in fluid management when results of blood volume measurements were available was determined. RESULTS: In a pilot study, the frequency
Danny M. Takanishi Jr; Elisabeth N. Biuk-Aghai; Mihae Yu; Fedor Lurie; Hideko Yamauchi; Hao C. Ho; Alyssa D. Chapital; Wega Koss
After more than two decades of nutritional awareness, we designed a prospective study to determine whether malnutrition is still a significant issue in hospitalized patients. Patients admitted to an intensive care unit (ICU) were divided into well-nourished and malnourished groups, according to their nutritional status as assessed by serum albumin level and weight\\/height ratio. Severity of illness, as assessed by
Manuel Giner; Alessandro Laviano; Michael M. Meguid; John R. Gleason
Nutritional support is given to many patients in surgical intensive care after major trauma and serious sepsis but rarely after major elective surgery. We have quantified the changes in body composition that occur in these patients and have found that serious losses of body protein still occur after trauma and sepsis despite nutritional support. Correct nutritional management of critically ill
Background. Obese patients are known to have more chronic medical conditions. Objective. To compare the frequency of encounter for episodes of the 10 most common illnesses in general practice between obese and non-overweight patients. Methods. Data were derived from the Continuous Morbidity Registration, containing data from four general practices in and around Nijmegen (The Netherlands). In this research and registration
C. A. M. van Wayenburg; M. B. T. Lerniengre; A. H. van Reenen-Schimmel; J. H. J. Bor; J. C. Bakx; W. A. van Staveren; C. van Weel; J. J. van Binsbergen
There is controversy over whether traditional intermittent bolus dosing or continuous infusion of beta-lactam antibiotics is preferable in critically illpatients. No significant difference between these two dosing strategies in terms of patient outcomes has been shown yet. This is despite compelling in vitro and in vivo pharmacokinetic/pharmacodynamic (PK/PD) data. A lack of significance in clinical outcome studies may be due to several methodological flaws potentially masking the benefits of continuous infusion observed in preclinical studies. In this review, we explore the methodological shortcomings of the published clinical studies and describe the criteria that should be considered for performing a definitive clinical trial. We found that most trials utilized inconsistent antibiotic doses and recruited only small numbers of heterogeneous patient groups. The results of these trials suggest that continuous infusion of beta-lactam antibiotics may have variable efficacy in different patient groups. Patients who may benefit from continuous infusion are critically illpatients with a high level of illness severity. Thus, future trials should test the potential clinical advantages of continuous infusion in this patient population. To further ascertain whether benefits of continuous infusion in critically illpatients do exist, a large-scale, prospective, multinational trial with a robust design is required.
The risk of venous thromboembolism (VTE) in hospitalised medically illpatients is often underestimated, despite the fact that it remains a major cause of preventable morbidity and mortality in this group. It is not well recognised that the risk of VTE in many hospitalised medically illpatients is at least as high as in populations after surgery. This may partly be attributed to the clinically silent nature of VTE in many patients, and the difficulty in predicting which patients might develop symptoms or fatal pulmonary embolism. Two large studies, Prospective Evaluation of Dalteparin Efficacy for Prevention of VTE in Immobilized Patients Trial and prophylaxis in MEDical patients with ENOXaparin, have shown that low?molecular?weight heparins provide effective thromboprophylaxis in medically illpatients, without increasing bleeding risk. Recent guidelines from the American College of Chest Physicians recommend that acutely medically illpatients admitted with congestive heart failure or severe respiratory disease, or those who are confined to bed and have at least one additional risk factor for VTE, should receive thromboprophylaxis.
OBJECTIVE--To determine the 11 year outcome of neurotic disorder in general practice. DESIGN--Cohort study over 11 years. SETTING--Two general practices in Warwickshire England. SUBJECTS--100 patients selected to be representative of those identified nationally by general practitioners as having neurotic disorders. MAIN OUTCOME MEASURES--Mortality, morbidity, and use of health services. RESULTS--At 11 years 87 subjects were traced. The 11 year standardised mortality ratio was 173 (95% confidence interval 164 to 200). 47 were cases on the general health questionnaire, 32 had a relapsing or chronic psychiatric course, and 49 a relapsing or chronic physical course. Treatment for psychiatric illness was mainly drugs. The mean number of consultations per year was 10.8 (median 8.7). A persistent psychiatric diagnosis at one year follow up was associated with high attendance ( > 12 visits a year for 11 years) at follow up after age, sex, and physical illness were adjusted for. Severity of psychiatric illness (general health questionnaire score) at outset predicted general health questionnaire score at 11 year follow up, course of psychiatric illness, and high consultation rate. CONCLUSION--These data support the view that a neurotic illness can become chronic and is associated with raised mortality from all causes and high use of services. Such patients need effective intervention, particularly those with a more severe illness who do not recover within one year.
The Task Force reviewed and discussed the available literature on the effectiveness of physiotherapy for acute and chronic\\u000a critically ill adult patients. Evidence from randomized controlled trials or meta-analyses was limited and most of the recommendations\\u000a were level C (evidence from uncontrolled or nonrandomized trials, or from observational studies) and D (expert opinion). However,\\u000a the following evidence-based targets for physiotherapy
R. Gosselink; J. Bott; M. Johnson; E. Dean; S. Nava; M. Norrenberg; B. Schönhofer; K. Stiller; H. van de Leur; J. L. Vincent
The purpose of this paper was to review the potential utility of ampicillin/sulbactam (SAM) as a therapy for serious infections in critically illpatients. Data for this review were identified by searches of PubMed and of the reference lists of the included articles. We found that SAM appears to have a number of characteristics that support its use in the treatment of serious infections in critically illpatients. SAM demonstrates extensive penetration into many infection sites, supporting its use in a wide range of infection types. Microbiologically, sulbactam has strong intrinsic antibiotic activity against multidrug-resistant (MDR) bacteria, including Acinetobacter baumannii, which supports its use for the treatment of infections mediated by this pathogen. Of some concern, there have been reports showing a decline in susceptibility of some bacteria to SAM. As such, use of lower doses (4/2g/day), particularly for MDR A. baumannii, has been linked with a 30% reduced success rate in critically illpatients. The therapeutic challenges for ensuring achievement of optimal dosing of SAM result partly from bacterial susceptibility but also from the pharmacokinetic (PK) alterations common to ?-lactam agents in critical illness. These PK changes are likely to reduce the ability of standard dosing to achieve the concentrations observed in non-critically illpatients. Optimisation of therapy may be more likely with the use of higher doses, administration by 4h infusion or by combination therapy, particularly for the treatment of infections caused by MDR pathogens. PMID:24041466
Adnan, Syamhanin; Paterson, David L; Lipman, Jeffrey; Roberts, Jason A
Admission of cancer patients with serious medical complications to the ICU remains controversial primarily because of the\\u000a high short-term mortality rates in these patients. However, the cancer patient population is heterogeneous regarding age,\\u000a underlying conditions, and curability of their disease, suggesting that large variations may occur in the effectiveness of\\u000a intensive care within this subgroup of critically illpatients.Objectives: To
E. Azoulay; D. Moreau; C. Alberti; G. Leleu; C. Adrie; M. Barboteu; P. Cottu; V. Levy; J.-R. Le Gall; B. Schlemmer
Muslims arriving as first generation immigrants in Western countries gradually grow old and increasingly appeal to Western healthcare. This study presents and discusses the perspectives of elderly (age > or =55) Muslim women on medicine, illness and suffering. We found that theological considerations, centring around God's almightiness, are central for these Muslim women dealing with illness and suffering in a meaningful way. This study concludes that spirituality is an important dimension of their patient care: it not only makes an impact on these patients' ritual needs (e.g. prayer), but also on the ways they deal with illness, suffering, and concrete medical decision-making. The findings are of particular importance for both Muslim and multi-faith hospital chaplains who might act as spiritual care references in medical teams, by informing physicians and nurses about potential specific sensibilities and perspectives of Muslim patients. PMID:23461098
The aim of this study was to investigate traditional and alternative therapy for mental illness in Jamaica: patients' conceptions and practitioners' attitudes. The sample included 60 psychiatric patients selected from Ward 21 at the University of the West Indies, Kingston as well as Princess Margaret outpatient clinic, and 30 Afro-centric psychiatric nurses, psychiatrist and clinical psychologists from Kingston and St. Thomas, Jamaica. Patients were interviewed with the Short Explanatory Model Interview (SEMI) and practitioners completed a self administered questionnaire on attitudes towards traditional and alternative medicine. Results indicate that among psychiatric patients more than a third expressed the belief that the overall cause of their mental illness was as a result of supernatural factors. In general, the majority of patients felt that their perception of their problems did not concur with the western practitioner, which in turn caused distress for these patients. In case for those who also sought traditional medicine, they were more inclined to feel pleased about their interaction and the treatment they received. Results from western trained practitioners found that although they acknowledged that traditional medicine plays a major role in the treatment of mental illness among psychiatric patients the treatment was not advantageous. For the most part when all three traditional approaches were examined alternative medicine seemed more favourable than traditional healing and traditional herbal treatment. There is a need to develop models of collaboration that promote a workable relationship between the two healing systems in treating mental illness. PMID:23983326
Background Critical illness, mediated by trauma or sepsis, can lead to physiological changes that alter the pharmacokinetics of antibiotics\\u000a and may result in sub-therapeutic concentrations at the sites of infection. The first aim of this project is to identify the\\u000a clinical characteristics of critically illpatients with significant trauma that have been recently admitted to ICU that may\\u000a predict the dosing
Jason A Roberts; Michael S Roberts; Andrew Semark; Andrew A Udy; Carl MJ Kirkpatrick; David L Paterson; Matthew J Roberts; Peter Kruger; Jeffrey Lipman
Patients with advanced liver disease (ALD) leading to admission to the ICU are often evaluated for possible orthotopic liver transplan- tation (OLT). Those deemed ineligible for listing for OLT must be managed by medical therapy. The number of patients not eligible for OLT listing will likely increase given the current organ trans- plant shortage. We performed a retrospective multivariate analy-
JOHN P. KRESS; ARNON RUBIN; ANNE S. POHLMAN; JESSE B. HALL
The objective of this study was to evaluate the properties of ciprofloxacin in intensive care patients using a population approach. Seventy patients received ciprofloxacin. On Day 1, three to eight blood samples were taken over a 12-h period. Peak drug concentration (Cmax) and 24-h area under the concentration–time curve (AUC) were compared with the French breakpoint defining antibiotic susceptibility. A
Jean-Marie Conil; Bernard Georges; Anne de Lussy; Dalia Khachman; Thierry Seguin; Stéphanie Ruiz; Pierre Cougot; Olivier Fourcade; Georges Houin; Sylvie Saivin
This was a prospective study designed to evaluate the extent to which intestinal mucosal compromise occurs in adult critical care patients with and without systemic inflammatory response syndrome (SIRS) and to correlate the degree of intestinal injury with outcome. Ten patients from a university hospital surgical intensive care unit were identified who manifested SIRS at the time of admission to the intensive care unit. Five other critical care patients without SIRS were also evaluated. The Acute Physiology and Chronic Health Evaluation II score was determined. Intestinal mucosal viability was assessed by serial measurement of serum and urine iFABP intestinal fatty acid binding protein (iFABP), a sensitive and specific marker for mucosal injury. Outcome in terms of the development of multiorgan dysfunction syndrome, adult respiratory distress syndrome, and survival was determined. iFABP was detectable in the serum or urine in 8 out of 10 patients with SIRS. Among the 4 patients with detectable serum iFABP, 2 died and 1 developed severe adult respiratory distress syndrome. Nine of 11 patients without detectable serum iFABP recovered without major morbidity. iFABP was detectable in most patients with SIRS, suggesting that subclinical intestinal mucosal compromise is a frequent component of this syndrome. When iFABP was detectable, particularly in the serum, the prognosis was poor, even in the absence of SIRS, indicating that iFABP may be a relevant and independent predictor of outcome in critical care patients. PMID:9915525
Gollin, G; Zieg, P M; Cohn, S M; Lieberman, J M; Marks, W H
A religious Sect (Jéhovah witness), its mental patients, its doctor and its psychiatrists. The authors study religious sects, specially Jéhovoah witness. Such 15 mentally illpatients 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
Objective A lack of published pharmacokinetic data on statins in sepsis has prompted concerns about their safety and toxicity. This\\u000a study determined single dose pharmacokinetics of Atorvastatin administered orally to acutely illpatients.\\u000a \\u000a \\u000a \\u000a Design, setting and participants A prospective open label study conducted in a tertiary referral centre on 5 healthy volunteers, 5 acutely illpatients admitted\\u000a to the medical ward and
Peter S. Kruger; Noelle M. Freir; Bala Venkatesh; Thomas A. Robertson; Michael S. Roberts; Mark Jones
Purpose To discuss the techniques currently available to evaluate the microcirculation in critically illpatients. In addition, the\\u000a most clinically relevant microcirculatory alterations will be discussed.\\u000a \\u000a \\u000a \\u000a \\u000a Methods Review of the literature on methods used to evaluate the microcirculation in humans and on microcirculatory alterations in\\u000a critically illpatients.\\u000a \\u000a \\u000a \\u000a \\u000a Results In experimental conditions, shock states have been shown to be associated with a decrease
Daniel De Backer; Gustavo Ospina-Tascon; Diamantino Salgado; Raphaël Favory; Jacques Creteur; Jean-Louis Vincent
Critically illpatients 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 illpatients. The efficacy of perioperative recombinant human erythropoietin (rHuEPO) has been demonstrated in a variety of elective surgical settings. Similarly, in critically illpatients 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 illpatients.
Abstract Objective It is not known how often physicians use metaphors and analogies, or whether they improve patients' perceptions of their physicians' ability to communicate effectively. Therefore, the objective of this study was to determine whether the use of metaphors and analogies in difficult conversations is associated with better patient ratings of their physicians' communication skills. Design Cross-sectional observational study of audio-recorded conversations between patients and physicians. Setting Three outpatient oncology practices. Patients Ninety-four patients with advanced cancer and 52 physicians. Intervention None. Main outcome measures Conversations were reviewed and coded for the presence of metaphors and analogies. Patients also completed a 6-item rating of their physician's ability to communicate. Results In a sample of 101 conversations, coders identified 193 metaphors and 75 analogies. Metaphors appeared in approximately twice as many conversations as analogies did (65/101, 64% versus 31/101, 31%; sign test p?0.001). Conversations also contained more metaphors than analogies (mean 1.6, range 0–11 versus mean 0.6, range 0–5; sign rank test p?0.001). Physicians who used more metaphors elicited better patient ratings of communication (??=?0.27; p?=?0.006), as did physicians who used more analogies (Spearman ??=?0.34; p?0.001). Conclusions The use of metaphors and analogies may enhance physicians' ability to communicate.
Pickard, Amy; Fishman, Jessica M.; Alexander, Stewart C.; Arnold, Robert M.; Pollak, Kathryn I.; Tulsky, James A.
Amikacin pharmacokinetic data in Kuwaiti (Arab) intensive care unit (ICU) patients are lacking. Fairly sparse serum amikacin peak and trough concentrations data were obtained from adult Kuwaiti ICU patients. The data were analysed using a nonparametric adaptive grid (NPAG) maximum likelihood algorithm. The estimations of the developed model were assessed using mean error (ME) as a measure of bias and mean squared error (MSE) as a measure of precision. A total of 331 serum amikacin concentrations were obtained from 56 patients. The mean (± SD) model parameter values found were Vc = 0.2302 ± 0.0866 L/kg, kslope = 0.004045 ± 0.00705 min per unit of creatinine clearance, k12 = 2.2121 ± 5.506 h(-1), and k21 = 1.431 ± 2.796 h(-1). The serum concentration data were estimated with little bias (ME = -0.88) and good precision (MSE = 13.08). The present study suggests that amikacin pharmacokinetics in adult Kuwaiti ICU patients are generally rather similar to those found in other patients. This population model would provide useful guidance in developing initial amikacin dosage regimens for such patients, especially using multiple model (MM) dosage design, followed by appropriate Bayesian adaptive control, to optimize amikacin dosage regimens for each individual patient. PMID:23484093
Matar, Kamal M; Al-lanqawi, Yousef; Abdul-Malek, Kefaya; Jelliffe, Roger
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
Muschalla, Beate; Glatz, Johannes; Linden, Michael
Management of many types of chronic diseases suchas diabetes and asthma relies heavily on patients'self-monitoring of their disease conditions. In recentyears, internet-based home telemonitoring systemsthat allow transmission of patient data to a centraldatabase and offer immediate access to the data bythe care providers have become available. However,these systems often work with only one or a few typesof medical devices and
To evaluate the attributable morbidity and mortality of ventilator-associated pneumonia (VAP) in in- tensive care unit (ICU) patients, we conducted a prospective, matched cohort study. Patients ex- pected to be ventilated for . 48 h were prospectively followed for the development of VAP. To de- termine the excess ICU stay and mortality attributable to VAP, we matched patients with VAP
DAREN K. HEYLAND; DEBORAH J. COOK; LAUREN GRIFFITH; SEAN P. KEENAN
Introduction The paucity of data on resource use in critically illpatients with hematological malignancy and on these patients' perceived\\u000a poor outcome can lead to uncertainty over the extent to which intensive care treatment is appropriate. The aim of the present\\u000a study was to assess the amount of intensive care resources needed for, and the effect of treatment of, hemato-oncological\\u000a patients
Tobias M Merz; Pascale Schär; Michael Bühlmann; Jukka Takala; Hans U Rothen
Microbial colonization and the incidence of catheter-related bloodstream infections (CR-BSI) associated with Oligon Vantex® silver central venous catheters (CVC) in critically illpatients were determined. A prospective, randomized, controlled 17-month trial was carried out in an intensive care unit (ICU). All patients requiring a triple-lumen CVC for four days or longer were enrolled. Patients were randomized to receive a standard
L Corral; M Nolla-Salas; J Ibañez-Nolla; M. A León; R. M D??az; M Cruz Mart??n; R Iglesia; R Catalan
Objective: To evaluate the prognostic value of hemoglobin lev- els in critically illpatients with acute renal failure (ARF) requiring dialysis. Design and setting: A prospective observational cohort study in two adult medical ICUs. Patients: 206 consecutive patients with ARF who required dialysis. Overall 28-day mortality was 48%. Measurements and results: At ICU admission mean hemoglobin level was 9.1€2.1 g\\/dl.
Damien Cheyron; Jean-Jacques Parienti; Mohamed Fekih-Hassen; Cédric Daubin; Pierre Charbonneau
Impaired monocyte cytokine production in critically illpatients with acute renal failure.BackgroundPlasma levels of pro- and anti-inflammatory cytokines are predictive of mortality in patients with acute renal failure (ARF). Anti-inflammatory strategies are postulated to be beneficial in treatment. However, there are few studies simultaneously examining monocyte cytokine production and plasma cytokine levels in patients with ARF.MethodsStudy populations consisted of 20
JONATHAN HIMMELFARB; PHUONG LE; JENNIFER KLENZAK; STEPHANIE FREEDMAN; M. Elizabeth McMenamin; T. Alp Ikizler
Introduction Anemia is a common problem in critically illpatients. The etiology of anemia of critical illness is often determined to be multifactorial in the clinical setting, but the pathophysiology remains to be elucidated. Erythropoietin (EPO) is an endogenous glycoprotein hormone that serves as the primary stimulus for erythropoiesis. Recent evidence has demonstrated a blunted EPO response as a factor contributing to anemia of critical illness in specific subsets of patients. Critically illpatients requiring mechanical ventilation who exhibit anemia have not been the subject of previous studies. Our goal was to evaluate the erythropoietic response to anemia in the critically ill mechanically ventilated patient. Methods A prospective observational study was undertaken in the medical intensive care unit of a tertiary care, military hospital. Twenty patients admitted to the medical intensive care unit requiring mechanical ventilation for at least 72 hours were enrolled as study patients. EPO levels and complete blood count were measured 72 hours after admission and initiation of mechanical ventilation. Admission clinical and demographic data were recorded, and patients were followed for the duration of mechanical ventilation. Twenty patients diagnosed with iron deficiency anemia in the outpatient setting were enrolled as a control population. Control patients had baseline complete blood count and iron panel recorded by primary care physicians. EPO levels were measured at the time of enrollment in conjunction with complete blood count. Results The mean EPO level for the control population was 60.9 mU/ml. The mean EPO level in the mechanically ventilated patient group was 28.7 mU/ml, which was significantly less than in the control group (P = 0.035). The mean hemoglobin value was not significantly different between groups (10.6 g/dl in mechanically ventilated patients versus 10.2 g/dl in control patients; P > 0.05). Conclusion Mechanically ventilated patients demonstrate a blunted EPO response to anemia. Further study of therapies directed at treating anemia of critical illness and evaluating its potential impact on mechanical ventilation outcomes and mortality is warranted.
DeAngelo, Alan J; Bell, David G; Quinn, Michael W; Long, Deborah Ebert; Ouellette, Daniel R
Laboratory test results are a valuable source of information. Nurses need to assess laboratory test results as part of the physical assessment of their patients. Comparison of laboratory test results and changes with abnormal physical findings provides the basis for changes in the nursing care plan. Progressive monitoring of laboratory results and prompt interventions might lessen the seriousness of the health problem. In acute care units, the initial group of laboratory tests serves as a baseline for assessing additional test results. Several reference values should be remembered, particularly the electrolytes (potassium, sodium, and calcium), glucose, BUN, creatinine, and albumin. Specific group profiles assist in identifying and in monitoring the patient's health status. Incorporating laboratory test results into the plan and evaluation of care will result in safer and more effective patient care. Referring to laboratory test findings and comparing them with physical assessment findings are required for the delivery of professional nursing care. PMID:2235630
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
Rushton, Cynda Hylton; Reina, Michelle L; Reina, Dennis S
Cardiovascular drugs are a common cause of poisoning, and toxic bradycardias can be refractory to standard ACLS protocols. It is important to consider appropriate antidotes and adjunctive therapies in the care of the poisoned patient in order to maximize outcomes. While rigorous studies are lacking in regards to treatment of toxic bradycardias, there are small studies and case reports to help guide clinicians' choices in caring for the poisoned patient. Antidotes, pressor support, and extracorporeal therapy are some of the treatment options for the care of these patients. It is important to make informed therapeutic decisions with an understanding of the available evidence, and consultation with a toxicologist and/or regional Poison Control Center should be considered early in the course of treatment.
Patients may experience wounds at or near the end of life that are difficult to treat and may not be amenable to healing. In these cases, hospice and palliative care may be considered. Palliative care approaches include stabilization of existing wounds, prevention of new wounds, and symptom management with a focus on quality of life. Treatment goals for nonhealing wounds at the end of life include managing exudate, controlling odor, maximizing mobility and function, preventing infection, and controlling pain and other symptoms. Complementary components of palliative care are also instituted including communication and psychosocial support for patients and families. PMID:20463544
Letizia, MariJo; Uebelhor, Jonathan; Paddack, Elizabeth
BACKGROUND Patients with depression and poorly controlled diabetes, coronary heart disease, or both have an increased risk of adverse outcomes and high health care costs. We conducted a study to determine whether coordinated care management of multiple conditions improves disease control in these patients. METHODS We conducted a single-blind, randomized, controlled trial in 14 primary care clinics in an integrated health care system in Washington State, involving 214 participants with poorly controlled diabetes, coronary heart disease, or both and coexisting depression. Patients were randomly assigned to the usual-care group or to the intervention group, in which a medically supervised nurse, working with each patient’s primary care physician, provided guideline-based, collaborative care management, with the goal of controlling risk factors associated with multiple diseases. The primary outcome was based on simultaneous modeling of glycated hemoglobin, low-density lipoprotein (LDL) cholesterol, and systolic blood-pressure levels and Symptom Checklist–20 (SCL-20) depression outcomes at 12 months; this modeling allowed estimation of a single overall treatment effect. RESULTS As compared with controls, patients in the intervention group had greater overall 12-month improvement across glycated hemoglobin levels (difference, 0.58%), LDL cholesterol levels (difference, 6.9 mg per deciliter [0.2 mmol per liter]), systolic blood pressure (difference, 5.1 mm Hg), and SCL-20 depression scores (difference, 0.40 points) (P<0.001). Patients in the intervention group also were more likely to have one or more adjustments of insulin (P = 0.006), antihypertensive medications (P<0.001), and antidepressant medications (P<0.001), and they had better quality of life (P<0.001) and greater satisfaction with care for diabetes, coronary heart disease, or both (P<0.001) and with care for depression (P<0.001). CONCLUSIONS As compared with usual care, an intervention involving nurses who provided guideline-based, patient-centered management of depression and chronic disease significantly improved control of medical disease and depression. (Funded by the National Institute of Mental Health; ClinicalTrials.gov number, NCT00468676.)
Katon, Wayne J.; Lin, Elizabeth H.B.; Von Korff, Michael; Ciechanowski, Paul; Ludman, Evette J.; Young, Bessie; Peterson, Do; Rutter, Carolyn M.; McGregor, Mary; McCulloch, David
Management of many types of chronic diseases such as diabetes and asthma relies heavily on patients' self-monitoring of their disease conditions. In recent years, internet-based home telemonitoring systems that allow transmission of patient data to a central database and offer immediate access to the data by the care providers have become available. However, these systems often work with only one or a few types of medical devices and thus are limited in the types of diseases they can monitor. For example, a system designed to collect spirometry data from asthmatic patients cannot be easily adapted to collect blood glucose data from diabetic patients. This is because different medical devices produce different types of data and the existing telemonitoring systems are generally built around a proprietary data schema specific for the device used. In this paper, we describe a generic data schema for a telemonitoring system that is applicable to different types of medical devices and different diseases, and show an implementation of the schema in a relational database suitable for a variety of telemonitoring activities. PMID:11079856
Uncertainty is believed to be a central feature in illness experiences. Conversations between a consultant hematologist and 61 seriously illpatients 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.
Critically ill spinal cord injury (SCI) patients are at high risk for pressure ulcers. Research is needed to identify risk factors for pressure ulcers. The aim of this study was to investigate risk factors and outcomes of pressure ulcers in critically ill SCI patients. This is a retrospective cohort study. Data were gathered from medical records of adult patients with SCI admitted to surgical intensive care units. Ninety-four SCI patients participated in this study. Clinical variables associated with pressure ulcers were as follows: fecal management systems, incontinence, acidosis, support surfaces, steroids, and additional equipment. Hypotension was the strongest predictor of pressure ulcers. Nursing interventions may address risk factors and improve patient outcomes. PMID:22415500
The present study investigates illness perceptions of inflammatory bowel disease patients in an outpatient population, examining whether these illness perceptions are related to disease severity, quality of life and psychological adjustment. A cohort of 102 inflammatory bowel disease outpatients was prospectively enrolled on the study. The participants completed a questionnaire assessing illness perceptions, anxiety, depression and disease-specific symptoms. The study has identified specific illness perceptions of inflammatory bowel disease sufferers that are strongly associated with patients' quality of life. By raising and addressing these issues, clinicians may be able to allay these significant and often unexpressed concerns, and improve quality of life for patients with inflammatory bowel disease. PMID:23027780
Objective: Our objective was to determine if a nasopharyngeal airway (rectal trumpet) could be used as a fecal containment device with less trauma than traditional devices, such as a fecal incontinence pouch or balloon rectal catheter. Design: A single-subject clinical series was used. Setting and Subjects: A nonrandom sample of critically ill adult and geriatric patients (n = 22) with
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)
Jorge L. Munoz-Jordan; Cynthia S. Collins; Edgardo Vergne; Gilberto A. Santiago; Lyle Petersen; Wellington Sun; Jeffrey M. Linnen
Concerns about inefficiency and excessive expenditures has stimulated interest in the measurement of the output of the hospital, an organization that produces a wide variety of products. Diagnosis Related Groups and a number of severity measures including Disease Staging, the Severity of Illness Index, and Patient Management Categories are described and evaluated. Using criteria such as reliability, clinical validity, homogeneity,
Background: Diarrhea is common with many types of chemo- therapy and can have a major impact on maintaining dose intensity and treatment effectiveness, and on over- all health care resource consumption. In this study, a cost of illness analysis was conducted to estimate the overall economic impact of grade III\\/IV diarrhea in patients with colorectal cancer receiving adjuvant or palliative
Purpose To describe the association of intensive care with trajectories of functional, emotional, social, and physical well-being in patients with 3 common advanced illnesses Methods Cross-sectional cohort study of 42 patients admitted to the intensive care unit selected from 210 patients with stage IV breast, prostate, or colon cancer or stage IIIb or IV lung cancer; New York Heart Association class III or IV congestive heart failure; and chronic obstructive pulmonary disease with hypercapnea (Pco2 > 46 mm Hg). Scores on subscales of the Functional Assessment of Chronic Illness Therapy-General survey were measured monthly for 6 months before and after admission to the intensive care unit and were analyzed by using the unit admission date as a point of discontinuous change to illustrate trajectories before and after the admission. Results Overall, trajectories of well-being declined sharply after admission to the intensive care unit. Declines in physical, functional, and emotional well-being were statistically significant. During the 6 months after admission, physical, functional, and emotional well-being scores trended back up to baseline while social well-being scores continued to decline. Conclusions Well-being trajectories declined sharply after admission to the intensive care unit, with recovery in the subsequent 6 months, and may be characterized by common patterns. These results help to better describe intensive care as a marker for advancing illness in patients with advanced chronic illness.
Chiarchiaro, Jared; Olsen, Maren K.; Steinhauser, Karen E.; Tulsky, James A.
Objective. To identify predictors of 30-day mortality and to assess the impact of neutropenia recovery (NR) on 30-day mortality in critically ill cancer patients (CICPs). Design and setting. Retrospective review of the medical records of the 102 neutropenic CICPs admitted to a medical intensive care unit (ICU) over a 10-year period. Intervention. None. Measurements and results. Malignancies consisted of acute
Michael Darmon; Elie Azoulay; Corinne Alberti; Fabienne Fieux; Delphine Moreau; Jean-Roger Le Gall; Benoît Schlemmer
Background: Significant progress has been made in the field of renal replacement therapy for critically illpatients with acute renal failure (ARF) over the past few years. This review highlights these developments. Methods: Recent studies assessing the clinical utility of the RIFLE classification system for the diagnosis of ARF were reviewed. Clinical outcome studies evaluating the effect of continuous renal
William R. Clark; Jeffrey J. Letteri; Shigehiko Uchino; Rinaldo Bellomo; Claudio Ronco
INTRODUCTION: The best modality, for continuous renal replacement therapy (CRRT) is currently uncertain and it is poorly understood how transport of different solutes, whether convective or diffusive, changes over time. METHODS: We conducted a prospective cross over study in a cohort of critically illpatients, comparing small (urea and creatinine) and middle (?2 microglobulin) molecular weight solute clearance, filter lifespan
Zaccaria Ricci; Claudio Ronco; Alessandra Bachetoni; Giuseppe D'amico; Stefano Rossi; Elisa Alessandri; Monica Rocco; Paolo Pietropaoli
Background: There is increasing evidence that vascular disease contributes to cognitive impairment and dementia. Clarification of the role of vascular risk factors in dementia is important because most are modifiable, in contrast to other risk factors such as age and genetics. Methods: In 428 patients with mental illness we have investigated the relation of vascular disease to diagnoses, and a
We report a typhoid-like illness with fever and altered consciousness in a 22-year-old man with growth of Salmonella enterica serovar Virchow in blood and stool culture. Bacteremia and invasive disease due to non-typhoid salmonellae (NTS) are known in severely immunocompromised patients, but so far have not been described in immunocompetent adults. PMID:20463163
Eckerle, Isabella; Zimmermann, Stefan; Kapaun, Annette; Junghanss, Thomas
Hyperglycaemia is a major health risk and a negative determinant of surgical outcome. Despite its increasing prevalence, the limited treatments for restoration of normoglycaemia make its effective management a highly complex individualized clinical art. In this context, we review the mechanisms leading to hyperglycaemic damage as the basis for effective management of surgical complications of diabetic and non diabetic critically illpatients.
|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,…
Background: A significant number of studies have shown that critically illpatients with brain injury (BI) frequently exhibit abnormal pi- tuitary hormonal responses during the immediate postinjury period. Discus- sion: The elucidation of endocrine alterations depends on the criteria used, the diagnostic tests applied, and the timing of testing in relation to BI. The pattern of the detected hormonal abnormalities
The purpose of this paper is to present the outcome of Phase 2 of the sedation assessment project, namely, development of a new sedation assessment scale for critically illpatients. The authors define each of the five scale domains and present informatio...
M. J. DeJong S. M. Burns M. L. Campbell M. Chulay M. J. Grap
INTRODUCTION: The aim of transferring a critically illpatient to the intensive care unit (ICU) of a tertiary referral centre is to improve prognosis. The transport itself must be as safe as possible and should not pose additional risks. We performed a prospective audit of the quality of interhospital transports to our university hospital-based medical ICU. METHODS: Transfers were undertaken
Jack JM Ligtenberg; L Gert Arnold; Ymkje Stienstra; Tjip S van der Werf; John HJM Meertens; Jaap E Tulleken; Jan G Zijlstra
Summary The aim of this review is to analyse the evidence related to the relationship between facial expression and pain assessment tools in the critically ill non-communicative patients. Pain assessment is a significant challenge in critically ill adults, especially those who are unable to communicate their pain level. During critical illness, many factors alter verbal communication with patients including tracheal intubation, reduced level of consciousness and administration of sedation and analgesia. The first step in providing adequate pain relief is using a systematic, consistent assessment and documentation of pain. However, no single tool is universally accepted for use in these patients. A common component of behavioural pain tools is evaluation of facial behaviours. Although use of facial expression is an important behavioural measure of pain intensity, there are inconsistencies in defining descriptors of facial behaviour. Therefore, it is important to understand facial expression in non-communicative critically illpatients experiencing pain to assist in the development of concise descriptors to enhance pain evaluation and management. This paper will provide a comprehensive review of the current state of science in the study of facial expression and its application in pain assessment tools.
BACKGROUND: Influenza is a major cause of morbidity and hospitalization among children. While less often reported in adults, gastrointestinal symptoms have been associated with influenza in children, including abdominal pain, nausea, vomiting, and diarrhea. METHODS: From September 2005 and April 2008, pediatric patients in Indonesia presenting with concurrent diarrhea and influenza-like illness were enrolled in a study to determine the
Charisma Dilantika; Endang R Sedyaningsih; Matthew R Kasper; Magdarina Agtini; Erlin Listiyaningsih; Timothy M Uyeki; Timothy H Burgess; Patrick J Blair; Shannon D Putnam
Critically-illpatients are at risk of developing renal dis- orders as a consequence of systemic hypoperfusion. Ischemic acute tubular necrosis and resulting acute re- nal failure are caused by hypotension or therapeutic management. In this study, we tested the change of O2 availability induced by fenoldopam mesylate using the continuous measurement of urinary oxygen tension (Puo2), a relatively noninvasive technique
Andrea Morelli; Monica Rocco; Giorgio Conti; Alessandra Orecchioni; Roberto Alberto De Blasi; Flaminia Coluzzi; Paolo Pietropaoli
Three chronic conditions were examined—acute alcohol intoxication, seizure disorder, and respiratory illness—to quantify the extent of repetitive emergency medical services (EMS) use in a defined population. Urban EMS system ambulance data from 1992 to 1994 were analyzed for the three designated conditions with respect to transports by condition and individual patient. Analysis by ?2 was used for comparing proportions. Analysis
Jennifer Brokaw; Lenora Olson; Lynne Fullerton; Dan Tandberg; David Sklar
We examined the literature relating to the safe care of acutely ill hospitalized patients, and found that there are substantial opportunities for improvement. Recent research suggests substantial benefit may be obtained by systems of outreach care that facilitate better integration, co-ordination, collaboration and continuity of multidisciplinary care. Herein we review the various approaches that are being adopted, and suggest the
We assessed patient-physician communication about terminal care in Japan by examining the accuracy of physicians' estimation of their patients' preferences as regards (1) information about diagnosis and prognosis, (2) the place of death and (3) the therapeutic strategy at terminal stage (life prolongation vs pain control). We conducted a questionnaire survey on inpatients (n = 201) in three hospitals; two
The role of the fiberscope in the management of difficult and failed intubations has been well established and the importance of learning this valuable skill has been emphasized. Nonetheless, the fiberscope is underutilized in anesthesia and critical care practices because of a high rate of intubation failure. The main cause of failure is lack of expertise in maneuvering the fiberscope. Other technical causes of failure include fogging or clouding of the fiberscope's lens, drifting off the midline, and inability to advance the endotracheal tube or withdraw the fiberscope after completing intubation. Proper selection of the size of the fiberscope in relation to the size of the endotracheal tube, adequate lubrication, and careful passage of the fiberscope through the distal opening of the tracheal tube (not the Murphy eye) prevent difficulties encountered during advancement of the tube or upon withdrawal of the bronchoscope. Patient-related causes include inadequate topical anesthesia, which leads to abrupt movement of the larynx, laryngeal spasm, coughing, and copious secretions; a large floppy epiglottis; and tumor and edema of the upper airway, which also interfere with exposure of the larynx. Various approaches for learning and applying fiberoptic endoscopy have been instituted. The key to increased success involves initial training and practice with an intubation model and tracheobronchial tree. These models enable the learner to develop the eye-hand coordination skills needed to use the fiberscope properly. The fiberscope is best used in patients after learning to perform three simultaneous movements--advancing the fiberscope, coordinated rotation of the insertion cord, and bending the tip of the fiberscope while traversing the airway. After the technical skills of the fiberscope become second nature, the endoscopist can give more attention to patient-related factors to improve the success rate of tracheal intubation. Expert use of the fiberscope can be a life-saving measure through alleviating major airway complications and unnecessary tracheostomies. PMID:7736270
Objective To investigate whether timing of intensive insulin therapy (IIT) after intensive care unit (ICU) admission influences outcome. Design and setting Single-center prospective cohort study in the 14-bed medical ICU of a 1,171-bed tertiary teaching hospital. Patients The study included 127 patients started on ITT within 48 h of ICU admission (early group) and 51 started on ITT thereafter (late group); the groups did not differ in age, gender, race, BMI, APACHE III, ICU steroid use, admission diagnosis, or underlying comorbidities. Measurements and results The early group had more ventilator-free days in the first 28 days after ICU admission (median 12 days, IQR 0–24, vs. 1 day, 0–11), shorter ICU stay (6 days, IQR 3–11, vs. 11 days, vs. 7–17), shorter hospital stay (15 days, IQR 9–30, vs. 25 days, 13–43), lower ICU mortality (OR 0.48), and lower hospital mortality (OR 0.27). On multivariate analysis, early therapy was still associated with decreased hospital mortality (ORadj 0.29). The strength and direction of association favoring early IIT was consistent after propensity score modeling regardless of method used for analysis. Conclusions Early IIT was associated with better outcomes. Our results raise questions about the assumption that delayed administration of IIT has the same benefit as early therapy. A randomized study is needed to determine the optimal timing of therapy.
Honiden, Shyoko; Schultz, Atara; Im, Shelly A.; Nierman, David M.
OBJECTIVE: To identify differences and similarities between immigrants of Turkish origin and native German patients in therapeutically relevant dimensions such as subjective illness perceptions and personality traits. METHOD: Turkish and native German mentally disordered in-patients were interviewed in three psychiatric clinics in Hessen, Germany. The Revised Illness Perception Questionnaire (IPQ-Revised) and the Neuroticism-Extraversion-Openness Five-Factor Inventory (NEO-FFI) were used. Differences of scales and similarities by k-means cluster analyses were estimated. RESULTS: Of the 362 total patients, 227 (123 immigrants and 104 native Germans) were included. Neither demographic nor clinical differences were detected. Socioeconomic gradients and differences on IPQ-R scales were identified. For each ethnicity, the cluster analysis identified four different patient types based on NEO-FFI and IPQ-R scales. The patient types of each ethnicity appeared to be very similar in their structure, but they differed solely in the magnitude of the cluster means on included subscales according to ethnicity. CONCLUSION: When subjective illness perceptions and personality traits are considered together, basic patient types emerge independent of the ethnicity. Thus, the ethnical impact on patient types diminishes and a convergence was detected. PMID:23590836
Franz, M; Salize, H J; Lujic, C; Koch, E; Gallhofer, B; Jacke, C O
Background Incomplete medication adherence is a major problem in health care worldwide. Patients who adhere to medical treatment have a better prognosis and create fewer costs. Objective To assess the degree of incomplete adherence of chronically ill routine primary care patients in a German setting and analyze the association between incomplete medication adherence, as well as clinical and sociodemographic patient characteristics. Methods: In a cross-sectional survey, chronically illpatients were asked to assess their adherence in primary care retrospectively using the Medication Adherence Report Scale (MARS-D) questionnaire. To investigate the association of incomplete adherence with sociodemographic and clinical data, univariate and multivariate analyses were conducted. Results In total, 62.1% of 190 patients were categorized as incompletely adherent. The mean MARS-D score was 23.5 (standard deviation = 2.7). Analyses revealed no statistically significant associations at P < 0.05 between degree of adherence and patient characteristics. The total explained variance amounted to 11.8% (Nagelkerke’s R2 = 0.118) in the multivariate analysis. Conclusion Previously reported results regarding associations of sociodemographic and clinical data with incomplete medication adherence could not be confirmed for this sample of chronically illpatients. In order to be able to provide guidelines for the reduction of incomplete medication adherence in German primary care, further research is needed.
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 terminalillnesses. 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.
Critical care hospitalisation is emotionally overwhelming for the relatives of patients. Research has shown that religiosity is an effective coping resource for people with health related problems and has been correlated with better health outcomes. However the processes by which religiosity is utilized and its effects on relatives of critically illpatients have not been adequately explored. This article presents relatives' experiences and processes of religiosity; it is part of a wider grounded theory study on the experiences of critically illpatients' relatives in Greece. Twenty-five relatives of patients in the intensive care units of three public general district hospitals in Athens, Greece, participated in 19 interviews. Religiosity was found to be the main source of hope, strength and courage for relatives and was expressed with church/monastery attendance, belief in God, praying, and performing religious rituals. Health care professionals should pay attention and understand these aspects of coping. PMID:21955270
Plakas, Sotirios; Boudioni, Markella; Fouka, Georgia; Taket, Ann
Critically illpatients with acute kidney injury may be treated with a variety of renal replacement therapies (RRTs). Each of these RRTs has profound yet differing effects on drug dosing. Although the doses of some drugs can be titrated to an immediately observable pharmacodynamic effect, the effects of many drugs, such as antibiotics for example, are not immediately apparent. Attainment of desired pharmacodynamic response is a complex interplay between patient, RRT, and pharmacokinetic factors. In the case of antibiotics, microorganism-specific factors also must be considered. Rational and effective drug dosing in this clinical setting cannot occur until all these issues are addressed by the clinician. Failure to account for the pharmacokinetic influences of critical illness, kidney disease, and choice of intermittent hemodialysis or prolonged intermittent or continuous RRT can contribute to the high mortality rates seen in these patients. Pharmacotherapy considerations for each of these therapies are addressed in this article by applying them to a patient case. PMID:23127618
INTRODUCTION: Sleep disturbances are common in critically illpatients and when sleep does occur it traverses the day-night periods. The reduction in plasma melatonin levels and loss of circadian rhythm observed in critically illpatients receiving mechanical ventilation may contribute to this irregular sleep-wake pattern. We sought to evaluate the effect of exogenous melatonin on nocturnal sleep quantity in these
INTRODUCTION: Tracheostomy is one of the more commonly performed procedures in critically illpatients yet the optimal method of performing tracheostomies in this population remains to be established. The aim of this study was to systematically review and quantitatively synthesize all randomized clinical trials (RCTs), comparing elective percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in adult critically illpatients
Background: Evidence-based guidelines recommend that acutely ill hospitalized medical patients who are at risk of venous thromboembolism (VTE) should receive prophylaxis. Our aim was to characterize the clinical practices for VTE prophylaxis in acutely ill hospitalized medical patients enrolled in the International Medical Prevention Registry on Venous Thromboembolism (IM- PROVE). Methods: IMPROVE is an ongoing, multinational, observational study. Participating hospitals
Victor F. Tapson; H. Decousus; M. Pini; B. H. Chong; J. B. Froehlich; M. Monreal; A. C. Spyropoulos; G. J. Merli; R. B. Zotz; J.-F. Bergmann; R. Pavanello; A. G. G. Turpie; M. Nakamura; F. Piovella; A. K. Kakkar; F. A. Spencer; G. FitzGerald; F. A. Anderson
Neuropathic complication often occurs in critically illpatients, and changes in the microcirculation of the peripheral nerve have been suggested to play a role in the pathogenesis of the nerve lesion. We report the results of a pathological and immunohistochemical study of superficial peroneal nerve biopsy specimens in a series of 22 critically illpatients with sepsis and neuromuscular disorders.
BackgroundThe impact of diuretic usage and dosage on the mortality of critically illpatients with acute kidney injury is still unclear.Methods and ResultsIn this prospective, multicenter, observational study, 572 patients with postsurgical acute kidney injury receiving hemodialysis were recruited and followed daily. Thirty-day postdialysis mortality was analyzed using Cox's proportional hazards model with time-dependent covariates. The mean age of the
Objective. To determine the correlation between activated clotting time (ACT) and activated partial thromboplastin time (aPTT) in patients receiving intravenous unfractionated heparin therapy, and the accuracy of the ACT in predicting the level of anticoagulation. Design. Paired aPTT and ACT measurements were obtained from a convenience sample of critically illpatients requiring intravenous unfractionated heparin. The aPTT was determined in
Jan J. De Waele; Sebastiaan Van Cauwenberghe; Eric Hoste; Dominique Benoit; Francis Colardyn
Objective: Sedation by the enteral route is unusual in intensive medicine. We analysed the feasibili- ty\\/efficacy of long-term enteral se- dation in ventilated critically ill pa- tients. Design: Prospective interven- tional cohort study. Setting: General ICU. Patients and participants: For- ty-two patients needing ventilation and sedation for at least 4 days. In- terventions: At admission, sedation was induced with propofol
Marco Cigada; Angelo Pezzi; Piero Di Mauro; Silvia Marzorati; Andrea Noto; Federico Valdambrini; Matteo Zaniboni; Morena Astori; Gaetano Iapichino
BackgroundThe purpose of this study was to determine the incidence of candiduria in critically illpatients admitted to intensive care medical units (ICUs), to identify risk factors for candiduria and to assess the frequency distribution of different Candidaspp.Subjects and methodsThis was a prospective cohort observational and multicenter study. A total of 1,765 patients older than 18 years of age who were
Francisco Álvarez-Lerma; Juan Nolla-Salas; Cristobal León; Mercedes Palomar; Ricard Jordá; Nieves Carrasco; Felipe Bobillo
Critically illpatients whose course is complicated by acute kidney injury often receive renal replacement therapy (RRT).\\u000a For these patients, initiation of RRT results in a considerable escalation in both the complexity and associated cost of care.\\u000a While RRT is extensively used in clinical practice, there remains uncertainty about the ideal circumstances of when to initiate\\u000a RRT and for what
Sean M Bagshaw; Dinna N Cruz; RT Noel Gibney; Claudio Ronco
ObjectiveTo assess the predictive ability of preillness and illness variables, impact of care, and discharge variables on the post-intensive care mortality.Setting and patients5,805 patients treated with high intensity of care in 89 ICUs in 12 European countries (EURICUS-I study) surviving ICU stay.MethodsCase-mix was split in training sample (logistic regression model for post-ICU mortality: discrimination assessed by area under ROC curve)
Gaetano Iapichino; Alberto Morabito; Giovanni Mistraletti; Luca Ferla; Danilo Radrizzani; Dinis Reis Miranda
OBJECTIVE--To assess the health status of patients with 11 common illnesses--asthma, diabetes, arthritis, back pain, sciatica, hypertension, angina, anxiety, depression, and heart attack and stroke. DESIGN--Face to face interview using a structured questionnaire which contained the Short Form 36 questionnaire (SF-36) and questions on lifestyle, health service utilisation, and self reported conditions treated by physicians. SETTING--Patients' homes, in West Glamorgan,
. \\u000a \\u000a Objective: Changing the position from supine to prone is an emerging strategy to improve gas exchange in patients with the acute respiratory\\u000a distress syndrome (ARDS). The aim of this study was to evaluate the acute effects on gas exchange, hemodynamics, and respiratory\\u000a system mechanics of turning critically illpatients with ARDS from supine to prone. Design: Open, prospective study.
L. Blanch; J. Mancebo; M. Perez; M. Martinez; A. Mas; A. J. Betbese; D. Joseph; J. Ballús; U. Lucangelo; E. Bak
Objective End-stage liver disease is frequently complicated by renal function disturbances. Cirrhotic patients with renal failure admitted\\u000a to intensive care units (ICUs) have high mortality rates. This study analyzed the outcomes of critically ill cirrhotic patients\\u000a and identified the association between prognosis and RIFLE (risk of renal failure, injury to kidney, failure of kidney function,\\u000a loss of kidney function, and end-stage
This paper describes a social work service to critically ill non-hospitalized cancer patients based upon Heimler's theory and method of Human Social Functioning. Despite severe constraints arising from physical deterioration and emotional distress of the patients and certain aspects of the treatment setting, efforts were made to validate the effectiveness of the service through pre= and post-intervention measures of patients'
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.
McCorkle, Ruth; Ercolano, Elizabeth; Lazenby, Mark; Schulman-Green, Dena; Schilling, Lynne S.; Lorig, Kate; Wagner, Edward H.
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.
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.
Objective Families and other surrogate decision-makers for chronically critically illpatients often lack information about patient prognosis or options for care. This study describes an approach to develop and validate a printed information brochure about chronic critical illness aimed at improving comprehension of the disease process and outcomes for patients’ families and other surrogate decision-makers. Design Investigators reviewed existing literature to identify key domains of informational needs. Content of these domains was incorporated in a draft brochure that included graphics and a glossary of terms. Clinical sensibility, balance, and emotional sensitivity of the draft brochure were tested in a series of evaluations by cohorts of experienced clinicians (n=49) and clinical content experts (n=8), with revisions after each review. Cognitive testing of the brochure was performed through interviews of 10 representative family members of chronically critically illpatients with quantitative and qualitative analysis of responses. Measurements and Main Results Clinical sensibility and balance were rated in the two most favorable categories on a 5-point scale by more than two thirds of clinicians and content experts. After review, family members described the brochure as clear and readable and recommended that the brochure be delivered to family members by clinicians, followed by a discussion of its contents. They indicated that the glossary was useful and recommended supplementation by additional lists of local resources. After reading the brochure, their prognostic estimates became more consistent with actual outcomes. Conclusions We have developed and validated a printed information brochure that may improve family comprehension of chronic critical illness and its outcomes. The structured process that is described can serve as a template for the development of other information aids for use with seriously ill populations.
Carson, Shannon S.; Vu, Maihan; Danis, Marion; Camhi, Sharon L.; Scheunemann, Leslie P.; Cox, Christopher E.; Hanson, Laura C.; Nelson, Judith E.
Rationale Critically illpatients are highly susceptible to hospital-acquired infection. Neutrophil function in critical illness remains poorly understood. Objectives To characterize and define mechanisms of peripheral blood neutrophil (PBN) dysfunction in critically illpatients. To determine whether the inflamed lung contributes additional phagocytic impairment. Methods Prospective collection of blood and bronchoalveolar lavage fluid from patients with suspected ventilator-associated pneumonia and from age- and sex-matched volunteers; laboratory analysis of neutrophil functions. Measurements and Main Results Seventy-two patients and 21 volunteers were included. Phagocytic capacity of PBNs was 36% lower in patients than in volunteers (P < 0.0001). From several biologically plausible candidates only activated complement was significantly associated with impaired PBN phagocytosis (P < 0.0001). Phagocytosis was negatively correlated with serum C3a and positively correlated with expression of C5a receptor type 1 (CD88) on PBNs. C5a recapitulated impaired PBN phagocytosis and significantly down-regulated CD88 expression in vitro. C5a-mediated phagocytic impairment was prevented by blocking either CD88 or phosphoinositide 3-kinase, and completely reversed by granulocyte-macrophage colony-stimulating factor. C5a also impaired killing of Pseudomonas aeruginosa by, and migration of, PBNs, indicating that effects were not restricted to phagocytosis. Bronchoalveolar lavage fluid leukocytes from patients also demonstrated significantly impaired function, and lavage supernatant reduced phagocytosis in healthy neutrophils by 43% (P = 0.0001). However, lavage fluid did not affect CD88 expression and lavage-mediated impairment of phagocytosis was not blocked by anti-CD88 antibody. Conclusions Critically illpatients have significant dysfunction of PBNs, which is mediated predominantly by activated complement. Further, profound complement-independent neutrophil dysfunction occurs in the inflamed lung.
Morris, Andrew Conway; Kefala, Kallirroi; Wilkinson, Thomas S.; Dhaliwal, Kevin; Farrell, Lesley; Walsh, Tim; Mackenzie, Simon J.; Reid, Hamish; Davidson, Donald J.; Haslett, Chris; Rossi, Adriano G.; Sallenave, Jean-Michel; Simpson, A. John
Patients with acute medical illnesses are at increased risk of venous thromboembolism (VTE), a significant cause of morbidity and mortality. Thromboprophylaxis is recommended in these patients but questions remain regarding the optimal duration of therapy. The aim of this study is to determine whether oral rivaroxaban is non-inferior to standard-duration (approximately 10 days) subcutaneous (s.c.) enoxaparin for the prevention of VTE in acutely ill medical patients, and whether extended-duration (approximately 5 weeks) rivaroxaban is superior to standard-duration enoxaparin. Patients aged 40 years or older and hospitalized for various acute medical illnesses with risk factors for VTE randomly receive either s.c. enoxaparin 40 mg once daily (od) for 10 ± 4 days or oral rivaroxaban 10 mg od for 35 ± 4 days. The primary efficacy outcomes are the composite of asymptomatic proximal deep vein thrombosis (DVT), symptomatic DVT, symptomatic non-fatal pulmonary embolism (PE), and VTE-related death up to day 10 + 4 and up to day 35 + 4. The primary safety outcome is the composite of treatment-emergent major bleeding and clinically relevant non-major bleeding. As of July 2010, 8,101 patients from 52 countries have been randomized. These patients have a broad range of medical conditions: approximately one-third were diagnosed with acute heart failure, just under one-third were diagnosed with acute infectious disease, and just under one-quarter were diagnosed with acute respiratory insufficiency. MAGELLAN will determine the efficacy, safety, and pharmacological profile of oral rivaroxaban for the prevention of VTE in a diverse population of medically illpatients and the potential of extended-duration therapy to reduce incidence of VTE. PMID:21359646
Cohen, Alexander Thomas; Spiro, Theodore Erich; Büller, Harry Roger; Haskell, Lloyd; Hu, Dayi; Hull, Russell; Mebazaa, Alexandre; Merli, Geno; Schellong, Sebastian; Spyropoulos, Alex; Tapson, Victor
Rather than a specific entity, delirium is at the midpoint on a spectrum of potential mental status changes that ranges from full consciousness to deep coma. The extremes are relatively easy to recognize, but other points along the spectrum may go unrecognized or be misdiagnosed. If recognized and treated expeditiously, delirium may be reversed in some patients. It is imperative that those caring for critically illpatients with cancer have the knowledge and tools necessary to identify and manage delirium appropriately. Although all critically illpatients are at risk for delirium, cancer presents additional assaults to the central nervous system via direct tumor invasion or iatrogenic provocations. This article describes delirium in cancer, and addresses diagnostic and management issues across the course of the disease. PMID:12574707
Over 350,000 immigrants are detained by U.S. Immigration and Customs Enforcement (ICE) each year. An unknown fraction of these detainees have serious mental illnesses and are taken into ICE custody even though a criminal court has ordered them to enter inpatient mental health care. The authors report findings from 16 such cases in which they have provided advocacy over the past four years. In some cases, they were able to secure release of detainees into inpatient care in community (nonforensic) settings, which involved substantial logistical challenges. Given the well-documented concerns about securing adequate care for ICE detainees with mental illness, a logical policy change would be for ICE to allow these patients to enter court-ordered inpatient care. This move would improve care for patients and would also unburden ICE from the untenable proposition of caring for patients that the criminal justice system has deemed unfit for incarceration. PMID:22476303
Objective To determine the incidence and duration of adrenal inhibition induced by a single dose of etomidate in critically illpatients.\\u000a \\u000a \\u000a \\u000a Design Prospective, observational cohort study.\\u000a \\u000a \\u000a \\u000a Setting Three intensive care units in a university hospital.\\u000a \\u000a \\u000a \\u000a Patients Forty critically illpatients without sepsis who received a single dose of etomidate for facilitating endotracheal intubation.\\u000a \\u000a \\u000a \\u000a Measurements and main results Serial serum cortisol and 11?-deoxycortisol samples were taken at baseline and
Marc Vinclair; Christophe Broux; Patrice Faure; Julien Brun; Céline Genty; Claude Jacquot; Olivier Chabre; Jean-François Payen
PurposeThe aim of the study was to determine whether the use of specialist transport personnel improves patient outcome at the receiving hospital for critically illpatients transferred to higher centers.
Dean Belway; William Henderson; Sean P. Keenan; Adrian R. Levy; Peter M. Dodek
In this review, the role of coping in the development of psychosocial interventions for chronically illpatients is discussed. After summarizing the theoretical issues involved in the translation of the coping concept into an intervention, a review is undertaken of 35 studies concerned with the impact of interventions aimed at improving coping on patients' quality of life. These studies concern seven different chronic disease types (AIDS, asthma, cancer, cardiovascular diseases, chronic pain, diabetes, and rheumatoid arthritis) and show explicit consideration of attempts to manage illness in terms of coping to be rare. Many studies nevertheless address the equivalent of coping, namely behaviors and/or cognitions intended to deal with an illness situation appraised as stressful. The results of these studies are encouraging, although largely limited to the improvement of one or two particular coping strategies and problem-focused strategies in particular. It is argued that in order to expand on these initially positive findings, greater and more explicit consideration should be given to the potential of the coping concept for intervention with the chronically ill. The appraisal of stressful situations, the use of coping resources, and the strategic application of particular coping strategies should, for example, be given more careful consideration. PMID:11293366
The diagnosis of acute cholecystitis in critically illpatients 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 illpatients who underwent the insertion of cholecystostomy tubes for the initial treatment of acute cholecystitis. This is a retrospective review of critically illpatients 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 illpatients, 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
Morse, Bryan C; Smith, J Brandon; Lawdahl, Richard B; Roettger, Richard H
Background Somatisation is particularly challenging in multicultural contexts where patients and physicians often differ in terms of their illness-related beliefs and practices and health care expectations. This paper reports on a exploratory study aimed at better understanding how asylum seeker and refugee patients from the former country of Yugoslavia who were identified by their physicians as somatising make sense of their suffering. Methods We conducted semi-structured interviews with 26 asylum seeker and refugee patients from the former country of Yugoslavia who attended the general medicine outpatient clinic of a Swiss teaching Hospital and were identified as presenting with somatisation. Interviews explored patients' illness perspectives and health care expectations. Interviews were audio taped, transcribed verbatim and analyzed to identify key themes in patients' narratives. Results Patients attributed the onset of symptoms to past traumatic experiences and tended to attribute their persistence to current living conditions and uncertain legal status. Patients formulated their suffering in both medical and social/legal terms, and sought help from physicians for both types of problems. Conclusion Awareness of how asylum seeker and refugee patients make sense of their suffering can help physicians to better understand patients' expectations of the clinical encounter, and the particular nature and constraints of the patient-provider relationship in the context of asylum.
In a prospective randomized placebo-controlled study, we assessed potential physiological effects of nonthyroidal illness syndrome (NTIS) in acute illness. Coronary artery bypass graft surgery was employed as a prospective model of acute illness and NTIS. Triiodothyronine (T(3)) or placebo was infused for 24 h after surgery, with a T(3) dose selected to maintain postoperative serum T(3) concentrations at preoperative levels. Patients were evaluated before coronary artery bypass graft and during the postoperative period. Cardiovascular function was monitored with Swan-Ganz catheter measurements and ECG. Urinary nitrogen excretion and L-[1-(13)C]leucine flux were used to evaluate protein metabolism. Serum measurements of relevant hormones, iron, and total iron-binding capacity were used to assess effects on sex steroid, growth hormone axis, and iron responses to illness. Cardiovascular function was not affected by T(3) infusion, except for a transient higher cardiac index in the T(3) group 6 h after surgery (3.04 +/- 0.12 for T(3) and 2.53 +/- 0.08 for placebo, P = 0.0016). Protein metabolism was not affected; changes in urinary nitrogen excretion and L-[1-(13)C]leucine flux were equivalent in the two groups (P = 0.35 and P = 0.95, respectively). No differences were observed in changes in testosterone, estrogens, growth hormone, insulin-like growth hormone I, iron, or total iron-binding capacity between T(3) and placebo groups. We conclude that, in the early stages of major illness, the decrease in circulating T(3) concentrations in NTIS has only a minimal transient physiological impact on cardiac function and plays no significant role in protecting against protein catabolism or modulating other endocrine responses or iron responses to illness. PMID:17426111
Spratt, D I; Frohnauer, M; Cyr-Alves, H; Kramer, R S; Lucas, F L; Morton, J R; Cox, D F; Becker, K; Devlin, J T
Although generalized anxiety disorder (GAD) is associated with significant occupational disability, it has, however, received little attention with regard to adjustment to illness. Subjects included 102 chronic dialysis (CD) patients, 58 kidney transplant (KT) patients, and 42 GAD patients. The evaluations included the Psychosocial Adjustment to Physical Illness Scale (PAIS), the Hamilton Anxiety Rating Scale (HAM-A) and the Hamilton Depression
Tzung Lieh Yeh; Chieh Liang Huang; Yen Kuang Yang; Yih Dar Lee; Chwen Cheng Chen; Po See Chen
Influenza-like illness (ILI) is often defined as fever (>38.0C) with cough or sore throat. In this study, we tested the sensitivity, specificity, and positive and negative predictive values of this case definition in a Cambodia patient population. Methods...
L. Sovann M. R. Kasper P. J. Blair S. D. Putnam T. F. Wierzba
Background Patients with chest pain or palpitations often have poor outcomes following a negative cardiac evaluation, with symptom persistence, limitations in everyday activities, and reduced health-related quality of life. The aims of this study were to evaluate illness perceptions before and after negative cardiac evaluations and measure the ability of a self-report questionnaire to predict outcomes. Methods Patients (N?=?138) referred for chest pain or palpitations to a cardiac outpatient clinic were assessed before and six months after a negative cardiac evaluation. In addition to Brief Illness Perception Questionnaire (BIPQ), all patients completed the Beck Depression Inventory and SF-36 Health Survey. Results The emotional reactions to and understanding of symptoms had not improved six months after a negative cardiac evaluation. A stronger correlation between illness perceptions and health at follow-up than before the cardiac evaluation might explain the tendency for poor outcomes among these patients. Most of the eight BIPQ item scores before the negative cardiac evaluation were predictive of the outcome six months later. A single question asking about the perceived consequences of the complaints (BIPQ Item 1) rated before the cardiac evaluation was collapsed into a dichotomous variable with a cut-off at ?4 which yields a sensitivity of 51%, a specificity of 85%, a positive predictive value of 71%, a negative predictive value of 69%, and an odds ratio of 5.7 (r?=?.38, p?.001) in predicting poor outcomes. Conclusions Assessing illness perceptions is important in patients with negative cardiac tests for understanding and predicting outcomes.
Background Skeletal muscle mass is controlled by myostatin and Akt-dependent signaling on mammalian target of rapamycin (mTOR), glycogen synthase kinase 3? (GSK3?) and forkhead box O (FoxO) pathways, but it is unknown how these pathways are regulated in critically ill human muscle. To describe factors involved in muscle mass regulation, we investigated the phosphorylation and expression of key factors in these protein synthesis and breakdown signaling pathways in thigh skeletal muscle of critically ill intensive care unit (ICU) patients compared with healthy controls. Methodology/Principal Findings ICU patients were systemically inflamed, moderately hyperglycemic, received insulin therapy, and showed a tendency to lower plasma branched chain amino acids compared with controls. Using Western blotting we measured Akt, GSK3?, mTOR, ribosomal protein S6 kinase (S6k), eukaryotic translation initiation factor 4E binding protein 1 (4E-BP1), and muscle ring finger protein 1 (MuRF1); and by RT-PCR we determined mRNA expression of, among others, insulin-like growth factor 1 (IGF-1), FoxO 1, 3 and 4, atrogin1, MuRF1, interleukin-6 (IL-6), tumor necrosis factor ? (TNF-?) and myostatin. Unexpectedly, in critically ill ICU patients Akt-mTOR-S6k signaling was substantially higher compared with controls. FoxO1 mRNA was higher in patients, whereas FoxO3, atrogin1 and myostatin mRNAs and MuRF1 protein were lower compared with controls. A moderate correlation (r2?=?0.36, p<0.05) between insulin infusion dose and phosphorylated Akt was demonstrated. Conclusions/Significance We present for the first time muscle protein turnover signaling in critically ill ICU patients, and we show signaling pathway activity towards a stimulation of muscle protein synthesis and a somewhat inhibited proteolysis.
Jespersen, Jakob G.; Nedergaard, Anders; Reitelseder, S?ren; Mikkelsen, Ulla R.; Dideriksen, Kasper J.; Agergaard, Jakob; Kreiner, Frederik; Pott, Frank C.; Schjerling, Peter; Kjaer, Michael
Critically illpatients 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 (? (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.
Introduction Various cohort studies have shown that acute (short-term) mortality rates in unselected critically illpatients may have improved during the past 15 years. Whether these benefits also affect acute and long-term prognosis in chronically critically illpatients is unclear, as are determinants relevant to prognosis. Methods We conducted a retrospective analysis of data collected from March 1993 to February 2005. A cohort of 390 consecutive surgical patients requiring intensive care therapy for more than 28 days was analyzed. Results The intensive care unit (ICU) survival rate was 53.6%. Survival rates at one, three and five years were 61.8%, 44.7% and 37.0% among ICU survivors. After adjustment for relevant covariates, acute and long-term survival rates did not differ significantly between 1993 to 1999 and 1999 to 2005 intervals. Acute prognosis was determined by disease severity during ICU stay and by primary diagnosis. However, only the latter was independently associated with long-term prognosis. Advanced age was an independent prognostic determinant of poor short-term and long-term survival. Conclusion Acute and long-term prognosis in chronically critically ill surgical patients has remained unchanged throughout the past 12 years. After successful surgical intervention and intensive care, long-term outcome is reasonably good and is mainly determined by age and underlying disease.
Hartl, Wolfgang H; Wolf, Hilde; Schneider, Christian P; Kuchenhoff, Helmut; Jauch, Karl-Walter
Acute and chronic critical conditions are associated with reduced serum levels of free triiodothyronine (FT(3)), free thyroxine FT(4), and thyrotropin, known as nonthyroidal illness syndrome (NTIS). It is still controversial whether these changes reflect a protective mechanism or a maladaptive process during prolonged illness. However, larger studies to determine the prevalence of the NTIS and its association with outcome in medical intensive care units (ICUs) are missing. Complete thyroid hormone levels from 247 of 743 patients admitted to our ICU between October 2002 and February 2004 were retrospectively evaluated. From these patients, Acute Physiology and Chronic Health II scores, ICU mortality, length of stay, mechanical ventilation, and concomitant medication were recorded. Ninety-seven patients (44.1%) had low FT(3) levels indicating an NTIS, either with normal (23.6%) or reduced (20.5%) serum thyrotropin levels. Of 97 patients with NTIS, 24 (23.3%) also showed reduced serum FT(4) levels. The NTIS was significantly associated with Acute Physiology and Chronic Health II scores, mortality, length of stay, and mechanical ventilation. In a multivariate Cox regression analysis, the combination of low FT(3) and low FT(4) was an independent risk factor for survival. Nonthyroidal illness syndrome is frequent at a medical ICU. A reduction of FT(4) together with FT(3) is associated with an increase in mortality and might reflect a maladaptive process, thereby worsening the disease. PMID:17224339
Plikat, Katharina; Langgartner, Julia; Buettner, Roland; Bollheimer, L Cornelius; Woenckhaus, Ulrike; Schölmerich, Jürgen; Wrede, Christian E
Background Transport of critically illpatients for diagnostic or therapeutic procedures is at risk of complications. Adverse events during transport are common and may have significant consequences for the patient. The objective of the study was to collect prospectively adverse events that occurred during intrahospital transports of critically illpatients and to determine their risk factors. Methods This prospective, observational study of intrahospital transport of consecutively admitted patients with mechanical ventilation was conducted in a 38-bed intensive care unit in a university hospital from May 2009 to March 2010. Results Of 262 transports observed (184 patients), 120 (45.8%) were associated with adverse events. Risk factors were ventilation with positive end-expiratory pressure >6 cmH2O, sedation before transport, and fluid loading for intrahospital transports. Within these intrahospital transports with adverse events, 68 (26% of all intrahospital transports) were associated with an adverse event affecting the patient. Identified risk factors were: positive end-expiratory pressure >6 cmH2O, and treatment modification before transport. In 44 cases (16.8% of all intrahospital transports), adverse event was considered serious for the patient. In our study, adverse events did not statistically increase ventilator-associated pneumonia, time spent on mechanical ventilation, or length of stay in the intensive care unit. Conclusions This study confirms that the intrahospital transports of critically illpatients leads to a significant number of adverse events. Although in our study adverse events have not had major consequences on the patient stay, efforts should be made to decrease their incidence.
Objective To determine the effectiveness of early, routine antioxidant supplementation using ?-tocopherol and ascorbic acid in reducing the rate of pulmonary morbidity and organ dysfunction in critically ill surgical patients. Summary Background Data Oxidative stress has been associated with the development of the acute respiratory distress syndrome (ARDS) and organ failure through direct tissue injury and activation of genes integral to the inflammatory response. In addition, depletion of endogenous antioxidants has been associated with an increased risk of nosocomial infections. The authors postulated that antioxidant supplementation in critically ill surgical patients may reduce the incidence of ARDS, pneumonia, and organ dysfunction. Methods This randomized, prospective study was conducted to compare outcomes in patients receiving antioxidant supplementation (?-tocopherol and ascorbate) versus those receiving standard care. The primary endpoint for analysis was pulmonary morbidity (a composite measure of ARDS and nosocomial pneumonia). Secondary endpoints included the development of multiple organ failure, duration of mechanical ventilation, length of ICU stay, and mortality. Results Five hundred ninety-five patients were enrolled and analyzed, 91% of whom were victims of trauma. The relative risk of pulmonary morbidity was 0.81 (95% confidence interval 0.60–1.1) in patients receiving antioxidant supplementation. Multiple organ failure was significantly less likely to occur in patients receiving antioxidants than in patients receiving standard care, with a relative risk of 0.43 (95% confidence interval 0.19–0.96). Patients randomized to antioxidant supplementation also had a shorter duration of mechanical ventilation and length of ICU stay. Conclusions The early administration of antioxidant supplementation using ?-tocopherol and ascorbic acid reduces the incidence of organ failure and shortens ICU length of stay in this cohort of critically ill surgical patients.
Nathens, Avery B.; Neff, Margaret J.; Jurkovich, Gregory J.; Klotz, Patricia; Farver, Katherine; Ruzinski, John T.; Radella, Frank; Garcia, Iris; Maier, Ronald V.
BACKGROUND The optimal intensity of renal-replacement therapy in critically illpatients with acute kidney injury is controversial. METHODS We randomly assigned critically illpatients with acute kidney injury and failure of at least one nonrenal organ or sepsis to receive intensive or less intensive renal-replacement therapy. The primary end point was death from any cause by day 60. In both study groups, hemodynamically stable patients underwent intermittent hemodialysis, and hemodynamically unstable patients underwent continuous venovenous hemodiafiltration or sustained low-efficiency dialysis. Patients receiving the intensive treatment strategy underwent intermittent hemodialysis and sustained low-efficiency dialysis six times per week and continuous venovenous hemodiafiltration at 35 ml per kilogram of body weight per hour; for patients receiving the less-intensive treatment strategy, the corresponding treatments were provided thrice weekly and at 20 ml per kilogram per hour. RESULTS Baseline characteristics of the 1124 patients in the two groups were similar. The rate of death from any cause by day 60 was 53.6% with intensive therapy and 51.5% with less-intensive therapy (odds ratio, 1.09; 95% confidence interval, 0.86 to 1.40; P = 0.47). There was no significant difference between the two groups in the duration of renalreplacement therapy or the rate of recovery of kidney function or nonrenal organ failure. Hypotension during intermittent dialysis occurred in more patients randomly assigned to receive intensive therapy, although the frequency of hemodialysis sessions complicated by hypotension was similar in the two groups. CONCLUSIONS Intensive renal support in critically illpatients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy involving a defined dose of intermittent hemodialysis three times per week and continuous renal-replacement therapy at 20 ml per kilogram per hour. (ClinicalTrials.gov number, NCT00076219.)
Background It is currently unclear whether parenteral selenium supplementation should be recommended in the management of critically illpatients. 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 illpatients 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 illpatients with sepsis (relative risk [RR] 0.83, 95% CI 0.70–0.99, p?=?0.04, I2?=?0%). Subgroup analyses demonstrated that the administration schedule employing longer duration (RR 0.77, 95% CI 0.63–0.94, p?=?0.01, I2?=?0%), loading boluses (RR 0.73, 95% CI 0.58–0.94, p?=?0.01, I2?=?0%) or high-dose selenium treatment (RR 0.77, 95% CI 0.61–0.99, 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 illpatients 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
Introduction Sepsis has been identified as a risk factor for human cytomegalovirus (CMV) reactivation in critically illpatients. However,\\u000a the contribution of CMV reactivation on morbidity and mortality is still controversial. Therefore, we analyzed the incidence\\u000a and impact of CMV reactivation on outcome in patients with severe sepsis.\\u000a \\u000a \\u000a \\u000a \\u000a Methods In a prospective longitudinal double-blinded observational study, 97 adult nonimmunosuppressed CMV-seropositive patients with
Alexandra Heininger; Helene Haeberle; Imma Fischer; Robert Beck; Reimer Riessen; Frank Rohde; Christoph Meisner; Gerhard Jahn; Alfred Koenigsrainer; Klaus Unertl; Klaus Hamprecht
Introduction Acid–base abnormalities are common in the intensive care unit (ICU). Differences in outcome exist between respiratory and metabolic acidosis in similar pH ranges. Some forms of metabolic acidosis (for example, lactate) seem to have worse outcomes than others (for example, chloride). The relative incidence of each type of disorder is unknown. We therefore designed this study to determine the nature and clinical significance of metabolic acidosis in critically illpatients. Methods An observational, cohort study of critically illpatients was performed in a tertiary care hospital. Critically illpatients were selected on the clinical suspicion of the presence of lactic acidosis. The inpatient mortality of the entire group was 14%, with a length of stay in hospital of 12 days and a length of stay in the ICU of 5.8 days. Results We reviewed records of 9,799 patients admitted to the ICUs at our institution between 1 January 2001 and 30 June 2002. We selected a cohort in which clinicians caring for patients ordered a measurement of arterial lactate level. We excluded patients in which any necessary variable required to characterize an acid–base disorder was absent. A total of 851 patients (9% of ICU admissions) met our criteria. Of these, 548 patients (64%) had a metabolic acidosis (standard base excess < -2 mEq/l) and these patients had a 45% mortality, compared with 25% for those with no metabolic acidosis (p < 0.001). We then subclassified metabolic acidosis cases on the basis of the predominant anion present (lactate, chloride, or all other anions). The mortality rate was highest for lactic acidosis (56%); for strong ion gap (SIG) acidosis it was 39% and for hyperchloremic acidosis 29% (p < 0.001). A stepwise logistic regression model identified serum lactate, SIG, phosphate, and age as independent predictors of mortality. Conclusion In critically illpatients in which a measurement of lactate level was ordered, lactate and SIG were strong independent predictors of mortality when they were the major source of metabolic acidosis. Overall, patients with metabolic acidosis were nearly twice as likely to die as patients without metabolic acidosis.
Gunnerson, Kyle J; Saul, Melissa; He, Shui; Kellum, John A
Considerable evidence has shown that adequate antibiotic therapy is of utmost importance in the critically ill septic patient. However, antibiotic concentration may be insufficient early in infection course. We propose the concept of dose modulation, meaning front-line variability of antibiotic dose, according to patient and microorganism characteristics, followed by its reduction after clinical response and patient recovery. Therefore, dose modulation means concentrating the largest weight of antibiotics at the front-end, when the microbial load is higher and the pharmacokinetic changes poses the highest risk of underdosing and nibbling off antibiotic dose, when the sepsis syndrome is improving, guided by pharmacokinetic and pharmacodynamic data. PMID:23337485
Inappropriate antimicrobial therapy of pneumonia, severe sepsis and bacteraemia is associated with high mortality. Adjustment of insufficient initial antibiotics after susceptibility testing does not reduce mortality. Guidelines on critically illpatients should focus on antibiograms for each intensive care unit to ensure full coverage of initial therapy with a broad-spectrum antibiotic with high tissue penetration, minimal organ toxicity and low risk of resistance development. Early reassessment and withdrawal of antibiotics, if not indicated, are important elements in reducing antibiotic resistance. The initial broad-spectrum should be narrowed according to bacterial susceptibility data. This evidence-based intervention ensures appropriate antimicrobial treatment to critically illpatients to improve outcome and reduction of the use of broad-spectrum antibiotics. PMID:17313920
Abstract This study reports Aspergillus isolation in critically illpatients who underwent extracorporeal membrane oxygenation (ECMO) and highlights the difficulty in establishing a diagnosis of aspergillosis in this population. The diagnosis of Aspergillus infection or colonization was retrospectively performed using the proposed modified criteria of the European Organization for Research and Treatment of Cancer and the Mycoses Study Group (EORTC/MSG) adapted to critically illpatients. Between 2005 and 2011, 11 of 151 patients (7.2%) who underwent ECMO had Aspergillus sp. isolates, 10 in a pulmonary sample and 1 in a mediastinal wound sample. Five patients did not have any classical risk factors for aspergillosis. One patient had a proven invasive pulmonary aspergillosis (IPA), 2 had a putative IPA, and 1 patient had a possible Aspergillus mediastinitis, whilst in 7 patients this was considered colonization. However, the clinical relevance of Aspergillus isolation was based on an algorithm not validated in patients undergoing ECMO. Our data support the need to implement non-invasive diagnostic procedures for aspergillosis in this population. PMID:23746344
Aubron, Cecile; Pilcher, David; Leong, Tim; Cooper, D James; Scheinkestel, Carlos; Pellegrino, Vince; Cheng, Allen C
Objective To evaluate the benefits and harms of antithrombin III in critically illpatients.Design Systematic review and meta-analysis of randomised trials.Data sources CENTRAL, Medline, Embase, International Web of Science, LILACS, the Chinese Biomedical Literature Database, and CINHAL (to November 2006); hand search of reference lists, contact with authors and experts, and search of registers of ongoing trials.Review methods Two reviewers
Arash Afshari; Jørn Wetterslev; Jesper Brok; Ann Møller
According to Leventhal’s Self-Regulatory Model of Illness, patients have ideas and action plans related to the management of their disease. The aim of this study is to examine whether ideas and action plans relating to hypertension change as a result of general practitioner’s (GP’s) discussing them during consultation, and whether these changed ideas and actions plans affect adherence. The study
Nicolet C. M Theunissen; Denise T. D de Ridder; Jozien M Bensing; Guy E. H. M Rutten
Purpose Inflammation-induced anemia is frequent among critically illpatients and can be aggravated by true iron deficiency (ID) resulting\\u000a from blood losses. The serum hepcidin level controls the availability of iron for erythropoiesis, and its determination offers\\u000a new perspectives for the diagnosis of ID in the presence of inflammation. We conducted a prospective observational study to\\u000a determine the cutoff value and
Sigismond Lasocki; Gabriel Baron; Fathi Driss; Mark Westerman; Hervé Puy; Isabelle Boutron; Carole Beaumont; Philippe Montravers